The Shoulder Unit 16

Upper Extremity Injuries Upper extremities are vulnerable to a variety of injuries depending on the sport, including: Sprains Strains Dislocations Fractures

Upper Extremity Injuries Upper extremities are vulnerable to a variety of injuries depending on the sport, including: Separations to the thoracic cage, shoulder, arm, and hand Repetitive motion injuries such as arthritis, bursitis, tendonitis

Shoulder Complex Physiology Bones Muscles Tendons Ligaments Articulations

Bones Humerus Scapula Clavicle

THE JOINTS Sternoclavicular joint (SC joint) Coracoclavicular joint Sternoclavicular ligament Coracoclavicular joint Coracoclavicular ligament Acromioclavicular joint (AC joint) Acromioclavicular ligament Coracoacromial joint Coracoacromial ligament

Scapulothoracic articulation Glenohumeral joint Glenohumeral ligaments Scapulothoracic articulation

Muscles in motion FLEXION Anterior deltoid Biceps brachii Primary mover Biceps brachii Secondary mover

EXTENSION Posterior deltoid Prim. Mover Triceps brachii Sec. Mover

ABDUCTION Supraspinatus Middle deltoid Trapezius 1st 5-10 degrees Last 90 degrees Trapezius Assists in movement above 90 degrees

ADDUCTION Latissimus dorsi Pectoralis major

HORIZONTAL FLEXION Pectoralis major Anterior deltoid

HORIZONTAL EXTENSION Posterior deltoid Infraspinatus Teres minor/major Rhomboids Trapezius Stabilizer

CIRCUMDUCTION Basically all muscles of the shoulder

INTERNAL ROTATION Subscapularis Pectoralis major EXTERNAL ROTATION Little help EXTERNAL ROTATION Infraspinatus Teres minor/major

Scapular Elevation Scapular Depression Scapular protraction Scapular retraction ****find muscles that perform these motions

Assessing Shoulder Injuries P S

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?

Observation Elevation or depression of shoulder tips Position and shape of clavicle Acromion process Biceps and deltoid symmetry Postural assessment (kyphosis, lordosis, shoulders) Position of head and arms Scapular elevation and symmetry Scapular protraction or winging Muscle symmetry Scapulohumeral rhythm

Palpation Bony structure palpation should occur bilaterally and simultaneously if possible Palpate soft tissue structures for point tenderness, swelling, spasms, lumps, guarding or trigger points Be sure to palpate anteriorly and posteriorly

Special Tests ROM test for external rotation of the shoulder ROM test for internal rotation of the shoulder Specific ROM tests for the shoulder including abduction, adduction, flexion, extension, horizontal adduction, horizontal abduction

Manual muscle tests for the shoulder External rotation strength tests Internal rotation strength test for the shoulder Extension strength test for the shoulder Flexion strength test for the shoulder Abduction and adduction strength tests for the shoulder Empty can test

Apprehension test (Crank test) Apprehension test used for anterior glenohumeral instability This motion should not be forced

Test for Shoulder Impingement Neer’s test and Hawkins-Kennedy test for impingement used to assess impingement of soft tissue structures Positive test is indicated by pain and grimace

Test for Supraspinatus Weakness Empty Can Test 90 degrees of shoulder flexion, internal rotation and 30 degrees of horizontal abduction Downward pressure is applied Weakness and pain are assessed bilaterally

Types of Shoulder Injuries Fractures Clavicle, humerus, scapula Cause: fall on outstretched arm, direct blow S/S: pain, deformity, decreased ROM, swelling Perform percussion test, compression test

Treatment Prevention: Sling/splint PRICE Physcian/EMS Follow orders Instruct how to fall Proper equipment

Hockey Clavicle Fracture

Dislocations and subluxations AC, SC, GH jts Cause: head of humerus forced/displaced from glenoid S/S: pop, dead arm, pain, deformity, swelling, loss of ROM/strength

Treatment Prevention DO NOT relocated PRICE Check circulation/sensation Physician / x-rays Follow orders Prevention Strengthen jt Proper equipment Falling

Anterior Posterior

Posterior

Shoulder dislocation-rugby Dwayne Wade http://www.youtube.com/watch?v=09ZZbJzeKUA

