Shoulder Seminar

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Anatomy Review

Shoulder Girdle

Anatomy ReviewBony Anatomy

ScapulaClavicle

Anatomy ReviewBony Anatomy

HumerusRibs

Anatomy ReviewAnterior musculature of the

shoulder girdle

Anatomy ReviewMusculature of posterior shoulder girdle

Anatomy ReviewShoulder ligaments

Anatomy Review

Shoulder joint capsule and cartilage

Anatomy Review

Blood Supply and Intervention

Shoulder Evaluation (History)

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

Shoulder Evaluation (Observation)

Elevation or depression of shoulder tipsPosition and shape of clavicleAcromion processBiceps and deltoid symmetryPostural assessment (kyphosis, lordosis, shoulders)

Position of head and armsScapular elevation and symmetryScapular protraction or wingingMuscle symmetry Scapulohumeral rhythm

Shoulder Evaluation (Observation)

Scapulohumeral RhythmMovement of scapula relative to the humerusInitial 30 degrees of glenohumeral abduction does not incorporate scapular motion (setting phase)30 to 90 degrees the scapula abducts and upwardly rotates 1 degree for every 2 degrees of humeral elevationAbove 90 degrees the scapula and humerus move in 1:1 ratio

Shoulder Evaluation (Palpation)

Bony StructuresSternoclavicular jointClavicular shaftAcromioclavicular jointCoracoid processAcromion processHumeral headGreater and lesser tuberosityBicipital groove Spine of scapulaScapular vertebral border

Scapular lateral borderScapular superior angleScapular inferior angle

Shoulder Evaluation (Palpation)

Soft Tissue Palpation

Sternoclavicular, acromioclavicular and coracoclavicular ligamentsRotator cuff muscles and tendonsSubacromial bursaSternocleidomastoidBiceps and tendonCoracoacromial ligament

Glenohumeral joint capsuleDeltoidRhomboidsLatissimus dorsiSerratus AnteriorLevator scapulaeTrapeziusSupraspinatusInfraspinatusTeres major and minor

Shoulder Evaluation (Special Tests)

Active Range of Motion (ROM)

Flexion @ 180o

Extension @ 50o

Abduction @ 180o

Adduction @ 40o

Internal Rotation @ 90o

External Rotation @ 90o

Manual Muscle TestingFive Point grading system

5 = Complete ROM against gravity, with full resistance4 = Complete ROM against gravity, with some resistance3 = Complete ROM against gravity, with no resistance2 = Complete ROM, with gravity omitted1 = Some muscle contractility with no joint motion0 = No muscle contractility

Shoulder Evaluation (Special Testing)

SternoclavicularInstability

Manipulation of clavicle for excess motion

Shoulder Evaluation (Special Tests)

AcromioclavicluarInstability

Piano Key signHorizontal Adduction TestAC Compression Test (Sheer Test)Joint Distraction Test

Shoulder Evaluation (Special Testing)

GlenohumeralInstability

Load / Shift Test

Shoulder Evaluation (Special Tests)

GlenohumeralInstability

Sulcus Sign

Shoulder Evaluation (Special Tests)

Glenohumeral InstabilityApprehension Test

Shoulder Evaluation (Special Tests)

Glenohumeral InstabilityAnt. DrawerPost. DrawerClunk Test

Shoulder Evaluation (Special Tests)

Shoulder Impingement TestsHawkins-Kennedy TestNeer’s Test

Shoulder Evaluation (Special Tests)

Supraspinatus WeaknessDrop Arm TestEmpty Can Test

Shoulder Evaluation (Special Tests)

Bicep Tendon Irritation

Speed’s TestYerdason’s Test

Shoulder Evaluation (Special Tests)

Serratus Anterior WeaknessThoracic Outlet Synderome (TOS)

Adson’s TestRoo’s TestAllen’s Test

Recognition and Management of Specific Injuries

Clavicular FracturesEtiology

Fall on outstretched arm, fall on tip of shoulder or direct impactOccur primarily in middle third (greenstick fracture often occurs in young athletes)

