1. The Shoulder Unit 16

2. Upper Extremity Injuries
Upper extremities are vulnerable to a variety of injuries depending on the sport, including:
Sprains
Strains
Dislocations
Fractures

3. Upper Extremity Injuries
Upper extremities are vulnerable to a variety of injuries depending on the sport, including:
Separations to the thoracic cage, shoulder, arm, and hand
Repetitive motion injuries such as arthritis, bursitis, tendonitis

4. Shoulder Complex Physiology
Bones
Muscles
Tendons
Ligaments
Articulations

5. Bones
Humerus
Scapula
Clavicle

9. THE JOINTS Sternoclavicular joint (SC joint) Coracoclavicular joint
Sternoclavicular ligament
Coracoclavicular joint
Coracoclavicular ligament
Acromioclavicular joint (AC joint)
Acromioclavicular ligament
Coracoacromial joint
Coracoacromial ligament

10. Scapulothoracic articulation
Glenohumeral joint
Glenohumeral ligaments
Scapulothoracic articulation

14. Muscles in motion FLEXION Anterior deltoid Biceps brachii
Primary mover
Biceps brachii
Secondary mover

15. EXTENSION
Posterior deltoid
Prim. Mover
Triceps brachii
Sec. Mover

16. ABDUCTION Supraspinatus Middle deltoid Trapezius 1st 5-10 degrees
Last 90 degrees
Trapezius
Assists in movement above 90 degrees

17. ADDUCTION
Latissimus dorsi
Pectoralis major

18. HORIZONTAL FLEXION
Pectoralis major
Anterior deltoid

19. HORIZONTAL EXTENSION Posterior deltoid Infraspinatus Teres minor/major
Rhomboids
Trapezius
Stabilizer

20. CIRCUMDUCTION
Basically all muscles of the shoulder

21. INTERNAL ROTATION Subscapularis Pectoralis major EXTERNAL ROTATION
Little help
EXTERNAL ROTATION
Infraspinatus
Teres minor/major

22. Scapular Elevation
Scapular Depression
Scapular protraction
Scapular retraction
****find muscles that perform these motions

25. Assessing Shoulder InjuriesP S

26. History What is the cause of pain? Mechanism of injury?
Previous history?
Location, duration and intensity of pain?
Creptitus, numbness, distortion in temperature
Weakness or fatigue?
What provides relief?

27. Observation Elevation or depression of shoulder tips
Position and shape of clavicle
Acromion process
Biceps and deltoid symmetry
Postural assessment (kyphosis, lordosis, shoulders)
Position of head and arms
Scapular elevation and symmetry
Scapular protraction or winging
Muscle symmetry
Scapulohumeral rhythm

28. Palpation
Bony structure palpation should occur bilaterally and simultaneously if possible
Palpate soft tissue structures for point tenderness, swelling, spasms, lumps, guarding or trigger points
Be sure to palpate anteriorly and posteriorly

29. Special Tests ROM test for external rotation of the shoulder
ROM test for internal rotation of the shoulder
Specific ROM tests for the shoulder
including abduction, adduction, flexion, extension,
horizontal adduction, horizontal abduction

30. Manual muscle tests for the shoulder
External rotation strength tests
Internal rotation strength test for the shoulder
Extension strength test for the shoulder
Flexion strength test for the shoulder
Abduction and adduction strength tests for the shoulder
Empty can test

31. Apprehension test (Crank test)
Apprehension test used for anterior glenohumeral instability
This motion should not be forced

32. Test for Shoulder Impingement
Neer’s test and Hawkins-Kennedy test for impingement used to assess impingement of soft tissue structures
Positive test is indicated by pain and grimace

33. Test for Supraspinatus Weakness
Empty Can Test
90 degrees of shoulder flexion, internal rotation and 30 degrees of horizontal abduction
Downward pressure is applied
Weakness and pain are assessed bilaterally

34. Types of Shoulder Injuries
Fractures
Clavicle, humerus, scapula
Cause: fall on outstretched arm, direct blow
S/S: pain, deformity, decreased ROM, swelling
Perform percussion test, compression test

35. Treatment Prevention: Sling/splint PRICE Physcian/EMS Follow orders
Instruct how to fall
Proper equipment

38. Hockey Clavicle Fracture

41. Dislocations and subluxations
AC, SC, GH jts
Cause: head of humerus forced/displaced from glenoid
S/S: pop, dead arm, pain, deformity, swelling, loss of ROM/strength

42. Treatment Prevention DO NOT relocated PRICE
Check circulation/sensation
Physician / x-rays
Follow orders
Prevention
Strengthen jt
Proper equipment
Falling

