Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Conditions Chapter 14

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Shoulder ConditionsShoulder Conditions

Chapter 14


Shoulder ComplexShoulder Complex

• Extremely mobile; minimal stability

• Joints

– Sternoclavicular joint

– Acromioclavicular joint

– Coracoclavicular joint

– Scapulothoracic joint

– Glenohumeral joint


Shoulder Complex (cont.)Shoulder Complex (cont.)



• Sternoclavicular joint– Superior sternum with

the proximal clavicle• Joint capsule and

ligaments• Ball-and-socket joint



• Acromioclavicular joint (AC)– Acromion process of scapula with distal end of

clavicle– Irregular joint; permits movement in all 3 planes– Capsule; minimal stability ligaments; strong

stabilizers• Superior and inferior AC ligament• Coracoclavicular ligament


Shoulder Complex (cont.)Shoulder Complex (cont.)• Coracoclavicular joint

– Coracoid process of scapula with the inferior surface of clavicle

• Coracoclavicular ligament

– Minimal movement permitted



• Scapulothoracic joint– Muscles attached to scapula permit its motion

with the trunk and thorax– Functions of scapular muscles

• Stabilization of shoulder region• Facilitate movement of upper extremity

through appropriate positioning of glenohumeral joint



• Glenohumeral joint

– Glenoid fossa of scapula with the head of the humerus

– Most ROM of any joint in body, but poor stability

• Head has greater surface area than fossa

• Shallow fossa (glenoid labrum)



• Glenohumeral joint (cont.)

– Joint capsule and ligaments

• Superior, middle, and inferior glenohumeral ligaments (anterior)

• Coracohumeral ligament (superior)

– Rotator cuff muscles (SITS)

• Tendons form a collagenous cuff around joint

• Tension helps hold the head against the glenoid fossa


Shoulder MusclesShoulder Muscles


Shoulder MusclesShoulder Muscles


BursaBursa

• Subacromial bursa

– Lies in subacromial space

– Cushions rotator cuff muscles from acromion (especially supraspinatus)

– Compressed during overhead arm action

• Subcoracoid; subscapularis


NervesNerves

• Brachial plexus innervates upper extremity


Blood VesselsBlood Vessels

• Subclavian; axillary—several branches


KinematicsKinematics

• Movement in 3 planes

– Sagittal

• Flexion and extension

– Frontal

• Abduction and adduction

– Transverse

• Medial rotation and lateral rotation


Kinematics (cont.)Kinematics (cont.)• Throwing motion

– Wind-up– Stride– Cocking phase

• From foot contact until maximum shoulder external rotation

– Acceleration phase• From maximum shoulder external

rotation until ball release– Deceleration and follow-through

phase• From ball release until maximum

shoulder internal rotation and balanced position is achieved


Kinematics (cont.)Kinematics (cont.)

• Scapulohumeral rhythm

– Coordinated movement of the scapula needed to facilitate motion of the humerus


KineticsKinetics

• Glenohumeral joint sustains much greater loads than other shoulder joints

• Throwing motion critical instances

– Cocking phase

– After ball release


Prevention of Shoulder ConditionsPrevention of Shoulder Conditions

• Protective equipment

– Shoulder pads

• Physical conditioning

– Flexibility

– Strength

• Proper skill technique

– Throwing motion

– Proper falling technique


Sternoclavicular (SC) SprainSternoclavicular (SC) Sprain

• MOI– Indirect force through

humerus– Blow to the clavicle

• Displacement: superior and anterior

• S&S– 2: unable to horizontally

adduct; holds arm forward and close to body

– 3: prominent displacement of proximal clavicle

• Management: physician referral; immobilization


Sternoclavicular (SC) Sprain (cont.)Sternoclavicular (SC) Sprain (cont.)

• Posterior SC sprain– Difficulty swallowing; diminished pulse;

respiratory distress– Management: activate EMS


Acromioclavicular (AC) SprainAcromioclavicular (AC) Sprain

• MOI– Direct blow– Fall on point of shoulder– Fall on outstretched arm

• Type I: mild stretching of ligaments– Discomfort on abduction >90– Mild point tender over joint line


Acromioclavicular (AC) Sprain (cont.)Acromioclavicular (AC) Sprain (cont.)

