Chapter 22: The Shoulder Complex

Jennifer Doherty-Restrepo, MS, LAT, ATC

Academic Program Director, Entry-Level ATEP

Florida International University

Acute Care and Injury Prevention

The shoulder is an extremely complicated region of the body

Joint with a high degree of mobility, but, not without compromising stability

Involved in a variety of overhead activities relative to sport

Susceptible to a number of repetitive and overused type injuries

Introduction

Functional Anatomy Great mobility, limited stability

Round humeral head articulates with flat glenoid Rotator cuff and long head of the biceps provide dynamic

stability during overhead motion Supraspinatus compresses the humeral head Other rotator cuff muscles depress the humeral head Integration

of the capsule and rotator cuff

Scapula stabilizing muscles also provide dynamic stability Relationship with the other joints of the shoulder complex and

the G-H joint is critical

Scapulohumeral Rhythm Movement of scapula relative to the humerus Initial 30 degrees of G-H abduction

Does not incorporate scapular motion Setting phase

30 to 90 degrees of G-H abduction Scapula abducts and upwardly rotates 1 degree for

every 2 degrees of humeral elevation Above 90 degrees of G-H abduction

Scapula and humerus move in 1:1 ratio

Functional Anatomy

Prevention of Shoulder Injuries Proper physical conditioning is key Sport-specific conditioning Strengthen through a full ROM Warm-up should be used before explosive arm

movements are attempted Contact and collision sport athletes should receive

proper instruction on falling Protective equipment Proper mechanics

Assessment of the Shoulder History

What is the cause of pain? Mechanism of injury? Previous history? Location, duration and intensity of pain? Creptitus, numbness, distortion in temperature Weakness or fatigue? What provides relief?

Assessment of the Shoulder Observation

Elevation or depression of shoulder tips

Position and shape of clavicle

Position of head and arms

Acromion process Biceps and deltoid

symmetry

Postural assessment (kyphosis, lordosis, shoulder)

Scapular elevation and symmetry

Scapular protraction or winging

Muscle symmetry Scapulohumeral rhythm

Palpation: Bony Tissue Sternoclavicular joint Clavicular shaft Acromioclavicular joint Coracoid process Acromion process Humeral head Greater and lesser

tuberosity Bicipital groove

Spine of scapula Scapular vertebral

border Scapular lateral border Scapular superior angle Scapular inferior angle

Palpation: Soft Tissue Sternoclavicular,

acromioclavicular, and coracoclavicular ligaments

Rotator cuff muscles and tendons

Subacromial bursa Sternocleidomastoid Biceps and tendon Coracoacromial ligament

Glenohumeral joint capsule Deltoid Rhomboids Latissimus dorsi Serratus Anterior Levator scapulae Trapezius Supraspinatus Infraspinatus Teres major and minor

Active, Passive, and Resistive ROM Flexion and extension Abduction and adduction Internal and external rotation

Manual Muscle Testing Shoulder muscles and scapular stabilizers RROM and Break tests

Special Tests

Assesses sternoclavicular joint instability Athlete in seated position Apply pressure to the SC joint anteriorly,

superiorly, and inferiorly Determine stability or pain associated with a

joint sprain

Special Tests: SC Joint Instability

Special Tests: AC Joint Instability Assesses acromioclavicular joint instability Athlete in seated position Palpate for displacement of acromion and

distal head of clavicle Apply pressure in all 4 directions

Determine stability or pain associated with a joint sprain

Special Tests: GH Joint Instability Assesses glenohumeral joint instability Special tests

Anterior and Posterior Drawer Tests Sulcus Test Clunk Test Anterior and Posterior Apprehension Tests Relocation Test

Anterior and Posterior Drawer Tests

Sulcus Test

Clunk Test

Anterior and Posterior Apprehension Tests

Anterior Apprehension Test

Posterior Apprehension Test

Relocation Test

Uses external rotation and posteriorly directed pressure to allow for increased external rotation

O’Brien Test (Active Compression Test) Flexion of GH joint to 90 degrees and

horizontally adduction to 15 degrees Passively place humerus into full IR and ER If pain results with internal rotation but decreases

with external rotation and if clicking is present, possible SLAP lesion

Pain in AC joint may indicate AC joint pathology

Special Tests: Impingement

Special Tests: Impingement

Neer’s Test Assesses impingement

of soft tissue structures Positive test is

indicated by pain and grimace

Special Tests: Impingement Hawkins-Kennedy Test Assesses impingement

of soft tissue structures Positive test is

indicated by pain and grimace

Special Tests: Rotator Cuff Drop Arm Test

Assesses supraspinatus muscle weakness or tears

Athlete abducts shoulder and gradually lowers to starting position

Inability to lower arm slowly and controlled will indicate torn supraspinatus

Special Tests: Rotator Cuff Empty Can Test

Place shoulder in position of 90 degrees of shoulder flexion, IR, and 30 degrees of horizontal abduction

