Chapter 22: The Shoulder Complex

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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

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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

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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

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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 11 ratio

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Specific Injuries

• Clavicular Fractures
• Etiology
• 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

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• 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

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Specific Injuries

• Scapular Fractures
• Etiology
• 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

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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

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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

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Specific Injuries

• Sternoclavicular Sprain
• Etiology
• 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

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Specific Injuries

• Sternoclavicular Sprain (continued)
• Management
• RICE
• Refer for reduction if necessary
• Immobilize for 3-5 weeks
• After immobilization period, begin PRE exercises

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Specific Injuries

• Acromioclavicular Sprain
• Etiology
• MOI direct blow (from any direction) or upward
  force from the humerus
• Graded from 1 - 6 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

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• 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

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• 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

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• A Grade 1
• B Grade 2
• C Grade 3
• D Grade 4
• E Grade 5
• F Grade 6

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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

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Specific Injuries

• Glenohumeral Joint Sprain (continued)
• Management
• RICE for 24-48 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)

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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

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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

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• 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

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Possible Complications of Shoulder Dislocations

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

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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

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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

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• 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

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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

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• 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

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Neers 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 lt 25 years old

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Neers 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

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Neers 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 25 - 40 years old

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Neers 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

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Specific Injuries

• Rotator cuff tear
• Etiology
• 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

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• Rotator cuff tear (continued)
• Management
• NSAIDs 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

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Specific Injuries

• Shoulder Bursitis
• Etiology
• 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

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• Shoulder Bursitis
• Management
• Reduce inflammation
• Cold, ultrasound, NSAIDs
• Remove mechanisms precipitating condition
• Maintain full ROM to reduce the risk of
  contractures and adhesions forming

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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

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Specific Injuries

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

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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

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• 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)

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Specific Injuries

• Biceps Brachii Rupture
• Etiology
• Generally occurs near origin of muscle at
  bicipital groove
• MOI powerful contraction

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• 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

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Specific Injuries

• Bicipital Tenosynovitis
• Etiology
• 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

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• Bicipital Tenosynovitis (continued)
• Management
• Rest, ice, and ultrasound to treat inflammation
• NSAIDs
• Gradual program of strengthening and stretching

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Specific Injuries

• Contusion of Upper Arm
• Etiology
• 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

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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