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. Functional Anatomy Scapulohumeral Rhythm
Movement of scapula relative to the humerus
Initial 30 degrees of G-H abduction
Does not incorporate scapular motion
Setting phase
30 to 90 degrees of G-H abduction
Scapula abducts and upwardly rotates 1 degree for every 2 degrees of humeral elevation
Above 90 degrees of G-H abduction
Scapula and humerus move in 1:1 ratio

13. 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

14. Assessment of the Shoulder
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?

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

16. Palpation: Bony Tissue
Sternoclavicular joint
Clavicular shaft
Acromioclavicular joint
Coracoid process
Acromion process
Humeral head
Greater and lesser tuberosity
Bicipital groove
Spine of scapula
Scapular vertebral border
Scapular lateral border
Scapular superior angle
Scapular inferior angle

17. Palpation: Soft Tissue
Glenohumeral joint capsule
Deltoid
Rhomboids
Latissimus dorsi
Serratus Anterior
Levator scapulae
Trapezius
Supraspinatus
Infraspinatus
Teres major and minor
Sternoclavicular, acromioclavicular, and coracoclavicular ligaments
Rotator cuff muscles and tendons
Subacromial bursa
Sternocleidomastoid
Biceps and tendon
Coracoacromial ligament

18. Special Tests Active, Passive, and Resistive ROM Manual Muscle Testing
Flexion and extension
Abduction and adduction
Internal and external rotation
Manual Muscle Testing
Shoulder muscles and scapular stabilizers
RROM and Break tests

19. Special Tests: SC Joint Instability
Assesses sternoclavicular joint instability
Athlete in seated position
Apply pressure to the SC joint anteriorly, superiorly, and inferiorly
Determine stability or pain associated with a joint sprain

20. Special Tests: AC Joint Instability
Assesses acromioclavicular joint instability
Athlete in seated position
Palpate for displacement of acromion and distal head of clavicle
Apply pressure in all 4 directions
Determine stability or pain associated with a joint sprain

21. Special Tests: GH Joint Instability
Assesses glenohumeral joint instability
Special tests
Anterior and Posterior Drawer Tests
Sulcus Test
Clunk Test
Anterior and Posterior Apprehension Tests
Relocation Test

22. Anterior and Posterior Drawer Tests

23. Sulcus Test

24. Clunk Test

25. Anterior and Posterior Apprehension Tests
Anterior Apprehension Test
Posterior Apprehension Test

26. Relocation Test
Uses external rotation and posteriorly directed pressure to allow for increased external rotation

27. Special Tests: Impingement
O’Brien Test (Active Compression Test)
Flexion of GH joint to 90 degrees and horizontally adduction to 15 degrees
Passively place humerus into full IR and ER
If pain results with internal rotation but decreases with external rotation and if clicking is present, possible SLAP lesion
Pain in AC joint may indicate AC joint pathology

28. Special Tests: Impingement
Neer’s Test
Assesses impingement of soft tissue structures
Positive test is indicated by pain and grimace

29. Special Tests: Impingement
Hawkins-Kennedy Test
Assesses impingement of soft tissue structures
Positive test is indicated by pain and grimace

30. Special Tests: Rotator Cuff
Drop Arm Test
Assesses supraspinatus muscle weakness or tears
Athlete abducts shoulder and gradually lowers to starting position
Inability to lower arm slowly and controlled will indicate torn supraspinatus

31. Special Tests: Rotator Cuff
Empty Can Test
Place shoulder in position of 90 degrees of shoulder flexion, IR, and 30 degrees of horizontal abduction
Apply downward pressure
Assesses supraspinatus muscle weakness or tears

32. Special Tests: Serratus Anterior
Wall Push-up
Observe for winging scapula
Assesses for serratus anterior weakness
Could indicate injury to long thoracic nerve

33. Special Tests: Biceps Yergason’s Test Speed’s Test Ludington’s Test
Determines presence of biceps irritation and possible subluxation of biceps tendon
Speed’s Test
Ludington’s Test
Assesses for possible rupture of biceps
Palpate alternating contractions of each biceps

34. Special Tests: Thoracic Outlet Syndrome
Adson’s Test
Assesses for anterior scalene syndrome
Compression of subclavian artery by scalenes
Athlete looks toward extended arm and takes a deep breath
Palpate radial pulse
Disappearance of pulse indicates a positive test

35. Special Tests: Thoracic Outlet Syndrome
Roo’s Test
Assesses for costoclavicular syndrome
Compression of subclavian artery between clavicle and first rib
Athlete assumes military brace position and turns head in opposite direction
Athlete opens and closes hand for 3 minutes Palpate radial pulse
Test is positive if…
Pulse disappears
Grip strength decreases

36. Special Tests: Thoracic Outlet Syndrome
Allen’s Test
Assesses for hyperabduction syndrome
Determines if pressure from pectoralis minor is compressing brachial plexus and subclavian artery

37. 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

38. 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

40. 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

41. 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

42. 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

43. Specific Injuries Sternoclavicular Sprain Etiology Signs and Symptoms
MOI = indirect force or blunt trauma
Signs and Symptoms
Grade 1 - pain and slight disability
Grade 2 - pain, subluxation deformity, swelling, point tenderness, and decreased ROM
Grade 3 - gross deformity (dislocation), pain, swelling, and decreased ROM
Possibly life-threatening if dislocates posteriorly

