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SHOULDER ASSESSMENT                               

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Presentation on theme: "SHOULDER ASSESSMENT                               "— Presentation transcript:

1 SHOULDER ASSESSMENT                             

2 BONY PALPATIONS

3 Shoulder Complex

4 Scapulothoracic Articulation
Not a true anatomical joint Resting position of scapula is: Superior angle is level with spinous process T2 Inferior angle level with spinous process T7 Medial border of scapula is 5-6 cm or three fingers width from spinous processes

5 SHOULDER LIGAMENTS

6 STERNOCLAVICULAR LIGAMENTS

7 Motions @ Sternoclavicular Joint
SC Joint acts like ball and socket joint Motions at joint: Elevation- Depression Rotation : upward-downward Rotation: forward-downward; backward- upward

8 AC Joint Characteristics
Synovial joint Keeps glenoid fossa continually facing the humeral head Articular disc between acromion and distal clavicular head Capsule – lax to allow for complex shoulder motion

9 AC Joint Superior and inferior acromioclavicular lig.
Strengthen upper aspect of joint Limits approx. 90% of anterior-posterior translation

10 Coracoclavicular Ligament
.: Limits 80% of superior translation of the clavicle- acts as a tie bar to hold clavicle down Maintains a constant relationship of the scapula on the clavicle

11 Coracoacromial ligament
Forms roof over humeral head Prevents upward displacement of humeral head and protects underlying structures Sharp lateral edge may impinge on bursa and supraspinatus tendon

12 Superior Transverse Ligament
Bridges lesser scapular notch Provides a passage for suprascapular nerve

13 Glenohumeral Joint Synovial Joint: humeral head articulates with glenoid cavity Humeral head points medially, backward and tilts upward Glenoid is ½ as long and 1/3 as wide as the humeral head Contact area is limited Surface area of humeral head is 3-4 times larger than the fossa

14 Glenohumeral Capsule

15 GLENOHUMERAL AND CORACOHUMERAL LIGAMENTS
Coracohumeral Lig.- One of the most important ligament structures 1. Blends with rotator cuff, fills space b/t subscapularis and supraspinatus MaintainsGH relationship Involved with frozen shoulder

16 GLENOHUMERAL LIGAMENTS

17 Glenoid labrum Rim of cartilaginous tissue attached around margin of glenoid fossa Serves as attachment for ligaments Deepens articular cavity Increases glenoid contact with humeral head & serves “chock block” function

18 Glenoid Fossa with Rotator Cuff Muscles

19 Muscles of Shoulder

20 Shoulder Bursae 1. Subacromial or Subdeltoid bursa
2. B/t coracoid & glenohumeral Jt. Capsule 3. Summit of the acromion 4. B/t infraspinatus & joint capsule 5. B/t teres major & long head biceps 6. B/t subscapularis & Joint capsule 7. Tendinous insertion of latissimus dorsi 8. Behind the coracobrachialis muscle

21 Blood Supply to Shoulder Complex

22 Blood Supply

23 Neurovascular Bundle

24 Brachial Plexus

25 Upper Extremity Dermatomes

26 Posterior Dermatomes

27 1st Phase Scapulohumeral Rhythm
Phase I: Humerus: 30 degrees Abduction Scapula: Minimal movement Clavicle: degree elevation

28 2nd Phase Scapulohumeral Rhythm
Phase II: Humerus: 40 degrees Abduction Scapula:20 degree rotation Clavicle: degree elevation

29 3rd Phase Scapulohumeral Rhythm
Phase III: Humerus: 60 degrees Abduction 90 degree lateral rotation Scapula:30 degree rotation Clavicle: degree posterior rotation up to 30 degree elevation

30 Biceps tendon mobility
Biceps tendon does not move in the bicipital groove during movement Humeral head moves over the fixed tendon

31 Shoulder Patterns: Closed packed position= 90 degrees abduction and external rotation Open packed position= arm down by side up to degrees abduction

32 Clavicle Fractures Most common Fx. Results :
Fall on out stretched arm Fall on tip of shoulder Direct impact Occurs most often in junction of middle and outer thirds of clavicle

33 X-ray of Clavicle Fracture

34 Signs and Symptoms of Clavicle Fractures
Athlete supporting arm held in tight to body with head tilted toward injury On inspection , injured clavicle appears slightly lower than unaffected side Palpation reveals swelling, point tenderness, mild deformity

35 Management of Fx. Clavicle
Apply a sling and swathe bandage or figure 8 harness Obtain x-rays Nearly all are treated with closed reduction Keep immobilized for 6-8 weeks Open reduction: Vascular complications, displaced epiphysis in skeletally immatue pt., Fx. Ends threaten skin, near AC joint

