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

 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 Introduction

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

 Scapulohumeral Rhythm Movement of scapula relative to the humerus Initial 30 degrees of G-H abduction  Does not incorporate scapular motion  Setting phase 30 to 90 degrees of G-H abduction  Scapula abducts and upwardly rotates 1 degree for every 2 degrees of humeral elevation Above 90 degrees of G-H abduction  Scapula and humerus move in 1:1 ratio Functional Anatomy

Specific Injuries  Clavicular Fractures Etiology  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

 Scapular Fractures Etiology  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

 Sternoclavicular Sprain Etiology  MOI = indirect force or blunt trauma Signs and Symptoms  Grade 1 - pain and slight disability  Grade 2 - pain, subluxation deformity, swelling, point tenderness, and decreased ROM  Grade 3 - gross deformity (dislocation), pain, swelling, and decreased ROM Possibly life-threatening if dislocates posteriorly Specific Injuries

 Sternoclavicular Sprain (continued) Management  RICE  Refer for reduction if necessary  Immobilize for 3-5 weeks  After immobilization period, begin PRE exercises Specific Injuries

 Acromioclavicular Sprain Etiology  MOI = direct blow (from any direction) or upward force from the humerus  Graded from 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 Specific Injuries

 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 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

 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 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 Specific Injuries

 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

 Brachial nerves and vessels may be compromised  Rotator cuff injuries  Fractures  Bicipital tendon subluxation  Transverse ligament rupture Possible Complications of Shoulder Dislocations

 Chronic Recurrent Instabilities Etiology  MOI = traumatic, microtraumatic (repetitive overuse), atraumatic, congenital, and neuromuscular  As supporting tissue become more lax, mobility increases  Results in damage to other soft tissue structures Specific Injuries

 Chronic Recurrent Instabilities (continued) Signs and Symptoms  Anterior - may have clicking or pain; complain of dead arm during cocking phase (when throwing); pain posteriorly; possible impingement; positive apprehension test  Posterior - possible impingement; loss IR; crepitation; increased laxity; pain anteriorly and posteriorly  Multidirectional - inferior laxity; positive sulcus sign; pain and clicking with arm at side; possible signs and symptoms associated with anterior and posterior instability Specific Injuries

 Chronic Recurrent Instabilities (continued) Management  Conservative treatment involves extensive strengthening of the rotator cuff and scapula stabilizers Should be pursued before surgery is considered  Avoid joint mobilizations and ROM exercises Various braces can be used to limit motion  Surgical stabilization may be required to improve function and comfort

 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 Specific Injuries

 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

 Stage I Result of supraspinatus or biceps tendon injury Presents with point tenderness; pain with ABD and resisted supination with external rotation; edema; thickening of rotator cuff and bursa Occurs in athletes < 25 years old Neer’s progressive stages of shoulder impingement…

 Stage II Permanent thickening and fibrosis of supraspinatus and biceps tendon Presents with aching during activity that worsens at night May experience restricted arm motion Neer’s progressive stages of shoulder impingement…

 Stage III History of shoulder problems and pain Tendon defect (less than 3/8 of an inch) or possible muscle tear Permanent scar tissue and thickening of rotator cuff Occurs in athletes years old Neer’s progressive stages of shoulder impingement…

 Stage IV Infraspinatus and supraspinatus atrophy Presents with pain during ABD, limited AROM and PROM, weak RROM Tendon defect (greater than 3/8 of an inch) Clavicle degeneration Neer’s progressive stages of shoulder impingement…

 Rotator cuff tear Etiology  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 Specific Injuries

 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

 Shoulder Bursitis Etiology  Chronic inflammatory condition resulting from fibrosis or fluid build-up  MOI = direct trauma or overuse  Usually occurs in the subacromial bursa Signs and Symptoms  Pain with motion, pain during palpation of subacromial space  Positive impingement tests Specific Injuries

 Shoulder Bursitis Management  Reduce inflammation Cold, ultrasound, NSAID’s  Remove mechanisms precipitating condition  Maintain full ROM to reduce the risk of contractures and adhesions forming

 Frozen Shoulder (Adhesive Capsulitis) Etiology  Contracted and thickened joint capsule with little synovial fluid  Chronic inflammation resulting in contracted, inelastic rotator cuff muscles Signs and Symptoms  Pain in all directions both with AROM and PROM  Patient resists moving the shoulder due to pain Specific Injuries

 Frozen Shoulder (continued) Management  Aggressive joint mobilizations  Stretching of tight musculature  Electrical stimulation for pain control  Ultrasound for deep heating 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 Specific Injuries

 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

 Bicipital Tenosynovitis Etiology  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 Specific Injuries

 Bicipital Tenosynovitis (continued) Management  Rest, ice, and ultrasound to treat inflammation  NSAID’s  Gradual program of strengthening and stretching

 Contusion of Upper Arm Etiology  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 Specific Injuries

 Peripheral Nerve Injuries Etiology  MOI = blunt trauma or overstretching-type injuries Signs and Symptoms  Constant pain, muscle weakness, paralysis, or atrophy Management  RICE  Transient muscle weakness may occur  If muscle atrophy occurs, referral to a physician is necessary Specific Injuries