Apply downward pressure

Assesses supraspinatus muscle weakness or tears

Wall Push-up Observe for winging scapula Assesses for serratus anterior weakness Could indicate injury to long thoracic

nerve

Special Tests: Serratus Anterior

Yergason’s Test Determines presence of biceps irritation and possible

subluxation of biceps tendon Speed’s Test

Determines presence of biceps irritation and possible subluxation of biceps tendon

Ludington’s Test Assesses for possible rupture of biceps Palpate alternating contractions of each biceps

Special Tests: Biceps

Adson’s Test Assesses for anterior scalene syndrome Compression of subclavian artery by scalenes Athlete looks toward extended arm and takes a

deep breath Palpate radial pulse Disappearance of pulse indicates a positive test

Special Tests: Thoracic Outlet Syndrome

Roo’s Test Assesses for costoclavicular syndrome Compression of subclavian artery between clavicle and

first rib Athlete assumes military brace position and turns head in

opposite direction Athlete opens and closes hand for 3 minutes Palpate

radial pulse Test is positive if…

Pulse disappears Grip strength decreases

Special Tests: Thoracic Outlet Syndrome

Allen’s Test Assesses for hyperabduction syndrome Determines if pressure from pectoralis minor

is compressing brachial plexus and subclavian artery

Special Tests: Thoracic Outlet Syndrome

Specific Injuries Clavicular Fractures

Etiology MOI = fall on outstretched arm, fall on tip of shoulder, or

direct impact Occurs primarily in middle third

Signs and Symptoms Athlete supports arm, head tilted towards injured side with

chin turned away Clavicle may appear lower Palpation reveals pain, swelling, deformity, and point

tenderness

Clavicular Fractures (continued) Management

Closed reduction - sling and swathe immediately Refer for X-ray Immobilize with brace for 6-8 weeks After removal of brace, rehabilitation includes:

Joint mobilizations Isometric exercises Use of a sling for 3-4 weeks

May require surgical treatment

Scapular Fractures Etiology

MOI = direct impact or force transmitted up through humerus

Signs and Symptoms Pain during shoulder movement Swelling and point tenderness

Management Sling immediately and refer for X-ray Use sling for 3 weeks then begin PRE exercises

Specific Injuries

Fractures of the Humerus Etiology

MOI = direct impact, force transmitted up through humerus, or fall on outstretched arm

Proximal fractures occur due to direct blow Dislocations occur due to fall on outstretched arm Epiphyseal fractures are more common in young

athletes and occur due to direct blow or indirect blow traveling along long axis of humerus

Specific Injuries

Fractures of the Humerus (continued) Signs and Symptoms

Pain, swelling, point tenderness, decreased ROM Management

Immediate application of splint Refer for X-ray Treat for shock

Specific Injuries

Sternoclavicular Sprain Etiology

MOI = indirect force or blunt trauma

Signs and Symptoms Grade 1 - pain and slight disability Grade 2 - pain, subluxation deformity, swelling, point

tenderness, and decreased ROM Grade 3 - gross deformity (dislocation), pain, swelling, and

decreased ROM Possibly life-threatening if dislocates posteriorly

Specific Injuries

Sternoclavicular Sprain (continued) Management

RICE Refer for reduction if necessary Immobilize for 3-5 weeks After immobilzation period, begin PRE exercises

Specific Injuries

Acromioclavicular Sprain Etiology

MOI = direct blow (from any direction) or upward force from the humerus

Graded from 1 - 6 according to severity of injury

Signs and Symptoms Grade 1 - point tenderness, pain with movement

No disruption of AC joint

Grade 2 - tear or rupture of AC ligament, pain, point tenderness, and decreased ROM (abd/add) Partial displacement of lateral end of clavicle

Specific Injuries

Acromioclavicular Sprain (continued) Signs and Symptoms

Grade 3 - rupture of AC and CC ligaments AC joint separation

Grade 4 - posterior dislocation of clavicle Grade 5 – rupture of AC and CC ligaments, tearing of

deltoid and trapezius attachments, gross deformity, severe pain, decreased ROM

Grade 6 - displacement of clavicle behind the coracobrachialis

Acromioclavicular Sprain (continued) Management

Ice, sling and swathe Referral to physician Grades 1 – 3: non-operative treatment

1 - 2 weeks of immobilization Grades 4 – 6: surgery required Aggressive rehab is required for all AC sprains

Joint mobilizations, flexibility exercises, and PRE exercises should occur immediately

