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Chapter 22: The Shoulder Complex. Jennifer Doherty-Restrepo, MS, LAT, ATC Academic Program Director, Entry-Level ATEP Florida International University Acute Care and Injury Prevention. Introduction. The shoulder is an extremely complicated region of the body

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Chapter 22: The Shoulder Complex

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chapter 22 the shoulder complex

Chapter 22: The Shoulder Complex

Jennifer Doherty-Restrepo, MS, LAT, ATC

Academic Program Director, Entry-Level ATEP

Florida International University

Acute Care and Injury Prevention

  • The shoulder is an extremely complicated region of the body
  • Joint with a high degree of mobility, but, not without compromising stability
  • Involved in a variety of overhead activities relative to sport
  • Susceptible to a number of repetitive and overused type injuries
functional anatomy
Functional Anatomy
  • Great mobility, limited stability
    • Round humeral head articulates with flat glenoid
    • Rotator cuff and long head of the biceps provide dynamic stability during overhead motion
      • Supraspinatus compresses the humeral head
      • Other rotator cuff muscles depress the humeral head Integration of the capsule and rotator cuff
    • Scapula stabilizing muscles also provide dynamic stability
      • Relationship with the other joints of the shoulder complex and the G-H joint is critical
functional anatomy11
Functional Anatomy
  • Scapulohumeral Rhythm
    • Movement of scapula relative to the humerus
    • Initial 30 degrees of G-H abduction
      • Does not incorporate scapular motion
      • Setting phase
    • 30 to 90 degrees of G-H abduction
      • Scapula abducts and upwardly rotates 1 degree for every 2 degrees of humeral elevation
    • Above 90 degrees of G-H abduction
      • Scapula and humerus move in 1:1 ratio
prevention of shoulder injuries
Prevention of Shoulder Injuries
  • Proper physical conditioning is key
  • Sport-specific conditioning
  • Strengthen through a full ROM
  • Warm-up should be used before explosive arm movements are attempted
  • Contact and collision sport athletes should receive proper instruction on falling
  • Protective equipment
  • Proper mechanics
assessment of the shoulder
Assessment of the Shoulder
  • 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?
assessment of the shoulder15

Elevation or depression of shoulder tips

Position and shape of clavicle

Position of head and arms

Acromion process

Biceps and deltoid symmetry

Postural assessment (kyphosis, lordosis, shoulder)

Scapular elevation and symmetry

Scapular protraction or winging

Muscle symmetry

Scapulohumeral rhythm

Assessment of the Shoulder
palpation bony tissue
Spine of scapula

Scapular vertebral border

Scapular lateral border

Scapular superior angle

Scapular inferior angle

Palpation: Bony Tissue
  • Sternoclavicular joint
  • Clavicular shaft
  • Acromioclavicular joint
  • Coracoid process
  • Acromion process
  • Humeral head
  • Greater and lesser tuberosity
  • Bicipital groove
palpation soft tissue
Sternoclavicular, acromioclavicular, and coracoclavicular ligaments

