1. Injuries to the Shoulder
Anatomy
Injuries
Special Tests

2. Shoulder Anatomy Review..
* Head of the humerus – Upper portion of the humerus, where the bone attaches to the scapula.
* Glenoid Fossa – a slightly concave projection of the scapula
* Glenohumeral (GH) joint – the synovial ball-and-socket joint of the shoulder
* Acromion process – lateral projection of the spine of the scapula that forms the point of the shoulder and articulates with the clavicle
* Acromioclavicular joint – joint formed by the acromion of scapula and the clavicle
* Sternoclavicular joint – area where the sternum and clavicle connect
* Scapulothoracic joint – area that provides movement of the scapula over the back side of the ribcage

3. Shoulder Anatomy

4. Rotator Cuff
* Collective set of four deep muscles of the glenohumeral joint; critical for shoulder movement; commonly involved in shoulder injuries
*All four muscles arise from the scapula and insert on the superior aspect of the humerus, wrapping the head of the humerus.
Supraspinatus – inserts onto the humerus anterosuperiorly
Infraspinatus – inserts onto the humerus posterosuperiorly
Teres minor – inserts onto the humerus posteriorly
Subscapularis – inserts onto the humerus anteriorly

5. Rotator CUff

6. Shoulder INjuries
~ A good percentage of shoulder injuries are considered OVERUSE injuries.
~Usually due to
Poor posture at rest
Muscular imbalance during exercise

7. Overuse INjuries
Impingement Syndrome
Bicep Tendonitis

8. Impingement Syndrome
Basic Info: space between humeral head and acromion becomes narrowed; bones then squeeze or “impinge” the structures that occupy the space
S/S: pain/tenderness in GH area; pain/weakness with active abduction; limited internal rotation; tenderness to palpation in subacromial area
Tx: mechanics and postural evaluation; referral to PT
Rehab/RTP: LOTS of stretching, postural corrections, progressive strengthening of rotator cuff muscles. RTP decided by physical therapist and/or Dr.

9. Special Tests: Neer’s Impingement Test
Patient position: sitting or standing
Examiner position: standing on involved side, one hand stabilizing scapula, other hand holding pt’s wrist
Action: internally rotate humerus; move GH joint through flexion (don’t allow scapular movement)
+: pain in anterior or lateral shoulder from 90 to full flexion = rotator cuff impingement (supraspinatus)
Notes: none

10. Special Tests: Hawkins-Kennedy
Patient position: sitting or standing
Examiner position: standing on involved side, holding pt’s arm at elbow jt.
Action: flex elbow to 90, lift arm to shoulder height in scapular plane; internally rotate humerus
+: pain, especially at end ROM = rotator cuff pathology (supraspinatus)
Notes: don’t allow humeral movement toward midline during test = false positive.

11. Special Tests: Empty Can Test
Patient position: standing, arms abducted to 90 and at 45 angle in front (“V”)
Examiner position: standing facing the patient
Action: active internal rotation of humerus; examiner applies downward pressure against patient resistance
+: pain and/or weakness (unable to maintain abduction) = rotator cuff pathology (supraspinatus)
Notes: if concern is of supraspinatus TEAR, don’t internally rotate (Full Can)

12. Bicep Tendonitis
Basic info – tendon inflammation where bicep connects to the shoulder
S/S – pain/tenderness in anterior shoulder, especially with palpation during internal and external rotation
Tx – rest; mechanical/postural corrections
Rehab/RTP – will involve LOTS of stretching to anterior shoulder and bicep; RTP – once symptoms resolve; determined by physical therapist and/or Dr.

13. Special Tests: Yergason’s Test
Patient position: sitting or standing, elbow flexed to 90, palm up
Examiner position: standing lateral and JUST behind patient; one hand on superior shoulder; other hand holding wrist
Action: resist active elbow flexion while moving GH joint into external rotation
+: pain or ‘snapping’ in bicipital groove = bicep tendonitis or incomplete tear
Notes: none

14. Rotator Cuff INjury
Basic info – can be acute (tear) or chronic; partial (do not completely sever the tendon) or full-thickness
S/S – pain, “catching,” weakness; partial = pain, but full/normal ROM; full-thickness = unable to perform AROM overhead
Tx – ice, NSAIDs, referral to Dr.; partial = rehab; full-thickness = surgical repair
Rehab/RTP – will depend on surgical v non-surgical; rehab will focus on functional strengthening and postural/mechanical corrections; RTP will be decided by combo of PT and referring Dr.

15. Special Tests: Drop Arm Test
Patient position: sitting or standing, with arm completely overhead
Examiner position: standing in proximity to the patient/athlete
Action: athlete actively lowers the arm to the side (adduction)
+: weakness through mid-range of adduction (arm will drop once it approaches degrees of adduction.
Notes: Use caution in having athlete raise arm overhead to start test – if this motion causes significant pain, do not proceed with test.

16. Acute INjuries Bicep Tendon Rupture GH Dislocation AC Separation
Fractures
Acute INjuries

17. Bicep Tendon Rupture
Basic info: long head of the bicep tendon tears at proximal end; more common in weightlifting than athletics
S/S: ecchymosis in upper, anterior arm; inability to flex elbow, severe pain
Tx: complete rest for a period of time (while tendon heals); ice and probable immobilization; referral to physician/surgeon
Rehab/RTP: slowly progressive strengthening; if surgical, clearance needs to be from surgeon and Dr. If not, Dr. can release to athletics with physical therapist advice.

18. SPEED’s Test
Patient Position: standing or sitting; shoulder flexed to 90, supinated.
Examiner Position: standing lateral to patient
Action: resist active shoulder flexion (apply downward pressure)
+: pain or weakness in bicipital groove; or patient unable to maintain flexion
Notes: if patient cannot perform flexion to 90, DO NOT attempt to apply resistance!

19. GH Dislocation
Basic info: head of humerus falls completely off glenoid fossa; 3 types – anterior/inferior (most common), inferior, posterior; can also result in glenoid labrum tear.
S/S: severe pain; deformity (Sulcus sign), potential for neurological symptoms into involved arm
Tx: immediate referral to physician, immobilization, further evaluation to determine need for surgery
Rehab/RTP: extremely slow progression, but becomes aggressive strengthening to avoid recurring injuries

20. Jerk Test
Patient Position: supine, at lateral edge of table, abducted to 90 and elbow flexed to 90
Examiner Position: standing lateral to patient’s shoulder, one hand stabilizing scapula, other hand on outer point of elbow
Action: apply axial load to elbow; then passively (horizontally) adduct while maintaining axial load
+: “Clunk” noise that may or may not be painful = GH instability and/or glenoid labrum tear
Notes: DO NOT PERFORM TEST IF SUBLUXED OR DISLOCATED!!!

21. AC Separation
Basic info: traumatic sprain to the AC joint, MOI is usually direct contact/trauma to tip of shoulder; classified in degrees (1st, 2nd, 3rd)
S/S: pain surrounding the AC joint, deformity (clavicle will appear elevated in complete separation (picture on the next slide)
Tx: remove from play; ice; referral to physician; additional treatment varied depending on degree
Rehab/RTP: ROM and light strengthening exercises will begin rehab

22. AC Separation Grading

23. O’Brien’s Test (Active Compression Test)
Patient Position: standing, shoulder flexed to 90, very slightly adducted
Examiner Position: in front of patient, one hand over posterior aspect of distal forearm
Action: patient resists downward force exerted by examiner
+: pain over AC joint = AC sprain/separation
Notes: none

24. Fractures
Basic info:
S/S:
Tx:
Rehab/RTP: