1. THE SHOULDER: Evaluation and Treatment of Common Injuries

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

3. 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

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

5. Shoulder Anatomy: Joints
Sternoclavicular
Scapulothoracic articulation
Glenohumeral
Acromioclavicular

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

7. Shoulder Anatomy: Rotator Cuff Muscles
Depress humeral head against glenoid

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

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

10. 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)

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

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

13. Shoulder Pain: Physical Examination

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

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

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

17. PE: Inspection
Scapulothoracic motion
Dyskinesia or winging

19. 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

20. 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

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

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

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

24. 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

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

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

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

28. 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

29. 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

30. 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

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

32. 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

33. 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

34. 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

35. 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

36. 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

37. Shoulder Pain: Common Injuries

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

39. AC Joint Sprain
Six classifications of injury:

40. 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

41. 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

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

43. 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

44. 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

45. 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

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

47. Rotator Cuff Impingement/Tendinitis
Strengthening Exercises

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

49. 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

50. 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

51. Clavicle Fracture

52. 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

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

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

55. 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

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

57. 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)

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

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

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

61. Anterior Shoulder Dislocation
Stimson maneuver

62. 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

63. 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 !!!