Signs and SymptomsGenerally presents w/ supporting of arm, head tilted towards injured side w/ chin turned awayClavicle may appear lowerPalpation reveals pain, swelling, deformity and point tenderness

ManagementClosed reduction - sling and swathe, immobilize w/ figure 8 brace for 6-8 weeksRemoval of brace should be followed w/ joint mobes, isometrics and use of a sling for 3-4 weeks

Clavicular Fractures (cont’d)

Clavicular Fractures (cont’d)

EtiologyResult of direct impact or force transmitted up through humerus

Signs and SymptomsPain during shoulder movement as well as swelling and point tenderness

ManagementSling immediately and follow-up w/ X-rayUse sling for 3 weeks w/ overhead strengthening beginning at week 1

Scapular Fractures

EtiologyHumeral shaft fractures occur as a result of a direct blow, or fall on outstretched armProximal fractures occur due to direct blow, dislocation, fall on outstretched arm

May pose danger to nerve and blood supplyEpiphyseal fractures are more common in young athletes -occur due to direct blow or indirect blow travelling along long axis of humerus

Signs and SymptomsPain, swelling, point tenderness, decreased ROM

ManagementImmediate application of splint, treat for shock and refer

Humeral fractures- remove from activity for 3-4 monthsProximal fracture - incapacitation 2-6 monthsEpiphyseal fracture - quick healing - 3 weeks

Fractures of the Humerus

EtiologyIndirect force, blunt trauma (may cause displacement)

Signs and SymptomsGrade 1 - pain and slight disabilityGrade 2 - pain, subluxation w/ deformity, swelling and point tenderness and decreased ROMGrade 3 - gross deformity (dislocation), pain, swelling, decreased ROM

Possibly life-threatening if dislocates posteriorly

ManagementRICE, reduction if necessaryImmobilize for 3-5 weeks followed by graded reconditioning

Sternoclavicular Sprain

EtiologyResult of direct blow (from any direction), upward force from humerus, Can be graded from 1-6 depending on severity

Signs and SymptomsGrade 1 - point tenderness and pain w/ movement; no disruption of AC jointGrade 2 - tear or rupture of AC ligament, partial displacement of lateral end of clavicle; pain, point tenderness and decreased ROM (abduction/adduction)Grade 3 - Rupture of AC and CC ligamentsGrade 4 - posterior dislocation of clavicle

Acromioclavicular Sprain

Signs and SymptomsGrade 5 - loss of AC and CC ligaments; tearing of deltoid and trapezius attachments; gross deformity, severe pain, decreased ROMGrade 6 - displacement of clavicle behind the coracobrachialis

ManagementIce, stabilization, referral to physicianGrades 1-3 (non-operative) will require 3-4 days and 2 weeks of immobilization respectivelyGrades 4-6 will require surgeryAggressive rehab is required w/ all grades

Joint mobilizations, flexibility exercises, & strengthening should occur immediatelyProgress as athlete is able to tolerate w/out pain and swellingPadding and protection may be required until pain-free ROM returns

Acromioclavicular Sprain

EtiologyForced abduction and/or external rotation or a direct blow

Signs and SymptomsPain during movement especially when re-creating MOIDecreased ROM and pain w/ palpation

ManagementRICE for 24-48 hours; slingAfter hemorrhaging subsides, cryotherapy, ultrasound and massage can be used along w/ passive and active exercise to regain full ROMWhen full ROM achieved w/out pain, resistance exercises can be initiatedMust be aware of potential development of chronic conditions

Glenohumeral Joint Sprain

EtiologySubluxation involves excessive translation of humeral head w/out complete separation from jointAnterior dislocation is the result of an anterior force on the shoulder, forced abduction and external rotationPosterior dislocation occurs due to forced adduction and internal rotation or falling on an extended and internally rotated shoulder

Signs and SymptomsAnterior dislocation - flattened deltoid, prominent humeral head in axilla; arm carried in slight abduction and external rotation; moderate pain and disability

Acute Subluxations and Dislocations

Signs and SymptomsPosterior dislocation - severe pain and disability; arm carried in adduction and internal rotation; prominent acromion and coracoid process; limited external rotation and elevation

