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 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 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

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

Specific Injuries Clavicular Fractures Etiology Signs and Symptoms 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 Injuries Scapular Fractures Etiology Signs and Symptoms 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 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 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 Injuries Acromioclavicular Sprain Etiology Signs and Symptoms 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 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 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 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 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

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

Specific Injuries Rotator cuff tear Etiology Signs and Symptoms 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 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 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 Injuries Bicipital Tenosynovitis Etiology Signs and Symptoms 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 Injuries Contusion of Upper Arm Etiology Signs and Symptoms 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

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