Contusions Myositis ossificans Cause: direct blow/bony area or muscles S/S: pain, decreased ROM, r/o other injuries Treatment: ice, padding, rehab, flexibility Prevention: proper equipment, mechanics Myositis ossificans

Sprains Cause: over stretch/tear ligament, capsule What motions/events would cause this? S/S: pt tender, weak, swelling, instability, possible deformity, decreased ROM Treatment PRICE Physician, follow orders Rehab Prevention Proper equipment/technique Strengthening/stretching Inspect playing areas Taping/bracing

Sternoclavicular Sprain Cause of Injury Indirect force, blunt trauma (may cause displacement) Signs of Injury Grade 1 - pain and slight disability Grade 2 - pain, subluxation w/ deformity, swelling and point tenderness and decreased ROM Grade 3 - gross deformity (dislocation), pain, swelling, decreased ROM Possibly life-threatening if dislocates posteriorly Care PRICE, immobilization Immobilize for 3-5 weeks followed by graded reconditioning

Acromioclavicular Sprain Cause of Injury Result of direct blow (from any direction), upward force from humerus, fall on outstretched arm Signs of Injury Grade 1 - point tenderness and pain w/ movement; no disruption of AC joint Grade 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 ligaments with dislocation of clavicle; gross deformity, pain, loss of function and instability

Care Ice, stabilization, referral to physician Grades 1-3 (non-operative) will require 3-4 days (grade 1) and 2 weeks of immobilization ( grade 3) respectively Aggressive rehab is required w/ all grades Joint mobilizations, flexibility exercises, & strengthening should occur immediately Progress as athlete is able to tolerate w/out pain and swelling Padding and protection may be required until pain-free ROM returns

Specific tests Sulcus test, apprehension test for sprain of the anterior capsule Acromioclavicular (AC) sprain test Sternoclavicular (SC) sprain test

Types of Shoulder Injuries Strains Cause: overstretching of muscles S/S: similar to sprains Treatment: PRICE, physician if necessary, follow orders, rehab Prevention Stretching, strengthening Drop arm test-specific test

What do you see? L clavicle elevation, bruising, left shoulder higher What do you think the injury is? Grade 2 AC sprain, left. Bull rider

Impingement Cause: pinching of soft tissue w/overhead activity; overuse S/S: pain, weakness, pt tenderness Hawkins-Kennedy test, winged scapula test Treatment PRICE, decrease inflam., physician Strengthen RC, scapular stabilizers Prevention RC strengthening, proper mechanics

Rotator cuff tear Signs of Injury Involves supraspinatus or rupture of other rotator cuff tendons Primary mechanism - acute trauma (high velocity rotation) Occurs near insertion on greater tuberosity Full thickness tears usually occur in those athletes w/ a long history of impingement or instability (generally does not occur in athlete under age 40) Signs of Injury Present with pain with muscle contraction Tenderness on palpation and loss of strength due to pain Loss of function, swelling With complete tear, impingement and empty can test are positive

Care RICE for modulation of pain Progressive strengthening of rotator cuff Reduce frequency and level of activity initially with a gradual and progressive increase in intensity

Shoulder Bursitis Etiology Signs of Injury Management Chronic inflammatory condition due to trauma or overuse - subacromial bursa May develop from direct impact or fall on tip of shoulder Signs of Injury Pain w/ motion and tenderness during palpation in subacromial space; positive impingement tests Management Cold packs and NSAID’s to reduce inflammation Remove mechanisms precipitating condition Maintain full ROM to reduce chances of contractures and adhesions from forming

Bicipital Tenosynovitis Cause of Injury Repetitive overhead athlete - ballistic activity that involves repeated stretching of biceps tendon causing irritation to the tendon and sheath Signs of Injury Tenderness over bicipital groove, swelling, crepitus due to inflammation Pain when performing overhead activities Care Rest and ice to treat inflammation NSAID’s Gradual program of strengthening and stretching

Types of Shoulder Injuries Tendonitis Cause: overuse to tendons Speed’s test Treatment: PRICE, anti-inflammatory, rehab, etc Prevention: Ice post activity, conditioning, mechanics,

Synovitis and bursitis Cause: inflammation of synovial lining/bursa Overuse, direct trauma S/S: pain, crepitus, swelling, decreased mobility Treatment: PRICE or heat, stretching pain free ROM, mechanics, etc Prevention: mechanics