The ShoulderUnit 16

Upper Extremity Injuries

Upper extremities are vulnerable to a variety of injuries depending on the sport, including:– Sprains– Strains– Dislocations– Fractures

Upper Extremity Injuries

Upper extremities are vulnerable to a variety of injuries depending on the sport, including:– Separations to the thoracic cage, shoulder,

arm, and hand– Repetitive motion injuries such as arthritis,

bursitis, tendonitis

Shoulder Complex Physiology

Bones Muscles Tendons Ligaments Articulations

Bones

Humerus Scapula Clavicle

THE JOINTS

Sternoclavicular joint (SC joint)– Sternoclavicular ligament

Coracoclavicular joint– Coracoclavicular ligament

Acromioclavicular joint (AC joint)– Acromioclavicular ligament

Coracoacromial joint– Coracoacromial ligament

Glenohumeral joint– Glenohumeral ligaments

Scapulothoracic articulation

Muscles in motion

FLEXION

Anterior deltoid– Primary mover

Biceps brachii– Secondary mover

EXTENSION

Posterior deltoid– Prim. Mover

Triceps brachii– Sec. Mover

ABDUCTION

Supraspinatus – 1st 5-10 degrees

Middle deltoid– Last 90 degrees

Trapezius– Assists in movement above 90 degrees

ADDUCTION Latissimus dorsi Pectoralis major

HORIZONTAL FLEXION Pectoralis major Anterior deltoid

HORIZONTAL EXTENSION Posterior deltoid Infraspinatus Teres minor/major Rhomboids Trapezius

– Stabilizer

CIRCUMDUCTION Basically all muscles of the shoulder

INTERNAL ROTATION Subscapularis Pectoralis major

– Little help

EXTERNAL ROTATION Infraspinatus Teres minor/major

Scapular Elevation Scapular Depression Scapular protraction Scapular retraction ****find muscles that perform these motions

Assessing Shoulder Injuries

H O P S

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?

Observation– Elevation or depression of shoulder tips– Position and shape of clavicle– Acromion process– Biceps and deltoid symmetry– Postural assessment (kyphosis, lordosis,

shoulders)– Position of head and arms– Scapular elevation and symmetry– Scapular protraction or winging– Muscle symmetry – Scapulohumeral rhythm

Palpation– Bony structure palpation should occur bilaterally

and simultaneously if possible– Palpate soft tissue structures for point

tenderness, swelling, spasms, lumps, guarding or trigger points

– Be sure to palpate anteriorly and posteriorly

Special Tests– ROM test for external rotation of the shoulder– ROM test for internal rotation of the shoulder– Specific ROM tests for the shoulder

including abduction, adduction, flexion, extension,

horizontal adduction, horizontal abduction

Manual muscle tests for the shoulder – External rotation strength tests– Internal rotation strength test for the shoulder– Extension strength test for the shoulder – Flexion strength test for the shoulder– Abduction and adduction strength tests for the shoulder– Empty can test

• Apprehension test (Crank test)

Apprehension test used for anterior glenohumeral instability – This motion

should not be forced

• Test for Shoulder Impingement– Neer’s test and Hawkins-Kennedy test for

impingement used to assess impingement of soft tissue structures

– Positive test is indicated by pain and grimace

Test for Supraspinatus Weakness

Empty Can Test– 90 degrees of

shoulder flexion, internal rotation and 30 degrees of horizontal abduction

– Downward pressure is applied

– Weakness and pain are assessed bilaterally

Types of Shoulder Injuries

Fractures Clavicle, humerus, scapula Cause: fall on outstretched arm, direct

blow S/S: pain, deformity, decreased ROM,

swelling Perform percussion test, compression

test

Treatment– Sling/splint– PRICE– Physcian/EMS– Follow orders

Prevention: – Instruct how to fall– Proper equipment

Hockey Clavicle Fracture

Dislocations and subluxations AC, SC, GH jts Cause: head of humerus forced/displaced

from glenoid S/S: pop, dead arm, pain, deformity,

swelling, loss of ROM/strength

Treatment– DO NOT relocated– PRICE– Check circulation/sensation– Physician / x-rays– Follow orders

Prevention– Strengthen jt– Proper equipment– Falling

Anterior Posterior

Posterior

Shoulder dislocation-rugby Dwayne Wade http://www.youtube.com/watch?

v=09ZZbJzeKUA

Contusions– Cause: direct blow/bony area or muscles– S/S: pain, decreased ROM, r/o other

injuries– Treatment: ice, padding, rehab, flexibility– Prevention: proper equipment, mechanics

Myositis ossificans

Sprains– Cause: over stretch/tear ligament, capsule

What motions/events would cause this?

