shoulder assessment. bony palpations shoulder complex

SHOULDER ASSESSMENT

BONY PALPATIONS

Shoulder Complex

Scapulothoracic Articulation

Not a true anatomical joint

Resting position of scapula is:

Superior angle is level with spinous process T2

Inferior angle level with spinous process T7

Medial border of scapula is 5-6 cm or three fingers width from spinous processes

SHOULDER LIGAMENTS

STERNOCLAVICULAR LIGAMENTS

Motions @ Sternoclavicular Joint

SC Joint acts like ball and socket joint

Motions at joint: Elevation- Depression Rotation : upward-downward Rotation: forward-downward;

backward-upward

AC Joint Characteristics Synovial joint

Keeps glenoid fossa continually facing the humeral head

Articular disc between acromion and distal clavicular head

Capsule – lax to allow for complex shoulder motion

AC Joint Superior and

inferior acromioclavicular lig. Strengthen upper

aspect of joint Limits approx.

90% of anterior-posterior translation

Coracoclavicular Ligament .: Limits 80% of

superior translation of the clavicle- acts as a tie bar to hold clavicle down

Maintains a constant relationship of the scapula on the clavicle

Coracoacromial ligament Forms roof over humeral

head Prevents upward

displacement of humeral head and protects underlying structures

Sharp lateral edge may impinge on bursa and supraspinatus tendon

Superior Transverse Ligament

Bridges lesser scapular notch Provides a passage for suprascapular

nerve

Glenohumeral Joint Synovial Joint: humeral head articulates

with glenoid cavity Humeral head points medially,

backward and tilts upward Glenoid is ½ as long and 1/3 as wide as

the humeral head Contact area is limited Surface area of humeral head is 3-4

times larger than the fossa

Glenohumeral Capsule

GLENOHUMERAL AND CORACOHUMERAL LIGAMENTS

Coracohumeral Lig.- One of the most important ligament structures

1. Blends with rotator cuff, fills space b/t subscapularis and supraspinatus

MaintainsGH relationship

Involved with frozen shoulder

GLENOHUMERAL LIGAMENTS

Glenoid labrum Rim of cartilaginous

tissue attached around margin of glenoid fossa

Serves as attachment for ligaments

Deepens articular cavity

Increases glenoid contact with humeral head & serves “chock block” function

Glenoid Fossa with Rotator Cuff Muscles

Muscles of Shoulder

Shoulder Bursae 1. Subacromial or Subdeltoid

bursa 2. B/t coracoid &

glenohumeral Jt. Capsule 3. Summit of the acromion 4. B/t infraspinatus & joint

capsule 5. B/t teres major & long

head biceps 6. B/t subscapularis & Joint

capsule 7. Tendinous insertion of

latissimus dorsi 8. Behind the

coracobrachialis muscle

Blood Supply to Shoulder Complex

Blood Supply

Neurovascular Bundle

Brachial Plexus

Upper Extremity Dermatomes

Posterior Dermatomes

1st Phase Scapulohumeral Rhythm

Phase I:

Humerus: 30 degrees Abduction

Scapula: Minimal movement

Clavicle: 0-15 degree elevation

2nd Phase Scapulohumeral Rhythm

Phase II: Humerus: 40

degrees Abduction

Scapula:20 degree rotation

Clavicle: 30-36 degree elevation

3rd Phase Scapulohumeral Rhythm

Phase III: Humerus: 60 degrees

Abduction 90 degree lateral rotation

Scapula:30 degree rotation

Clavicle: 30-50 degree posterior rotation

up to 30 degree elevation

Biceps tendon mobility Biceps tendon

does not move in the bicipital groove during movement

Humeral head moves over the fixed tendon

Shoulder Patterns: Closed packed position= 90

degrees abduction and external rotation

Open packed position= arm down by side up to 20-25 degrees abduction

Clavicle Fractures Most common Fx. Results :

Fall on out stretched arm

Fall on tip of shoulder Direct impact

Occurs most often in junction of middle and outer thirds of clavicle

X-ray of Clavicle Fracture

Signs and Symptoms of Clavicle Fractures Athlete supporting arm held in

tight to body with head tilted toward injury

On inspection , injured clavicle appears slightly lower than unaffected side

Palpation reveals swelling, point tenderness, mild deformity

Management of Fx. Clavicle Apply a sling and swathe bandage or

figure 8 harness Obtain x-rays Nearly all are treated with closed

reduction Keep immobilized for 6-8 weeks Open reduction:

Vascular complications, displaced epiphysis in skeletally immatue pt., Fx. Ends threaten skin, near AC joint

