Shoulder Injuries

Sternoclavicular Joint Sprain Mechanism Force applied to lateral aspect of shoulder (travels medially through clavicle) Force applied anterior or posterior to shoulder Stretching of SC ligament from direct or indirect force to joint Rare-traction force (i.e. uneven bars)

Signs and symptoms Point tenderness over SC joint Pain with active/passive stretch Loss of function Pain with protraction/retraction Dislocations tend to occur anterior or superior Although posterior can occur and is a medical emergency

Signs and Symptoms (cont.) Inflammation Hemorrhage Ecchymosis Deformity Instability (with 2nd,3rd degree)

Special Tests Diagnostic Procedure Active and resistive movements Passive stress Diagnostic Procedure Refer to ortho X-Ray *If posterior emergent

Acromioclavicular Joint Sprain Mechanisms Downward force on point of shoulder with arm adducted Blow to acromion process which drives scapula inferior Stretching of AC ligament due to direct or indirect force applied to joint

AC Classification System Slight partial damage to AC ligament, negative laxity, point tenderness II Rupture AC and partial CC, slight laxity III Complete AC and CC, dislocation distal clavicle/acromion IV, V, VI AC/CC/tearing deltoid/trap fascia

Signs and Symptoms Pain on A/P/RROM Loss of function Tenderness over AC joint Swelling Hemorrhage Ecchymosis Inflammation Step deformity

Signs and Symptoms (cont) Pain on shoulder abduction Pain on distraction of AC joint Abnormal motion of distal clavicle Deformity Instability (2nd and 3rd degree)

Special Tests Diagnostic Procedure Distraction (piano key) AC Traction/Compression Pain on Abduction A/R ROM Apley’s scratch test Diagnostic Procedure Ortho X-Ray

Subcoracoid glenohumeral luxation(dislocation) Mechanism Force applied to an abducted, ER arm above 90 deg Signs and symptoms Pain Loss of function Deformity Swelling Tenderness on anterior aspect of shoulder

Special Tests Diagnostic Procedure Check pulse Check sensation over axillary n. Diagnostic Procedure Refer to ortho X-ray

Glenohumeral/subglenoid luxation(dislocation) Mechanism Force applied to an abducted arm Signs and Symptoms Pain Loss of function Marked deformity Swelling Pt. Tenderness Flattened deltoid

Special Tests Diagnostic Procedure Check pulse at wrist Check for sensory loss in arm and hand Diagnostic Procedure Refer to ortho X-ray

Posterior Glenohumeral Luxation(dislocation) Mechanism Fall on outstretched arm Blow to the front of the shoulder Signs and Symptoms Pain Loss of function Marked deformity Swelling Pt. Tenderness

Special Tests Diagnostic Procedure Check pulse at wrist Check sensation of arm/hand Diagnostic Procedure Refer to ortho X-Ray

Glenohumeral Instability Result of ligamentous or labral pathology Grade of severity is based on joint glide movements GH instability has a close relationship with pathological changes in RC

Anterior Glenohumeral Instability Mechanism Acute Repetitive microtrauma involving ER when GH joint is abducted to 90 degrees

Signs and symptoms Sensation of slipping out of place Increased laxity Positive apprehension/relocation test Increased anterior glide Flattened deltoid Diffuse pain Tenderness to anterior GH joint RC atrophy

Special Tests Positive Apprehension Positive relocation sign Sulcus sign Glenohumeral translation

Glenoid Labrum tear Mechanism Repetition of shoulder motion Acute Trauma Ant. Subluxation of glenohumeral jt.

Special tests Diagnostic Clunk test Resistive ROM Apprehension test Ortho MRI

Signs and symptoms Pain Loss of smooth shoulder motion Pop or snap on extended rotation Pain with ER at 90 deg of abduction Possible positive clunk test Pain with forced abduction Pain on forced horizontal adduction Weakness of RC

Anterior Glenohumeral Subluxation Mechanism Leverage force applied to an abducted and ER arm Signs and Symptoms Pain Loss of function Sensation of shoulder slipping out of place

Signs and Symptoms (continued) Obvious deformity before reduction Spasm Positive apprehension test Head of humerus is palpable while slipping forward

Special Tests Diagnostic Procedure Apprehension test Relocation test Sulcus sign Glenohumeral translation Clunk test Diagnostic Procedure Refer to ortho