36 Scapular Fractures Rare in sports
Cause: direct contact with force directed through humerus to scapula Locations: body, glenoid, acromion, coracoid

37 X-ray Fracture of Scapula Body

38 Signs and Symptoms of Scapular Fractures
Pain and tenderness around back of the shoulder Athlete typically holds arm securely at the side and avoids any attempt to move humerus Diagnostic Test: X-ray Treatment: Nonoperative Treatment: Sling and early ROM with in 1 week

39 Fractures of Proximal Humeral
Cause: direct blow, a dislocation or the impact received from FOOSH injury Can be mistaken for shoulder dislocation Can occur at anatomical neck, tuberosity or surgical neck Most occur at surgical neck

40 Humeral Shaft Fractures

41 Humeral Shaft Fractures
Cause: direct blow or Foosh Injury Type: comminuted or transverse fractures Signs & Symptoms: Severe pain, swelling, deformity Complication: radial nerve involvement- loss of wrist and finger extension and sensation over the back of dorsal surface- within 6 months radial nerve should be fine Treatment: Nonoperative- x-ray views followed by splints and pressure wrap and casting with sling for 1st week

42 Sternoclavicular Sprains & Dislocations
Relatively uncommon in sports Cause: indirect force transmitted through the humerus and down shaft of clavicle Medial end of clavicle can be displaced upward and forward or slightly anteriorly

43 Sternoclavicular Sprains and Dislocations
3 Classification of Injury: 1st Degree: little pain or disability, pt. Tenderness, no jt. Deformity 2nd Degree: displays subluxation of SCJ with visible deformity, pain, swelling, pt. Tenderness, inability to abduct the shoulder FROM or horizontally abduct arm = ligamentous instability 3rd Degree: Complete Dislocation with gross displacement of clavicle at sternal junction, swelling, loss of function= rupture SCL and Costoclavicular Lig Danger: Posterior Dislocation – pressure placed on blood vessels, esophagus and or trachea causing life- or death situation

44 Management of Sternoclavicular Sprains and Dislocations
Treatment: RICE, immobilization, emergency care for breathing X-ray Physician reduction Immobilization 3-6 weeks Recurrence is very high in these injuries

45 Acromioclavicular Sprain/Separation
Commonly caused by falling directly onto the tip of acromion Common in hockey, rugby, football, equestrian accidents and martial arts Injuries are classified into 6 types based on the severity of injury and degree of clavicular separation

46 AC Pathology

47 AC Separation

48 Acromioclavicular Treatment
1st and 2nd degrees are treated conservatively with ice & ROM exercise and immobilization 3rd – 6th – could require operative intervention in cases where intra-articular disc is damaged and or interarticular fx occur Operative : place a k-wire around clavicle to hold it down – 12 weeks post surgery rehab and immobilization

49 AC Joint Harness

50 Glenohumeral Dislocations
Most common are anterior displaced with arm abducted and externally rotated Capsule can remain in tact or be severely damaged as head of humerus in forced out ot glenoid fossa in anterior inferior direction Secondary labrum injuries – Bankhart Lesion and /or Hill-Sachs Lesions

51 Glenohumeral Dislocation

52 Anterior Glenohumeral Dislocation
Signs & Symptoms: Flattened Deltoid contour Palpation of axilla reveals prominence of humeral head Athlete carries affected arm in slight abduction and external rotation Severe Pain with initial dislocation Tingling and numbness extends down the arm into hand

53 Bankhart Lesion

54 X-Ray finding of Bankhart Lesions

55 Hill-Sachs Lesion Small articular Cartilage defect on the humeral head caused by the impact of humeral head on the glenoid fossa as the humerus dislocates

56 Hill-Sachs Lesion

57 Anterior Dislocation Reduction

58 Posterior Glenohumeral Dislocation
Fairly rare and only account for 1-4 % of all shoulder dislocations Mechanism of injury: a forced adduction and internal rotation of the shoulder usually directed to anterior compartment or a fall on an extended and internally rotated arm Signs & Symptoms: severe pain and disability – Arm is fixed in adduction and internal rotation, deltoid muscle is flattened, acromion and coracoid processes are more prominent than normal and the head of the humerus may be posterior. Head is usually dislodged in the posterior rotator cuff musculature Usually reduced spontaneously

59 Posterior Dislocation Management
Same as with Anterior Dislocations

60 Recurrent Dislocations and Subluxations
Cause capsule to stretch out allowing for multiple reoccurrences Athlete complains of arm feeling like it is “Going Dead”- commonly referred to as Dead Arm Syndrome These need to be repaired with Bristow Repair or Bankhart procedure to prevent Multidirectional shoulder instability (MSI)

