Injuries to the Shoulder

Brief Epidemiology Shoulder pain: a common complaint in primary care –2 nd only to knee pain for specialist referrals –Most common cause in adults (ages 40-60) Rotator cuff problems Athletic injuries –Shoulder: 8-13% of all athletic injuries

Brief Epidemiology Second most common musculoskeletal complaint Difficult joint to examine Multidirectional range of motion- UNIQUE! Shoulder injury can affect nearly every sport and many daily activities

Anatomy of the Shoulder Bones of shoulder complex: –Connects upper extremity with axial skeleton clavicle (collar bone) –distal and proximal scapula (shoulder blade) proximal end of humerus

Anterior/Posterior View of Bones of Shoulder

Bony Landmarks of the Humerus Proximal Humerus –Head –Greater tuberosity –Lesser tuberosity –Bicipital groove

Bony Landmarks of the Scapula Scapula –Glenoid Fossa –Acromion Process –Coracoid Process –Superior Angle/Border –Inferior Angle/Border –Lateral/Axillary Border –Medial/Vertebral Border –Spinous Process (posterior)

Anatomy of the Shoulder

Bones of the Shoulder Complex

X-ray View of Shoulder

Articulations of the Shoulder Sternoclavicular (SC) joint –between the sternum and proximal clavicle Acromioclavicular (AC) joint –between distal clavicle and acromion process Glenohumeral (GH) joint –between head of humerus and glenoid fossa of the scapula –ball and socket joint

Anatomy of Shoulder Labrum –Cartilage of the shoulder –Forms a “lip” around humeral head –Helps to stabilize the glenohumeral joint

Identify Boney Landmarks

Identify Bony Landmarks

Identify Structures of Shoulder

Ligaments of the Shoulder Sternoclavicular Coracoclavicular Acromioclavicular Coraco-acromial Coraco-humeral Glenohumeral Ligaments –Also called “joint capsule” –Superior –Middle –Inferior

ROM of Shoulder Joint Flexion Extension Abduction Adduction External rotation Internal rotation Shoulder Range of MotionShoulder Range of Motion Horizontal abduction Horizontal adduction Circumduction

Muscles of the Shoulder Joint Rotator Cuffs (SITS) –“dynamic stabilizers” Supraspinatus –Superior –Abduction Infraspinatus –Posterior –External Rotation Teres Minor –Posterior –External Rotation Subscapularis –Anterior –Internal Rotation Rotator Cuff Tutorial

Rotator Cuffs Supraspinatus Infraspinatus Teres minor Supscapularis

Lateral View of Rotator Cuffs

Main Muscles of Shoulder Complex Biceps brachii Deltoid Teres Major Levator Scapulae Trapezius Triceps brachii –Attaches humerus to shoulder girdle Trapezius Rhomboid Major Rhomboid Minor Serratus Anterior Pectoralis Minor Pectoralis Major –Attaches shoulder girdle to trunk of body

Muscles of the Shoulder Pectoralis Major and Minor Biceps Brachii

Muscles of the Shoulder Teres Major –Anterior view –Posterior view Deltoid

Muscles of the Shoulder TrapeziusLatissimus Dorsi

Muscles of the Shoulder Rhomboids –Major and Minor Levator Scapulae

Muscles of the Shoulder Triceps

Major Arteries and Veins of Arm Arteries –Subclavian –Axillary –Brachial –Radial & Ulnar Veins –Radial & Ulnar –Brachial –Axillary –Subclavian

Major Nerves of the Arm Brachial Plexus –Axillary –Musculocutaneous –Radial - extensors –Medial - flexors –Ulnar – flexors Nerve damage results in numbness, pain, and/or tingling

Review of Shoulder Anatomy Shoulder Anatomy Animated TutorialShoulder Anatomy Animated Tutorial

Injuries to the Shoulder Fractures –Usually clavicle or head of humerus –Clavicle FractureClavicle Fracture Mechanism of Injury 1. direct blow 2. falling on outstretched hand 3. landing on acromion process Symptoms – pain, swelling, deformity – hanging arm to side – and unable to lift arm

Fractures Fractures Special Tests –Percussion Test Lightly tap distal aspect of involved arm Tuning forks often used –Compression Test Compress area above and below injured site Be careful not to place hands on injured area

Fractures Immediate Treatment –Place in sling or splint –Ice only if will not increase pain –Send to physician or call EMS

