Shoulder Injuries

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Shoulder Injuries
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Sternoclavicular Joint Sprain

• Mechanism
• Force applied to lateral aspect of shoulder
  (travels medially through clavicle)
• Force applied anterior or posterior to shoulder
• Stretching of SC ligament from direct or indirect
  force to joint
• Rare-traction force (i.e. uneven bars)

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• Signs and symptoms
• Point tenderness over SC joint
• Pain with active/passive stretch
• Loss of function
• Pain with protraction/retraction
• Dislocations tend to occur anterior or superior
• Although posterior can occur and is a medical
  emergency

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• Signs and Symptoms (cont.)
• Inflammation
• Hemorrhage
• Ecchymosis
• Deformity
• Instability (with 2nd,3rd degree)

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• Special Tests
• Active and resistive movements
• Passive stress
• Diagnostic Procedure
• Refer to ortho
• X-Ray
• If posterior emergent

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Acromioclavicular Joint Sprain

• Mechanisms
• Downward force on point of shoulder with arm
  adducted
• Blow to acromion process which drives scapula
  inferior
• Stretching of AC ligament due to direct or
  indirect force applied to joint

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AC Classification System

• I
• Slight partial damage to AC ligament, negative
  laxity, point tenderness
• II
• Rupture AC and partial CC, slight laxity
• III
• Complete AC and CC, dislocation distal
  clavicle/acromion
• IV, V, VI
• AC/CC/tearing deltoid/trap fascia

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• Signs and Symptoms
• Pain on A/P/RROM
• Loss of function
• Tenderness over AC joint
• Swelling
• Hemorrhage
• Ecchymosis
• Inflammation
• Step deformity

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• Signs and Symptoms (cont)
• Pain on shoulder abduction
• Pain on distraction of AC joint
• Abnormal motion of distal clavicle
• Deformity
• Instability (2nd and 3rd degree)

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• Special Tests
• Distraction (piano key)
• AC Traction/Compression
• Pain on Abduction
• A/R ROM
• Apleys scratch test
• Diagnostic Procedure
• Ortho
• X-Ray

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Subcoracoid glenohumeral luxation(dislocation)

• Mechanism
• Force applied to an abducted, ER arm above 90 deg
• Signs and symptoms
• Pain
• Loss of function
• Deformity
• Swelling
• Tenderness on anterior aspect of shoulder

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• Special Tests
• Check pulse
• Check sensation over axillary n.
• Diagnostic Procedure
• Refer to ortho
• X-ray

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Glenohumeral/subglenoid luxation(dislocation)

• Mechanism
• Force applied to an abducted arm
• Signs and Symptoms
• Pain
• Loss of function
• Marked deformity
• Swelling
• Pt. Tenderness
• Flattened deltoid

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• Special Tests
• Check pulse at wrist
• Check for sensory loss in arm and hand
• Diagnostic Procedure
• Refer to ortho
• X-ray

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Posterior Glenohumeral Luxation(dislocation)

• Mechanism
• Fall on outstretched arm
• Blow to the front of the shoulder
• Signs and Symptoms
• Pain
• Loss of function
• Marked deformity
• Swelling
• Pt. Tenderness

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• Special Tests
• Check pulse at wrist
• Check sensation of arm/hand
• Diagnostic Procedure
• Refer to ortho
• X-Ray

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Glenohumeral Instability

• Result of ligamentous or labral pathology
• Grade of severity is based on joint glide
  movements
• GH instability has a close relationship with
  pathological changes in RC

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Anterior Glenohumeral Instability

• Mechanism
• Acute
• Repetitive microtrauma involving ER when GH joint
  is abducted to 90 degrees

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Signs and symptoms

• Sensation of slipping out of place
• Increased laxity
• Positive apprehension/relocation test
• Increased anterior glide
• Flattened deltoid
• Diffuse pain
• Tenderness to anterior GH joint
• RC atrophy

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Special Tests

• Positive Apprehension
• Positive relocation sign
• Sulcus sign
• Glenohumeral translation

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Glenoid Labrum tear

• Mechanism
• Repetition of shoulder motion
• Acute Trauma
• Ant. Subluxation of glenohumeral jt.

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• Special tests
• Clunk test
• Resistive ROM
• Apprehension test
• Diagnostic
• Ortho
• MRI

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• Signs and symptoms
• Pain
• Loss of smooth shoulder motion
• Pop or snap on extended rotation
• Pain with ER at 90 deg of abduction
• Possible positive clunk test
• Pain with forced abduction
• Pain on forced horizontal adduction
• Weakness of RC

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Anterior Glenohumeral Subluxation

• Mechanism
• Leverage force applied to an abducted and ER arm
• Signs and Symptoms
• Pain
• Loss of function
• Sensation of shoulder slipping out of place

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• Signs and Symptoms (continued)
• Obvious deformity before reduction
• Spasm
• Positive apprehension test
• Head of humerus is palpable while slipping forward

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• Special Tests
• Apprehension test
• Relocation test
• Sulcus sign
• Glenohumeral translation
• Clunk test
• Diagnostic Procedure
• Refer to ortho