Progress as tolerated – no pain and no additional swelling Padding and protection may be required until pain-free ROM

returns

A: Grade 1 B: Grade 2 C: Grade 3 D: Grade 4 E: Grade 5 F: Grade 6

Glenohumeral Joint Sprain Etiology

MOI = forced abduction and/or external rotation; or a direct blow

Signs and Symptoms Pain during movement

Especially when re-creating the MOI Decreased ROM Point tenderness

Specific Injuries

Glenohumeral Joint Sprain (continued) Management

RICE for 24-48 hours Sling After hemorrhaging subsides, modalities may be

utilized along with PROM and AROM exercises to regain full ROM

When full ROM achieved without pain, PRE exercises can be initiated

Must be aware of potential development of chronic conditions (instability)

Specific Injuries

Acute Subluxations and Dislocations Etiology

Subluxation = excessive translation of humeral head without complete separation from joint

Anterior dislocation = results from an anterior force on the shoulder with forced ABD and ER

Posterior dislocation = results from forced ADD and IR, or, falling on an extended and internally rotated shoulder

Specific Injuries

Acute Subluxations and Dislocations (continued) Signs and Symptoms

Anterior dislocation - flattened deltoid; prominent humeral head in axilla; arm carried in slight ABD and ER rotation; moderate pain and disability

Posterior dislocation - severe pain and disability; arm carried in ADD and IR; prominent acromion and coracoid process; limited ER and elevation

Specific Injuries

Acute Subluxations and Dislocations (continued) Management

Sling and swathe and refer for reduction Immobilize for 3 weeks following reduction Perform isometrics while in sling After immobilization period, begin PRE exercises as

pain allows Protective bracing when return to play

Bankart lesion Permanent anterior defect of labrum

Hill Sachs lesion Caused by compression of cancellous bone against anterior

glenoid rim creating a divot in the humeral head

SLAP lesion Defect in superior labrum that begins posteriorly and extends

anteriorly impacting attachment of long head of biceps on labrum

Possible Complications of Shoulder Dislocations

Brachial nerves and vessels may be compromised Rotator cuff injuries Fractures Bicipital tendon subluxation Transverse ligament rupture

Chronic Recurrent Instabilities Etiology

MOI = traumatic, microtraumatic (repetitive overuse), atraumatic, congenital, and neuromuscular

As supporting tissue become more lax, mobility increases

Results in damage to other soft tissue structures

Specific Injuries

Chronic Recurrent Instabilities (continued) Signs and Symptoms

Anterior - may have clicking or pain; complain of dead arm during cocking phase (when throwing); pain posteriorly; possible impingement; positive apprehension test

Posterior - possible impingement; loss IR; crepitation; increased laxity; pain anteriorly and posteriorly

Multidirectional - inferior laxity; positive sulcus sign; pain and clicking with arm at side; possible signs and symptoms associated with anterior and posterior instability

Specific Injuries

Chronic Recurrent Instabilities (continued) Management

Conservative treatment involves extensive strengthening of the rotator cuff and scapula stabilizers Should be pursued before surgery is considered

Avoid joint mobilizations and ROM exercises Various braces can be used to limit motion

Surgical stabilization may be required to improve function and comfort

Shoulder Impingement Syndrome Etiology

Mechanical compression of supraspinatus tendon, subacromial bursa, and long head of biceps tendon due to decreased space under coracoacromial arch

MOI = overhead repetitive activities Exacerbating factors

Laxity and inflammation Postural mal-alignments

Kyphosis and/or rounded shoulders

Specific Injuries

Shoulder Impingement Syndrome (continued) Signs and Symptoms

Diffuse pain Increased pain with palpation of subacromial space Decreased strength of external rotators compared to

internal rotators Tightness in posterior and inferior capsule Positive impingement and empty can tests

Stage I Result of supraspinatus or biceps tendon

injury Presents with point tenderness; pain with ABD

and resisted supination with external rotation; edema; thickening of rotator cuff and bursa

Occurs in athletes < 25 years old

Neer’s progressive stages of shoulder impingement…

Stage II Permanent thickening and fibrosis of

supraspinatus and biceps tendon Presents with aching during activity that

worsens at night May experience restricted arm motion

Neer’s progressive stages of shoulder impingement…

Stage III History of shoulder problems and pain Tendon defect (less than 3/8 of an inch) or

possible muscle tear Permanent scar tissue and thickening of rotator

cuff Occurs in athletes 25 - 40 years old

Neer’s progressive stages of shoulder impingement…

Stage IV Infraspinatus and supraspinatus atrophy Presents with pain during ABD, limited

AROM and PROM, weak RROM Tendon defect (greater than 3/8 of an inch) Clavicle degeneration

Neer’s progressive stages of shoulder impingement…

Rotator cuff tear Etiology

Occurs near insertion on greater tuberosity Involve supraspinatus or rupture of other rotator cuff

tendons Partial or complete thickness tear

Full thickness tears usually occur in athletes with a long history of rotator cuff pathology

