THE SHOULDER: Evaluation and Treatment of Common Injuries

The Shoulder Anatomy History Physical Examination Common shoulder injuries Acromioclavicular joint sprain Impingement Rotator Cuff Tear Adhesive Capsulitis Clavicle Fractures Shoulder Subluxation/Dislocation

Shoulder Pain Very common problem in sports medicine Unique anatomy & range of motion make diagnoses challenging Thorough understanding of anatomy & biomechanics is important to helpful Bony, soft tissues & nerve injuries Acute or chronic pain

Shoulder Anatomy: Bony Anatomy Humerus Scapula Glenoid Acromion Coracoid Scapular body Clavicle Sternum

Shoulder Anatomy: Joints Sternoclavicular Scapulothoracic articulation Glenohumeral Acromioclavicular

Glenohumeral Joint Most common dislocated joint Lacks bony stability Composed of: Fibrous capsule Ligaments Surrounding muscles Glenoid labrum

Shoulder Anatomy: Rotator Cuff Muscles Depress humeral head against glenoid

Shoulder anatomy: Rotator cuff muscles Supraspinatus: Abduction Infraspinatus: External rotation Teres Minor: Subscapularis: Internal rotation

Shoulder Anatomy: Other Musculature Pectoralis major, deltoid, latissimus dorsi, biceps Rhomboids, trapezius, levator scapulae, serratus anterior

History Mechanism of injury Specific sport/activity when injury occurred Duration of symptoms Acute event or chronic Aggravating/alleviating factors Pain (Location/Character/Night pain)

History Sensation of instability Weakness Popping/Crepitus: painful/non-painful Stiffness Numbness/Tingling Shoulder activities involved in patients occupation

History Past medical history of shoulder injury/surgery Previous history of injections Hand dominance

Shoulder Pain: Physical Examination

Physical Examination Inspection Palpation Range of Motion Strength Neurovascular status Neck & elbow exam

PE: Inspection Compare to normal shoulder for obvious deformities Abnormalities of: Humeral head Clavicle AC joint SC joint

PE: Inspection Muscle atrophy Appearance of skin: May indicate nerve damage or disuse atrophy Appearance of skin: Swelling Ecchymosis Erythema Venous distention

PE: Inspection Scapulothoracic motion Dyskinesia or winging

PE: Palpation Bony structures: Soft tissue structures SC joint Clavicle AC joint Acromion Greater tuberosity Coracoid process Spine of scapula Soft tissue structures Short & long heads of biceps Subacromial bursa Musculature of shoulder Anterior capsule Posterior capsule Pericapsular musculature

PE: Range of Motion Passive & Active Compare to unaffected side Pain w/ movement? Dominant shoulder (“Overhead athletes”) 5° to 10° more external rotation 5° to 10° less internal rotation

PE: Range of Motion Forward Flexion Abduction Adduction Internal Rotation External Rotation

PE: Muscle testing Compare to unaffected side Differentiate between true weakness & weakness due to pain

PE: Muscle Testing Supraspinatus Empty Can Test 90° abduction 30° forward flexion Thumbs pointing downward Patient attempts elevation against examiner’s resistance

PE: Muscle testing Subscapularis “Lift-off test” Internally rotate shoulder Dorsum of hand against lower back Patient attempts to push away examiner’s hand Modified: Place hand on abdomen and resist internal rotation

PE: Muscle Testing Infraspinatus/Teres Minor Patient’s arms adducted @ sides Elbows flexed to 90° Patient attempts external rotation against examiner’s resistance

Tests Impingement signs AC Joint Biceps tendon Glenohumeral joint stability Labral signs Cervical spine signs

Impingement Signs: Neer’s Test Scapula stabilized Arm fully pronated Examiner brings shoulder into maximal forward flexion Pain  subacromial impingement

Impingement Signs: Hawkins’ Test Patient’s arm forward flexed to 90° Elbow flexed to 90° Shoulder forcibly internally rotated by examiner Pain  subacromial impingement or rotator cuff tendinitis

Rotator Cuff sign: Drop Arm Test Passively abduct patient’s shoulder Observe as patient slowly lowers arm to waist If arm drops to patient’s side, suggests rotator cuff tear &/or supraspinatus dysfunction

AC joint: Crossover Test Patient raises affected arm to 90° Actively adducts arm across body Forces acromion into distal end of clavicle Isolates AC joint & painful if positive

Biceps Tendon: Speed’s Test Elbow flexed 20°-30° Forearm supinated Arm in 60° flexion Patient forward flexes arm against examiner’s resistance

Anterior Instability Testing: Apprehension Test Supine, sitting or standing Arm abducted to 90° Apply slight anterior pressure & slowly externally rotate Apprehension may indicate anterior instability Pain w/out apprehension is more likely impingement

Inferior Instability Testing: Sulcus Sign Arm in neutral position Pull downward on elbow or wrist Observe for depression lateral or inferior to acromion Positive if > 1 cm Indicates inferior instability Compare to other side

