Bony Anatomy Sternum Manubrium, body, xiphoid process Clavicle Sternal (proximal) and acromial...

Prevention and Care of Prevention and Care of Athletic InjuriesAthletic Injuries

Shoulder Evaluation and InjuriesShoulder Evaluation and Injuries

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AnatomyAnatomy

Bony AnatomyBony Anatomy

SternumSternumManubriumManubrium, body, , body, xiphoidxiphoid processprocess

ClavicleClavicleSternalSternal (proximal) and (proximal) and acromialacromial (distal) ends(distal) endsCharacteristic Characteristic ““ss--shapeshape””

HumerusHumerusHead, neck, greater/lesser Head, neck, greater/lesser tuberositytuberosity, , bicipitalbicipital ((intertubercularintertubercular) ) groove, deltoid groove, deltoid tuberositytuberosity

ScapulaScapulaVertebral (medial)/Vertebral (medial)/axillaryaxillary (lateral)/superior borders, (lateral)/superior borders, inferior/superior angles, inferior/superior angles, coracoid/acromioncoracoid/acromion processes, spine, processes, spine, glenoid/supraspinous/infraspinous/subscapularglenoid/supraspinous/infraspinous/subscapular fossasfossas

Bony AnatomyBony Anatomy

Bony AnatomyBony Anatomy

ArticulationsArticulations

SternoclavicularSternoclavicular (SC) joint(SC) jointProximal clavicle and sternumProximal clavicle and sternumAnterior/posterior SC ligamentsAnterior/posterior SC ligaments

AcromioclavicularAcromioclavicular (AC) joint(AC) jointDistal clavicle and Distal clavicle and acromionacromion processprocessSuperior/inferior AC ligaments, Superior/inferior AC ligaments, coracoclavicularcoracoclavicular ligamentsligaments

GlenohumeralGlenohumeral (GH) joint(GH) jointHead of Head of humerushumerus and and glenoidglenoid fossafossa of scapulaof scapulaJoint capsule is primary Joint capsule is primary ligamentousligamentous restraintrestraintReinforced by Reinforced by glenoidglenoid labrumlabrum

ScapulothoracicScapulothoracic jointjointNot a Not a ““truetrue”” joint, but significant for shoulder ROMjoint, but significant for shoulder ROM

ArticulationsArticulations

ArticulationsArticulations

Muscular AnatomyMuscular Anatomy

Muscles acting on the scapulaMuscles acting on the scapulaRhomboid major/minorRhomboid major/minorLevatorLevator scapulaescapulaeSerratusSerratus anterioranteriorPectoralisPectoralis major/minormajor/minorTrapeziusTrapeziusLatissimusLatissimus dorsidorsi

Muscular AnatomyMuscular Anatomy

Muscles acting on the Muscles acting on the humerushumerusRotator cuff (SITS)Rotator cuff (SITS)

SupraspinatusSupraspinatus, , infraspinatusinfraspinatus, , teresteres minor, minor, subscapularissubscapularis

DeltoidDeltoidPectoralisPectoralis majormajorLatissimusLatissimus dorsidorsiTeresTeres majormajorLong head of triceps Long head of triceps brachiibrachiiBiceps Biceps brachiibrachii (short/long heads)(short/long heads)CoracobrachialisCoracobrachialis

Neurological AnatomyNeurological Anatomy

Brachial plexus from Brachial plexus from cervical spinecervical spine

Nerve rootsNerve rootsAssociated peripheral Associated peripheral nervesnerves

Vascular AnatomyVascular Anatomy

SubclavianSubclavian artery artery becomes becomes axillaryaxillaryartery becomes artery becomes brachial arterybrachial artery

EvaluationEvaluation

HistoryHistory

Mechanism of injury (etiology)Mechanism of injury (etiology)Direct trauma Direct trauma –– contusion, fracture, dislocationcontusion, fracture, dislocationAbduction/external rotation Abduction/external rotation –– anterior GH dislocationanterior GH dislocationFall on outstretched arm Fall on outstretched arm –– dislocations, fracturedislocations, fractureFall on tip of shoulder Fall on tip of shoulder –– AC sprain, clavicle fracture, AC sprain, clavicle fracture, SC sprainSC sprainRepetitive overhead movements Repetitive overhead movements –– tendonitis, tendonitis, impingement syndromes, bursitisimpingement syndromes, bursitis

HistoryHistory

Location of painLocation of painLocalized to shoulder Localized to shoulder –– general shoulder pathologygeneral shoulder pathologyRadiating pain Radiating pain –– neurological involvementneurological involvement