Bankhart Lesion Inferior GH ligament may be avulsed along with a portion of the labrum Complains of pain/crepitus as humeral head moves against anterior labrum during GH glide testing

Hills-Sach Lesion Common finding associated with anterior GH dislocation Small defect in posterior humeral head’s articular cartilage Caused by impact of humeral head on glenoid fossa as humerus attempts to relocate

Superior Labrum Anteroposterior Lesions Known as SLAP lesions Tear in superior glenoid labrum located near the attachment of the long head of biceps brachii tendon

Rotator Cuff Impingement Mechanisms Decreased space in subacromial arch Structures beneath are impinged between acromion and humeral head Chronic microtrauma Vascular impairment Partial tear RC- altered mechanics Anatomic variation of arch

Signs and Symptoms Increase in pain from IR to ER Snapping sensation Loss of function Pain with overhead activity Painful arc Pain on superolateral aspect of shoulder

Signs and Symptoms (cont.) Pain on active abduction between 70 and 130 degree Pain on extreme forward flexion with forearm supinated Pain on internal rotation with arm abducted at 90 and forearm pronated

Special tests Diagnostic Procedure Impingement test (Neer and Hawkins) Forward Flexion test Empty can test RROM Diagnostic Procedure Ortho

Rotator Cuff Tendinitis/Strain Mechanisms Trauma due to excessive forcible contraction or stretching Muscle fatigue Overuse Slow onset Decrease muscle balance between IR and ER Capsular laxity Poor vascularization of tendons Supraspinatus most commonly injured

Symptoms and Signs Pain with A/P/RROM Loss of function Snapping Tenderness Spasm Swelling Ecchymosis

Signs and Symptoms Pt. Tenderness over RC tendons Inflammation Hematoma formation Muscle defect Pain on abduction/ER/ and flexion of shoulder

Special Test Apley’s scratch Impingement Drop Arm Forward Flexion Empty can *Refer to Ortho

Tenosynovitis of Shoulder Mechanism Overuse Direct or repeated trauma Poor throwing techniques Signs and symptoms Pain on A/P/RROM Loss of function Tenderness Swelling Thickening of tendon

Special Tests A/P/RROM Diagnostic Procedure Refer to ortho

Bicep Tendon Pathology Biceps Tendinitis Luxation of bicep tendon Long Head of biceps rupture

Bicep tendinitis Mechanism Irritation of biceps tendon in the groove Rotator cuff dysfunction Repeated microtrauma Overuse Degenerative changes impingement

Signs and symptoms Pain on P/A/RROM Loss of function Overuse activity Tenderness Errythema Swelling Inflammation Crepitus

Special Tests Diagnostic Procedure A/P/RROM RC muscle test Physician if symptoms persist

Luxation of biceps tendon Mechanism Inadequate muscle development Overuse in throwing Tearing of transverse humeral ligament Shallow bicipital groove of humerus Faulty mechanics

Signs and Symptoms Pain in anterior aspect of shoulder Loss of shoulder function Snapping sensation followed by dull ache in arm or arm feeling dead Tenderness over bicipital groove Inflammation

Special Tests Diagnostic Procedure Yergason Speed’s Ludington Refer to physician

Long head of biceps rupture Mechanism Violent contraction against resistance Symptoms/signs Pain Loss of function Sensation of something rolling up arm Protruding bulge in biceps Tenderness along long head Loss of strength

Special Tests Ludington’s test Diagnostic Procedure Refer to ortho

Contusion of biceps Mechanism Signs and Symptoms Direct Trauma Pain Loss of elbow flexion and extension Transitory paralysis Pt. Tenderness Ecchymosis Hematoma Formation Inflammation

Diagnostic Procedures Special Tests A/P/RROM Diagnostic Procedures Refer if symptoms persist

Exostosis/Myositis Ossificans Mechanism Repeated trauma (humerus) Signs and Symptoms Pain Point tenderness Possible paresthesia Swelling Loss of Function

Proximal Humerus Epiphyseal Plate Injury Mechanism Direct trauma Indirect trauma traveling along length of humerus

Signs and Symptoms Sudden pain Tenderness Deformity Rapid Swelling Possible bony deviations Crepitus Ecchymosis