Rotator cuff muscles and tendons

Subacromial bursa


Biceps and tendon

Coracoacromial ligament

Glenohumeral joint capsule



Latissimus dorsi

Serratus Anterior

Levator scapulae




Teres major and minor

Palpation: Soft Tissue
special tests
Special Tests
  • Active, Passive, and Resistive ROM
    • Flexion and extension
    • Abduction and adduction
    • Internal and external rotation
  • Manual Muscle Testing
    • Shoulder muscles and scapular stabilizers
    • RROM and Break tests
special tests sc joint instability
Special Tests: SC Joint Instability
  • Assesses sternoclavicular joint instability
  • Athlete in seated position
  • Apply pressure to the SC joint anteriorly, superiorly, and inferiorly
  • Determine stability or pain associated with a joint sprain
special tests ac joint instability
Special Tests: AC Joint Instability
  • Assesses acromioclavicular joint instability
  • Athlete in seated position
  • Palpate for displacement of acromion and distal head of clavicle
    • Apply pressure in all 4 directions
  • Determine stability or pain associated with a joint sprain
special tests gh joint instability
Special Tests: GH Joint Instability
  • Assesses glenohumeral joint instability
  • Special tests
    • Anterior and Posterior Drawer Tests
    • Sulcus Test
    • Clunk Test
    • Anterior and Posterior Apprehension Tests
    • Relocation Test
anterior and posterior apprehension tests
Anterior and Posterior Apprehension Tests
  • Anterior Apprehension Test
  • Posterior Apprehension Test
relocation test
Relocation Test
  • Uses external rotation and posteriorly directed pressure to allow for increased external rotation
special tests impingement
Special Tests: Impingement
  • O’Brien Test (Active Compression Test)
    • Flexion of GH joint to 90 degrees and horizontally adduction to 15 degrees
    • Passively place humerus into full IR and ER
    • If pain results with internal rotation but decreases with external rotation and if clicking is present, possible SLAP lesion
    • Pain in AC joint may indicate AC joint pathology
special tests impingement28
Special Tests: Impingement
  • Neer’s Test
  • Assesses impingement of soft tissue structures
  • Positive test is indicated by pain and grimace
special tests impingement29
Special Tests: Impingement
  • Hawkins-Kennedy Test
  • Assesses impingement of soft tissue structures
  • Positive test is indicated by pain and grimace
special tests rotator cuff
Special Tests: Rotator Cuff
  • Drop Arm Test
    • Assesses supraspinatus muscle weakness or tears
    • Athlete abducts shoulder and gradually lowers to starting position
    • Inability to lower arm slowly and controlled will indicate torn supraspinatus
special tests rotator cuff31
Special Tests: Rotator Cuff
  • Empty Can Test
    • Place shoulder in position of 90 degrees of shoulder flexion, IR, and 30 degrees of horizontal abduction
    • Apply downward pressure
    • Assesses supraspinatus muscle weakness or tears
special tests serratus anterior
Special Tests: Serratus Anterior
  • Wall Push-up
  • Observe for winging scapula
  • Assesses for serratus anterior weakness
  • Could indicate injury to long thoracic nerve
special tests biceps
Special Tests: Biceps
  • Yergason’s Test
    • Determines presence of biceps irritation and possible subluxation of biceps tendon
  • Speed’s Test
    • Determines presence of biceps irritation and possible subluxation of biceps tendon
  • Ludington’s Test
    • Assesses for possible rupture of biceps
    • Palpate alternating contractions of each biceps
special tests thoracic outlet syndrome
Special Tests: Thoracic Outlet Syndrome
  • Adson’s Test
    • Assesses for anterior scalene syndrome
    • Compression of subclavian artery by scalenes
    • Athlete looks toward extended arm and takes a deep breath
    • Palpate radial pulse
    • Disappearance of pulse indicates a positive test
special tests thoracic outlet syndrome35
Special Tests: Thoracic Outlet Syndrome
  • Roo’s Test
    • Assesses for costoclavicular syndrome
    • Compression of subclavian artery between clavicle and first rib
    • Athlete assumes military brace position and turns head in opposite direction
    • Athlete opens and closes hand for 3 minutes Palpate radial pulse
    • Test is positive if…
      • Pulse disappears
      • Grip strength decreases
special tests thoracic outlet syndrome36
Special Tests: Thoracic Outlet Syndrome
  • Allen’s Test
  • Assesses for hyperabduction syndrome
  • Determines if pressure from pectoralis minor is compressing brachial plexus and subclavian artery
specific injuries
Specific Injuries
  • Clavicular Fractures
    • Etiology
      • MOI = fall on outstretched arm, fall on tip of shoulder, or direct impact
      • Occurs primarily in middle third
    • Signs and Symptoms
      • Athlete supports arm, head tilted towards injured side with chin turned away
      • Clavicle may appear lower
      • Palpation reveals pain, swelling, deformity, and point tenderness
Clavicular Fractures (continued)
    • Management
      • Closed reduction - sling and swathe immediately
      • Refer for X-ray
      • Immobilize with brace for 6-8 weeks
      • After removal of brace, rehabilitation includes:
        • Joint mobilizations
        • Isometric exercises
        • Use of a sling for 3-4 weeks
      • May require surgical treatment
specific injuries40
Specific Injuries
  • Scapular Fractures
    • Etiology
      • MOI = direct impact or force transmitted up through humerus
    • Signs and Symptoms
      • Pain during shoulder movement
      • Swelling and point tenderness
    • Management
      • Sling immediately and refer for X-ray
      • Use sling for 3 weeks then begin PRE exercises
specific injuries41
Specific Injuries
  • Fractures of the Humerus
    • Etiology
      • MOI = direct impact, force transmitted up through humerus, or fall on outstretched arm
      • Proximal fractures occur due to direct blow
      • Dislocations occur due to fall on outstretched arm
      • Epiphyseal fractures are more common in young athletes and occur due to direct blow or indirect blow traveling along long axis of humerus
specific injuries42
Specific Injuries
  • Fractures of the Humerus (continued)
    • Signs and Symptoms
      • Pain, swelling, point tenderness, decreased ROM
    • Management
      • Immediate application of splint
      • Refer for X-ray
      • Treat for shock
specific injuries43
Specific Injuries
  • Sternoclavicular Sprain
    • Etiology
      • MOI = indirect force or blunt trauma
    • Signs and Symptoms
      • Grade 1 - pain and slight disability
      • Grade 2 - pain, subluxation deformity, swelling, point tenderness, and decreased ROM
      • Grade 3 - gross deformity (dislocation), pain, swelling, and decreased ROM
        • Possibly life-threatening if dislocates posteriorly
specific injuries44
Specific Injuries
  • Sternoclavicular Sprain (continued)
    • Management
      • RICE
      • Refer for reduction if necessary
      • Immobilize for 3-5 weeks
      • After immobilzation period, begin PRE exercises
specific injuries45
Specific Injuries
  • Acromioclavicular Sprain
    • Etiology
      • MOI = direct blow (from any direction) or upward force from the humerus
      • Graded from 1 - 6 according to severity of injury
    • Signs and Symptoms
      • Grade 1 - point tenderness, pain with movement
        • No disruption of AC joint
      • Grade 2 - tear or rupture of AC ligament, pain, point tenderness, and decreased ROM (abd/add)
        • Partial displacement of lateral end of clavicle
Acromioclavicular Sprain (continued)
    • Signs and Symptoms
      • Grade 3 - rupture of AC and CC ligaments
        • AC joint separation
      • Grade 4 - posterior dislocation of clavicle
      • Grade 5 – rupture of AC and CC ligaments, tearing of deltoid and trapezius attachments, gross deformity, severe pain, decreased ROM
      • Grade 6 - displacement of clavicle behind the coracobrachialis
Acromioclavicular Sprain (continued)
    • Management
      • Ice, sling and swathe
      • Referral to physician
      • Grades 1 – 3: non-operative treatment
        • 1 - 2 weeks of immobilization
      • Grades 4 – 6: surgery required
      • Aggressive rehab is required for all AC sprains
        • Joint mobilizations, flexibility exercises, and PRE exercises should occur immediately
        • Progress as tolerated – no pain and no additional swelling
        • Padding and protection may be required until pain-free ROM returns
A: Grade 1
  • B: Grade 2
  • C: Grade 3
  • D: Grade 4
  • E: Grade 5
  • F: Grade 6
specific injuries49
Specific Injuries
  • Glenohumeral Joint Sprain
    • Etiology
      • MOI = forced abduction and/or external rotation; or a direct blow
    • Signs and Symptoms
      • Pain during movement
        • Especially when re-creating the MOI
      • Decreased ROM
      • Point tenderness
specific injuries50
Specific Injuries
  • Glenohumeral Joint Sprain (continued)
    • Management
      • RICE for 24-48 hours
      • Sling
      • After hemorrhaging subsides, modalities may be utilized along with PROM and AROM exercises to regain full ROM
      • When full ROM achieved without pain, PRE exercises can be initiated
      • Must be aware of potential development of chronic conditions (instability)
specific injuries51
Specific Injuries
  • Acute Subluxations and Dislocations
    • Etiology
      • Subluxation = excessive translation of humeral head without complete separation from joint
      • Anterior dislocation = results from an anterior force on the shoulder with forced ABD and ER
      • Posterior dislocation = results from forced ADD and IR, or, falling on an extended and internally rotated shoulder
specific injuries52
Specific Injuries
  • Acute Subluxations and Dislocations (continued)
    • Signs and Symptoms
      • Anterior dislocation - flattened deltoid; prominent humeral head in axilla; arm carried in slight ABD and ER rotation; moderate pain and disability
      • Posterior dislocation - severe pain and disability; arm carried in ADD and IR; prominent acromion and coracoid process; limited ER and elevation
Acute Subluxations and Dislocations (continued)
    • Management
      • Sling and swathe and refer for reduction
      • Immobilize for 3 weeks following reduction
      • Perform isometrics while in sling
      • After immobilization period, begin PRE exercises as pain allows