Unusual sounds/sensationsUnusual sounds/sensations

History of previous injuryHistory of previous injuryResidual weakness from neck/shoulder injuryResidual weakness from neck/shoulder injuryBiomechanical changes from prior injury can result in Biomechanical changes from prior injury can result in increased risk of overuse injuriesincreased risk of overuse injuries

HistoryHistory

Change in activityChange in activityIntensity, duration, frequency, surface change, footwear changeIntensity, duration, frequency, surface change, footwear change

Acute/gradual onset of symptomsAcute/gradual onset of symptomsMacrotraumaticMacrotraumatic vs. vs. microtruamaticmicrotruamatic

Characterize painCharacterize painLocation (point with 1 finger)Location (point with 1 finger)Dull, sharp, burning, throbbing, etc.Dull, sharp, burning, throbbing, etc.Rate on scale (1Rate on scale (1--10)10)What increases or decreases?What increases or decreases?

Treatment, medication, evaluation to dateTreatment, medication, evaluation to date

Inspection/ObservationInspection/Observation

General postureGeneral postureHead position, arm splinted to side, Head position, arm splinted to side, ““dead armdead arm””, deformity with , deformity with dislocationsdislocations

AnteriorAnteriorLevel of shoulders, clavicle contour, deltoid contour, biceps Level of shoulders, clavicle contour, deltoid contour, biceps brachiibrachiicontourcontour

LateralLateralDeltoid, Deltoid, acromionacromion process, process, humerushumerus positionposition

PosteriorPosteriorVertebral alignment (scoliosis), level of scapulae, muscle toneVertebral alignment (scoliosis), level of scapulae, muscle tone

Palpation Palpation –– Anterior StructuresAnterior Structures

SC jointSC jointClavicleClavicleAcromionAcromionAC jointAC jointCoracoidCoracoid processprocessHumeral headHumeral headGreater Greater tuberositytuberosity

Lesser Lesser tuberositytuberosityBicipitalBicipital groovegrooveHumeral shaftHumeral shaftPectoralisPectoralis majormajorCoracobrachialisCoracobrachialisDeltoidDeltoidBiceps Biceps brachiibrachii

Palpation Palpation –– Posterior StructuresPosterior Structures

Spine of scapulaSpine of scapulaSuperior angleSuperior angleInferior angleInferior angleRotator cuffRotator cuff

SubscapularisSubscapularisSupraspinatusSupraspinatusInfraspinatusInfraspinatusTeresTeres minorminor

TeresTeres majormajorRhomboidsRhomboidsLevatorLevator scapulaescapulaeTrapeziusTrapeziusLatissimusLatissimus dorsidorsiPosterior deltoidPosterior deltoidTriceps Triceps brachiibrachii

Special TestsSpecial Tests

ROMROMActive Active –– patient/athlete moves jointpatient/athlete moves jointPassive Passive –– clinician moves joint, evaluates end feelclinician moves joint, evaluates end feelResistive Resistive –– proximal stabilization and distal application proximal stabilization and distal application of resistance (of resistance (““breakbreak”” test vs. resistance through test vs. resistance through ROM)ROM)

NeurovascularNeurovascular

Special testsSpecial tests

Range of MotionRange of Motion

Flexion (~180 degrees)Flexion (~180 degrees)Biceps Biceps brachiibrachii, , coracobrachialiscoracobrachialis, anterior and middle deltoid, , anterior and middle deltoid, pectoralispectoralismajor (major (clavicularclavicular head)head)

Extension (~60 degrees)Extension (~60 degrees)Posterior deltoid, Posterior deltoid, latissimuslatissimus dorsidorsi, , teresteres major, triceps major, triceps brachiibrachii (long (long head)head)

Abduction (~180 degrees)Abduction (~180 degrees)Deltoid, Deltoid, supraspinatussupraspinatus, biceps , biceps brachiibrachii

Adduction (~45 degrees)Adduction (~45 degrees)PectoralisPectoralis major, major, latissimuslatissimus dorsidorsi, , teresteres major, major, coracobrachialiscoracobrachialis, triceps , triceps brachiibrachii

Range of MotionRange of Motion

Internal rotation (~70Internal rotation (~70--80 degrees at 90/90)80 degrees at 90/90)SubscapularisSubscapularis, , pectoralispectoralis major, major, latissimuslatissimus dorsidorsi, , teresteres major, major, anterior deltoidanterior deltoid

External rotation (~80External rotation (~80--90 degrees at 90/90)90 degrees at 90/90)InfraspinatusInfraspinatus, , teresteres minor, minor, supraspinatussupraspinatus, posterior deltoid, posterior deltoid

Horizontal abduction (~45 degrees at 90)Horizontal abduction (~45 degrees at 90)Posterior deltoid, Posterior deltoid, infraspinatusinfraspinatus, , teresteres minorminor