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Bankhart Lesion

• Inferior GH ligament may be avulsed along with a
  portion of the labrum
• Complains of pain/crepitus as humeral head moves
  against anterior labrum during GH glide testing

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Hills-Sach Lesion

• Common finding associated with anterior GH
  dislocation
• Small defect in posterior humeral heads
  articular cartilage
• Caused by impact of humeral head on glenoid fossa
  as humerus attempts to relocate

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Superior Labrum Anteroposterior Lesions

• Known as SLAP lesions
• Tear in superior glenoid labrum located near the
  attachment of the long head of biceps brachii
  tendon

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Rotator Cuff Impingement

• Mechanisms
• Decreased space in subacromial arch
• Structures beneath are impinged between acromion
  and humeral head
• Chronic microtrauma
• Vascular impairment
• Partial tear RC- altered mechanics
• Anatomic variation of arch

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• Signs and Symptoms
• Increase in pain from IR to ER
• Snapping sensation
• Loss of function
• Pain with overhead activity
• Painful arc
• Pain on superolateral aspect of shoulder

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• Signs and Symptoms (cont.)
• Pain on active abduction between 70 and 130
  degree
• Pain on extreme forward flexion with forearm
  supinated
• Pain on internal rotation with arm abducted at 90
  and forearm pronated

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• Special tests
• Impingement test (Neer and Hawkins)
• Forward Flexion test
• Empty can test
• RROM
• Diagnostic Procedure
• Ortho

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Rotator Cuff Tendinitis/Strain

• Mechanisms
• Trauma due to excessive forcible contraction or
  stretching
• Muscle fatigue
• Overuse
• Slow onset
• Decrease muscle balance between IR and ER
• Capsular laxity
• Poor vascularization of tendons
• Supraspinatus most commonly injured

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• Symptoms and Signs
• Pain with A/P/RROM
• Loss of function
• Snapping
• Tenderness
• Spasm
• Swelling
• Ecchymosis

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• Signs and Symptoms
• Pt. Tenderness over RC tendons
• Inflammation
• Hematoma formation
• Muscle defect
• Pain on abduction/ER/ and flexion of shoulder

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• Special Test
• Apleys scratch
• Impingement
• Drop Arm
• Forward Flexion
• Empty can
• Refer to Ortho

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Tenosynovitis of Shoulder

• Mechanism
• Overuse
• Direct or repeated trauma
• Poor throwing techniques
• Signs and symptoms
• Pain on A/P/RROM
• Loss of function
• Tenderness
• Swelling
• Thickening of tendon

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• Special Tests
• A/P/RROM
• Diagnostic Procedure
• Refer to ortho

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Bicep Tendon Pathology

• Biceps Tendinitis
• Luxation of bicep tendon
• Long Head of biceps rupture

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Bicep tendinitis

• Mechanism
• Irritation of biceps tendon in the groove
• Rotator cuff dysfunction
• Repeated microtrauma
• Overuse
• Degenerative changes
• impingement

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• Signs and symptoms
• Pain on P/A/RROM
• Loss of function
• Overuse activity
• Tenderness
• Errythema
• Swelling
• Inflammation
• Crepitus

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• Special Tests
• A/P/RROM
• RC muscle test
• Diagnostic Procedure
• Physician if symptoms persist

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Luxation of biceps tendon

• Mechanism
• Inadequate muscle development
• Overuse in throwing
• Tearing of transverse humeral ligament
• Shallow bicipital groove of humerus
• Faulty mechanics

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• Signs and Symptoms
• Pain in anterior aspect of shoulder
• Loss of shoulder function
• Snapping sensation followed by dull ache in arm
  or arm feeling dead
• Tenderness over bicipital groove
• Inflammation

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• Special Tests
• Yergason
• Speeds
• Ludington
• Diagnostic Procedure
• Refer to physician

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Long head of biceps rupture

• Mechanism
• Violent contraction against resistance
• Symptoms/signs
• Pain
• Loss of function
• Sensation of something rolling up arm
• Protruding bulge in biceps
• Tenderness along long head
• Loss of strength

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• Special Tests
• Ludingtons test
• Diagnostic Procedure
• Refer to ortho

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• Contusion of biceps
• Mechanism
• Direct Trauma
• Signs and Symptoms
• Pain
• Loss of elbow flexion and extension
• Transitory paralysis
• Pt. Tenderness
• Ecchymosis
• Hematoma Formation
• Inflammation

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• Special Tests
• A/P/RROM
• Diagnostic Procedures
• Refer if symptoms persist

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Exostosis/Myositis Ossificans

• Mechanism
• Repeated trauma (humerus)
• Signs and Symptoms
• Pain
• Point tenderness
• Possible paresthesia
• Swelling
• Loss of Function

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Proximal Humerus Epiphyseal Plate Injury

• Mechanism
• Direct trauma
• Indirect trauma traveling along length of humerus

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• Signs and Symptoms
• Sudden pain
• Tenderness
• Deformity
• Rapid Swelling
• Possible bony deviations
• Crepitus
• Ecchymosis