Posterior Instability Testing: Posterior Apprehension Test Supine or sitting Arm in 90° abduction, 90° elbow flexion Apply posteriorly directed force in attempt to displace humeral head posteriorly

Labral signs O’Brien’s test Arm forward flexed to 90° Elbow fully extended Arm adducted 10° - 15°, thumb down Downward pressure Repeat w/ palm up Suggestive of labral tear if more pain w/ thumb down

Cervical Spine: Spurling’s Maneuver Neck extended Head rotated toward affected shoulder Axial load placed on the spine Reproduction of patient’s shoulder/arm pain indicate possible nerve root compression

Shoulder Pain: Common Injuries

Acromioclavicular Joint Sprain Common “Shoulder separation” Mechanism: Fall landing on “point” or lateral aspect of shoulder Occasionally from fall on outstretched hand

AC Joint Sprain Six classifications of injury:

AC Joint Sprain Physical Exam: Well-localized swelling & tenderness over AC joint Painful active & passive range of motion Crossover testing increases pain Type II, III, V may have high riding clavicle May have tenderness to palpation over clavicle shaft, SC joint & clavicular attachments of trapezius & deltoids

AC Joint Sprain Treatment: Type I, II, III: Type IV and higher: Conservative treatment Ice, Rest, NSAIDS Begin ROM exercise as soon as tolerated Type IV and higher: May require further intervention

Rotator Cuff Impingement/Tendinitis Rotator cuff muscles, (especially supraspinatus) & biceps tendon Impinge against undersurface of acromion & coracoacromial ligament

Rotator Cuff Impingement/Tendinitis Mechanism: Subacromial bursa & rotator cuff tendon become inflamed secondary to friction against undersurface of acromion & coracoacromial ligament May result from overuse, rotator cuff weakness, mild anterior instability, direct trauma

Rotator Cuff Impingement/Tendinitis Predisposing factors: Repetitive motion of shoulder above horizontal plane (swimming, throwing, golf, tennis, etc.) Fatigue of rotator cuff  abnormal shoulder mechanics Upper extremity inflexibility, anterior sloped or hooked acromion, AC joint spurring/hypertrophy

Rotator Cuff Impingement/Tendinitis History: Pain referred to anterolateral aspect of shoulder w/ some radiation (not beyond elbow) Aggravated w/ overhead activities Night pain Clicking or popping sensation

Rotator Cuff Impingement/Tendinitis Treatment: Conservative Temporary avoidance of aggravating factors Ice NSAIDS Physical Therapy

Rotator Cuff Impingement/Tendinitis Strengthening Exercises

Rotator Cuff Impingement/Tendinitis Corticosteroid injection If not improving w/ PT May allow more effective participation in PT

Rotator Cuff Tear Full or partial thickness disruption of tendon fibers PE: + impingement signs (Neer’s, Hawkins’) Drop arm test + Diagnosis: MRI Conservative treatment Surgical evaluation if fail to improve

Clavicle Fracture Common Most occur in middle one-third of clavicle Mechanism: Fall on outstretched arm or point of shoulder Direct blow to midportion of clavicle less common

Clavicle Fracture

Clavicle Fracture Physical Exam: Visible & palpable deformity Local pain & swelling Pain may radiate into trapezius & neck Complete neuro exam important to detect brachial plexus injury

Clavicle Fracture Radiographs: AP and axillary view AP view w/ 45° cephalic tilt (Chest film if substantial trauma)

Clavicle Fracture Treatment: Conservative Sling for 2 to 4 weeks Displaced fractures may need referral for further evaluation

Anterior Shoulder Subluxation/Dislocation Complete separation of articular surfaces Subluxation: Abnormal translation of humeral head on glenoid without complete separation of articular surfaces Humeral head can dislocate anteriorly, posteriorly or inferiorly Anterior dislocation most common

Anterior Shoulder Subluxation/Dislocation Mechanism: Forced extension, abduction, external rotation Direct blow to posterior or posterolateral shoulder Repeated episodes of overuse (subluxation)

Anterior Shoulder Subluxation/Dislocation Physical Exam: Intense pain Arm held in abduction & external rotation Humeral head palpable anteriorly Unable to completely internally rotate or abduct the shoulder Thorough neuro exam (close relation of axillary nerve)

Anterior Shoulder Subluxation/Dislocation Radiographs: Axillary View True AP Y view

Anterior Shoulder Subluxation/Dislocation Radiographs: Helps to determine or confirm position If dislocated, obtain post-reduction films as well Anterior dislocation

Anterior Shoulder Dislocation Prompt reduction Many different methods of reduction Traction-countertraction

Anterior Shoulder Dislocation Stimson maneuver

Anterior Shoulder Subluxation/Dislocation Treatment: Sling Ice NSAIDS Protected range of motion Rotator cuff strengthening after acute pain resolves Return to sport when normal strength & motion regained

The shoulder Develop systematic approach to examination Make sure to evaluate above & below shoulder joint Thorough neuro examination Address potential causes of injury Physical therapy !!!