Humerus Fracture Mechanism Signs and Symptoms Direct trauma Fall on an outstretched arm Signs and Symptoms Sudden pain Loss of function Tenderness Deformity Rapid Swelling

Axillary N. Injury Mechanism Signs and symptoms Direct trauma to lateral arm 2nd to anterior dislocated arm Signs and symptoms Loss of shoulder abduction Tenderness Loss of function of deltoid/biceps Dermatome numbness in area of middle Deltoid

Diagnostic Procedures Special Tests A/RROM for Deltoid Sensation testing for Deltoid Diagnostic Procedures Neurologist

Subacromion Bursitis Mechanism Direct Trauma Overuse Fall on an outstretched hand RC impingement (i.e. stress from throwing)

Signs and Symptoms Similar to RC impingement Pain(at night/ ache with rest) Loss of function Tenderness Redness, swelling, inflammation Pain on rotation and/or abduction>80 deg

Special Tests Diagnostic Appley’s Scratch test Resistive movements Refer to physician

Subdeltoid bursitis Mechanism Direct Trauma Fall on outstretched hand Overuse

Signs and Symptoms Pain Loss of function Tenderness(under deltoid) Redness, swelling, inflammation Pain and/or weakness on abduction

Special Tests Diagnostic Apley’s scratch test Resistive movement tests Refer to physician

Clavicle Contusion Mechanisms Symptoms Direct trauma to clavicle Pain Loss of Function Transitory paralysis Point tenderness Inflammation

Special Tests Diagnostic Procedure Distraction Test (rule out AC sprain) Diagnostic Procedure Refer to orthopedic surgeon XRay

Deltoid Contusion Mechanism Symptoms Direct Trauma Pain Loss of function Point tenderness Transitory paralysis Weakness on shoulder abduction

Long Thoracic N. Contusion (Winging Scapula) Mechanism Indirect trauma to lat. Thoracic wall or shoulder Overuse of shoulder Prolonged traction (i.e. cycling) Signs and symptoms Scapular winging (scapula protrudes posteriorly) Dull ache around shoulder girdle Decrease motion with shoulder movement

Special Tests Diagnostic Procedure Scapula protraction test Physician Pushing against a wall will cause winging effect Diagnostic Procedure Physician EMG study (Electromyography)

Thoracic Outlet Syndrome Mechanism Pressure on medial cord of brachial plexus, subclavian artery a/o subclavian vein (neurmuscular bundle) Cervical rib Pect minor/scalene tightness Pressure on neurovascular bundle as it runs between clavicle and first rib

Signs and Symptoms Neurological Vascular C8-T1 medial because of closeness to 1t rib, ulnar n, occasionally median n. Vascular Vein-swelling Artery-decreased blood flow

Tests Adson’s Allen Costoclavicular (military brace)

Clavicle Fracture Fracture collar bone Mechanisms Fall on outstretched arm Direct contact

Signs and Symptoms Sudden pain Tenderness(direct /indirect) Loss of shoulder function Deformity(rapid swelling/bony deviation) Head tilt towards side of fracture Crepitus

Signs and symptoms (cont.) False joint motion Delayed ecchymosis Head tilted toward side of fracture Rounded shoulder Athlete may be supporting affected elbow with opposite hand *Refer to ortho/X-ray

Scapula Fracture Mechanism Signs and Symptoms Direct trauma Indirect trauma from fall (on shoulder or arm) Signs and Symptoms Sudden pain Loss of function Tenderness (direct/indirect) Possible crepitus

Signs and Symptoms (cont.) Rapid Swelling Bony deviations Crepitus False Joint Motion Delayed Ecchymosis *Refer to ortho/X-Ray

Proximal humerus Epiphyseal plate Injury Mechanisms Direct trauma Indirect along shaft Signs and symptoms Pain Loss of function Deformity Swelling Crepitus False joint

Blocker’s Extosis Myositis Ossificans Mechanisms Signs and symptoms Repetitive trauma to humerus Signs and symptoms Pain Pt. Tenderness Bony prominence Swelling Loss of function-elbow flexion/extension

Humerus Fracture Mechanism Signs and Symptoms Direct trauma from fall/external force Signs and Symptoms Pain Loss of function Deformity- shortened humerus Swelling False joint motion

Triceps strain Mechanism Signs and symptoms Tests Excessive forcible contraction or stretching Muscle fatigue Signs and symptoms Tests