Acute Shoulder injuriesAcute Shoulder injuries

Physical activity injuries Physical activity injuries 26/01/1026/01/10

Janis LeachJanis Leach

ObjectivesObjectives

Recap of anatomy of the shoulderRecap of anatomy of the shoulderIdentify key clinical features and Identify key clinical features and mechanisms of injury to the shoulder joint.mechanisms of injury to the shoulder joint.Complete an assessment of the areaComplete an assessment of the areaRead through literature on assessment Read through literature on assessment proceduresprocedures

Clinical perspectiveClinical perspective

Numerous structures can cause shoulder Numerous structures can cause shoulder pain. It is helpful if the problem can be pain. It is helpful if the problem can be narrowed down to one or more of the narrowed down to one or more of the following 5 categories of shoulder pain:following 5 categories of shoulder pain:– Rotator cuff muscles Rotator cuff muscles – InstabilityInstability– StiffnessStiffness– AC jointAC joint– Referred painReferred pain

Common causes of shoulder painCommon causes of shoulder pain

Rotator cuff injuryRotator cuff injuryGlenohumeral dislocation / instabilityGlenohumeral dislocation / instabilityGlenoid labral tearsGlenoid labral tearsClavicle fractureClavicle fractureAC joint sprainAC joint sprain

Rotator cuff injuriesRotator cuff injuries

Rotator cuff injury:Rotator cuff injury:Common cause of shoulder pain and Common cause of shoulder pain and impingement. The tendons become swollen and impingement. The tendons become swollen and weakweakClinical features:Clinical features:– Pain with overhead activity. Activities at less than 90 Pain with overhead activity. Activities at less than 90

degrees abduction – pain-free.degrees abduction – pain-free.– Tenderness over supraspinatus tendon at it’s Tenderness over supraspinatus tendon at it’s

insertion onto greater tuberosity.insertion onto greater tuberosity.– Painful arc between 70-120 degrees abduction.Painful arc between 70-120 degrees abduction.– Pain with resisted contraction of supraspinatus. Pain with resisted contraction of supraspinatus.

Rotator cuff strains / tearsRotator cuff strains / tears

Minor strains: Minor strains: – generally present with sudden onset of pain or generally present with sudden onset of pain or

‘twinge’ in shoulder area.‘twinge’ in shoulder area.– Some limitation of functionSome limitation of function– Respond quickly to rest, stretching and soft tissue Respond quickly to rest, stretching and soft tissue

therapy.therapy.Complete and partial tears:Complete and partial tears:– Common in older athletesCommon in older athletes– Pain during activityPain during activity– Inability to sleep on affected shoulderInability to sleep on affected shoulder– Weakness on supraspinatus testsWeakness on supraspinatus tests

Dislocation of glenohumeral jointDislocation of glenohumeral joint

Anterior dislocation (most common):Anterior dislocation (most common):One of the most common traumatic sports One of the most common traumatic sports injuries.injuries.Results from arm being forced into excessive Results from arm being forced into excessive abduction and external rotation.abduction and external rotation.Most anterior dislocations damage the Most anterior dislocations damage the attachment of the labrum to the anterior glenoid attachment of the labrum to the anterior glenoid margin (Bankart lesion)margin (Bankart lesion)May also be an associated fracture of anterior May also be an associated fracture of anterior glenoid rim, disruption of glenohumeral ligaments glenoid rim, disruption of glenohumeral ligaments or a compression fracture of humeral head (Hill-or a compression fracture of humeral head (Hill-Sachs lesion)Sachs lesion)

Anterior dislocation cont.Anterior dislocation cont.

Anterior dislocation cont.Anterior dislocation cont.

History:History:Acute trauma – either direct or indirect.Acute trauma – either direct or indirect.Sudden onset of painSudden onset of painPatient may describe a feeling of ‘popping out’.Patient may describe a feeling of ‘popping out’.Examination reveals:Examination reveals:– Prominent humeral head below acromionProminent humeral head below acromion– Loss of smooth contour compared with non-injured Loss of smooth contour compared with non-injured

side.side.– Occasional damage to axillary nerve = impaired Occasional damage to axillary nerve = impaired

sensation on lateral aspect of shoulder. sensation on lateral aspect of shoulder.

Labrum injuriesLabrum injuries

Labrum is primary attachment site for shoulder Labrum is primary attachment site for shoulder capsule and GH ligaments. The superior aspect capsule and GH ligaments. The superior aspect of labrum serves as attachment site for tendon of labrum serves as attachment site for tendon of long head of biceps muscle.of long head of biceps muscle.Injuries to labrum are divided into superior Injuries to labrum are divided into superior labrum anterior to posterior (SLAP) labrum anterior to posterior (SLAP) SLAP lesions are injuries that extend from SLAP lesions are injuries that extend from anterior of biceps tendon to posterior of biceps anterior of biceps tendon to posterior of biceps tendon. tendon.

Labrum injuriesLabrum injuries

Glenoid labral tearsGlenoid labral tears

Labrum injuriesLabrum injuries

Mechanism of injury:Mechanism of injury:– Repetitive overhead throwingRepetitive overhead throwing– Excessive inferior traction (catching a heavy object).Excessive inferior traction (catching a heavy object).

Clinical features:Clinical features:– Poorly localized pain in shoulder aggravated by Poorly localized pain in shoulder aggravated by

overhead and behind the back arm motions.overhead and behind the back arm motions.– Popping, catching or grinding may be present.Popping, catching or grinding may be present.– Tenderness over anterior aspect of shoulder.Tenderness over anterior aspect of shoulder.– Pain on resisted biceps contraction.Pain on resisted biceps contraction.

