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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