44. Anterior Posterior

45. Posterior

47. Shoulder dislocation-rugby
Dwayne Wade

48. Contusions Myositis ossificans Cause: direct blow/bony area or muscles
S/S: pain, decreased ROM, r/o other injuries
Treatment: ice, padding, rehab, flexibility
Prevention: proper equipment, mechanics
Myositis ossificans

49. Sprains Cause: over stretch/tear ligament, capsule
What motions/events would cause this?
S/S: pt tender, weak, swelling, instability, possible deformity, decreased ROM
Treatment
PRICE
Physician, follow orders
Rehab
Prevention
Proper equipment/technique
Strengthening/stretching
Inspect playing areas
Taping/bracing

50. Sternoclavicular Sprain
Cause of Injury
Indirect force, blunt trauma (may cause displacement)
Signs of Injury
Grade 1 - pain and slight disability
Grade 2 - pain, subluxation w/ deformity, swelling and point tenderness and decreased ROM
Grade 3 - gross deformity (dislocation), pain, swelling, decreased ROM
Possibly life-threatening if dislocates posteriorly
Care
PRICE, immobilization
Immobilize for 3-5 weeks followed by graded reconditioning

51. Acromioclavicular Sprain
Cause of Injury
Result of direct blow (from any direction), upward force from humerus, fall on outstretched arm
Signs of Injury
Grade 1 - point tenderness and pain w/ movement; no disruption of AC joint
Grade 2 - tear or rupture of AC ligament, partial displacement of lateral end of clavicle; pain, point tenderness and decreased ROM (abduction/adduction)
Grade 3 - Rupture of AC and CC ligaments with dislocation of clavicle; gross deformity, pain, loss of function and instability

52. Care Ice, stabilization, referral to physician
Grades 1-3 (non-operative) will require 3-4 days (grade 1) and 2 weeks of immobilization ( grade 3) respectively
Aggressive rehab is required w/ all grades
Joint mobilizations, flexibility exercises, & strengthening should occur immediately
Progress as athlete is able to tolerate w/out pain and swelling
Padding and protection may be required until pain-free ROM returns

53. Specific tests
Sulcus test, apprehension test for sprain of the anterior capsule
Acromioclavicular (AC) sprain test
Sternoclavicular (SC) sprain test

54. Types of Shoulder Injuries
Strains
Cause: overstretching of muscles
S/S: similar to sprains
Treatment: PRICE, physician if necessary, follow orders, rehab
Prevention
Stretching, strengthening
Drop arm test-specific test

55. What do you see?
L clavicle elevation, bruising, left shoulder higher
What do you think the injury is?
Grade 2 AC sprain, left. Bull rider

56. Impingement
Cause: pinching of soft tissue w/overhead activity; overuse
S/S: pain, weakness, pt tenderness
Hawkins-Kennedy test, winged scapula test
Treatment
PRICE, decrease inflam., physician
Strengthen RC, scapular stabilizers
Prevention
RC strengthening, proper mechanics

58. Rotator cuff tear Signs of Injury
Involves supraspinatus or rupture of other rotator cuff tendons
Primary mechanism - acute trauma (high velocity rotation)
Occurs near insertion on greater tuberosity
Full thickness tears usually occur in those athletes w/ a long history of impingement or instability (generally does not occur in athlete under age 40)
Signs of Injury
Present with pain with muscle contraction
Tenderness on palpation and loss of strength due to pain
Loss of function, swelling
With complete tear, impingement and empty can test are positive

59. Care RICE for modulation of pain
Progressive strengthening of rotator cuff
Reduce frequency and level of activity initially with a gradual and progressive increase in intensity

60. Shoulder Bursitis Etiology Signs of Injury Management
Chronic inflammatory condition due to trauma or overuse - subacromial bursa
May develop from direct impact or fall on tip of shoulder
Signs of Injury
Pain w/ motion and tenderness during palpation in subacromial space; positive impingement tests
Management
Cold packs and NSAID’s to reduce inflammation
Remove mechanisms precipitating condition
Maintain full ROM to reduce chances of contractures and adhesions from forming

61. Bicipital Tenosynovitis
Cause of Injury
Repetitive overhead athlete - ballistic activity that involves repeated stretching of biceps tendon causing irritation to the tendon and sheath
Signs of Injury
Tenderness over bicipital groove, swelling, crepitus due to inflammation
Pain when performing overhead activities
Care
Rest and ice to treat inflammation
NSAID’s
Gradual program of strengthening and stretching

62. Types of Shoulder Injuries
Tendonitis
Cause: overuse to tendons
Speed’s test
Treatment: PRICE, anti-inflammatory, rehab, etc
Prevention:
Ice post activity, conditioning, mechanics,

63. Synovitis and bursitis
Cause: inflammation of synovial lining/bursa
Overuse, direct trauma
S/S: pain, crepitus, swelling, decreased mobility
Treatment: PRICE or heat, stretching pain free ROM, mechanics, etc
Prevention: mechanics