1. Shoulder Injuries

2. Anatomy Shoulder Girdle: Clavicle, Scapula, Humerus Humerus: bicipital groove, greater/lesser tubercle, head, deltoid tuberosity Scapula: glenoid fossa, acromion process, coracoid process, and spine Clavicle: acromial end, sternal end

3. Anatomy Muscles: Rotator Cuff: Supraspinatus, Infraspinatus, Teres Minor, Subscapularis (SITS) Scapular: Rhomboids (major & minor), Pectoralis Minor, Trapezius, Levator Scapulae, Serratus Anterior (winging scapula/long thoracic nerve) Humeral: Latissimus Dorsi, Triceps, Pectoralis major, Biceps, Deltoid, Coracobrachialis, Teres Major

4. Rotator Cuff Muscles MuscleResisted ROM SupraspinatusInitiation of abduction of humerus InfraspinatusPrevent external rotation Teres MinorPrevent external rotation SubscapularisPrevent internal rotation

5. Anatomy Ligaments: Acromioclavicular, Coracoclavicular, Sternoclavicular, Coracoacromial, Joints: Glenohumeral (made for mobility, not stability) Acromioclavicular Sternoclavicular Coracoclavicular Scapulothoracic (not a true joint) Bursa: Subacromial Subdeltoid

6. Nerve Supply Cervical Plexus (C1, C2, C3, C4) Brachial Plexus (C5, C6, C7, C8, T1) Axillary Median Musculocutaneous Radial Ulnar

9. Scapulothoracic Rhythm 0-30° All humerus movement – setting phase 30-90° 2:1 humerus abduction: scapula abduct 90°- full abduction1:1 ratio

10. Evaluation - History MOI – direction of arm, was it planted on the ground, fall on outstretched arm, land on the tip, was it abducted w/ ext. rotation Location of pain (Can you touch it or is it deep?) Onset (acute vs. chronic) Sounds/Noises Did you feel anything slip? Prior history Pain scale (scale from 1-10) What activities recreates the pain?

11. Evaluation - Observation How is the arm being held? Willingness to move limb? Deformities – are the shoulders square or is there a drop off? Step Deformity? Levels of Shoulders – even, uneven Musculature - Are there any noticeable spasms in the muscles? Bony – Is anything sticking out in an abnormal direction? Position of Scapula – winging, rotated Discoloration Swelling

12. Observation: Symmetry between shoulders

13. Bilateral comparison of Shoulders Swelling, deformity, discoloration

14. Observe how athlete carries themselves or moves

15. Sternoclavicular Joint Clavicle Acromioclavicular Joint Humeral head Coracoid Process Spine of the scapula Intertubercular groove Soft Tissue: Deltoid Pectoral SIT (Supraspinatus, Infraspinatus, Teres Minor) Trapezus

16. 1.Sternoclavicular Joint 2.Clavicle 3.Acromioclavicular Joint 4.Humeral Head 5.Coracoid Process

17. Deltoid Muscle

18. 7. Spine of the Scapula 8. Supraspinatus Muscle 9. Infraspinatus Muscle 10. Trapezus Muscle

19. Painful Arc Pain is absent at the beginning of the ROM but occurs near the midrange of a movement and then ceases as this is passed. tender tissue is painfully squeezed in the passing of a certain point during the ROM. Best seen in AROM, normally indicates impingement Usually occurs between 60-120º abduction.

20. Evaluation – Stress Tests ROM Apley’s Scratch Test Shoulder flexion – neutral to 170-180° Shoulder extension – neutral to 50-60° Shoulder abduction – neutral to 170-180° Shoulder adduction – because of the torso, there is no true adduction Shoulder internal rotation – neutral to 80- 90° Shoulder external rotation – neutral to 80- 90° Gerber Lift-off Test

21. Myotomes C5 – shoulder abduction C6 – elbow flexion, wrist extension C7 – elbow extension, wrist flexion C8 – finger flexion, extension T1 – finger abduction, adduction

22. Dermatomes C5 – lateral aspect of shoulder (deltoid), policeman’s patch C6 – lateral elbow, lateral forearm, thumb & index finger C7 – middle finger C8 – 4 th & 5 th fingers, medial forearm T1 – medial elbow, medial humerus

