1. Shoulder and Upper Arm Pathologies
Chapter 15
Shoulder and Upper Arm Pathologies

2. Clinical Anatomy Bony anatomy Manubrium Jugular notch Clavicular notch
Clavicle
Scapula
Subscapular fossa
Vertebral border
Inferior and superior angle
Scapular spine
Supraspinous fossa
Acromion process
Coracoid process

3. Clinical Anatomy

4. Clinical Anatomy Bony anatomy Humerus Humeral head Anatomical neck
Bicipital groove
Greater tuberosity
Lesser tuberosity
Surgical neck
Deltoid tuberosity

5. Clinical Anatomy
Bony anatomy of the scapula

6. Clinical Anatomy Joints of the shoulder complex
Glenohumeral joint (GH)
Acromioclavicular joint (AC)
Sternoclavicular joint (SC)
Scapulothoracic articulation

7. Clinical Anatomy

8. Clinical Anatomy

9. Clinical Anatomy Scapulothoracic rhythm
GH and scapulothoracic articulation must function together.
2:1 ratio (GH elevation: STA rotation)
To accomplish 180 of GH elevation
120 from GH movement and 60 from scapular rotation

10. Clinical Anatomy Bursa of the shoulder complex Subacromial bursa
Above supraspinatus tendon
Buffers tendons’ contact with acromion process and the coracoacromial ligament
Inflamed bursa can lead to RTC impingement.
Subdeltoid bursa

11. Clinical Examination of Shoulder Injuries
Past medical history
History of the present condition
Previous history
AC or GH injury can alter biomechanics.
Cervical spine pathology
Can radiate pain to upper extremity
Location of the pain
Onset
Activity and injury mechanism
Symptoms

12. Clinical Examination of Shoulder Injuries
Inspection
Functional assessment
Pain in follow-through
Pain in cocked position
Pain in deceleration
Loss of control or velocity

13. Clinical Examination of Shoulder Injuries
Inspection
Anterior shoulders
Level of the shoulders
Position of the head
Position of the arm
Contour of the clavicles
Symmetry of the deltoid muscle group
Anterior humerus and biceps brachii muscle group

14. Clinical Examination of Shoulder Injuries
Fracture of left clavicle

15. Clinical Examination of Shoulder Injuries
Anterior GH dislocation

16. Clinical Examination of Shoulder Injuries
Inspection
Posterior structures
Alignment of the vertebral column
Position of the scapula
Sprengel deformity—congenitally undescended scapula
Muscle development
Position of the humerus

17. Clinical Examination of Shoulder Injuries
Palpation of the anterior shoulder
Jugular notch
Sternoclavicular joint
Clavicular shaft
Acromion process and AC joint
Coracoid process
Humeral head
Greater tuberosity
Lesser tuberosity
Bicipital groove
Humeral shaft
Pectoralis major
Pectoralis minor
Coracobrachialis
Deltoid group
Biceps brachii
Long head of the biceps
Short head of the biceps

18. Clinical Examination of Shoulder Injuries
Palpation of the posterior shoulder
Spine of the scapula
Superior angle
Inferior angle
Infraspinatus
Teres minor
Supraspinatus
Teres major
Rhomboid major
Rhomboid minor
Levator scapulae
Trapezius
Latissimus dorsi
Posterior deltoid
Triceps brachii

19. Clinical Examination of Shoulder Injuries
Joint and muscle function assessment
Active range of motion (AROM)
Flexion and extension
Abduction and adduction
Internal and external rotation
Horizontal adduction and abduction
Manual muscle testing (MMT)
Scapular movements
Passive range of motion (PROM)
Same motions as AROM

20. Selective Tissue Test: Drop Arm Test for Rotator Cuff Tendinopathy

21. Selective Tissue Test: Gerber Lift-Off Test for Subscapularis Pathology

22. Clinical Examination of Shoulder Injuries
Joint stability tests
Sternoclavicular joint play
Test for acromioclavicular joint laxity
Test for glenohumeral joint laxity
Neurological testing
Upper quarter screen
Referred pain from visceral organs

23. Pathologies of the Shoulder and Related Special Tests
Sternoclavicular joint sprains
MOI: Longitudinal force on the clavicle
FOOSH, hit on lateral portion of shoulder, or traction forces
Signs and symptoms
Pain with protraction, retraction, and joint play
Posterior dislocations = medical emergency!
Threat to subclavian artery and vein, trachea, and esophagus

26. Pathologies of the Shoulder and Related Special Tests
Acromioclavicular joint pathology
“Separated shoulder”
MOI: FOOSH, blow to superior acromion process
Classification of sprains depends on structures involved, degree of instability, and direction of displaced clavicle.