44. Specific Injuries Sternoclavicular Sprain (continued) Management RICE
Refer for reduction if necessary
Immobilize for 3-5 weeks
After immobilzation period, begin PRE exercises

45. 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

46. 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

47. 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

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

49. 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

50. 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)

51. 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

52. 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

53. 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

54. Possible Complications of Shoulder Dislocations
Bankart lesion
Permanent anterior defect of labrum
Hill Sachs lesion
Caused by compression of cancellous bone against anterior glenoid rim creating a divot in the humeral head
SLAP lesion
Defect in superior labrum that begins posteriorly and extends anteriorly impacting attachment of long head of biceps on labrum

55. Brachial nerves and vessels may be compromised
Rotator cuff injuries
Fractures
Bicipital tendon subluxation
Transverse ligament rupture

56. Specific Injuries Chronic Recurrent Instabilities Etiology
MOI = traumatic, microtraumatic (repetitive overuse), atraumatic, congenital, and neuromuscular
As supporting tissue become more lax, mobility increases
Results in damage to other soft tissue structures

57. Specific Injuries Chronic Recurrent Instabilities (continued)
Signs and Symptoms
Anterior - may have clicking or pain; complain of dead arm during cocking phase (when throwing); pain posteriorly; possible impingement; positive apprehension test
Posterior - possible impingement; loss IR; crepitation; increased laxity; pain anteriorly and posteriorly
Multidirectional - inferior laxity; positive sulcus sign; pain and clicking with arm at side; possible signs and symptoms associated with anterior and posterior instability

58. Chronic Recurrent Instabilities (continued)
Management
Conservative treatment involves extensive strengthening of the rotator cuff and scapula stabilizers
Should be pursued before surgery is considered
Avoid joint mobilizations and ROM exercises
Various braces can be used to limit motion
Surgical stabilization may be required to improve function and comfort

59. 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

61. 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

62. Neer’s progressive stages of shoulder impingement…
Stage I
Result of supraspinatus or biceps tendon injury
Presents with point tenderness; pain with ABD and resisted supination with external rotation; edema; thickening of rotator cuff and bursa
Occurs in athletes < 25 years old

63. Neer’s progressive stages of shoulder impingement…
Stage II
Permanent thickening and fibrosis of supraspinatus and biceps tendon
Presents with aching during activity that worsens at night
May experience restricted arm motion

64. Neer’s progressive stages of shoulder impingement…
Stage III
History of shoulder problems and pain
Tendon defect (less than 3/8 of an inch) or possible muscle tear
Permanent scar tissue and thickening of rotator cuff
Occurs in athletes years old

65. Neer’s progressive stages of shoulder impingement…
Stage IV
Infraspinatus and supraspinatus atrophy
Presents with pain during ABD, limited AROM and PROM, weak RROM
Tendon defect (greater than 3/8 of an inch)
Clavicle degeneration

66. 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

67. 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

68. Specific Injuries Shoulder Bursitis Etiology Signs and Symptoms
Chronic inflammatory condition resulting from fibrosis or fluid build-up
MOI = direct trauma or overuse
Usually occurs in the subacromial bursa
Signs and Symptoms
Pain with motion, pain during palpation of subacromial space
Positive impingement tests

69. Shoulder Bursitis Management Reduce inflammation
Cold, ultrasound, NSAID’s
Remove mechanisms precipitating condition
Maintain full ROM to reduce the risk of contractures and adhesions forming

70. Specific Injuries Frozen Shoulder (Adhesive Capsulitis) Etiology
Contracted and thickened joint capsule with little synovial fluid
Chronic inflammation resulting in contracted, inelastic rotator cuff muscles
Signs and Symptoms
Pain in all directions both with AROM and PROM
Patient resists moving the shoulder due to pain

71. Specific Injuries Frozen Shoulder (continued) Management
Aggressive joint mobilizations
Stretching of tight musculature
Electrical stimulation for pain control
Ultrasound for deep heating

72. 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

73. 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)

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

75. 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

76. 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

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

78. 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

79. Specific Injuries Peripheral Nerve Injuries Etiology
MOI = blunt trauma or overstretching-type injuries
Signs and Symptoms
Constant pain, muscle weakness, paralysis, or atrophy
Management
RICE
Transient muscle weakness may occur
If muscle atrophy occurs, referral to a physician is necessary

80. 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

81. Rehabilitation of the Shoulder
Joint Mobilizations
Used to re-establish appropriate joint arthrokinematics
Used if joint capsule tightness is present

82. Rehabilitation of the Shoulder
Flexibility
Codman’s pendulum exercises should begin early
Progress to Active Assisted ROM in pain free range
Cardinal planes

84. Rehabilitation of the Shoulder
Strengthening Exercises
Should include rotator cuff and scapula stabilizers

86. Rehabilitation of the Shoulder
Neuromuscular Control
Must regain appropriate firing sequence for specific muscles (scapulohumeral rhythm)
Biofeedback can be used to regain control
Proprioception
Closed kinetic chain exercises will be required in gymnasts, wrestlers, and weight lifters
Emphasize co-contraction muscle activity

88. Rehabilitation of the Shoulder
Functional Progressions
Incorporation of sports specific skills
Strengthening that involves PNF patterns
Throwing motion
Return to Activity
Based on pre-established criteria
Functional performance testing
Objective measures of strength and performance