Download Shoulder Injuries

Shoulder Injuries
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)
• Signs and symptoms
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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
• Signs and Symptoms (cont.)
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Inflammation
Hemorrhage
Ecchymosis
Deformity
Instability (with 2nd,3rd degree)
• Special Tests
– Active and resistive movements
– Passive stress
• Diagnostic Procedure
– Refer to ortho
– X-Ray
*If posterior emergent
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
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
• Signs and Symptoms
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Pain on A/P/RROM
Loss of function
Tenderness over AC joint
Swelling
Hemorrhage
Ecchymosis
Inflammation
Step deformity
• Signs and Symptoms (cont)
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Pain on shoulder abduction
Pain on distraction of AC joint
Abnormal motion of distal clavicle
Deformity
Instability (2nd and 3rd degree)
• Special Tests
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Distraction (piano key)
AC Traction/Compression
Pain on Abduction
A/R ROM
Apley’s scratch test
• Diagnostic Procedure
– Ortho
– X-Ray
Subcoracoid glenohumeral
luxation(dislocation)
• Mechanism
– Force applied to an abducted, ER arm above 90 deg
• Signs and symptoms
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Pain
Loss of function
Deformity
Swelling
Tenderness on anterior aspect of shoulder
• Special Tests
– Check pulse
– Check sensation over axillary n.
• Diagnostic Procedure
– Refer to ortho
– X-ray
Glenohumeral/subglenoid
luxation(dislocation)
• Mechanism
– Force applied to an abducted arm
• Signs and Symptoms
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Pain
Loss of function
Marked deformity
Swelling
Pt. Tenderness
Flattened deltoid
• Special Tests
– Check pulse at wrist
– Check for sensory loss in arm and hand
• Diagnostic Procedure
– Refer to ortho
– X-ray
Posterior Glenohumeral
Luxation(dislocation)
• Mechanism
– Fall on outstretched arm
– Blow to the front of the shoulder
• Signs and Symptoms
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Pain
Loss of function
Marked deformity
Swelling
Pt. Tenderness
• Special Tests
– Check pulse at wrist
– Check sensation of arm/hand
• Diagnostic Procedure
– Refer to ortho
– X-Ray
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
Anterior Glenohumeral
Instability
• Mechanism
– Acute
– Repetitive microtrauma involving ER when GH
joint is abducted to 90 degrees
Signs and symptoms
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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
Special Tests
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Positive Apprehension
Positive relocation sign
Sulcus sign
Glenohumeral translation
Glenoid Labrum tear
• Mechanism
– Repetition of shoulder motion
– Acute Trauma
– Ant. Subluxation of glenohumeral jt.
• Special tests
– Clunk test
– Resistive ROM
– Apprehension test
• Diagnostic
– Ortho
– MRI
• Signs and symptoms
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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
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
• Signs and Symptoms (continued)
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Obvious deformity before reduction
Spasm
Positive apprehension test
Head of humerus is palpable while slipping
forward
• Special Tests
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Apprehension test
Relocation test
Sulcus sign
Glenohumeral translation
Clunk test
• Diagnostic Procedure
– Refer to ortho
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
Hills-Sach Lesion
• Common finding associated with anterior
GH dislocation
• Small defect in posterior humeral head’s
articular cartilage
• Caused by impact of humeral head on
glenoid fossa as humerus attempts to
relocate
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
Rotator Cuff Impingement
• Mechanisms
– Decreased space in subacromial arch
– Structures beneath are impinged between
acromion and humeral head
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Chronic microtrauma
Vascular impairment
Partial tear RC- altered mechanics
Anatomic variation of arch
• Signs and Symptoms
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Increase in pain from IR to ER
Snapping sensation
Loss of function
Pain with overhead activity
Painful arc
Pain on superolateral aspect of shoulder
• 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
• Special tests
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Impingement test (Neer and Hawkins)
Forward Flexion test
Empty can test
RROM
• Diagnostic Procedure
– Ortho
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
• Symptoms and Signs
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Pain with A/P/RROM
Loss of function
Snapping
Tenderness
Spasm
Swelling
Ecchymosis
• Signs and Symptoms
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Pt. Tenderness over RC tendons
Inflammation
Hematoma formation
Muscle defect
Pain on abduction/ER/ and flexion of shoulder
• Special Test
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Apley’s scratch
Impingement
Drop Arm
Forward Flexion
Empty can
*Refer to Ortho
Tenosynovitis of Shoulder
• Mechanism
– Overuse
– Direct or repeated trauma
– Poor throwing techniques
• Signs and symptoms
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Pain on A/P/RROM
Loss of function
Tenderness
Swelling
Thickening of tendon
• Special Tests
– A/P/RROM
• Diagnostic Procedure
– Refer to ortho
Bicep Tendon Pathology
• Biceps Tendinitis
• Luxation of bicep tendon
• Long Head of biceps rupture
Bicep tendinitis
• Mechanism
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Irritation of biceps tendon in the groove
Rotator cuff dysfunction
Repeated microtrauma
Overuse
Degenerative changes
impingement
• Signs and symptoms
