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Shoulder Injuries
Anatomy
Shoulder Girdle: Clavicle, Scapula,
Humerus
Humerus: bicipital groove, greater/lesser
tubercle, head, deltoid tuberosity
Scapula: glenoid fossa, acromion process,
coracoid process, and spine
Clavicle: acromial end, sternal end
Anatomy
Muscles:
Rotator Cuff: Supraspinatus, Infraspinatus,
Teres Minor, Subscapularis (SITS)
Scapular: Rhomboids (major & minor),
Pectoralis Minor, Trapezius, Levator Scapulae,
Serratus Anterior (winging scapula/long
thoracic nerve)
Humeral: Latissimus Dorsi, Triceps, Pectoralis
major, Biceps, Deltoid, Coracobrachialis, Teres
Major
Rotator Cuff Muscles
Muscle
Resisted ROM
Supraspinatus
Initiation of abduction
of humerus
Infraspinatus
Prevent external
rotation
Teres Minor
Prevent external
rotation
Subscapularis
Prevent internal
rotation
Anatomy
Ligaments:
Acromioclavicular, Coracoclavicular, Sternoclavicular,
Coracoacromial,
Joints:
Glenohumeral (made for mobility, not stability)
Acromioclavicular
Sternoclavicular
Coracoclavicular
Scapulothoracic (not a true joint)
Bursa:
Subacromial
Subdeltoid
Nerve Supply
Cervical Plexus (C1, C2, C3, C4)
Brachial Plexus (C5, C6, C7, C8, T1)
Axillary
Median
Musculocutaneous
Radial
Ulnar
Scapulothoracic Rhythm
0-30°
All humerus movement
– setting phase
30-90°
2:1 humerus abduction:
scapula abduct
90°-full abduction
1:1 ratio
Evaluation - History
MOI – direction of arm, was it planted on the
ground, fall on outstretched arm, land on the
tip, was it abducted w/ ext. rotation
Location of pain (Can you touch it or is it
deep?)
Onset (acute vs. chronic)
Sounds/Noises
Did you feel anything slip?
Prior history
Pain scale (scale from 1-10)
What activities recreates the pain?
Evaluation - Observation
How is the arm being held? Willingness to
move limb?
Deformities – are the shoulders square or
is there a drop off? Step Deformity? Levels
of Shoulders – even, uneven
Musculature - Are there any noticeable
spasms in the muscles?
Bony – Is anything sticking out in an
abnormal direction?
Position of Scapula – winging, rotated
Discoloration
Swelling
Observation:
Symmetry between shoulders
Bilateral comparison of Shoulders
Swelling, deformity, discoloration
Observe how athlete carries
themselves or moves
Sternoclavicular Joint
Clavicle
Acromioclavicular Joint
Humeral head
Coracoid Process
Spine of the scapula
Intertubercular groove
Soft Tissue:
Deltoid
Pectoral
SIT (Supraspinatus, Infraspinatus, Teres
Minor)
Trapezus
1.
2.
3.
4.
5.
Sternoclavicular Joint
Clavicle
Acromioclavicular Joint
Humeral Head
Coracoid Process
Deltoid Muscle
7. Spine of the Scapula
8. Supraspinatus
Muscle
9. Infraspinatus Muscle
10. Trapezus Muscle
Painful Arc
Pain is absent at the beginning of the
ROM but occurs near the midrange of
a movement and then ceases as this
is passed.
tender tissue is painfully squeezed in
the passing of a certain point during
the ROM.
Best seen in AROM,
normally indicates impingement
Usually occurs between 60-120º
abduction.
Evaluation – Stress Tests
ROM
Apley’s Scratch Test
Shoulder flexion – neutral to 170-180°
Shoulder extension – neutral to 50-60°
Shoulder abduction – neutral to 170-180°
Shoulder adduction – because of the torso,
there is no true adduction
Shoulder internal rotation – neutral to 8090°
Shoulder external rotation – neutral to 8090°
Gerber Lift-off Test
Myotomes
C5 – shoulder abduction
C6 – elbow flexion, wrist extension
C7 – elbow extension, wrist flexion
C8 – finger flexion, extension
T1 – finger abduction, adduction
Dermatomes
C5 – lateral aspect of shoulder
(deltoid), policeman’s patch
C6 – lateral elbow, lateral forearm,
thumb & index finger
C7 – middle finger
C8 – 4th & 5th fingers, medial forearm
T1 – medial elbow, medial humerus
Shoulder Injuries
Soft Tissue:
Contusions: shoulder pointer
Acute bursitis: subdeltoid, subacromial
(impingement)
Sprains: AC, SC
Strains: rotator cuff, deltoid, pectoralis major
Tendonitis: rotator cuff, biceps
Structural:
Impingement Syndrome
Biceps Rupture
Brachial plexus: (traction or compression)
Thoracic Outlet Syndrome
Shoulder Injuries
Luxations:
GH dislocation; usually anteriorly
GH subluxation
Multi-directional instability
Fractures:
Humeral
Clavicular
Sternum
Acromionclavicular Joint Sprain
MOI
Falling on an outstretched arm (using arm to
catch one’s self)
Direct hit to AC Joint
Grade
Symptoms
I
Point Tenderness, slight
swelling, some arm motion
loss
Slight ligament damage,
acromioclavicular ligament
stretched
Greater tenderness, A - C joint
has some laxity, inability to
move arm with out severe
pain
Tearing of two of the three ligaments
supporting the joint,
acromioclavicular ligament and
either the conoid or trapezoid
ligaments have been torn.