ManagementRICE and reduction by a physicianImmobilize following reduction for 3 weeks Perform isometrics while in slingProgress to resistance exercises as pain allowsReturn to play when athlete has regained 20% of body weight when tested for internal and external rotationProtective bracing

Acute Subluxations and Dislocations

Possible Complications of Shoulder DislocationsBankart lesion - permanent anterior defect of labrumHill Sachs lesion - caused by compression of cancellous bone against anterior glenoid rim creating a divot in the humeral headSLAP lesion - defect in superior labrum that begins posteriorly and extends anteriorly impacting attachment of long head of biceps on labrumBrachial nerves and vessels may be compromisedRotator cuff injuriesBicipital tendon subluxation and transverse ligament rupture

Acute Subluxations and Dislocations

EtiologyTraumatic, atraumatic, microtraumatic (repetitive use), congenital and neuromuscularAs supporting tissue become more lax, mobility increases resulting in damage to other soft tissue structures

Signs and SymptomsAnterior - may have clicking or pain; complain of dead arm during cocking phase (when throwing); pain posteriorly; possible impingement; positive apprehension testPosterior - possible impingement, loss of internal rotation; crepitation; increased laxity; pain anteriorly and posteriorlyMultidirectional - inferior laxity; positive sulcus sign; pain and clicking w/ arm at side; possible signs and symptoms associated w/ anterior and posterior instability

Chronic Recurrent Instabilities

ManagementConservative treatment involves extensive strengthening (rotator cuff and scapula stabilizers)Avoid joint mobilizations and flexibility exercisesVarious harnesses and restraints can be used to limit motionSurgical stabilization may be required to improve function and comfortStrengthening should be continued for a reasonable time before surgery is opted for

Chronic Recurrent Instabilities

EtiologyMechanical compression of supraspinatus tendon, subacromial bursa and long head of biceps tendon due to decreased space under coracoacromial archSeen in over head repetitive activitiesExacerbating factors - laxity and inflammation, postural mal-alignments

kyphotic posture, rounded shoulders

Signs and SymptomsDiffuse pain, pain on palpation of subacromial spaceDecreased strength of external rotators compared to internal rotators; tightness in posterior and inferior capsulePositive impingement and empty can tests

Shoulder Impingement Syndrome

Neer’s progressive stages of shoulder impingementStage I - result of supraspinatus or biceps tendon injury presenting w/ point tenderness, pain w/ abduction and resisted supination w/ external rotation; edema, thickening of rotator cuff and bursa

Occurs in athlete < 25 years oldStage II - permanent thickening and fibrosis of supraspinatus and biceps tendon; presenting w/ aching during activity that worsens at night; May experience restricted arm motionStage III - history of shoulder problems and pain, tendon defect (3/8 “) or possible muscle tear and permanent scar tissue and thickening of rotator cuff

Athletes 25-40 years oldStage IV- infraspinatus and supraspinatus wasting, pain during abduction, tendon defect greater than 3/8”, limited active and full passive ROM, weak resistive ROM and clavicle degeneration

Shoulder Impingement Syndrome

Occurs near insertion on greater tuberosityPartial or complete thickness tearFull thickness tears usually occur in those athletes w/ a long history (generally does not occur in athlete under age 40)Primary mechanism - acute trauma or impingementInvolve supraspinatus or rupture of other rotator cuff tendons

ManagementAnalgesics, electrical stimulation for pain, NSAID’s and ultrasound for inflammationRestore appropriate mechanics and strengthen rotator cuff to depress and compress humeral head to restore spaceStrengthen lower extremity and trunk to reduce stress on shoulderStage III and IV cases may require immobilization and rest and potentially surgery

Rotator cuff tear

EtiologyChronic inflammatory condition due to trauma or overuse -subacromial bursaFibrosis, fluid build-up resulting in constant inflammation

Signs and SymptomsPain w/ motion and tenderness during palpation in subacromial space; positive impingement tests

