1. Derbyshire Sports Injuries Clinic presents
The Shoulder

2. Shoulder anatomy-bones

3. Shoulder anatomy-ligaments

4. Shoulder anatomy-muscles

5. Shoulder anatomy-bursae

6. The gleno-humeral joint
Ball & socket joint which is inherently unstable due to a shallow socket.
Additional stability is provided by:
Static:GH ligaments, labrum & capsule and
Dynamic constraints: rotator cuff & scapula stabilising. The RC muscles act as humeral depressors and centre the humerus in the joint. They work in opposition the deltoid and prevent the humerus rising up and impinging on the undersurface of the acromion
Labrum deepens the socket by 75% and widens it by 50%

7. Other joints involved in shoulder movement
Acromio-clavicular
Scapulo-thoracic
Sterno-clavicular
The smooth movement of all of the joints together is called ‘Scapulo-humeral rhythm’.
Upward rotation of the scapula ensures the coracoacromial arch is removed from the path of the upwardly elevating humerus
This also enhances stability at >90° by placing the glenoid fossa under the humeral head

8. Causes of shoulder pain
Rotator cuff musculature
Instability
Stiffness
AC joint
Referred pain

9. Rotator cuff Acute, chronic or acute on chronic
Acute: muscle strains, partial or complete tendon tears
RC tendon injuries frequently present as impingement

10. Instability
Pain from instability can arise from the anterior, posterior or superior shoulder capsule and labrum.
Glenoid labral lesions may occur either acutely or as a repetitive injury
Can be observed in people who have recurrent episodes of dislocation or subluxation
Initially instability causes symptoms like impingement or joint pain

11. AC Joint Often mistaken for shoulder pain
Is actually very specific pain and symptoms are localised on questioning

12. Shoulder stiffness Can be from:
Trauma
Post-surgical
Injury to the cervical nerve roots and/or brachial plexus
Spontaneously for no reason... Adhesive capsulitis

13. Referred pain
Very common referral site from the cervical spine, upper thoracic spine and associated soft tissue:
Levator scapulae
Trapezius
Rotator cuff muscles
Tumours
Axillary vein thrombosis
Perforated duodenal ulcer

14. Patient walks in c/o shoulder pain
Where is the pain?
How long have you had the pain?
Is there a mechanism of injury?
Sport?
Work activity?
Any neck pain, headaches, pins and needles, numbness, breathing difficulties
Popping in/ out?
Night pain is common in impingement and RC issues but other red flags should be screened for

15. Clinical pearls
In acute injuries the position of the shoulder when injury takes place is important:
Arm wrenched backwards in a vulnerable position: suspect anterior dislocation or subluxation
Fall onto the point of the shoulder: AC joint
Fall on outstretched arm: SLAP or Bankhart tear
In chronic injuries the position that hurts during activity is important to ascertain

16. Assessment of the shoulder
Active + passive movements:
Flexion
External rotation: arms by side and 90° abduction
Internal rotation
Horizontal flexion
Resisted movements:
External rotation
Subscapularis lift off test
Deltoid
Supraspinatus- ‘Empty can test’-scaption & internal rotation
Biceps- ‘Speed’s test- supination through range

17. Special tests AC joint Impingement: Instability:
Compression
‘Scarf test’: horizontal flexion
Impingement:
Neer’s: Full flexion EOR
Hawkin’s and Kennedy’s: flex to 90° and internally rotate
Instability:
Load and shift test: sitting, distract and move anteriorly and posteriorly
Aprehension test: supine abduct and externally rotate shoulder, posterior translation of the shoulder relieves dislocation apprehension, anterior translation exacerbates it
SLAP test: O’Brien’s test- pronation resisted

18. Impingement
The theory is that the impingement occurs when the rotator cuff tendons are impinged as they pass through the subacromial space
(the space formed between the acromion, coracoacromial arch and AC joint and the glenohumeral joint below)
The impingement causes mechanical irritation of the rotator cuff tendons and may result in swelling and damage to the tendons

19. Diagnoses associated with rotator cuff impingement
Subacromial bone spurs and/ or bursal hypertrophy
AC joint arthrosis and/ or bone spurs
Rotator cuff disease
Superior labral injury
Glenohumeral internal rotation deficit (GIRD)
Glenohumeral instability
Biceps tendinopathy
Scapular dyskinesis
Cervical radiculopathy

20. Types of impingement Primary external impingement:
Encroachment of the space due to acromion shape, either congenital or due to spurs
Secondary external impingement:
Due to inadequate muscular stabilisation of the scapula or weakness of the rotator cuff muscles creating a muscle imbalance
Internal impingement
Impingement of the RC occurs against the posterior-superior surface of the glenoid, eventually causes damage to the labrum