Obvious deformity, clavicle
end tenting the skin,
severe pain, inability to
move arm.
Complete rupture of the three
ligaments, may require surgery to
repair the joint.
II
III
Damage
Evaluation – Stress Tests
AC sprain
Shoulder shrugs
Distraction (traction) test
Piano Key Sign
Rotator Cuff Strain
Drop Arm test
Empty Can test (Centinella Test)
Gerber’s Lift Off test
Impingement Syndrome
MOI
repeated overhead arm movements
tennis, golf, swimming, weight lifting, or
pitching/throwing a ball
Baseball players usually suffer from impingement and
RC strains
The rotator cuff repeatedly had contact with
the acromion causing inflammation which
may cause the rotator cuff to get trapped or
pinched
Sub-Conditions
Tendonitis
Bursitis
Evaluation – Stress Tests
Impingement
Impingement Sign/Neer Impingement:
passive flexion
Hawkins-Kennedy Impingement Sign:
passive internal rotation @ 90° shoulder
flexion, elbow at 90°
Shoulder Dislocations
Dislocation vs. Subluxation
Dislocation is where the humerus comes out of
the Glenoid Fossa and stays out
Subluxation is when the humerus comes out of
the Glenoid Fossa and then goes right back in
Most common cause of Shoulder
Dislocations in Football is poor tackling
technique
Types of shoulder dislocations
Anterior (most common)
Posterior
Inferior (sulcus sign)
Complications of Relocation
Entrapment
Muscle
Nerves
Arteries
Fractures
Labrum tears
Axillary Nerve Damage
Evaluation – Stress Tests
Dislocation
Anterior Apprehension test for Anterior GH
laxity
Relocation test (Jobe’s Relocation test) for
Anterior GH laxity
Posterior Apprehension test for GH laxity
Sulcus sign for interior GH laxity – hollowing
out
Anterior/Posterior Drawer test
FX of Clavicle
80% happen in the Middle 1/3 of the
Clavicle
MOI
Falling on an outstretched arm
Direct hit
Falling on the outside of the shoulder
Shoulder Pointers
Contusion to the outer portion of the
Clavicle
MOI
Direct Blow to Clavicle
Bicep Tendonitis
Yergason’s Test: Stability of tendon of
long head of biceps in bicipital groove
Subluxation of the bicep tendon in the
intertubercular groove (bicipital groove)
Speed’s Test
Evaluation – Stress Tests
Thoracic Outlet Syndrome – pressure is
applied on the brachial plexus, subclavian artery
or subclavian vein
Brachial plexus (Neurological):
numbness, pain, paresthesia
Subclavian artery (Arterial): coldness of
skin, pallor, cyanosis in fingers,
muscular weakness
Subclavian vein (Venous): muscular &
joint stiffness, edema, venous swelling,
engorgement, thrombophlebitis
Evaluation – Stress Tests -  Pulse
Adson’s:
loss of radial pulse (compression of
subclavian artery)
Caused by ant. scalene muscle & pec. minor
Head looks towards abducted (30°) externally
rotated shoulder, & elbow extended w/ thumb
pointing up; deep breath
Allen Test:
loss of radial pulse (compression of
neurovascular bundle)
Caused by the pectoralis minor muscle
Head looks away while elbow is flexed (90°) &
shoulder abducted (90°); shoulder passively
horiz. abducted & ext. rotated
Evaluation – Stress Tests
Roos – diminished motor function of the hands,
and/or loss of sensation in the upper extremities
Both shoulders 90 degrees of abduction
and external rotation, and elbows in 90
degrees of flexion
Subject rapidly opens and closes both
hands for 3 minutes