Scapular Fractures

Rare in sports Cause: direct contact

with force directed through humerus to scapula

Locations: body, glenoid, acromion, coracoid

X-ray Fracture of Scapula Body

Signs and Symptoms of Scapular Fractures Pain and tenderness around back of the

shoulder Athlete typically holds arm securely at

the side and avoids any attempt to move humerus

Diagnostic Test: X-ray

Treatment: Nonoperative Treatment: Sling and early ROM with in 1 week

Fractures of Proximal Humeral

Cause: direct blow, a dislocation or the impact received from FOOSH injury

Can be mistaken for shoulder dislocation

Can occur at anatomical neck, tuberosity or surgical neck

Most occur at surgical neck

Humeral Shaft Fractures

Humeral Shaft Fractures Cause: direct blow or Foosh Injury Type: comminuted or transverse fractures Signs & Symptoms: Severe pain, swelling,

deformity Complication: radial nerve involvement- loss

of wrist and finger extension and sensation over the back of dorsal surface- within 6 months radial nerve should be fine

Treatment: Nonoperative- x-ray views followed by splints and pressure wrap and casting with sling for 1st week

Sternoclavicular Sprains & Dislocations

Relatively uncommon in sports

Cause: indirect force transmitted through the humerus and down shaft of clavicle

Medial end of clavicle can be displaced upward and forward or slightly anteriorly

Sternoclavicular Sprains and Dislocations

3 Classification of Injury: 1st Degree: little pain or disability, pt.

Tenderness, no jt. Deformity 2nd Degree: displays subluxation of SCJ with visible

deformity, pain, swelling, pt. Tenderness, inability to abduct the shoulder FROM or horizontally abduct arm = ligamentous instability

3rd Degree: Complete Dislocation with gross displacement of clavicle at sternal junction, swelling, loss of function= rupture SCL and Costoclavicular Lig

Danger: Posterior Dislocation – pressure placed on blood vessels, esophagus and or trachea causing life- or death situation

Management of Sternoclavicular Sprains and Dislocations

Treatment: RICE, immobilization, emergency care for breathing

X-ray Physician reduction Immobilization 3-6

weeks Recurrence is very

high in these injuries

Acromioclavicular Sprain/Separation

Commonly caused by falling directly onto the tip of acromion

Common in hockey, rugby, football, equestrian accidents and martial arts

Injuries are classified into 6 types based on the severity of injury and degree of clavicular separation

AC Pathology

AC Separation

Acromioclavicular Treatment 1st and 2nd degrees are treated

conservatively with ice & ROM exercise and immobilization

3rd – 6th – could require operative intervention in cases where intra-articular disc is damaged and or interarticular fx occur

Operative : place a k-wire around clavicle to hold it down – 12 weeks post surgery rehab and immobilization

AC Joint Harness

Glenohumeral Dislocations Most common are anterior displaced

with arm abducted and externally rotated

Capsule can remain in tact or be severely damaged as head of humerus in forced out ot glenoid fossa in anterior inferior direction

Secondary labrum injuries – Bankhart Lesion and /or Hill-Sachs Lesions

Glenohumeral Dislocation

Anterior Glenohumeral Dislocation

Signs & Symptoms: Flattened Deltoid

contour Palpation of axilla

reveals prominence of humeral head

Athlete carries affected arm in slight abduction and external rotation

Severe Pain with initial dislocation

Tingling and numbness extends down the arm into hand

Bankhart Lesion

X-Ray finding of Bankhart Lesions

Hill-Sachs Lesion

Small articular Cartilage defect on the humeral head caused by the impact of humeral head on the glenoid fossa as the humerus dislocates

Hill-Sachs Lesion

Anterior Dislocation Reduction

Posterior Glenohumeral Dislocation

Fairly rare and only account for 1-4 % of all shoulder dislocations

Mechanism of injury: a forced adduction and internal rotation of the shoulder usually directed to anterior compartment or a fall on an extended and internally rotated arm

Signs & Symptoms: severe pain and disability – Arm is fixed in adduction and internal rotation, deltoid muscle is flattened, acromion and coracoid processes are more prominent than normal and the head of the humerus may be posterior. Head is usually dislodged in the posterior rotator cuff musculature

Usually reduced spontaneously

Posterior Dislocation Management

Same as with Anterior Dislocations

Recurrent Dislocations and Subluxations Cause capsule to stretch out allowing

for multiple reoccurrences Athlete complains of arm feeling like it

is “Going Dead”- commonly referred to as Dead Arm Syndrome

These need to be repaired with Bristow Repair or Bankhart procedure to prevent Multidirectional shoulder instability (MSI)