ManagementCold, ultrasound and NSAID’s to reduce inflammationRemove mechanisms precipitating conditionMaintain full ROM to reduce chances of contractures and adhesions from forming

Shoulder Bursitis

EtiologyContracted and thickened joint capsule w/ little synovial fluidChronic inflammation w/ contracted inelastic rotator cuff musclesGeneralized pain w/ motions (active and passive) resulting in resistance of movement

Signs and SymptomsPain in all directions both w/ active and passive motion

ManagementAggressive joint mobilizations and stretching of tight musculatureElectric stim for pain and ultrasound for deep heating

Frozen Shoulder (Adhesive Capsulitis)

EtiologyCompression of brachial plexus, subclavian artery and vein due to 1) decreased space between clavicle and first rib, 2) scalenecompression, 3) compression by pec. minor, or 4) presence of cervical rib

Signs and SymptomsParesthesia and pain, sensation of cold, impaired circulation, muscle weakness, muscle atrophy and radial nerve palsyPositive anterior scalene test, costoclavicular test and hyperabduction test

ManagementConservative treatment - correct anatomical condition through stretching (pec minor and scalenes) and strengthening (trapezius, rhomboids, serratus anterior, erector spinae)

Thoracic Outlet Compression

Biceps Brachii RuptureEtiology

Result of a powerful contractionGenerally occurs near origin of muscle at bicipital groove

Signs and SymptomsAthlete hears a resounding snap and feels sudden and intense painProtruding bulge may appear near middle of bicepsDefinite weakness with elbow flexion and supination

ManagementIce for hemorrhaging, place arm in sling and refer to athleteAthletes will require surgeryOlder individual will be able to rely on brachialis which serves as primary elbow flexor

Biceps Brachii Rupture

EtiologyRepetitive overhead athlete - ballistic activity that involves repeated stretching of biceps tendon causing irritation to the tendon and sheath

Signs and SymptomsTenderness over bicipital groove, swelling, crepitus due to inflammationPain when performing overhead activities

ManagementRest, ice and ultrasound to treat inflammationNSAID’sGradual program of strengthening and stretching

Bicipital Tenosynovitis

EtiologyDirect blow

Signs and SymptomsTransitory paralysis and inability to use extensor muscles of forearm

ManagementRICE for at least 24 hoursProvide protection to contused area to prevent repeated episodes that could cause myositis ossificansMaintain ROM

Contusion of Upper Arm

EtiologyBlunt trauma or stretch type injury

Signs and SymptomsConstant pain, muscle weakness and paralysis or atrophy

ManagementRICETransient muscle weakness may occur w/ quick resolutionIf muscle wasting or atrophy occurs referral to a physician is necessary

Peripheral Nerve Injuries

Rehabilitation of the Shoulder Complex

ImmobilizationWill vary depending on injuryIsometrics can be performed during immobilizationTime in brace or splint are injury specificROM and strengthening are dictated by healing

General Body ConditioningMaintain cardiovascular endurance through cycling, running and walking

Shoulder Joint MobilizationUsed to re-establish appropriate joint arthrokinematicsUsed w/ joint capsule tightness

Rehabilitation of the Shoulder Complex

FlexibilityCodman’s pendulum exercises and sawing motions should begin earlyProgress to active assisted ROM in pain free range (cardinal planes)Should be performed in conjunction w/ rotator cuff and scapula strengthening exercises

Rehabilitation of the Shoulder Complex

Strengthening Exercises

Rehabilitation of the Shoulder Complex

Neuromuscular ControlMust regain appropriate firing sequence for specific musclesBiofeedback can be used to regain controlProprioceptionClosed kinetic chain exercises will be required in gymnasts, wrestlers and weight lifters

Emphasize co-contraction muscle activity

OKC and CKC are necessary in complete rehab plan

Rehabilitation of the Shoulder Complex

Functional ProgressionsIncorporation of sports specific skillsStrengthening that involves PNF patterns (resembles throwing)Gradual and progressive increase in angular velocities

Return to ActivityBased on pre-established criteriaFunctional performance testingObject measures of strength and performance

Rehabilitation of the Shoulder Complex