23. Shoulder Injuries Soft Tissue: Contusions: shoulder pointer Acute bursitis: subdeltoid, subacromial (impingement) Sprains: AC, SC Strains: rotator cuff, deltoid, pectoralis major Tendonitis: rotator cuff, biceps Structural: Impingement Syndrome Biceps Rupture Brachial plexus: (traction or compression) Thoracic Outlet Syndrome

24. Shoulder Injuries Luxations: GH dislocation; usually anteriorly GH subluxation Multi-directional instability Fractures: Humeral Clavicular Sternum

25. Acromionclavicular Joint Sprain MOI Falling on an outstretched arm (using arm to catch one’s self) Direct hit to AC Joint GradeSymptomsDamage IPoint Tenderness, slight swelling, some arm motion loss Slight ligament damage, acromioclavicular ligament stretched II Greater tenderness, A - C joint has some laxity, inability to move arm with out severe pain Tearing of two of the three ligaments supporting the joint, acromioclavicular ligament and either the conoid or trapezoid ligaments have been torn. IIIObvious deformity, clavicle end tenting the skin, severe pain, inability to move arm. Complete rupture of the three ligaments, may require surgery to repair the joint.

26. Evaluation – Stress Tests AC sprain Shoulder shrugs Distraction (traction) test Piano Key Sign Rotator Cuff Strain Drop Arm test Empty Can test (Centinella Test) Gerber’s Lift Off test

27. Impingement Syndrome MOI repeated overhead arm movements tennis, golf, swimming, weight lifting, or pitching/throwing a ball Baseball players usually suffer from impingement and RC strains The rotator cuff repeatedly had contact with the acromion causing inflammation which may cause the rotator cuff to get trapped or pinched Sub-Conditions Tendonitis Bursitis

28. Evaluation – Stress Tests Impingement Impingement Sign/Neer Impingement: passive flexion Hawkins-Kennedy Impingement Sign: passive internal rotation @ 90° shoulder flexion, elbow at 90°

29. Shoulder Dislocations Dislocation vs. Subluxation Dislocation is where the humerus comes out of the Glenoid Fossa and stays out Subluxation is when the humerus comes out of the Glenoid Fossa and then goes right back in Most common cause of Shoulder Dislocations in Football is poor tackling technique Types of shoulder dislocations Anterior (most common) Posterior Inferior (sulcus sign)

30. Complications of Relocation Entrapment Muscle Nerves Arteries Fractures Labrum tears Axillary Nerve Damage

31. Evaluation – Stress Tests Dislocation Anterior Apprehension test for Anterior GH laxity Relocation test (Jobe’s Relocation test) for Anterior GH laxity Posterior Apprehension test for GH laxity Sulcus sign for interior GH laxity – hollowing out Anterior/Posterior Drawer test

32. FX of Clavicle 80% happen in the Middle 1/3 of the Clavicle MOI Falling on an outstretched arm Direct hit Falling on the outside of the shoulder

33. Shoulder Pointers Contusion to the outer portion of the Clavicle MOI Direct Blow to Clavicle

34. Bicep Tendonitis Yergason’s Test: Stability of tendon of long head of biceps in bicipital groove Subluxation of the bicep tendon in the intertubercular groove (bicipital groove) Speed’s Test

35. Evaluation – Stress Tests Thoracic Outlet Syndrome – pressure is applied on the brachial plexus, subclavian artery or subclavian vein Brachial plexus (Neurological): numbness, pain, paresthesia Subclavian artery (Arterial): coldness of skin, pallor, cyanosis in fingers, muscular weakness Subclavian vein (Venous): muscular & joint stiffness, edema, venous swelling, engorgement, thrombophlebitis

36. Evaluation – Stress Tests -  Pulse Adson’s: loss of radial pulse (compression of subclavian artery) Caused by ant. scalene muscle & pec. minor Head looks towards abducted (30°) externally rotated shoulder, & elbow extended w/ thumb pointing up; deep breath Allen Test: loss of radial pulse (compression of neurovascular bundle) Caused by the pectoralis minor muscle Head looks away while elbow is flexed (90°) & shoulder abducted (90°); shoulder passively horiz. abducted & ext. rotated

37. Evaluation – Stress Tests Roos – diminished motor function of the hands, and/or loss of sensation in the upper extremities Both shoulders 90 degrees of abduction and external rotation, and elbows in 90 degrees of flexion Subject rapidly opens and closes both hands for 3 minutes