– S/S: pt tender, weak, swelling, instability, possible deformity, decreased ROM

– Treatment PRICE Physician, follow orders Rehab

– Prevention Proper equipment/technique Strengthening/stretching Inspect playing areas Taping/bracing

Sternoclavicular Sprain– Cause of Injury

Indirect force, blunt trauma (may cause displacement)

– Signs of Injury Grade 1 - pain and slight disability Grade 2 - pain, subluxation w/ deformity,

swelling and point tenderness and decreased ROM

Grade 3 - gross deformity (dislocation), pain, swelling, decreased ROM

– Possibly life-threatening if dislocates posteriorly

– Care PRICE, immobilization Immobilize for 3-5 weeks followed by graded

reconditioning

Acromioclavicular Sprain– Cause of Injury

Result of direct blow (from any direction), upward force from humerus, fall on outstretched arm

– Signs of Injury Grade 1 - point tenderness and pain w/ movement;

no disruption of AC joint Grade 2 - tear or rupture of AC ligament, partial

displacement of lateral end of clavicle; pain, point tenderness and decreased ROM (abduction/adduction)

Grade 3 - Rupture of AC and CC ligaments with dislocation of clavicle; gross deformity, pain, loss of function and instability

– Care Ice, stabilization, referral to physician Grades 1-3 (non-operative) will require 3-4

days (grade 1) and 2 weeks of immobilization ( grade 3) respectively

Aggressive rehab is required w/ all grades– Joint mobilizations, flexibility exercises, &

strengthening should occur immediately– Progress as athlete is able to tolerate w/out pain and

swelling– Padding and protection may be required until pain-

free ROM returns

Specific tests

– Sulcus test, apprehension test for sprain of the anterior capsule

– Acromioclavicular (AC) sprain test– Sternoclavicular (SC) sprain test

Types of Shoulder Injuries

Strains – Cause: overstretching of muscles– S/S: similar to sprains– Treatment: PRICE, physician if necessary,

follow orders, rehab– Prevention

Stretching, strengthening

– Drop arm test-specific test

What do you see?

L clavicle elevation, bruising, left shoulder higher

What do you think the injury is? Grade 2 AC sprain, left. Bull rider

Impingement – Cause: pinching of soft tissue w/overhead

activity; overuse– S/S: pain, weakness, pt tenderness

Hawkins-Kennedy test, winged scapula test– Treatment

PRICE, decrease inflam., physician Strengthen RC, scapular stabilizers

– Prevention RC strengthening, proper mechanics

– Rotator cuff tear Involves supraspinatus or rupture of other

rotator cuff tendons Primary mechanism - acute trauma (high

velocity rotation) Occurs near insertion on greater tuberosity Full thickness tears usually occur in those

athletes w/ a long history of impingement or instability (generally does not occur in athlete under age 40)

– Signs of Injury Present with pain with muscle contraction Tenderness on palpation and loss of strength

due to pain Loss of function, swelling With complete tear, impingement and empty

can test are positive

– Care RICE for modulation of pain Progressive strengthening of rotator cuff Reduce frequency and level of activity initially

with a gradual and progressive increase in intensity

Shoulder Bursitis– Etiology

Chronic inflammatory condition due to trauma or overuse - subacromial bursa

May develop from direct impact or fall on tip of shoulder

– Signs of Injury Pain w/ motion and tenderness during palpation

in subacromial space; positive impingement tests

– Management Cold packs and NSAID’s to reduce

inflammation Remove mechanisms precipitating condition Maintain full ROM to reduce chances of

contractures and adhesions from forming

Bicipital Tenosynovitis– Cause of Injury

Repetitive overhead athlete - ballistic activity that involves repeated stretching of biceps tendon causing irritation to the tendon and sheath

– Signs of Injury Tenderness over bicipital groove, swelling,

crepitus due to inflammation Pain when performing overhead activities

– Care Rest and ice to treat inflammation NSAID’s Gradual program of strengthening and

stretching

Types of Shoulder Injuries

Tendonitis– Cause: overuse to tendons

Speed’s test

– Treatment: PRICE, anti-inflammatory, rehab, etc

– Prevention: Ice post activity, conditioning, mechanics,

Synovitis and bursitis– Cause: inflammation of synovial lining/bursa

Overuse, direct trauma

– S/S: pain, crepitus, swelling, decreased mobility

– Treatment: PRICE or heat, stretching pain free ROM, mechanics, etc

– Prevention: mechanics