Download On-field inspection

Chapter 15
Shoulder and Upper Arm
Pathologies
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Clinical Anatomy
 Bony anatomy
 Manubrium
 Jugular notch
 Clavicular notch
 Clavicle
 Scapula
 Subscapular fossa
 Vertebral border
 Inferior and superior
angle
 Scapular spine
 Supraspinous fossa
 Acromion process
 Coracoid process
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Clinical Anatomy
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Clinical Anatomy
 Bony anatomy
 Humerus
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Humeral head
Anatomical neck
Bicipital groove
Greater tuberosity
Lesser tuberosity
Surgical neck
Deltoid tuberosity
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Clinical Anatomy
 Bony anatomy of the scapula
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Clinical Anatomy
 Joints of the shoulder complex
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Glenohumeral joint (GH)
Acromioclavicular joint (AC)
Sternoclavicular joint (SC)
Scapulothoracic articulation
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Clinical Anatomy
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Clinical Anatomy
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Clinical Anatomy
 Scapulothoracic
rhythm
 GH and
scapulothoracic
articulation must
function together.
 2:1 ratio (GH elevation:
STA rotation)
 To accomplish 180 of
GH elevation
 120 from GH
movement and 60 from
scapular rotation
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Clinical Anatomy
 Bursa of the shoulder complex
 Subacromial bursa
 Above supraspinatus tendon
 Buffers tendons’ contact with acromion process and the
coracoacromial ligament
 Inflamed bursa can lead to RTC impingement.
 Subdeltoid bursa
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Clinical Examination of Shoulder
Injuries
Past medical history
 Previous history
 AC or GH injury can alter
biomechanics.
 Cervical spine pathology
 Can radiate pain to
upper extremity
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History of the present
condition
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Location of the pain
Onset
Activity and injury mechanism
Symptoms
Clinical Examination of Shoulder Injuries
 Inspection
 Functional assessment
 Pain in follow-through
 Pain in cocked position
 Pain in deceleration
 Loss of control or velocity
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Clinical Examination of Shoulder
Injuries
 Inspection
 Anterior shoulders
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Level of the shoulders
Position of the head
Position of the arm
Contour of the clavicles
Symmetry of the deltoid
muscle group
 Anterior humerus and
biceps brachii muscle
group
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Clinical Examination of Shoulder
Injuries
Fracture of left clavicle
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Clinical Examination of Shoulder
Injuries
Anterior GH dislocation
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Clinical Examination of Shoulder
Injuries
 Inspection
 Posterior structures
 Alignment of the vertebral column
 Position of the scapula
 Sprengel deformity—congenitally undescended scapula
 Muscle development
 Position of the humerus
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Clinical Examination of Shoulder Injuries

Palpation of the anterior
shoulder
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Jugular notch
Sternoclavicular joint
Clavicular shaft
Acromion process and AC joint
Coracoid process
Humeral head
Greater tuberosity
Lesser tuberosity
Bicipital groove
Humeral shaft
Pectoralis major
Pectoralis minor
Coracobrachialis
Deltoid group
Biceps brachii
Long head of the biceps
Short head of the biceps
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Clinical Examination of Shoulder Injuries