      • Protective bracing when return to play
possible complications of shoulder dislocations
Possible Complications of Shoulder Dislocations
  • Bankart lesion
    • Permanent anterior defect of labrum
  • Hill Sachs lesion
    • Caused by compression of cancellous bone against anterior glenoid rim creating a divot in the humeral head
  • SLAP lesion
    • Defect in superior labrum that begins posteriorly and extends anteriorly impacting attachment of long head of biceps on labrum
Brachial nerves and vessels may be compromised
  • Rotator cuff injuries
  • Fractures
  • Bicipital tendon subluxation
  • Transverse ligament rupture
specific injuries56
Specific Injuries
  • Chronic Recurrent Instabilities
    • Etiology
      • MOI = traumatic, microtraumatic (repetitive overuse), atraumatic, congenital, and neuromuscular
      • As supporting tissue become more lax, mobility increases
      • Results in damage to other soft tissue structures
specific injuries57
Specific Injuries
  • Chronic Recurrent Instabilities (continued)
    • Signs and Symptoms
      • Anterior - may have clicking or pain; complain of dead arm during cocking phase (when throwing); pain posteriorly; possible impingement; positive apprehension test
      • Posterior - possible impingement; loss IR; crepitation; increased laxity; pain anteriorly and posteriorly
      • Multidirectional - inferior laxity; positive sulcus sign; pain and clicking with arm at side; possible signs and symptoms associated with anterior and posterior instability
Chronic Recurrent Instabilities (continued)
    • Management
      • Conservative treatment involves extensive strengthening of the rotator cuff and scapula stabilizers
        • Should be pursued before surgery is considered
      • Avoid joint mobilizations and ROM exercises
        • Various braces can be used to limit motion
      • Surgical stabilization may be required to improve function and comfort
specific injuries59
Specific Injuries
  • Shoulder Impingement Syndrome
    • Etiology
      • Mechanical compression of supraspinatus tendon, subacromial bursa, and long head of biceps tendon due to decreased space under coracoacromial arch
      • MOI = overhead repetitive activities
      • Exacerbating factors
        • Laxity and inflammation
        • Postural mal-alignments
          • Kyphosis and/or rounded shoulders
Shoulder Impingement Syndrome (continued)
    • Signs and Symptoms
      • Diffuse pain
      • Increased pain with palpation of subacromial space
      • Decreased strength of external rotators compared to internal rotators
      • Tightness in posterior and inferior capsule
      • Positive impingement and empty can tests
neer s progressive stages of shoulder impingement
Neer’s progressive stages of shoulder impingement…
  • Stage I
    • Result of supraspinatus or biceps tendon injury
    • Presents with point tenderness; pain with ABD and resisted supination with external rotation; edema; thickening of rotator cuff and bursa
    • Occurs in athletes < 25 years old
neer s progressive stages of shoulder impingement63
Neer’s progressive stages of shoulder impingement…
  • Stage II
    • Permanent thickening and fibrosis of supraspinatus and biceps tendon
    • Presents with aching during activity that worsens at night
    • May experience restricted arm motion
neer s progressive stages of shoulder impingement64
Neer’s progressive stages of shoulder impingement…
  • Stage III
    • History of shoulder problems and pain
    • Tendon defect (less than 3/8 of an inch) or possible muscle tear
    • Permanent scar tissue and thickening of rotator cuff
    • Occurs in athletes 25 - 40 years old
neer s progressive stages of shoulder impingement65
Neer’s progressive stages of shoulder impingement…
  • Stage IV
    • Infraspinatus and supraspinatus atrophy
    • Presents with pain during ABD, limited AROM and PROM, weak RROM
    • Tendon defect (greater than 3/8 of an inch)
    • Clavicle degeneration
specific injuries66
Specific Injuries
  • Rotator cuff tear
    • Etiology
      • Occurs near insertion on greater tuberosity
      • Involve supraspinatus or rupture of other rotator cuff tendons
      • Partial or complete thickness tear
        • Full thickness tears usually occur in athletes with a long history of rotator cuff pathology
        • Generally does not occur in athlete under age 40
      • MOI = acute trauma or impingement
    • Signs and Symptoms
      • Pain and weakness with shoulder ABD and IR
      • Point tenderness
Rotator cuff tear (continued)
    • Management
      • NSAID’s and analgesics
      • Modalities
        • Electrical stimulation for pain
        • Ultrasound for inflammation
      • Restore appropriate mechanics by strengthening rotator cuff to depress and compress humeral head to restore subacromial space
      • Severe cases may require rest, immobilization, and surgery
specific injuries68
Specific Injuries
  • Shoulder Bursitis
    • Etiology
      • Chronic inflammatory condition resulting from fibrosis or fluid build-up
      • MOI = direct trauma or overuse
      • Usually occurs in the subacromial bursa
    • Signs and Symptoms
      • Pain with motion, pain during palpation of subacromial space