Distal Clavicle Fx

Clavicle Fx

Humeral Head Fx

Injuries to the Shoulder Dislocation / Subluxations –Dislocation = head of humerus displaced –Subluxation = partial dislocation Mechanism of Injury 1. Falling on outstretched arm (Anterior) 2. Arm in 90° flexion forced back (Posterior) Symptoms Pain Loss of strength & ROM “dead arm” Slipping sensation

Dislocations/Subluxations Immediate Treatment –Place in comfortable position –Check for loss of circulation –Immobilize the joint & apply ice –Send to physician

Shoulder Dislocations Can –Tear labrum –Damage GH joint ligaments –Fracture humeral head –Tear rotator cuffs –Damage nerves

Most Common: Anterior Dislocation

Inferior & Posterior Dislocations

Shoulder Dislocations

Posterior & Inferior Shoulder Dislocation

Shoulder Dislocations Review of Shoulder DislocationsReview of Shoulder Dislocations

Injuries to the Shoulder Contusions Mechanism of Injury –Direct blow Symptoms 1. point tenderness 2. loss of ROM 3. discoloration Immediate Treatment –Ice –Protect

Injuries to the Shoulder Sprains –Stretching or tearing of ligaments around AC joint, SC joint or glenohumeral joint capsule Mechanism of Injury Outstretched arm Direct blow Symptoms 1. Point tenderness3. Swelling 2. Weakness4. Decreased ROM

Injuries to the Shoulder GH Ligaments Sprain –Stretching or tearing of GHL (GH joint capsule) –Causes instability of GH joint –Increases risk of shoulder pain and dislocations

Special Tests for GH Joint Instability Sulcus Test/Sign Downward distraction of the humerus assesses multidirectional instability of GH joint

Special Tests for GH Joint Instability Apprehension Standing behind the athlete with their arm abducted 90°, grab wrist and externally rotate the arm. At the sign of apprehension, stop. Assesses instability of anterior GH joint capsule

Review of Multidirectional InstabilityReview of Multidirectional Instability

Injuries to Shoulder Acromioclavicular Joint Sprain –also called a “separated shoulder” –AC Joint SprainsAC Joint Sprains Mechanism of injury: 1. blow to the lateral aspect of shoulder Treatment: 1. ice 2. place in sling 3. if grade 2 or 3, send to physician 4. Surgical Repair of AC Joint SeparationSurgical Repair of AC Joint Separation

Acromioclavicular Joint Separation

Injuries to Shoulder Sternoclavicular Joint Sprain/Dislocation Mechanism of injury: 1. blow to distal or proximal clavicle or sternum 2. rare in sports Treatment: 1. ice 2. sling 3. grade 2 or 3, send to physician

SC Joint Separation

Injuries to Shoulder Bursitis/Tendonitis –Inflammation of bursa sacs or tendons in the shoulder Mechanism of Injury 1. overuse Treatment 1. ice 2. rest 3. stretching and strengthening exercises 4. NSAIDS

Bursitis/Tendonitis Causes – Humeral head moves into >90° abduction – Structures under acromion process (supraspinatus/bursa sac) become pinched and inflamed

Injury to Shoulder Labrum Tears –Tearing of the glenoid labrum 2 Types –SLAP tears Most common in overhead throwing athletes Superior gh joint where biceps tendon attaches –Bankhart Lesions Occurs when shoulder dislocates

Labrum Tears Review of Labrum TearsReview of Labrum Tears SLAP Tear Repair Bankhart Lesion RepairBankhart Lesion Repair

Radiology of Labral Tears

Injury to Shoulder Biceps Tendonitis –Inflammation of the biceps tendon –Caused by repetitive overhead motion –Ice, rest, NSAIDS –Biceps TendonitisBiceps Tendonitis

Injury to Shoulder Impingement –> than 90° abduction –Supraspinatus tendon and bursa “pinched” under acromion process –Caused by overuse and repetitive overhead motions –Ice, rest, strengthening –Shoulder ImpingementShoulder Impingement

Shoulder Injuries Rotator Cuff Tears –Usually the supraspinatus –Usually acute injury in sports from fall –Partial tears Rest and physical Therapy –Full-thickness tears Surgery and physical therapy

Shoulder Injuries Rotator Cuff Tears –Supraspinatus TearSupraspinatus Tear –Rotator Cuff TearsRotator Cuff Tears

Rotator Cuff Tear

Review of the Shoulder Shoulder Anatomy ReviewShoulder Anatomy Review