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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

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 anatomy1
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
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 injuries1
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 injuries2
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 injuries3
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 injuries4
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 injuries5
Specific Injuries
  • Sternoclavicular Sprain (continued)
    • Management
      • RICE
      • Refer for reduction if necessary
      • Immobilize for 3-5 weeks
      • After immobilization period, begin PRE exercises
specific injuries6
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 injuries7
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 injuries8
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 injuries9
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 injuries10
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
  • Brachial nerves and vessels may be compromised
  • Rotator cuff injuries
  • Fractures
  • Bicipital tendon subluxation
  • Transverse ligament rupture
specific injuries11
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 injuries12
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 injuries13
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 impingement1
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 impingement2
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 impingement3
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 injuries14
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 injuries15
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 injuries16
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 injuries17
Specific Injuries
  • Frozen Shoulder (continued)
    • Management
      • Aggressive joint mobilizations
      • Stretching of tight musculature
      • Electrical stimulation for pain control
      • Ultrasound for deep heating
specific injuries18
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 injuries19
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 injuries20
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 injuries21
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 injuries22
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