      • Positive impingement tests
Shoulder Bursitis
    • Management
      • Reduce inflammation
        • Cold, ultrasound, NSAID’s
      • Remove mechanisms precipitating condition
      • Maintain full ROM to reduce the risk of contractures and adhesions forming
specific injuries70
Specific Injuries
  • Frozen Shoulder (Adhesive Capsulitis)
    • Etiology
      • Contracted and thickened joint capsule with little synovial fluid
      • Chronic inflammation resulting in contracted, inelastic rotator cuff muscles
    • Signs and Symptoms
      • Pain in all directions both with AROM and PROM
      • Patient resists moving the shoulder due to pain
specific injuries71
Specific Injuries
  • Frozen Shoulder (continued)
    • Management
      • Aggressive joint mobilizations
      • Stretching of tight musculature
      • Electrical stimulation for pain control
      • Ultrasound for deep heating
specific injuries72
Specific Injuries
  • Thoracic Outlet Compression
    • Etiology
      • Compression of brachial plexus, subclavian artery and vein
      • Due to
        • 1) decreased space between clavicle and first rib,
        • 2) scalene compression,
        • 3) compression by pectoralis minor, or
        • 4) presence of cervical rib
Thoracic Outlet Compression (continued)
    • Signs and Symptoms
      • Paresthesia, pain, sensation of cold, impaired circulation, muscle weakness, muscle atrophy, and radial nerve palsy
      • Positive anterior scalene test, costoclavicular test, and hyperabduction test
    • Management
      • Conservative treatment - correct anatomical condition through stretching (pec minor and scalenes) and strengthening (trapezius, rhomboids, serratus anterior, erector spinae)
specific injuries74
Specific Injuries
  • Biceps Brachii Rupture
    • Etiology
      • Generally occurs near origin of muscle at bicipital groove
      • MOI = powerful contraction
Biceps Brachii Rupture (continued)
    • Signs and Symptoms
      • Audible snap with sudden and intense pain
      • Protruding bulge may appear near middle of biceps
      • Weakness with elbow flexion and supination
    • Management
      • Ice for hemorrhaging
      • Immobilize with a sling and refer to physician
      • Athletes will require surgery
specific injuries76
Specific Injuries
  • Bicipital Tenosynovitis
    • Etiology
      • Ballistic activity involves repeated stretching of biceps tendon causing irritation to the tendon and sheath
      • MOI = repetitive overhead activities
    • Signs and Symptoms
      • Point tenderness over bicipital groove
      • Swelling, crepitus due to inflammation
      • Pain when performing overhead activities
Bicipital Tenosynovitis (continued)
    • Management
      • Rest, ice, and ultrasound to treat inflammation
      • NSAID’s
      • Gradual program of strengthening and stretching
specific injuries78
Specific Injuries
  • Contusion of Upper Arm
    • Etiology
      • MOI = Direct blow
    • Signs and Symptoms
      • Transitory paralysis and decreased ROM
    • Management
      • RICE for at least 24 hours
      • Provide protection to prevent repeated episodes that could cause myositis ossificans
      • Maintain ROM
specific injuries79
Specific Injuries
  • Peripheral Nerve Injuries
    • Etiology
      • MOI = blunt trauma or overstretching-type injuries
    • Signs and Symptoms
      • Constant pain, muscle weakness, paralysis, or atrophy
    • Management
      • RICE
      • Transient muscle weakness may occur
      • If muscle atrophy occurs, referral to a physician is necessary
rehabilitation of the shoulder
Rehabilitation of the Shoulder
  • Immobilization
    • Will vary depending on injury
    • Time in brace or splint are injury specific
    • Isometrics can be performed
    • ROM and strengthening are dictated by healing
  • General Body Conditioning
    • Maintain cardiovascular endurance through cycling, running, and walking
rehabilitation of the shoulder81
Rehabilitation of the Shoulder
  • Joint Mobilizations
    • Used to re-establish appropriate joint arthrokinematics
    • Used if joint capsule tightness is present
rehabilitation of the shoulder82
Rehabilitation of the Shoulder
  • Flexibility
    • Codman’s pendulum exercises should begin early
    • Progress to Active Assisted ROM in pain free range
      • Cardinal planes
rehabilitation of the shoulder84
Rehabilitation of the Shoulder
  • Strengthening Exercises
    • Should include rotator cuff and scapula stabilizers
rehabilitation of the shoulder86
Rehabilitation of the Shoulder
  • Neuromuscular Control
    • Must regain appropriate firing sequence for specific muscles (scapulohumeral rhythm)
    • Biofeedback can be used to regain control
    • Proprioception
    • Closed kinetic chain exercises will be required in gymnasts, wrestlers, and weight lifters
      • Emphasize co-contraction muscle activity
rehabilitation of the shoulder88
Rehabilitation of the Shoulder
  • Functional Progressions
    • Incorporation of sports specific skills
    • Strengthening that involves PNF patterns
      • Throwing motion
  • Return to Activity
    • Based on pre-established criteria
    • Functional performance testing
    • Objective measures of strength and performance