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1. MUSCULO-SKELETAL PT
Reference Text: MCRAE

2. SHOULDER JOINT COMPLEX

3. 1. Impingement syndrome
• Painful arc between 60° – 120° abduction
• Acute in sportsmen
• Chronic in elderly

4. • It is basically reduction in the size of
supraspinatus tunnel
• Thickening of subdeltoid bursa or R.C tendon
• Treatment:
• Decompression of the subacromial space
(excision of osteophytes, AC joint arthroplasty,
excision of crocaacromila ligament)

6. 2. Rotator cuff tear
• Most commonly of supraspinatus muscle
• Inability to initiate abduction
• Torn cuff impinges on acromion which causes pain
• In young patients, surgical repair is done
• In ability to rotate is also involved in older adults,
which leads to the diagnosis of frozen shoulder

7. 3.Rotator cuff arthropathy
• Impingement syndrome and rotator cuff tear
leads to rotator cuff arthropathy.
• Friction between the humeral head and
acromion may result in bony collapse and
gross degenerative changes in GH joint.
• It may leads to replacement of the joint

8. 4. Calcifying supraspinatus tendonitis
• Local deposition of calcium salts
• Continue without symptoms
• Radiographic changes are obvious
• It may give rise to inflammatory changes to
sub-deltoid bursa
• It results in severe pain, acute tenderness,
warmth and swelling in shoulder

9. • It must be differentiated from acute attack of
gout or infectious disease
Treatment:
• Aspiration, local injections of hydrocortisone

10. 5. Instabilities of shoulder
• Anterior instability
• Posterior instability
• Inferior instability

11. Anterior instability:
• Most common
• 20- 40 years of age
• History of repeated dislocations
• Shoulder is often asymptomatic between
incidents
• Pain & weakness may be seen

12. Treatment:
• Surgical repair after 3 to 4 dislocations

13. • Posterior dislocation:
• Less common
• Surgical reconstruction is required
“LOOSE Shoulder” shoulder with
multidirectional instabilities

14. 6. AC joint dislocations
• Fall on outstretched hand

15. 7. Snapping scapula
• Complain of grinding sensation from beneath
the scapula
• May be Due to rib prominence
• May also be caused by exostosis (a benign
outgrowth of cartilagenous tissues on a bone)
• Excision of exostosis is required

16. 8. Winging scapula
• Prominence of vertebral border of scapula
• Due to injury of long thoracic nerve or weakness
of serratus anterior

18. High scapula
Congenital anomalies
• Sprengel shoulder
• Klippel-Feil syndrome

19. Sprengel shoulder
• Small scapulas with high shoulders
• Web skin between neck and shoulders

21. Klippel Feil syndrome
• Short neck with multiple anomalies of cervical
vertebrae
• Fusion of cervical vertebrae
• Spina bifida
• Neurological involvement

23. EXAMINATION AND ASSESMENT OF
SHOULDER
• Subjective
• History
• Objective

24. Assessment of shoulder joint complex
1. Inspection
2. Palpation
3. Examination of movement
4. Special tests
5. Radiographs
6. Further investigations

25. Objective
• Inspection
• From front (prominent A-C,S-C joints, deformity
of clavicle, deltoid wasting)
• Side (any swelling of joint)
• Back ( scapular alignment, webbing of skin at
root of neck )
• From Above ( swelling, deformity of clavicle,
asymmetry of supraclavicular fossa)

27. Palpation
• Palpate the ant. and lateral aspect of G-H joint.
• Palpate the upper humeral shaft and head via
axilla
• Palpate A-C joint
• Press below acromion and abduct the arm.
• (tenderness during a portion of arc of
movement= inflammation or tear of rotator cuff
or sub deltoid bursa)
• Palpate the length of clavicle

28. MOVEMENTS
• ABDUCTION (0-170 DEGREES)
• ADDUCTION
• ADDUCTION IN EXTENSION ( 0-50 )
• FORWARD FLEXION ( 0-165 )
• BACKWARD EXTENSION ( 0-60)
• HORIZONTAL FLEXION AND ADDUCTION (0-140 )
• ROTATIONS
• IR IN ABDUCTION (70)
• ER IN ABDUCTION (100)
• IR IN EXTENSION ( 70)
• ER IN EXTENION ( 70)
• SHOULDER ELEVATION AND DEPRESSION (37, 8)

29. CERVICAL SPINE ASSESMENT
• Always screen the cervical spine in examining
a case of shoulder pain
• This is doubly important if shoulder movements
are found to be normal

