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Prevention and Care of
Athletic Injuries
Shoulder Evaluation and Injuries
Anatomy
Bony Anatomy
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Sternum
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Clavicle
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Sternal (proximal) and acromial (distal) ends
Characteristic “s-shape”
Humerus
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Manubrium, body, xiphoid process
Head, neck, greater/lesser tuberosity, bicipital (intertubercular)
groove, deltoid tuberosity
Scapula
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Vertebral (medial)/axillary (lateral)/superior borders,
inferior/superior angles, coracoid/acromion processes, spine,
glenoid/supraspinous/infraspinous/subscapular fossas
Bony Anatomy
Bony Anatomy
Articulations
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Sternoclavicular (SC) joint
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Acromioclavicular (AC) joint
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Distal clavicle and acromion process
Superior/inferior AC ligaments, coracoclavicular ligaments
Glenohumeral (GH) joint
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Proximal clavicle and sternum
Anterior/posterior SC ligaments
Head of humerus and glenoid fossa of scapula
Joint capsule is primary ligamentous restraint
Reinforced by glenoid labrum
Scapulothoracic joint
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Not a “true” joint, but significant for shoulder ROM
Articulations
Articulations
Muscular Anatomy
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Muscles acting on the scapula
Rhomboid major/minor
„ Levator scapulae
„ Serratus anterior
„ Pectoralis major/minor
„ Trapezius
„ Latissimus dorsi
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Muscular Anatomy
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Muscles acting on the humerus
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Rotator cuff (SITS)
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Supraspinatus, infraspinatus, teres minor, subscapularis
Deltoid
Pectoralis major
Latissimus dorsi
Teres major
Long head of triceps brachii
Biceps brachii (short/long heads)
Coracobrachialis
Neurological Anatomy
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Brachial plexus from
cervical spine
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Nerve roots
Associated peripheral
nerves
Vascular Anatomy
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Subclavian artery
becomes axillary
artery becomes
brachial artery
Evaluation
History
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Mechanism of injury (etiology)
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Direct trauma – contusion, fracture, dislocation
Abduction/external rotation – anterior GH dislocation
Fall on outstretched arm – dislocations, fracture
Fall on tip of shoulder – AC sprain, clavicle fracture,
SC sprain
Repetitive overhead movements – tendonitis,
impingement syndromes, bursitis
History
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Location of pain
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Localized to shoulder – general shoulder pathology
Radiating pain – neurological involvement
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Unusual sounds/sensations
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History of previous injury
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Residual weakness from neck/shoulder injury
Biomechanical changes from prior injury can result in
increased risk of overuse injuries
History
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Change in activity
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Acute/gradual onset of symptoms
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Macrotraumatic vs. microtruamatic
Characterize pain
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Intensity, duration, frequency, surface change, footwear change
Location (point with 1 finger)
Dull, sharp, burning, throbbing, etc.
Rate on scale (1-10)
What increases or decreases?
Treatment, medication, evaluation to date
Inspection/Observation
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General posture
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Anterior
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Level of shoulders, clavicle contour, deltoid contour, biceps brachii
contour
Lateral
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Head position, arm splinted to side, “dead arm”, deformity with
dislocations
Deltoid, acromion process, humerus position
Posterior
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Vertebral alignment (scoliosis), level of scapulae, muscle tone
Palpation – Anterior Structures
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SC joint
Clavicle
Acromion
AC joint
Coracoid process
Humeral head
Greater tuberosity
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Lesser tuberosity
Bicipital groove
Humeral shaft
Pectoralis major
Coracobrachialis
Deltoid
Biceps brachii
Palpation – Posterior Structures
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Spine of scapula
Superior angle
Inferior angle
Rotator cuff
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Subscapularis
Supraspinatus
Infraspinatus
Teres minor
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Teres major
Rhomboids
Levator scapulae
Trapezius
Latissimus dorsi
Posterior deltoid
Triceps brachii
Special Tests
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ROM
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Active – patient/athlete moves joint
Passive – clinician moves joint, evaluates end feel
Resistive – proximal stabilization and distal application
of resistance (“break” test vs. resistance through
ROM)
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Neurovascular
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Special tests
Range of Motion
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Flexion (~180 degrees)
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Extension (~60 degrees)
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Posterior deltoid, latissimus dorsi, teres major, triceps brachii (long
head)
Abduction (~180 degrees)
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Biceps brachii, coracobrachialis, anterior and middle deltoid, pectoralis
major (clavicular head)
Deltoid, supraspinatus, biceps brachii
Adduction (~45 degrees)
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Pectoralis major, latissimus dorsi, teres major, coracobrachialis, triceps
brachii
Range of Motion
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Internal rotation (~70-80 degrees at 90/90)
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External rotation (~80-90 degrees at 90/90)
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Infraspinatus, teres minor, supraspinatus, posterior deltoid
Horizontal abduction (~45 degrees at 90)
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Subscapularis, pectoralis major, latissimus dorsi, teres major,
anterior deltoid
Posterior deltoid, infraspinatus, teres minor
Horizontal adduction (~120 degrees at 90)
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Pectoralis major, anterior deltoid
Range of Motion
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Scapular protraction
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Scapular retraction
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Lower trapezius, pectoralis minor, subclavius
Scapular downward rotation
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Upper trapezius, levator scapulae, rhomboids
Scapular depression
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Trapezius, rhomboids, levator scapulae
Scapular elevation
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Serratus anterior, pectoralis minor
Rhomboids, pectoralis minor
Scapular upward rotation
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Trapezius, serratus anterior
Neurovascular
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Neurological evalation
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Nerve root level and peripheral nerve sensory and
motor distributions
Vascular evaluation
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Skin temperature/color
Capillary refill
Radial pulse
Brachial pulse
Axillary pulse
Special Tests
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Anterior/posterior translation – SC joint
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“Piano key” test – AC joint
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Apprehension test – GH joint (anterior)
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Relocation test – GH joint (anterior)
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Anterior/posterior glide tests – GH joint
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Sulcus test – GH joint (inferior)
Special Tests
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Neer test – rotator cuff impingement
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Hawkins-Kennedy test – rotator cuff impingement
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Yergason’s test – biceps tendon instability
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Speed’s test – biceps tendon irritation
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Empty can test – supraspinatus impingement
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Drop arm test – rotator cuff tear
Injuries
Injuries
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SC joint injuries
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AC joint injuries
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GH joint injuries
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Rotator cuff injuries
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Biceps tendon injuries
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Fractures
SC Joint Injuries
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Most common direction of displacement is
anterior
Significant potential concerns if posterior
AC Joint Injuries
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Horizontal stability from superior/inferior AC
ligaments
Vertical stability from coracoclavicular ligaments
If “step-off” is present, indicates complete tear
of AC ligaments and at least partial tear of
coracoclavicular ligaments
AC Joint Injuries
GH Joint Injuries
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Anterior much more
common than posterior
If occurs before age 30,
>90% chance of
recurrence – surgery
If after age 30 – choose
between surgery/rehab
Rotator Cuff Injuries
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Impingement syndromes
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Tendonitis
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“Pinching” of tendons under acromion process
Poor blood supply, “wrung out” with rotation
Rotator cuff tears
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Usually from cumulative effects
Biceps Tendon Injuries
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Tendonitis
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Secondary to biomechanical issues and/or repetitive
overuse movements
Biceps tendon rupture
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Can occur to long head from glenoid rim, short head
from coracoid process or distal tendon from radius at
elbow
Typically has resultant deformity
Fractures
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Scapula
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Clavicle
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Rarely suffers bony injury
If so, processes most common
site
Commonly fractured in middle
1/3
Humerus
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Head often injured with GH
dislocations
Shaft rarely injured unless
severe forces