Subacromion Bursitis

Shoulder Subacromion Bursitis Typically an overuse syndrome Occurs most often to subacromion

bursa Occurs to as: Swimmer, baseball,

and tennis players MOI: same as impingement , not

isolated but a multifaceted problem accompany impingement, rotator cuff problems

Signs and Symptoms:

Unable to move shoulder in abduction, rotation

Muscle atrophy occurring due to disuse Can be sudden or insidious onset Inability to sleep at night Point tenderness on the anterior and lateral

edges of the acromion process Painful arch between 70-120 degrees Assessment: Pain on passive and active

motion in the same direction

Management of Bursitis

RICE immediately Deep heat with ultrasound and/or hot

packs NSAIDs and activity modification Injections but must be compliant for 2

weeks Avoid Frozen shoulder

Neurovascular Bundle

Thoracic Outlet Syndrome

Thoracic Outlet Syndrome

Signs and Symptoms: Parenthesis and pain in side or back of neck extending

across the shoulder down the medial are to the ulnar aspect of hand

Sensation of cold – caused by arterial involvement- usually symptoms occur very rapidly after exercise or activity using hand

Impaired circulation could lead to gangrene of the fingers

Weakness of muscle leading to decreased grip strength Muscle atrophy Radial nerve palsy

Orthopedic Test Used to Assess TOS

Adison’s Test- Test for costioclavicular encroachment

Allen’s Test- Stretch the scalenes

Military Press Test- Hyper abduction places pect minor on stretch

Roos’s Test- Combination

Management of TOS Conservative approach should be taken with

early and mild cases: works in 50%-80% of cases

Sling support and tension reduction Anti-inflammatory medication Exercise to strengthen trapezius, serratus

anterior, and erector muscles of the spine to counter act pull of pect minor

Postural correction- especially in cases of drooped or forward tilted shoulder: emphasize stretch the anterior muscles and strengthening posterior muscles

Brachial Plexus Injury Etiology: Transient

neurapraxia resulting from stretching or compression of the BP

Neurapraxia involves a disruption in normal function of a peripheral nerve without any degenerative changes

Common terms: stinger, burner, or pinched nerve

Brachial Plexus Injuries Mechanism of injury: neck is forced laterally to

the opposite side while the shoulder is depressed as occurs with a shoulder blocking football Or compresses the brachial plexus when the neck

extended , compressed and rotated toward the affected side

S&S: burning sensation, numbness, tingling and pain extending from shoulder down to the hand with some loss of function of arm and hand

Symptoms rarely last for more than several days Neck ROM is normal Repeated BP injuries may result in neuritis,

muscular atrophy and perm ant damage

Management of Brachial Plexus Injuries

Push the shoulder pads up off the shoulder

Ask athlete to move fingers and arm around to get sensation back – hold ice in hand

After symptoms have completely resolve , the athlete may return to full activity

Fit shoulder pads with a cervical roll to limit neck ROM during impact

Biceps Tendon Pathology

Bicipital Tendonitis: Occurs to long head

of Biceps as it lies in the tubular sheath in the bicipital groove

Causes: repetitive motion of the shoulder

Assess with: Speeds Test

Biceps Tendon Tendonitis

Subluxation of Biceps Tendon

Cause: Tear of Transverse Humeral Lig.

Test : Yeagerson’s Test

Rupture of Biceps Tendon

Signs & Symptoms of Rupture Biceps Tendon

Maybe indistinguishable from impingement syndrome

Pain n the glenohumeral joint itself Pain on active and resistive supination and

flexion of forearm No pain with passive ROM Most common ruptures : near or in bicipital

groove Orthopedic Test: Resistive and Active ROM Ludington Test

Glenoid Labrum Lesions Lesions occur with

shoulder dislocations and traumatic subluxation

Labrum can be detached from the glenoid rim: frank tear

Long head of biceps is typically involved in superior tear or SLAP lesions

2 Classic Types of Lesions SLAP = Superior Lesion Anterior to

Posterior – 10 – 2 o’clock

Bankhart Lesion – 4-6 o’clock on the rim of the labrum

4 Classifications of Lesions

Rotator Cuff Impingement Syndrome

Referred to as: Swimmer’s Shoulder, Thrower’s Shoulder, or Painful Arch Syndrome

Anatomy: impingement occurs to supraspinatus muscle at anterior edge of acromion and coracoacrominal ligament

Etiology : repeated use of arm aoe the horizontal plane causes a reductionof space for the supraspinatus muscle to pass under the acromion

