1. 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

2. Introduction
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

10. 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

11. Prevention of Shoulder Injuries
Proper physical conditioning is key
Sport-specific conditioning
Strengthen through a full ROM
Warm-up should be used before explosive arm movements are attempted
Contact and collision sport athletes should receive proper instruction on falling
Protective equipment
Proper mechanics

12. Specific Injuries Clavicular Fractures Etiology Signs and Symptoms
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

13. 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

15. Specific Injuries Scapular Fractures Etiology Signs and Symptoms
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

16. 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

17. 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

18. Specific Injuries Acromioclavicular Sprain Etiology Signs and Symptoms
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

19. 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

20. Acromioclavicular Sprain (continued)
Management
Ice, sling and swathe
Referral to physician
Grades 1 – 3: non-operative treatment
1 - 2 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

21. A: Grade 1
B: Grade 2
C: Grade 3
D: Grade 4
E: Grade 5
F: Grade 6

22. Specific Injuries 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

23. 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)

24. 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

25. 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

26. 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

27. Specific Injuries 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

29. 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

30. Specific Injuries Rotator cuff tear Etiology Signs and Symptoms
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

31. 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

32. 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

33. 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)

34. Specific Injuries Biceps Brachii Rupture Etiology
Generally occurs near origin of muscle at bicipital groove
MOI = powerful contraction

35. 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

36. Specific Injuries Bicipital Tenosynovitis Etiology Signs and Symptoms
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

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

38. Specific Injuries Contusion of Upper Arm Etiology Signs and Symptoms
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

39. Rehabilitation of the Shoulder
Immobilization
Will vary depending on injury
Time in brace or splint are injury specific
Isometrics can be performed
ROM and strengthening are dictated by healing
General Body Conditioning
Maintain cardiovascular endurance through cycling, running, and walking