61 Subacromion Bursitis

62 Shoulder Subacromion Bursitis
Typically an overuse syndrome Occurs most often to subacromion bursa Occurs to as: Swimmer, baseball, and tennis players MOI: same as impingement , not isolated but a multifaceted problem accompany impingement, rotator cuff problems

63 Signs and Symptoms: Unable to move shoulder in abduction, rotation
Muscle atrophy occurring due to disuse Can be sudden or insidious onset Inability to sleep at night Point tenderness on the anterior and lateral edges of the acromion process Painful arch between degrees Assessment: Pain on passive and active motion in the same direction

64 Management of Bursitis
RICE immediately Deep heat with ultrasound and/or hot packs NSAIDs and activity modification Injections but must be compliant for 2 weeks Avoid Frozen shoulder

65 Neurovascular Bundle

66 Thoracic Outlet Syndrome

67 Thoracic Outlet Syndrome
Signs and Symptoms: Parenthesis and pain in side or back of neck extending across the shoulder down the medial are to the ulnar aspect of hand Sensation of cold – caused by arterial involvement- usually symptoms occur very rapidly after exercise or activity using hand Impaired circulation could lead to gangrene of the fingers Weakness of muscle leading to decreased grip strength Muscle atrophy Radial nerve palsy

68 Orthopedic Test Used to Assess TOS
Adison’s Test- Test for costioclavicular encroachment Allen’s Test- Stretch the scalenes Military Press Test- Hyper abduction places pect minor on stretch Roos’s Test- Combination

69 Management of TOS Conservative approach should be taken with early and mild cases: works in 50%-80% of cases Sling support and tension reduction Anti-inflammatory medication Exercise to strengthen trapezius, serratus anterior, and erector muscles of the spine to counter act pull of pect minor Postural correction- especially in cases of drooped or forward tilted shoulder: emphasize stretch the anterior muscles and strengthening posterior muscles

70 Brachial Plexus Injury
Etiology: Transient neurapraxia resulting from stretching or compression of the BP Neurapraxia involves a disruption in normal function of a peripheral nerve without any degenerative changes Common terms: stinger, burner, or pinched nerve

71 Brachial Plexus Injuries
Mechanism of injury: neck is forced laterally to the opposite side while the shoulder is depressed as occurs with a shoulder blocking football Or compresses the brachial plexus when the neck extended , compressed and rotated toward the affected side S&S: burning sensation, numbness, tingling and pain extending from shoulder down to the hand with some loss of function of arm and hand Symptoms rarely last for more than several days Neck ROM is normal Repeated BP injuries may result in neuritis, muscular atrophy and perm ant damage

72 Management of Brachial Plexus Injuries
Push the shoulder pads up off the shoulder Ask athlete to move fingers and arm around to get sensation back – hold ice in hand After symptoms have completely resolve , the athlete may return to full activity Fit shoulder pads with a cervical roll to limit neck ROM during impact

73 Biceps Tendon Pathology
Bicipital Tendonitis: Occurs to long head of Biceps as it lies in the tubular sheath in the bicipital groove Causes: repetitive motion of the shoulder Assess with: Speeds Test

74 Biceps Tendon Tendonitis

75 Subluxation of Biceps Tendon
Cause: Tear of Transverse Humeral Lig. Test : Yeagerson’s Test

76 Rupture of Biceps Tendon

77 Signs & Symptoms of Rupture Biceps Tendon
Maybe indistinguishable from impingement syndrome Pain n the glenohumeral joint itself Pain on active and resistive supination and flexion of forearm No pain with passive ROM Most common ruptures : near or in bicipital groove Orthopedic Test: Resistive and Active ROM Ludington Test

78 Glenoid Labrum Lesions
Lesions occur with shoulder dislocations and traumatic subluxation Labrum can be detached from the glenoid rim: frank tear Long head of biceps is typically involved in superior tear or SLAP lesions

79 2 Classic Types of Lesions
SLAP = Superior Lesion Anterior to Posterior – 10 – 2 o’clock Bankhart Lesion – 4-6 o’clock on the rim of the labrum

80 4 Classifications of Lesions

81 Rotator Cuff Impingement Syndrome
Referred to as: Swimmer’s Shoulder, Thrower’s Shoulder, or Painful Arch Syndrome Anatomy: impingement occurs to supraspinatus muscle at anterior edge of acromion and coracoacrominal ligament Etiology : repeated use of arm aoe the horizontal plane causes a reductionof space for the supraspinatus muscle to pass under the acromion

82 Rotator Cuff Impingement

83 Causes of Rotator Cuff Impingement
1. Shape of the acromion The contact pattern of the rotator cuff on the undersurface of the acromion Contact can be determined by the shape of the acromion

84 Causes of Rotator Cuff Impingement
2. Instability of Glenohumeral Joint- if capsule is laxed or dynamic stabilizers are inadequate, the humeral head will displace excessive which can cause secondary impingement

85 Causes of Rotator Cuff Impingement
3. Scapular hypermobility: When the scapula glides excessively laterally (protraction) during arm elevation causing the glenoid fossa to “open up” which may contribute to excessive movement of the humeral head anteriorly and superiorly – Inadequate scapular stability

86 Scapulohumeral Force Couple

87 Orthopedic Test to Assess RC Impingement
Kennedy-Hawkins Test Cross-Over Test Neer’s Test O’Brian Test

88 3 stages of RC Impingement
Stage I: Reversible Damage Injury to supraspinatus or Long head Biceps Aching after activity Pt. tenderness high over supraspinatus at greater tuberosity of humerus Pain with abduction = Painful arch Positive impingement sign Biceps Tendon: Pt. tender over biceps tendon, pain at biceps tendon with straight arm flexion (Speed’s Test), pain resisted supination & ER

89 Stage II RC Impingement
Lesions are impossible to reverse, can take years Fibrotic symptoms set in: Aching during activity , worse at night Some restricted ROM No obvious muscle defect Muscle fiber separation Permanent thicken of RC and Acromial bursa

90 Stage III RC Impingement
Long history of shoulder problems Shoulder pain during activity with increased pain at night Muscle defect of1cm or less Possible parrtial muscle tear Permanent thickening of rotator cuff and subacromial bursa with scar tissue Complaint of weakness in everyday endeavors

91 Stage IV RC Impingement
Obvious infraspinous and supraspinous strophy Complete tear of rotator cuff with severe to minimal pain Tenderness over greater tuberosity, anterior acromion, AC Jt. Very painful Arch Muscle defect greater than 1cm Limited active and full passive ROM Possible degeneration of clavicle Positive impingement sign

92 Treatment for RC Impingement
Stage I & II: Change mechanic of raising arm above head= changing swimming stroke or throwing motion Ice after workout and avoid heat Ultrasound Rest Steroid injection to decrease inflammation Stretch rotator cuff

93 Treatment Stage III Conservative
Emphasis placed on ROM and Strengthening external rotators

94 Stage III & IV Surgical Treatment
Anterior Acromoplasty: Involves resection the coracoacrominal ligament and shaving under surfaces of the acromion without disrupting the deltoid muscle

95 Rotator Cuff Tears Most common tears= supraspinatus
Most often fails near its periphery , near the attachment at greater tubeorsity – described as: Partial thickness tears – involves superficial surface Full thickness tears – extends through the articular surface to bursal surface

96 Rotator Cuff Tears Described as acute or chronic and partial and full thickness Classified by size of tear Can be torn is single traumatic event or failure can occur over a longer period of time and present in an insidious manner

97 Overhead Athletes Generally have partial articular –side tear
Acute tears usually found in athletes younger than 40 Commonly recall a single traumtic event and present with shoulder pain, weakness, and a positive shrug sign (shrugging shoulder with an attempted abduction of the arm)

98 Older Athletes Tend to have chronic, full thickness tears

99 Management of Rotator Cuff Tears
Arthroscopic evaluation necessary: Some have intact cuff with marked thickened, inflammed , and fibrotic subacromial bursa – arthroscopic subacromial decompression is indicated Partial RCT are debrided and the instability is corrected. Tears involving less than 50% of the tendon thickness can be debrided arthoscopically , while larger tear may require repair

100 Signs and Symptoms of Rotator Cuff Tears
Pain with shoulder elevation and abduction and external rotation Night pain , inability to lay on shoulder Weakness, and diminished function Shoulder muscular atrophy Orthopedic Test: Drop Arm I and II; Empty Can Test, Pain on Active motion in one direction and pain on passive ROM in opposite direction

101 Adhesive Capsulitis Referred to a “Frozen Shoulder”
Exhibits a classical capsular pattern with loss of active and passive ROM due to adhesions in the capsule Glenohumeral joint capsule becomes inflammed , thickened, and excessively scarred with adhesion forming to humeral head Common in yr. old women Higher incidence in pt. with diabetes mellitus

102 Three Stages of Adhesive Capsulitis
Stage I= painful phase, gradual onset diffuse pain, worse at night, last 2-9 months Stage II= Stiffening phase – last months- significant loss of ROM especially overhead movements and reaching into back pocket Stage III= Thawing phase- Gradual regaining of ROM Orthopedic Test - None


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