Clavicle fractureClavicle fractureCommon fracture in sporting activities.Common fracture in sporting activities.Mechanism of injury: Mechanism of injury: – Fall onto the point of the shoulder (i.e. horse riding or cycling) Fall onto the point of the shoulder (i.e. horse riding or cycling)

OROR– Direct contact with opponents in sports such as football / rugby.Direct contact with opponents in sports such as football / rugby.

Most common fracture site – middle third of clavicle.Most common fracture site – middle third of clavicle.Lateral end displaces inferiorly and medial end displaces Lateral end displaces inferiorly and medial end displaces superiorly.superiorly.Clinical features:Clinical features:– Very painfulVery painful– Localised tenderness, deformity, swelling.Localised tenderness, deformity, swelling.

Clavicle fractureClavicle fracture

Clavicle fractureClavicle fracture

Management:Management:Provide pain reliefProvide pain reliefAlmost always heal in 4-6 weeks.Almost always heal in 4-6 weeks.The ends often overlap and clavicle is shortened The ends often overlap and clavicle is shortened causing a number of functional problems.causing a number of functional problems.– A figure of 8 bandage prevents this shortening rather A figure of 8 bandage prevents this shortening rather

than sling.than sling.– Surgery may be required if the clavicle has Surgery may be required if the clavicle has

compromised the skin.compromised the skin.

Acromioclavicular joint injuriesAcromioclavicular joint injuries

AC joint injuries cont.AC joint injuries cont.

Another common injury in athletes who fall Another common injury in athletes who fall onto point of shoulder.onto point of shoulder.Clinical features:Clinical features:– Localised tendernessLocalised tenderness– Pain on movement, especially horizontal Pain on movement, especially horizontal

adduction.adduction.– Palpable step deformity – visual in more Palpable step deformity – visual in more

severe injury.severe injury.

AC joint injury managementAC joint injury management

Follow the general principles of management of Follow the general principles of management of ligamentous injuries:ligamentous injuries:– Initially ice is applied to minimise degree of damage Initially ice is applied to minimise degree of damage

and pain relief.and pain relief.– Injured limb should be immobilised in a sling for up to Injured limb should be immobilised in a sling for up to

2-3 days in type 1 injuries or up to six weeks in severe 2-3 days in type 1 injuries or up to six weeks in severe type 2 or type 3 injuries.type 2 or type 3 injuries.

– Isometric strengthening exercises can commence Isometric strengthening exercises can commence once pain permits.once pain permits.

– Tape can be applied to AC joint to provide protection Tape can be applied to AC joint to provide protection on return to sport. on return to sport.

ReviewReview

Normal shoulder function is essential for Normal shoulder function is essential for many popular sports and shoulder many popular sports and shoulder dysfunction causes significant impairment dysfunction causes significant impairment of everyday quality of life.of everyday quality of life.The shoulder is a challenging region for The shoulder is a challenging region for sports medicine practitioners. A sound sports medicine practitioners. A sound background knowledge in the functional background knowledge in the functional anatomy is essential in the treatment and anatomy is essential in the treatment and management of shoulder injuries.management of shoulder injuries.

Assessment of ShoulderAssessment of Shoulder

ObservationObservationPalpationPalpation– Suprasternal notchSuprasternal notch– Sternoclavicular jointSternoclavicular joint– ClavicleClavicle– AcromionAcromion– Acromioclavicular jointAcromioclavicular joint– Head of the humerusHead of the humerus– Spine of the scapula Spine of the scapula

ROMROMFlexion Flexion ExtensionExtensionAbductionAbductionAdductionAdductionInternal rotationInternal rotationExternal rotationExternal rotationHorizontal abductionHorizontal abductionHorizontal adductionHorizontal adductionDepressionDepressionElevationElevationScapula RetractionScapula RetractionScapula ProtractionScapula Protraction

Special testsSpecial tests

Apprehension test for dislocationApprehension test for dislocationApley scratchApley scratchScapula wingingScapula wingingEmpty can testEmpty can testLift off testLift off testDrop arm testDrop arm testAC compressionAC compression

Apprehension test for dislocationApprehension test for dislocation

Apley scratchApley scratch

Loss ROM – rotator cuff injuryLoss ROM – rotator cuff injury

Scapula wingingScapula winging

Weak Serratus Anterior muscleWeak Serratus Anterior muscleDamage to Long thoracic nerveDamage to Long thoracic nerve

– Assessed by wall press upAssessed by wall press up

Empty can testEmpty can test

Supraspinatus injurySupraspinatus injury

Lift off testLift off test

SubscapularisSubscapularis

Drop arm testDrop arm test

SupraspinatusSupraspinatusPassively abduct patient’s shoulderPassively abduct patient’s shoulderArm lowered slowly to the waistArm lowered slowly to the waistPatient may lower the arm until the final part of the Patient may lower the arm until the final part of the movement as deltoid will work at firstmovement as deltoid will work at first

AC compressionAC compression

AC joint dysfunctionAC joint dysfunction

Cross over test – forward elevation to 90 degrees, Cross over test – forward elevation to 90 degrees, followed by active horizontal adductionfollowed by active horizontal adduction

Labral tears – clunk sign Labral tears – clunk sign – The patient's arm is rotated and loaded (force The patient's arm is rotated and loaded (force

applied) from extension through to forward applied) from extension through to forward flexion. A clunk sound or clicking can indicate flexion. A clunk sound or clicking can indicate a labral tear. a labral tear.

PracticalPractical

Work in pairs to assess the shoulderWork in pairs to assess the shoulder

Use your notes and discuss the procedures with Use your notes and discuss the procedures with each othereach other