Generally does not occur in athlete under age 40 MOI = acute trauma or impingement

Signs and Symptoms Pain and weakness with shoulder ABD and IR Point tenderness

Specific Injuries

Rotator cuff tear (continued) Management

NSAID’s and analgesics Modalities

Electrical stimulation for pain Ultrasound for inflammation

Restore appropriate mechanics by strengthening rotator cuff to depress and compress humeral head to restore subacromial space

Severe cases may require rest, immobilization, and surgery

Shoulder Bursitis Etiology

Chronic inflammatory condition resulting from fibrosis or fluid build-up

MOI = direct trauma or overuse Usually occurs in the subacromial bursa

Signs and Symptoms Pain with motion, pain during palpation of subacromial

space Positive impingement tests

Specific Injuries

Shoulder Bursitis Management

Reduce inflammation Cold, ultrasound, NSAID’s

Remove mechanisms precipitating condition Maintain full ROM to reduce the risk of contractures

and adhesions forming

Frozen Shoulder (Adhesive Capsulitis) Etiology

Contracted and thickened joint capsule with little synovial fluid

Chronic inflammation resulting in contracted, inelastic rotator cuff muscles

Signs and Symptoms Pain in all directions both with AROM and PROM Patient resists moving the shoulder due to pain

Specific Injuries

Frozen Shoulder (continued) Management

Aggressive joint mobilizations Stretching of tight musculature Electrical stimulation for pain control Ultrasound for deep heating

Specific Injuries

Thoracic Outlet Compression Etiology

Compression of brachial plexus, subclavian artery and vein

Due to 1) decreased space between clavicle and first rib, 2) scalene compression, 3) compression by pectoralis minor, or 4) presence of cervical rib

Specific Injuries

Thoracic Outlet Compression (continued) Signs and Symptoms

Paresthesia, pain, sensation of cold, impaired circulation, muscle weakness, muscle atrophy, and radial nerve palsy

Positive anterior scalene test, costoclavicular test, and hyperabduction test

Management Conservative treatment - correct anatomical condition

through stretching (pec minor and scalenes) and strengthening (trapezius, rhomboids, serratus anterior, erector spinae)

Specific Injuries Biceps Brachii Rupture

Etiology Generally occurs near origin of muscle at bicipital groove MOI = powerful contraction

Biceps Brachii Rupture (continued) Signs and Symptoms

Audible snap with sudden and intense pain Protruding bulge may appear near middle of biceps Weakness with elbow flexion and supination

Management Ice for hemorrhaging Immobilize with a sling and refer to physician Athletes will require surgery

Bicipital Tenosynovitis Etiology

Ballistic activity involves repeated stretching of biceps tendon causing irritation to the tendon and sheath

MOI = repetitive overhead activities

Signs and Symptoms Point tenderness over bicipital groove Swelling, crepitus due to inflammation Pain when performing overhead activities

Specific Injuries

Bicipital Tenosynovitis (continued) Management

Rest, ice, and ultrasound to treat inflammation NSAID’s Gradual program of strengthening and stretching

Contusion of Upper Arm Etiology

MOI = Direct blow

Signs and Symptoms Transitory paralysis and decreased ROM

Management RICE for at least 24 hours Provide protection to prevent repeated episodes that could

cause myositis ossificans Maintain ROM

Specific Injuries

Peripheral Nerve Injuries Etiology

MOI = blunt trauma or overstretching-type injuries

Signs and Symptoms Constant pain, muscle weakness, paralysis, or atrophy

Management RICE Transient muscle weakness may occur If muscle atrophy occurs, referral to a physician is necessary

Specific Injuries

Rehabilitation of the Shoulder Immobilization

Will vary depending on injury Time in brace or splint are injury specific Isometrics can be performed ROM and strengthening are dictated by healing

General Body Conditioning Maintain cardiovascular endurance through

cycling, running, and walking

Joint Mobilizations Used to re-establish appropriate joint

arthrokinematics Used if joint capsule tightness is present

Rehabilitation of the Shoulder

Flexibility Codman’s pendulum exercises should begin early Progress to Active Assisted ROM in pain free

range Cardinal planes

Rehabilitation of the Shoulder

Strengthening Exercises Should include rotator cuff and scapula stabilizers

Rehabilitation of the Shoulder

Neuromuscular Control Must regain appropriate firing sequence for

specific muscles (scapulohumeral rhythm) Biofeedback can be used to regain control Proprioception Closed kinetic chain exercises will be required in

gymnasts, wrestlers, and weight lifters Emphasize co-contraction muscle activity

Rehabilitation of the Shoulder

Functional Progressions Incorporation of sports specific skills Strengthening that involves PNF patterns

Throwing motion

Return to Activity Based on pre-established criteria Functional performance testing Objective measures of strength and performance

Rehabilitation of the Shoulder