21. Rotator cuff injuries Common Rotator cuff tendon becomes swollen
Pain with overhead activities
Often associated instability... Symptoms of recurrent subluxations and ‘dead arms’
Painful arc between 70°-120°
MRI is assessment tool of choice
Patients respond well to physiotherapy: must correct the imbalances causing the injury
One single corticosteroid subacromial injection also shows good evidence of efficacy if in conjunction with rehabilitation
Calcific tendinopathy can occur (idiopathic), seen on X-ray/ ultrasound

22. Glenoid Labrum tears
Superior aspect of the glenoid labrum is the attachment site for the tendon of the long head of biceps (LHB)
Injuries to the labrum are
SLAP: extend from anterior to the biceps tendon to posterior to the tendon. There are 4 types of SLAP lesions.
SLAP tears are stable or unstable depending on how much of the biceps tendon is attached to the glenoid margin
Non-SLAP lesions include degenerative, flap, vertical labral tears and unstable Bankart lesions.

23. SLAP tears Repetitive throwing overhead Fall on outstretched arm
Pain is poorly localized, worse with overhead activities
Popping, grinding, catching are often present
Biceps is often tender on palpation and on testing
MR arthrography is the test of choice
All unstable labral tears require surgery

24. Dislocation of the GH joint
Anterior dislocation due to excessive abduction/ external rotation
Most result in a bony Bankart lesion or a Hill-Sach’s lesion (fracture of the humeral head posteriorly)
Acute trauma is always the cause
Most have a sensation of ‘popping out’
Dislocated shoulders should be X-rayed prior to reduction if possible as a fracture can be present
The arm should not be put in a sling, but needs resting at night in external rotation
Surgical results are good with only 10% re-dislocation, whereas non-surgical patients have very high re-dislocation rates

25. Shoulder instability Common in people with general laxity
Anterior instability: mainly post-traumatic but can also be with capsular laxity
Pain is usually due to RC tendon impingement
X-ray should be done to exclude any fracture associated with instability.
Posterior instability is normally associated with multidirectional instability

26. Adhesive Capsulitis Usually between 40-60 years of age
More commonly the left??
More prevalent in women
More common in diabetics, thyroid disorders and users of matrix degradation inhibitors
Shoulder becomes stiff in the ‘capsular pattern’ of limitation of abduction < external rotation <internal rotation
Post-surgical stiffness usually resolves in a year
Idiopathic Adhesive capsulitis normally resolves within 2.5 years
Surgical interventions are not very successful, steroid injections give some patients relief (particularly if done under X-ray, into the joint), physiotherapy helps some patients, and although range of movement is temporarily restored, an MUA often has a poor outcome.

27. Clavicle fractures
Most common fracture seen in sport... Usually a fall onto the point of the shoulder or direct contact.
Usually fractures in its middle 1/3rd with the outer fragment displacing inferiorly and the medial fragment superiorly
Very painful!
Localized tenderness
Swelling
Bony deformity
Principle treatment is pain relief, figure of 8 bandage can be used. During the first 4-6 weeks shoulder flexion is restricted to 90°
Distal clavicular fractures must be referred for an orthopaedic consult for assessment and management

28. AC joint injuries
Usually results from a fall onto the point of the shoulder
Grading system of injuries is I-VI
Surgery is suggested for Grade IV-IV and Grade III’s that fail conservative treatment (Grade III onwards presents with increasing amount of deformity and should be referred for an orthopaedic consult.
AC joint injuries are easy to diagnose with a diagnostic LA

29. Chronic AC joint pain
Repeated minor injuries to the joint after a previous AC injury which aggravates the already damaged meniscus of the AC joint
Osteolysis can be seen at the edge of the AC joint
X-ray shows marked osteoporosis
Physio, corticosteroid injections
and in some cases surgery is needed.

30. Referred pain Cx and Tx spine refer to the shoulder
Also, a sore shoulder can refer to the scapula and upper trapezius area.
Trigger points in the neck and scapula muscles have active referral areas to the shoulder
Adverse neural tension/ restricted neural dynamics can have a major part to play in shoulder pain

31. Don’t miss Ruptured LHB Pec Major tear Nerve entrapments:
Suprascapular nerve: C5,6- wasting of infraspinatus, supraspinatus, vague deep ache
Long thoracic nerve palsy: C5,6,7- serratus anterior palsy. This is the backpack injury!

32. Books to stand you in good stead
Clinical Sports Medicine 4th edition: Brukner & Khan
Orthopaedic Physical Assessment 5th edition: David J Magee