Palpation of the
posterior shoulder
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Spine of the scapula
Superior angle
Inferior angle
Infraspinatus
Teres minor
Supraspinatus
Teres major
Rhomboid major
Rhomboid minor
Levator scapulae
Trapezius
Latissimus dorsi
Posterior deltoid
Triceps brachii
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Clinical Examination of Shoulder
Injuries
 Joint and muscle function assessment
 Active range of motion (AROM)
 Flexion and extension
 Abduction and adduction
 Internal and external rotation
 Horizontal adduction and abduction
 Manual muscle testing (MMT)
 Scapular movements
 Passive range of motion (PROM)
 Same motions as AROM
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Selective Tissue Test: Drop Arm Test
for Rotator Cuff Tendinopathy
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Selective Tissue Test: Gerber Lift-Off
Test for Subscapularis Pathology
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Clinical Examination of Shoulder
Injuries
 Joint stability tests
 Sternoclavicular joint play
 Test for acromioclavicular
joint laxity
 Test for glenohumeral joint
laxity
 Neurological testing
 Upper quarter screen
 Referred pain from visceral
organs
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Pathologies of the Shoulder and
Related Special Tests
 Sternoclavicular joint sprains
 MOI: Longitudinal force on the clavicle
 FOOSH, hit on lateral portion of shoulder, or
traction forces
 Signs and symptoms
 Pain with protraction, retraction, and joint play
 Posterior dislocations = medical emergency!
 Threat to subclavian artery and vein, trachea, and
esophagus
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Pathologies of the Shoulder and
Related Special Tests
 Acromioclavicular joint pathology
 “Separated shoulder”
 MOI: FOOSH, blow to superior acromion process
 Classification of sprains depends on structures involved,
degree of instability, and direction of displaced clavicle.
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Classification System for
Acromioclavicular Joint Sprains
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Selective Tissue Test:
Acromioclavicular Traction Test
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Selective Tissue Test:
Acromioclavicular Compression Test
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Pathologies of the Shoulder and
Related Special Tests
 Glenohumeral instability
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Anterior instability
Posterior instability
Inferior instability
Multidirectional instability
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Selective Tissue Test: Apprehension Test
for Anterior Glenohumeral Laxity
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Selective Tissue Test: Relocation and Anterior
Release Tests for Anterior Glenohumeral Laxity
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Selective Tissue Test: Posterior Apprehension
Test for Glenohumeral Laxity
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Selective Tissue Test: Jerk (Posterior Stress)
Test for Labral Tears
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Selective Tissue Test: Sulcus Sign for Inferior
Glenohumeral Laxity
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Pathologies of the Shoulder and
Related Special Tests
 Rotator cuff pathology
 Impingement syndrome
 Rotator cuff
tendinopathy
 Subacromial bursitis
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Types of Impingement
Force
Source
Primary subacromial
impingement
• Irregularly shaped acromion
• Spur formation on acromion
• Os acromiale
Secondary subacromial
impingement
• Loss of humeral head depression or
stabilization
• Poor posture
• Repetitive overhead movement
• Scapular dyskinesis
• GH instability
• Supraspinatus hypertrophy
Internal impingement
• Glenohumeral internal rotation
deficit (GIRD)
• GH instability
• High volume of throwing or other
repetitive overhead activity
• Occupation requiring repetitive
overhead activity
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Selective Tissue Test: Neer
Impingement Test
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Selective Tissue Test: Hawkins
(Kennedy-Hawkins) Impingement Test
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Selective Tissue Test: Empty Can Test
for Supraspinatus Pathology
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Pathologies of the Shoulder and
Related Special Tests
 Biceps tendon pathology
 Bicipital tendinopathy
 Causes
 RTC dysfunction
 Impingement
 Superior labrum anterior to posterior lesions (SLAP
lesions)
 Tears of the superior aspect of the glenoid labrum that extend
anteriorly and posteriorly to the biceps insertion
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Classification of SLAP Lesions
Type
Pathology
I
Degenerative fraying of the labrum near the insertion of the LHBT
II
Avulsion of the glenoid labrum with an associated tear
of the LHBT
Type II SLAP lesions have been further classified
relative to the detachment of the labrum:
• Isolated to the anterior aspect
• Isolated to the posterior aspect
• Appearing in both aspects
III
A bucket-handle tear of the labrum with displacement
of the fragment; no involvement of the LHBT
IV
Bucket-handle tear of the labrum with associated
tearing of the LHBT
LHBT = long head of the biceps tendon; SLAP = superior labrum anterior to
posterior
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Selective Tissue Test: Yergason Test
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Selective Tissue Test: Speed Test for Long
Head of the Biceps Brachii Tendinopathy
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Selective Tissue Test: Active
Compression Test (O’Brien Test)
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Selective Tissue Test: Anterior Slide
Test
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Selective Tissue Test: Anterior Slide Test
Compression-Rotation (Grind) Test
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On-Field Examination of Shoulder
Injuries
 Equipment considerations
 Palpation under the shoulder pads
 Unlatch shoulder pad straps
 Palpate under cantilever or through neck opening
 Palpation should be gentle to begin.
 Removal of the shoulder pads
 Unlatch shoulder pad straps
 Remove uninjured arm
 Slide shirt and shoulder pads up over head
 If shirt is too tight, cut it off.
 Drop it down over injured arm
Copyright © 2015. F.A. Davis Company
On-Field Examination of Shoulder
Injuries
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On-Field Examination of Shoulder Injuries
On-field history
On-field inspection
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Location of pain
 Upper shoulder
 AC sprain
 Trapezius
 Brachial plexus injury
MOI
 Internal or external rotation
(with abduction)
 GH joint dislocation or
subluxation
 FOOSH
 Clavicular fracture, AC
sprain, SC sprain
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
Arm posture
 Arm splinted against torso
 Arm hanging limply at the side
 Arm “locked”
Gross deformity
On-Field Examination of Shoulder
Injuries
On-field palpation
Additional on-field tests
 If joint dislocation or bony
fracture have been ruled out
 Apley scratch test can be
used as a gross
assessment of the athlete’s
willingness to move the
involved extremity and the
amount of motion
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Position of the humeral head
AC joint alignment
Clavicle
Sternoclavicular joint
Humerus
Initial Management of On-Field
Shoulder Injuries
 Scapular fracture
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Body of the scapula
Glenoid fossa
Glenoid neck
Coracoid process
 Management
 Immobilize the arm on the affected side in a comfortable position
 Athlete then is transported.
 GH dislocation also needs a radiographic evaluation to rule out a
secondary fracture to the glenoid or coracoid process.
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On-Field Examination of Shoulder
Injuries
 Clavicular injuries
 Clavicular fracture
 Immobilization using a sling or triangular
bandage
 Transport for definitive diagnosis
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On-Field Examination of Shoulder
Injuries
 Sternoclavicular joint injuries
 Neurological and vascular examination of the
extremity and carotid artery
 Involved arm is immobilized.
 Athlete is immediately transported to an
emergency medical facility.
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On-Field Examination of Shoulder
Injuries
 Acromioclavicular joint injuries
 Immobilize in a position that lessens the
displacement between the clavicle and the
acromial process
 Protect joint with additional padding during
activity
Copyright © 2015. F.A. Davis Company
On-Field Examination of Shoulder
Injuries
 Glenohumeral dislocations
 Monitor the distal pulses, check for circulation
in the fingertips, and perform a sensory
screen
 Arm is fixed in the position it has assumed.
 Reductions of GH dislocations should only be
performed by those who are trained to do so.
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On-Field Examination of Shoulder
Injuries
 Glenohumeral dislocations (cont.)
 Forced reduction of the humeral head may
damage the glenoid fossa, the coracoid
process, or the neurovascular structures in
the area. Following reduction, assess distal
pulse and active range of motion, avoiding
external rotation and abduction. Stabilize the
shoulder using a sling, and refer the athlete
for further examination.
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On-Field Examination of Shoulder
Injuries
 Humeral fractures
 Splint in position found using moldable splint
or vacuum splint
 Leave wrist and fingers exposed to check
circulation
 Transport
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