• Type II – rupture of AC ligaments– + displacement; step off deformity– Unable to abduct through ROM; pain with horizontal

adduction– Pain with downward pressure on distal clavicle– Stability: vertical maintained; sagittal plane compromised


Acromioclavicular (AC) Sprain (cont.)Acromioclavicular (AC) Sprain (cont.)• Type III – rupture of AC ligaments and

coracoclavicular ligament

– Demonstrable instability

– Pain on palpation and depression of acromion process

• Types IV–VI

– Caused by more violent forces

– Extensive mobility due to tear of deltoid and trapezius attachment at distal clavicle

• Management

– Type III: controversial


Glenohumeral SprainGlenohumeral Sprain• MOI

– Forceful abduction– Forceful abduction and

external rotation • Joint capsule stretches or tears;

humeral head moves in an anterior inferior direction

• S&S– 1: AROM – slight limitation– 2: swelling, ecchymosis,

decreased ROM, especially abduction

• Management – Standard acute care– Pain-free ROM initiated early


Glenohumeral InstabilityGlenohumeral Instability• Anterior

– MOI• Blow to posterolateral shoulder• Indirect force with shoulder in abduction, external

rotation, and extension– Involves middle and inferior glenohumeral ligament

• Posterior– MOI: posterior forces with humerus in flexion and

internal rotation– More often due to repeated microtrauma


Glenohumeral Instability (cont.)Glenohumeral Instability (cont.)

• Inferior• Multidirectional instability (MDI)

– Damage in more than one plane– Can significantly alter joint mechanics


Glenohumeral DislocationGlenohumeral Dislocation• Anterior

– Intense pain; recurrent: less painful

– Tingling and numbness down arm

– Arm held in slight abduction and external rotation; stabilized against body by opposite hand

– Deformity – Individual will not permit

passive horizontal adduction or internal rotation

– Check pulse and sensation– + tests: apprehension,

distraction (sulcus sign), and clunk


Glenohumeral Dislocation (cont.)Glenohumeral Dislocation (cont.)• Posterior

– Pain radiating to tip of shoulder

– Arm carried tightly against chest and across the front of the trunk (rigid adduction and internal rotation)

– Side view:

• Anterior shoulder appears flat

• Coracoid process becomes prominent

• Possible posterior bulge (or could be hidden in deltoid)

– Attempt to abduct and externally rotate causes severe pain

– Unable to supinate forearm


Glenohumeral Dislocation (cont.)Glenohumeral Dislocation (cont.)

• Hill-Sachs lesion

– Defect in the articular cartilage of the humeral head

– Caused by the impact of the humeral head on the glenoid fossa as the humerus dislocates


Glenohumeral Dislocation (cont.)Glenohumeral Dislocation (cont.)• Management

– First-time dislocation – activate EMS

– Immobilize in a comfortable position

– If possible, apply sling

• Chronic dislocations

– Problem of reoccurrence

• Less force needed

• Less spasm, pain, swelling

• Sensation of arm going “dead”

– S&S: pain with crepitation and clicking after reduction; reduction often self-induced


Glenoid Labrum TearsGlenoid Labrum Tears• Bankart lesion

– Damage to the anterior lip of the glenoid labrum

– Associated with anterior dislocation or degeneration and aging

• SLAP lesion

– Involves superior labrum and disruption of the attachment of the long head of the biceps tendon


Glenoid Labrum Tears (cont.)Glenoid Labrum Tears (cont.)

• S&S

– Pain, catching, or weakness with arm overhead in abduction and external rotation

– Clicking or popping

– Symptoms reproduced with ROM and translation testing, especially clunk and compression rotation

– + Speed and Yergason's tests

• Management: poor response to conservative treatment; arthroscopic debridement


Overuse InjuriesOveruse Injuries

• Culprit – repetitive overhead activities

– Joint forces: shear and compression

– Deltoid vs. rotator cuff – force couple action


Rotator Cuff/ImpingementRotator Cuff/Impingement• Rotator cuff (primarily

supraspinatus)

– Partial tear more likely in young; total tear: adults over age 30

• Impingement syndrome

– Abutment of rotator cuff and subacromial bursa against the coracoacromial ligament and greater tubercle of the humerus


Rotator Cuff/Impingement (cont.)Rotator Cuff/Impingement (cont.)

• Contributing factors

– Repetitive overhead movement (overuse)

– Limited subacromial space under coracoacromial arch and limited flexibility of coracoacromial ligament

– Supraspinatus and biceps brachii tendon

• Thickness

• Lack of flexibility and strength

– Posterior cuff muscles

• Weakness

• Tightness


Rotator Cuff/Impingement (cont.)Rotator Cuff/Impingement (cont.)

