Download Shoulder Conditions

Shoulder
Conditions
Chapter 13
Shoulder 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
Coracoclavicular joint
 Coracoid process of
scapula with the
inferior surface of
clavicle
• Coracoclavicular
ligament
 Minimal movement
permitted
Shoulder Complex (cont.)
 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
Shoulder Complex (cont.)
 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
Shoulder Complex (cont.)

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)
Shoulder Complex (cont.)
 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 Muscles
Shoulder Muscles
Bursa
 Subacromial



bursa
Lies in subacromial space
Cushions rotator cuff muscles from
acromion (especially supraspinatus)
Compressed during overhead arm action
 Subcoracoid;
subscapularis
Nerves
 Brachial
plexus
innervates upper
extremity
Blood Vessels
 Subclavian;
axillary—
several branches
Kinematics

Movement in 3 planes




Flexion and extension
Abduction and
adduction
Medial rotation and
lateral rotation
Horizontal Abduction
and adduction
Prevention of Shoulder
Conditions
 Protective

Shoulder pads
 Physical



conditioning
Flexibility
Strength
 Proper

equipment
skill technique
Throwing motion
Proper falling technique
Sternoclavicular (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:
immobilization
physician referral;
Sternoclavicular (SC) Sprain
(cont.)
 Posterior


SC sprain
Difficulty swallowing; diminished pulse;
respiratory distress
Management: activate EMS
Acromioclavicular (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.)
 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.)
III – rupture of AC ligaments and
coracoclavicular ligament
 Type


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 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.)

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.)

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 Tears
 Bankart


Damage to the anterior lip of the glenoid
labrum
Associated with anterior dislocation or
degeneration and aging
 SLAP

lesion
lesion
Involves superior labrum and disruption of the
attachment of the long head of the biceps
tendon
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
Rotator 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.)

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
Hypermobility of the shoulder joints
Imbalance in muscle strength, coordination, and
endurance of the scapular muscles
Shape of the acromion
Rotator Cuff/Impingement (cont.)
 S&S



“Deep” pain
Painful arc: between 70° and 120°
Unable to sleep on involved side
 Stages
of impingement syndrome
 Management: restrict motion
Bursitis
 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 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.)
 S&S


Pain with interior and exterior rotation of
shoulder
Pain with passive stretch in extreme
shoulder extension with elbow extended
and forearm pronated
 Management:
restriction of rotational
activities that exacerbate symptoms
Biceps Tendon Rupture

Etiology



S&S





Prolonged tendinitis makes tendon vulnerable
Forceful flexion against resistance
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
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.)
 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.)

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 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
Range of Motion
 Active

range of motion (AROM)
Neck
• Flexion, extension,
rotation, lateral flexion

Shoulder
• Scapula



Depression
Elevation
Protraction
Range of Motion (cont.)
• Glenohumeral





Retraction
Flexion
Extension
Abduction/adduction
Horizontal abduction/adduction
ROM (cont.)
 Passive

ROM
Determine end feel
 Resisted

ROM
Begin with muscle on stretch
• Apply resistance through entire ROM
• Note any lag, weakness, painful arcs
Stress Tests

Stress tests


SC instability
AC instability
• AC instability test
• Piano key sign
• AC distractioncompression test
Stress Tests (cont.)

Glenohumeral
instability
• Apprehension test
for anterior
instability
• Relocation test for
anterior instability
• Sulcus Sign
Special Tests
 Labral


Lesions
Clunk test
Compression
rotation test
Special Tests (cont.)
 Shoulder
impingement


Neer test
Anterior
impingement
(HawkinsKennedy) test
Special Tests (cont.)
 Muscle
tendon
pathology



Lift-off test –
subscapularis
Drop arm test
Empty can test
– supraspinatus
pathology
Special Tests (cont.)
 Muscle
tendon
pathology


Yergason’s test –
bicipital tendinitis
Speed’s test –
bicipital tendinitis