Rotator Cuff Impingement

Causes of Rotator Cuff Impingement

1. Shape of the acromion

The contact pattern of the rotator cuff on the undersurface of the acromion

Contact can be determined by the shape of the acromion

Causes of Rotator Cuff Impingement

2. Instability of Glenohumeral Joint- if capsule is laxed or dynamic stabilizers are inadequate, the humeral head will displace excessive which can cause secondary impingement

Causes of Rotator Cuff Impingement 3. Scapular hypermobility: When

the scapula glides excessively laterally (protraction) during arm elevation causing the glenoid fossa to “open up” which may contribute to excessive movement of the humeral head anteriorly and superiorly – Inadequate scapular stability

Scapulohumeral Force Couple

Orthopedic Test to Assess RC Impingement

Kennedy-Hawkins Test Cross-Over Test Neer’s Test O’Brian Test

3 stages of RC Impingement

Stage I: Reversible Damage Injury to supraspinatus or Long head Biceps

Aching after activity Pt. tenderness high over supraspinatus at

greater tuberosity of humerus Pain with abduction = Painful arch Positive impingement sign

Biceps Tendon: Pt. tender over biceps tendon, pain at biceps tendon with straight arm flexion (Speed’s Test), pain resisted supination & ER

Stage II RC Impingement

Lesions are impossible to reverse, can take years

Fibrotic symptoms set in: Aching during activity , worse at night Some restricted ROM No obvious muscle defect Muscle fiber separation Permanent thicken of RC and Acromial bursa

Stage III RC Impingement Long history of shoulder problems Shoulder pain during activity with

increased pain at night Muscle defect of1cm or less Possible parrtial muscle tear Permanent thickening of rotator cuff and

subacromial bursa with scar tissue Complaint of weakness in everyday

endeavors

Stage IV RC Impingement Obvious infraspinous and supraspinous

strophy Complete tear of rotator cuff with severe to

minimal pain Tenderness over greater tuberosity, anterior

acromion, AC Jt. Very painful Arch Muscle defect greater than 1cm Limited active and full passive ROM Possible degeneration of clavicle Positive impingement sign

Treatment for RC Impingement

Stage I & II: Change mechanic of raising arm above

head= changing swimming stroke or throwing motion

Ice after workout and avoid heat Ultrasound Rest Steroid injection to decrease inflammation Stretch rotator cuff

Treatment Stage III Conservative Emphasis placed on ROM and

Strengthening external rotators

Stage III & IV Surgical Treatment

Anterior Acromoplasty: Involves resection the coracoacrominal ligament and shaving under surfaces of the acromion without disrupting the deltoid muscle

Rotator Cuff Tears Most common tears= supraspinatus Most often fails near its periphery , near

the attachment at greater tubeorsity – described as: Partial thickness tears – involves superficial

surface Full thickness tears – extends through the

articular surface to bursal surface

Rotator Cuff Tears Described as acute or

chronic and partial and full thickness

Classified by size of tear Can be torn is single

traumatic event or failure can occur over a longer period of time and present in an insidious manner

Overhead Athletes Generally have partial

articular –side tear Acute tears usually

found in athletes younger than 40 Commonly recall a single

traumtic event and present with shoulder pain, weakness, and a positive shrug sign (shrugging shoulder with an attempted abduction of the arm)

Older Athletes Tend to have

chronic, full thickness tears

Management of Rotator Cuff Tears

Arthroscopic evaluation necessary: Some have intact cuff with marked

thickened, inflammed , and fibrotic subacromial bursa – arthroscopic subacromial decompression is indicated

Partial RCT are debrided and the instability is corrected. Tears involving less than 50% of the tendon thickness can be debrided arthoscopically , while larger tear may require repair

Signs and Symptoms of Rotator Cuff Tears

Pain with shoulder elevation and abduction and external rotation

Night pain , inability to lay on shoulder Weakness, and diminished function Shoulder muscular atrophy

Orthopedic Test: Drop Arm I and II; Empty Can Test, Pain on Active motion in one direction and pain on passive ROM in opposite direction

Adhesive Capsulitis Referred to a “Frozen Shoulder” Exhibits a classical capsular pattern with loss

of active and passive ROM due to adhesions in the capsule

Glenohumeral joint capsule becomes inflammed , thickened, and excessively scarred with adhesion forming to humeral head

Common in 50-60 yr. old women Higher incidence in pt. with diabetes mellitus

Three Stages of Adhesive Capsulitis

Stage I= painful phase, gradual onset diffuse pain, worse at night, last 2-9 months

Stage II= Stiffening phase – last 4-12 months- significant loss of ROM especially overhead movements and reaching into back pocket

Stage III= Thawing phase- Gradual regaining of ROM

Orthopedic Test - None