– Hypermobility of the shoulder joints

– Imbalance in muscle strength, coordination, and endurance of the scapular muscles

– Shape of the acromion

– Training devices (e.g., use of hand paddles, tubing)


Rotator Cuff/Impingement (cont.)Rotator Cuff/Impingement (cont.)• S&S

– “Deep” pain– Painful arc: between 70° and 120°– Unable to sleep on involved side– Potential + tests:

• Drop arm• Empty can• Neer shoulder impingement• Anterior impingement

• Stages of impingement syndrome• Management: restrict motion


BursitisBursitis• Subacromial bursa

– S&S

• Sudden shoulder pain: initiation and acceleration phase of throwing

• Point tenderness on anterior and lateral edges of acromion process

• Painful arc during passive abduction

• Pain sleeping on involved side

– Management: physician referral


Bicipital TendinitisBicipital Tendinitis

• Etiology

– Repetitive overhead activities involving excessive elbow flexion and supination; tendon passes back and forth in groove

– Direct blow

– Subsequent to impingement syndrome


Bicipital Tendinitis (cont.)Bicipital Tendinitis (cont.)• S&S

– Pain with interior and exterior rotation of shoulder

– Pain with passive stretch in extreme shoulder extension with elbow extended and forearm pronated

– + tests: Yergason’s, Speed’s

• Management: restriction of rotational activities that exacerbate symptoms


Biceps Tendon RuptureBiceps Tendon Rupture• Etiology

– Prolonged tendinitis makes tendon vulnerable

– Forceful flexion against resistance

• S&S

– Hear and feel a snap

– Intense pain

– Visible palpable defect in muscle belly during flexion; “Popeye” appearance if mass moves distally

– Weakness: flexion and supination of forearm

• Management: immediate physician referral


Thoracic Outlet Compression SyndromeThoracic Outlet Compression Syndrome• Nerves and/or vessels become

compressed in the proximal neck or axilla


Thoracic Outlet Compression Syndrome (cont.)Thoracic Outlet Compression Syndrome (cont.)

• Stretch or compression involving lower trunk brachial plexus

• S&S– Aching pain, pins-and-

needles sensation, or numbness in the side or back of the neck extends across the shoulder down the medial arm to the ulnar aspect of the hand

– Weakness in grasp and atrophy of the hand

• Compression of subclavian artery or vein

• S&S– Vein: edema, hand

stiffness, venous engorgement of arm with cyanosis, symptoms may present several hours after exercise

– Artery: rapid onset of coolness, numbness entire arm, fatigue after overhead activity, obliterated radial pulse with Adson’s, Allen, or costoclavicular syndrome tests

neurologic syndrome vascular syndrome


Thoracic Outlet Compression Syndrome (cont.)Thoracic Outlet Compression Syndrome (cont.)• Blockage of the subclavian vein produces edema,

stiffness (especially in the hand), and venous engorgement of the arm with cyanosis


Thoracic Outlet Compression Syndrome (cont.)Thoracic Outlet Compression Syndrome (cont.)

• Management: immediate referral to a physician

• Other associated conditions

– Cervical rib syndrome

– Scalenus anterior syndrome

– Hyperabduction syndrome

– Costoclavicular space syndrome

– Poor posture with drooping shoulders


FracturesFractures• Atraumatic osteolysis of distal clavicle

– Etiology

• Due to repetitive trauma or posttraumatic injury to distal clavicle or AC joint

• Bone resorption causes cystic and erosive changes – remodeling cannot occur due to continued stress

– S&S

• Dull ache over AC joint – progresses to interfere with ADLs

• Point tender distal clavicle

• Pain with horizontal adduction and abduction >90º

– Management: conservative—rest


Fractures (cont.)Fractures (cont.)• Traumatic clavicular fracture

– MOI: direct or indirect force– S&S

• Proximal fragment – upward; distal shoulder collapses

• Visible and palpable deformity at fracture site

• Pain with any motion– Greenstick fracture– Management

• Immobilize and refer• Typically, fitted with

figure-8 brace


Fractures (cont.)Fractures (cont.)

• Scapular fracture

– MOI: direct or indirect force

– S&S

• Minimal pain

• Localized pain and hemorrhage

– Need to rule out pulmonary injury

– Management

• Immobilize with sling and swathe

• Refer to physician


Fractures (cont.)Fractures (cont.)