27. Classification System for Acromioclavicular Joint Sprains

30. Selective Tissue Test: Acromioclavicular Traction Test

31. Selective Tissue Test: Acromioclavicular Compression Test

32. Pathologies of the Shoulder and Related Special Tests
Glenohumeral instability
Anterior instability
Posterior instability
Inferior instability
Multidirectional instability

33. Selective Tissue Test: Apprehension Test for Anterior Glenohumeral Laxity

34. Selective Tissue Test: Relocation and Anterior Release Tests for Anterior Glenohumeral Laxity

35. Selective Tissue Test: Posterior Apprehension Test for Glenohumeral Laxity

36. Selective Tissue Test: Jerk (Posterior Stress) Test for Labral Tears

37. Selective Tissue Test: Sulcus Sign for Inferior Glenohumeral Laxity

38. Pathologies of the Shoulder and Related Special Tests
Rotator cuff pathology
Impingement syndrome
Rotator cuff tendinopathy
Subacromial bursitis

39. Types of Impingement Force Source Primary subacromial impingement
Irregularly shaped acromion
Spur formation on acromion
Os acromiale
Secondary subacromial impingement
Loss of humeral head depression or stabilization
Poor posture
Repetitive overhead movement
Scapular dyskinesis
GH instability
Supraspinatus hypertrophy
Internal impingement
Glenohumeral internal rotation
deficit (GIRD)
High volume of throwing or other
repetitive overhead activity
Occupation requiring repetitive
overhead activity

42. Selective Tissue Test: Neer Impingement Test

43. Selective Tissue Test: Hawkins (Kennedy-Hawkins) Impingement Test

44. Selective Tissue Test: Empty Can Test for Supraspinatus Pathology

45. Pathologies of the Shoulder and Related Special Tests
Biceps tendon pathology
Bicipital tendinopathy
Causes
RTC dysfunction
Impingement
Superior labrum anterior to posterior lesions (SLAP lesions)
Tears of the superior aspect of the glenoid labrum that extend anteriorly and posteriorly to the biceps insertion

46. Classification of SLAP Lesions
Type
Pathology I
Degenerative fraying of the labrum near the insertion of the LHBT II
Avulsion of the glenoid labrum with an associated tear
of the LHBT
Type II SLAP lesions have been further classified
relative to the detachment of the labrum:
• Isolated to the anterior aspect
• Isolated to the posterior aspect
• Appearing in both aspects
III
A bucket-handle tear of the labrum with displacement
of the fragment; no involvement of the LHBT IV
Bucket-handle tear of the labrum with associated
tearing of the LHBT
LHBT = long head of the biceps tendon; SLAP = superior labrum anterior to
posterior

47. Selective Tissue Test: Yergason Test

48. Selective Tissue Test: Speed Test for Long Head of the Biceps Brachii Tendinopathy

49. Selective Tissue Test: Active Compression Test (O’Brien Test)

50. Selective Tissue Test: Anterior Slide Test

51. Selective Tissue Test: Anterior Slide Test Compression-Rotation (Grind) Test

54. On-Field Examination of Shoulder Injuries
Equipment considerations
Palpation under the shoulder pads
Unlatch shoulder pad straps
Palpate under cantilever or through neck opening
Palpation should be gentle to begin.
Removal of the shoulder pads
Remove uninjured arm
Slide shirt and shoulder pads up over head
If shirt is too tight, cut it off.
Drop it down over injured arm

55. On-Field Examination of Shoulder Injuries

56. On-Field Examination of Shoulder Injuries
On-field history
On-field inspection
Location of pain
Upper shoulder
AC sprain
Trapezius
Brachial plexus injury
MOI
Internal or external rotation (with abduction)
GH joint dislocation or subluxation
FOOSH
Clavicular fracture, AC sprain, SC sprain
Arm posture
Arm splinted against torso
Arm hanging limply at the side
Arm “locked”
Gross deformity

57. On-Field Examination of Shoulder Injuries
On-field palpation
Additional on-field tests
If joint dislocation or bony fracture have been ruled out
Apley scratch test can be used as a gross assessment of the athlete’s willingness to move the involved extremity and the amount of motion
Position of the humeral head
AC joint alignment
Clavicle
Sternoclavicular joint
Humerus

58. Initial Management of On-Field Shoulder Injuries
Scapular fracture
Body of the scapula
Glenoid fossa
Glenoid neck
Coracoid process
Management
Immobilize the arm on the affected side in a comfortable position
Athlete then is transported.
GH dislocation also needs a radiographic evaluation to rule out a secondary fracture to the glenoid or coracoid process.

59. On-Field Examination of Shoulder Injuries
Clavicular injuries
Clavicular fracture
Immobilization using a sling or triangular bandage
Transport for definitive diagnosis

60. On-Field Examination of Shoulder Injuries
Sternoclavicular joint injuries
Neurological and vascular examination of the extremity and carotid artery
Involved arm is immobilized.
Athlete is immediately transported to an emergency medical facility.

61. On-Field Examination of Shoulder Injuries
Acromioclavicular joint injuries
Immobilize in a position that lessens the displacement between the clavicle and the acromial process
Protect joint with additional padding during activity

62. On-Field Examination of Shoulder Injuries
Glenohumeral dislocations
Monitor the distal pulses, check for circulation in the fingertips, and perform a sensory screen
Arm is fixed in the position it has assumed.
Reductions of GH dislocations should only be performed by those who are trained to do so.

63. On-Field Examination of Shoulder Injuries
Glenohumeral dislocations (cont.)
Forced reduction of the humeral head may damage the glenoid fossa, the coracoid process, or the neurovascular structures in the area. Following reduction, assess distal pulse and active range of motion, avoiding external rotation and abduction. Stabilize the shoulder using a sling, and refer the athlete for further examination.

64. On-Field Examination of Shoulder Injuries
Humeral fractures
Splint in position found using moldable splint or vacuum splint
Leave wrist and fingers exposed to check circulation
Transport