30. EXAMINATION AND ASSESMENT OF
ELBOW JOINT

33. 1.CUBITUS VARUS AND VALGUS
• A decrease or increase in carrying angle
• After supracondylar or other elbow #
• If fail to correct then osteotomy
• Can be followed by tardy nerve palsy

35. ELBOW INSTABILITY
• Medial instability occurs in athletes who
subject their elbows to severe valgus stress. e.g
in throwing
• Rupture or stretch of medial collateral
ligament
• Mild can be resolved by rest
• If severe then reconstructive surgery
• R.A, EHLERS-DANLOS SYNDROME, Charcot,s
disease

36. TARDY ULNAR NERVE PALSY
• A chronic clinical condition characterized by a
delayed onset ulnar neuropathy after an injury to
the elbow.
• Slow in onset and progression
• 30-50 years of age
• Elbow injury ischemic and fibrotic
changes in nerve, usually in childhood
• Mostly with cubitus valgus deformity
• Treatment:
• Reversal of the nerve from its normal position
behind the medial epicondyle to the front of the
joint.

37. ULNAR NEURITIS AND ULNAR TUNNEL
SYNDROME
• Local trauma at elbow or wrist ulnar neuritis
small muscle wasting and sensory impairment in
hand
• Ulnar tunnel syndrome:
• when ulnar nerve passes from cubital tunnel, or
ulnar tunnel in hand get pressurized due to any
reason

38. Olecranon bursitis
• Swelling of the olecranon bursa
• Common in carpenters, and those who
repeatedly traumatize the post. aspect of elbow.
• Also common in R.A
• Painless untill there is bacterial infection in the
bursa
• Excision is sometimes advised for cosmetic
reasons

39. PULLED ELBOW
• Under the age of 5
• Produced by traction on the arm
• Radial head slides out from under the
orbicular ligament
• Pain and limitation of supination
• Treatment:
• Reduction by forced supination and forced
radial deviation
• Spontaneous reduction if kept in sling within 48
hours of incident

40. O.A AND OSTEOCHONDRITIS DISSECANS
• O.A secondary to old fractures, can also lead to
osteochondritis dissecans
• Both associated with formation of loose
bodies which restricts movement or cause
locking
• Joint can be lock in any position
• If loose bodies are found excision
• Joint replacement surgery in O.A

41. R.A
• Can effect one or both elbow
• Marked synovitis, painful restriction of
movement, fixed flexion deformity ,
restricted and painful supination, pronation,
• If gross destruction of elbow then ulnar nerve
can be involved
• Steriod injections in early stages
• Synovectomy with radial head excision in later
stages
• Joint replacement surgery in gross instability

42. T.B OF ELBOW
• Very uncommon
• Marked swelling of elbow
• Local muscle wasting
• Investigation by aspiration and biopsy

43. Myositis Ossificans
• myositis ossificans and heterotrophic bone
formation after #
• heterotrophic bone formation in the brachialis
muscle
• Leads to mechanical block to flexion
• Common in association with head injuries
• Early stage: rest
• Later: excision
• Post operatively: radiotherapy

44. Overuse syndromes
• Tennis elbow:
Tennis elbow, also known as lateral epicondylitis, is a condition that can result
from overuse of the muscles and tendons in the elbow. Tennis elbow is often
linked to repeated motions of the wrist and arm.
• Golfer’s elbow:
Golfer's elbow (medial epicondylitis or pitcher's elbow) is tendinopathy caused
by overuse or overload and affects the medial common flexor tendon of the
elbow.

45. EXAMINATION AND ASSESMENT OF
ELBOW
• Subjective
• History
• Objective

46. Assessment of elbow joint complex
1. Inspection
2. Palpation
3. Examination of movement
4. Special tests
5. Radiographs
6. Further investigations

47. Objective
• Inspection
• Look for generalized swelling
• Muscle wasting
• Note that earliest clinical signs of effusion is
filing out of hollows seen in flexed elbow
above olecranon
• Look for rheumatoid nodules
• Note the carrying angles

48. PALPATION
• Begin by palpating the epicondlyes and
olecranon
• Palpate lateral epicondyle
• Palpate medial epicondyle
• Press thumb firmly into the space on the lateral
side of elbow btw radial head and humerus
then supinate and pronate arm
• Palpate front of elbow on both sides of biceps
while flexing and extending the elbow through
20 degrees

49. MOVEMENTS
• Extension=0 degrees
• Hyperextension=15degrees
• Flexion=145 degrees
• Supination = 80 degrees
• Pronation= 75 degrees