• Epiphyseal fracture– Little league shoulder –

proximal humerus; due to repetitive medial rotation and adduction

– S&S • Acute shoulder pain with

throwing hard• Pain with deep palpation in

axilla– Management

• Immobilize with sling and swathe

• Immediate referral to physician


Fractures (cont.)Fractures (cont.)• Avulsion fracture

– Coracoid process due to forceful throwing– Greater and lesser tubercles: associated with dislocation– S&S: pain with deep palpation at site– Management

• Immobilize with sling and swathe• Immediate referral to physician


Fractures (cont.)Fractures (cont.)• Humeral fracture

– MOI• Direct blow• Fall on upper arm• Fall on outstretched hand

with elbow extended– S&S

• Inability to move arm• Inability to supinate forearm• Possible paralysis

– Management• Immobilize with sling and

swathe• Immediate referral to

physician


Shoulder AssessmentShoulder Assessment• History

– Important to consider that the shoulder and upper arm are common sites for referred pain

• Observation/inspection– Step deformity – elevated distal clavicle at AC joint– Sprengel’s deformity – undescended scapula

• Palpation

• Physical examination tests

(refer to hand-out)


Range of MotionRange of Motion

• Active range of motion (AROM)

– Neck

• Flexion, extension, rotation, lateral flexion

– Shoulder

• Scapula

Depression

Elevation

Protraction


Range of Motion (cont.)Range of Motion (cont.)– Glenohumeral

Retraction Flexion Extension Abduction/

adduction Horizontal

abduction/adduction



ROM (cont.)ROM (cont.)

• Normal ranges

– Shoulder abduction – 170-180°

– Shoulder flexion – 160-180°

– Shoulder extension – 50-60°

– Lateral or external rotation – 80-90°

– Medial or internal rotation – 60-100°

– Adduction – 50-70°

– Horizontal abduction/adduction – 130°





• Passive ROM

– Determine end feel

• Resisted ROM

– Begin with muscle on stretch

• Apply resistance through entire ROM

• Note any lag, weakness, painful arcs


ROM (Cont.)ROM (Cont.)


ROM (Cont.)ROM (Cont.)



Stress Tests Stress Tests

• Stress tests

– SC instability

– AC instability

• Paxinos Sign

• AC instability test

• Piano key sign


Stress Tests Stress Tests • Stress tests

– AC instability (cont.)

• AC distraction-compression test


Stress Tests (cont.)Stress Tests (cont.)

– Glenohumeral instability• Apprehension test for anterior instability

• Relocation test for anterior instability


Stress Tests (cont.)Stress Tests (cont.)– Glenohumeral instability

• Anterior load and shift

• Posterior load and shift

• Posterior apprehension test

• Sulcus sign


Special TestsSpecial Tests• Labral Lesions

– Clunk test – Compression rotation test


Special Tests (cont.)Special Tests (cont.)• Shoulder impingement

– Neer test – Anterior impingement (Hawkins-Kennedy) test


Special Tests (cont.)Special Tests (cont.)• Muscle tendon pathology

– Serratus anterior test– Pectoralis major contracture test


Special Tests (cont.)Special Tests (cont.)

• Muscle tendon pathology– Lift-off test –

subscapularis


Special Tests (cont.)Special Tests (cont.)

• Muscle tendon pathology– Drop arm test



– Empty can test – supraspinatus pathology– Transverse humeral ligament



– Yergason’s test – bicipital tendinitis– Speed’s test – bicipital tendinitis– Ludington’s test – biceps pathology



– Ludington’s test – biceps pathology


Special Tests (cont.)Special Tests (cont.)• Thoracic outlet syndrome

– Adson’s test (1)

– Allen test (2)


Special Tests (cont.)Special Tests (cont.)• Thoracic outlet syndrome

– Military brace test (costoclavicular syndrome)


Neurologic Tests Neurologic Tests

• Neurologic tests– Myotomes

• Scapular elevation (C4) • Shoulder abduction (C5) • Elbow flexion and/or wrist extension (C6) • Elbow extension and/or wrist flexion (C7) • Thumb extension and/or ulnar deviation (C8)• Abduction and/or adduction of the hand intrinsics (T1)



• Neurologic tests– Reflexes

• Biceps (C5-C6) • Triceps (C7)



• Neurologic tests– Cutaneous patterns


Activity-Specific Functional TestsActivity-Specific Functional Tests

• All functional patterns should be fluid and pain free


RehabilitationRehabilitation• Restoration of motion

– Codman’s

– T-bar exercises

• Restoration of proprioception and balance

– Closed-chain exercises

• Muscular strength, endurance, and power

– Open-chain exercises

– PNF-resisted exercises

• Cardiovascular fitness


Rehabilitation (cont.)Rehabilitation (cont.)


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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Conditions Chapter 14