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Pain on P/A/RROM
Loss of function
Overuse activity
Tenderness
Errythema
Swelling
Inflammation
Crepitus
• Special Tests
– A/P/RROM
– RC muscle test
• Diagnostic Procedure
– Physician if symptoms persist
Luxation of biceps tendon
• Mechanism
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Inadequate muscle development
Overuse in throwing
Tearing of transverse humeral ligament
Shallow bicipital groove of humerus
Faulty mechanics
• 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
• Special Tests
– Yergason
– Speed’s
– Ludington
• Diagnostic Procedure
– Refer to physician
Long head of biceps rupture
• Mechanism
– Violent contraction against resistance
• Symptoms/signs
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Pain
Loss of function
Sensation of something rolling up arm
Protruding bulge in biceps
Tenderness along long head
Loss of strength
• Special Tests
– Ludington’s test
• Diagnostic Procedure
– Refer to ortho
• Contusion of biceps
– Mechanism
• Direct Trauma
– Signs and Symptoms
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Pain
Loss of elbow flexion and extension
Transitory paralysis
Pt. Tenderness
Ecchymosis
Hematoma Formation
Inflammation
• Special Tests
– A/P/RROM
• Diagnostic Procedures
– Refer if symptoms persist
Exostosis/Myositis Ossificans
• Mechanism
– Repeated trauma (humerus)
• Signs and Symptoms
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Pain
Point tenderness
Possible paresthesia
Swelling
Loss of Function
Proximal Humerus Epiphyseal
Plate Injury
• Mechanism
– Direct trauma
– Indirect trauma traveling along length of
humerus
• Signs and Symptoms
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Sudden pain
Tenderness
Deformity
Rapid Swelling
Possible bony deviations
Crepitus
Ecchymosis
Humerus Fracture
• Mechanism
– Direct trauma
– Fall on an outstretched arm
• Signs and Symptoms
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Sudden pain
Loss of function
Tenderness
Deformity
Rapid Swelling
Axillary N. Injury
• Mechanism
– Direct trauma to lateral arm
– 2nd to anterior dislocated arm
• Signs and symptoms
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Loss of shoulder abduction
Tenderness
Loss of function of deltoid/biceps
Dermatome numbness in area of middle Deltoid
• Special Tests
– A/RROM for Deltoid
– Sensation testing for Deltoid
• Diagnostic Procedures
– Neurologist
Subacromion Bursitis
• Mechanism
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Direct Trauma
Overuse
Fall on an outstretched hand
RC impingement (i.e. stress from throwing)
• Signs and Symptoms
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Similar to RC impingement
Pain(at night/ ache with rest)
Loss of function
Tenderness
Redness, swelling, inflammation
Pain on rotation and/or abduction>80 deg
• Special Tests
– Appley’s Scratch test
– Resistive movements
• Diagnostic
– Refer to physician
Subdeltoid bursitis
• Mechanism
– Direct Trauma
– Fall on outstretched hand
– Overuse
• Signs and Symptoms
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Pain
Loss of function
Tenderness(under deltoid)
Redness, swelling, inflammation
Pain and/or weakness on abduction
• Special Tests
– Apley’s scratch test
– Resistive movement tests
• Diagnostic
– Refer to physician
Clavicle Contusion
• Mechanisms
– Direct trauma to clavicle
• Symptoms
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Pain
Loss of Function
Transitory paralysis
Point tenderness
Inflammation
• Special Tests
– Distraction Test (rule out AC sprain)
• Diagnostic Procedure
– Refer to orthopedic surgeon
– XRay
Deltoid Contusion
• Mechanism
– Direct Trauma
• Symptoms
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Pain
Loss of function
Point tenderness
Transitory paralysis
Weakness on shoulder abduction
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
• Special Tests
– Scapula protraction test
• Pushing against a wall will cause winging effect
• Diagnostic Procedure
– Physician
– EMG study (Electromyography)
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
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
• Tests
– Adson’s
– Allen
– Costoclavicular (military brace)
Clavicle Fracture
• Fracture collar bone
• Mechanisms
– Fall on outstretched arm
– Direct contact
• Signs and Symptoms
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Sudden pain
Tenderness(direct /indirect)
Loss of shoulder function
Deformity(rapid swelling/bony deviation)
Head tilt towards side of fracture
Crepitus
• Signs and symptoms (cont.)
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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
Scapula Fracture
• Mechanism
– Direct trauma
– Indirect trauma from fall (on shoulder or arm)
• Signs and Symptoms
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Sudden pain
Loss of function
Tenderness (direct/indirect)
Possible crepitus
• Signs and Symptoms (cont.)
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Rapid Swelling
Bony deviations
Crepitus
False Joint Motion
Delayed Ecchymosis
*Refer to ortho/X-Ray
Proximal humerus Epiphyseal
plate Injury
• Mechanisms
– Direct trauma
– Indirect along shaft
• Signs and symptoms
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Pain
Loss of function
Deformity
Swelling
Crepitus
False joint
Blocker’s Extosis
• Myositis Ossificans
• Mechanisms
– Repetitive trauma to humerus
• Signs and symptoms
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Pain
Pt. Tenderness
Bony prominence
Swelling
Loss of function-elbow flexion/extension
Humerus Fracture
• Mechanism
– Direct trauma from fall/external force
• Signs and Symptoms
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Pain
Loss of function
Deformity- shortened humerus
Swelling
False joint motion
Triceps strain
• Mechanism
– Excessive forcible contraction or stretching
– Muscle fatigue
• Signs and symptoms
• Tests