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Humerus Fracture

• Mechanism
• Direct trauma
• Fall on an outstretched arm
• Signs and Symptoms
• Sudden pain
• Loss of function
• Tenderness
• Deformity
• Rapid Swelling

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Axillary N. Injury

• Mechanism
• Direct trauma to lateral arm
• 2nd to anterior dislocated arm
• Signs and symptoms
• Loss of shoulder abduction
• Tenderness
• Loss of function of deltoid/biceps
• Dermatome numbness in area of middle Deltoid

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• Special Tests
• A/RROM for Deltoid
• Sensation testing for Deltoid
• Diagnostic Procedures
• Neurologist

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Subacromion Bursitis

• Mechanism
• Direct Trauma
• Overuse
• Fall on an outstretched hand
• RC impingement (i.e. stress from throwing)

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• Signs and Symptoms
• Similar to RC impingement
• Pain(at night/ ache with rest)
• Loss of function
• Tenderness
• Redness, swelling, inflammation
• Pain on rotation and/or abductiongt80 deg

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• Special Tests
• Appleys Scratch test
• Resistive movements
• Diagnostic
• Refer to physician

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Subdeltoid bursitis

• Mechanism
• Direct Trauma
• Fall on outstretched hand
• Overuse

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• Signs and Symptoms
• Pain
• Loss of function
• Tenderness(under deltoid)
• Redness, swelling, inflammation
• Pain and/or weakness on abduction

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• Special Tests
• Apleys scratch test
• Resistive movement tests
• Diagnostic
• Refer to physician

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Clavicle Contusion

• Mechanisms
• Direct trauma to clavicle
• Symptoms
• Pain
• Loss of Function
• Transitory paralysis
• Point tenderness
• Inflammation

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• Special Tests
• Distraction Test (rule out AC sprain)
• Diagnostic Procedure
• Refer to orthopedic surgeon
• XRay

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Deltoid Contusion

• Mechanism
• Direct Trauma
• Symptoms
• Pain
• Loss of function
• Point tenderness
• Transitory paralysis
• Weakness on shoulder abduction

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Long Thoracic N. Contusion (Winging Scapula)

• Mechanism
• Indirect trauma to lat. Thoracic wall or shoulder
• Overuse of shoulder
• Prolonged traction (i.e. cycling)
• Signs and symptoms
• Scapular winging (scapula protrudes posteriorly)
• Dull ache around shoulder girdle
• Decrease motion with shoulder movement

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• Special Tests
• Scapula protraction test
• Pushing against a wall will cause winging effect
• Diagnostic Procedure
• Physician
• EMG study (Electromyography)

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Thoracic Outlet Syndrome

• Mechanism
• Pressure on medial cord of brachial plexus,
  subclavian artery a/o subclavian vein
  (neurmuscular bundle)
• Cervical rib
• Pect minor/scalene tightness
• Pressure on neurovascular bundle as it runs
  between clavicle and first rib

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Signs and Symptoms

• Neurological
• C8-T1 medial because of closeness to 1t rib,
  ulnar n, occasionally median n.
• Vascular
• Vein-swelling
• Artery-decreased blood flow

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• Tests
• Adsons
• Allen
• Costoclavicular (military brace)

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Clavicle Fracture

• Fracture collar bone
• Mechanisms
• Fall on outstretched arm
• Direct contact

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• Signs and Symptoms
• Sudden pain
• Tenderness(direct /indirect)
• Loss of shoulder function
• Deformity(rapid swelling/bony deviation)
• Head tilt towards side of fracture
• Crepitus

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• Signs and symptoms (cont.)
• False joint motion
• Delayed ecchymosis
• Head tilted toward side of fracture
• Rounded shoulder
• Athlete may be supporting affected elbow with
  opposite hand
• Refer to ortho/X-ray

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Scapula Fracture

• Mechanism
• Direct trauma
• Indirect trauma from fall (on shoulder or arm)
• Signs and Symptoms
• Sudden pain
• Loss of function
• Tenderness (direct/indirect)
• Possible crepitus

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• Signs and Symptoms (cont.)
• Rapid Swelling
• Bony deviations
• Crepitus
• False Joint Motion
• Delayed Ecchymosis
• Refer to ortho/X-Ray

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Proximal humerus Epiphyseal plate Injury

• Mechanisms
• Direct trauma
• Indirect along shaft
• Signs and symptoms
• Pain
• Loss of function
• Deformity
• Swelling
• Crepitus
• False joint

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Blockers Extosis

• Myositis Ossificans
• Mechanisms
• Repetitive trauma to humerus
• Signs and symptoms
• Pain
• Pt. Tenderness
• Bony prominence
• Swelling
• Loss of function-elbow flexion/extension

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Humerus Fracture

• Mechanism
• Direct trauma from fall/external force
• Signs and Symptoms
• Pain
• Loss of function
• Deformity- shortened humerus
• Swelling
• False joint motion

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Triceps strain

• Mechanism
• Excessive forcible contraction or stretching
• Muscle fatigue
• Signs and symptoms
• Tests