Horizontal adduction (~120 degrees at 90)Horizontal adduction (~120 degrees at 90)PectoralisPectoralis major, anterior deltoidmajor, anterior deltoid

Range of MotionRange of Motion

Scapular protractionScapular protractionSerratusSerratus anterior, anterior, pectoralispectoralis minorminor

Scapular retractionScapular retractionTrapeziusTrapezius, rhomboids, , rhomboids, levatorlevator scapulaescapulae

Scapular elevationScapular elevationUpper Upper trapeziustrapezius, , levatorlevator scapulae, rhomboidsscapulae, rhomboids

Scapular depressionScapular depressionLower Lower trapeziustrapezius, , pectoralispectoralis minor, minor, subclaviussubclavius

Scapular downward rotationScapular downward rotationRhomboids, Rhomboids, pectoralispectoralis minorminor

Scapular upward rotationScapular upward rotationTrapeziusTrapezius, , serratusserratus anterioranterior

NeurovascularNeurovascular

Neurological Neurological evalationevalationNerve root level and peripheral nerve sensory and Nerve root level and peripheral nerve sensory and motor distributionsmotor distributions

Vascular evaluationVascular evaluationSkin temperature/colorSkin temperature/colorCapillary refillCapillary refillRadial pulseRadial pulseBrachial pulseBrachial pulseAxillaryAxillary pulsepulse

Special TestsSpecial Tests

Anterior/posterior translation Anterior/posterior translation –– SC jointSC joint

““Piano keyPiano key”” test test –– AC jointAC joint

Apprehension test Apprehension test –– GH joint (anterior)GH joint (anterior)

Relocation test Relocation test –– GH joint (anterior)GH joint (anterior)

Anterior/posterior glide tests Anterior/posterior glide tests –– GH jointGH joint

SulcusSulcus test test –– GH joint (inferior)GH joint (inferior)

Special TestsSpecial Tests

NeerNeer test test –– rotator cuff impingementrotator cuff impingement

HawkinsHawkins--Kennedy test Kennedy test –– rotator cuff impingementrotator cuff impingement

YergasonYergason’’ss test test –– biceps tendon instabilitybiceps tendon instability

SpeedSpeed’’s test s test –– biceps tendon irritationbiceps tendon irritation

Empty can test Empty can test –– supraspinatussupraspinatus impingementimpingement

Drop arm test Drop arm test –– rotator cuff tearrotator cuff tear

InjuriesInjuries

InjuriesInjuries

SC joint injuriesSC joint injuries

AC joint injuriesAC joint injuries

GH joint injuriesGH joint injuries

Rotator cuff injuriesRotator cuff injuries

Biceps tendon injuriesBiceps tendon injuries

FracturesFractures

SC Joint InjuriesSC Joint Injuries

Most common direction of displacement is Most common direction of displacement is anterioranterior

Significant potential concerns if posteriorSignificant potential concerns if posterior

AC Joint InjuriesAC Joint Injuries

Horizontal stability from superior/inferior AC Horizontal stability from superior/inferior AC ligamentsligaments

Vertical stability from Vertical stability from coracoclavicularcoracoclavicular ligamentsligaments

If If ““stepstep--offoff”” is present, indicates complete tear is present, indicates complete tear of AC ligaments and at least partial tear of of AC ligaments and at least partial tear of coracoclavicularcoracoclavicular ligamentsligaments

AC Joint InjuriesAC Joint Injuries

GH Joint InjuriesGH Joint Injuries

Anterior much more Anterior much more common than posteriorcommon than posterior

If occurs before age 30, If occurs before age 30, >90% chance of >90% chance of recurrence recurrence –– surgerysurgery

If after age 30 If after age 30 –– choose choose between surgery/rehabbetween surgery/rehab

Rotator Cuff InjuriesRotator Cuff Injuries

Impingement syndromesImpingement syndromes““PinchingPinching”” of tendons under of tendons under acromionacromion processprocess

TendonitisTendonitisPoor blood supply, Poor blood supply, ““wrung outwrung out”” with rotationwith rotation

Rotator cuff tearsRotator cuff tearsUsually from cumulative effectsUsually from cumulative effects

Biceps Tendon InjuriesBiceps Tendon Injuries

TendonitisTendonitisSecondary to biomechanical issues and/or repetitive Secondary to biomechanical issues and/or repetitive overuse movementsoveruse movements

Biceps tendon ruptureBiceps tendon ruptureCan occur to long head from Can occur to long head from glenoidglenoid rim, short head rim, short head from from coracoidcoracoid process or distal tendon from radius at process or distal tendon from radius at elbowelbowTypically has resultant deformityTypically has resultant deformity

FracturesFractures

ScapulaScapulaRarely suffers bony injuryRarely suffers bony injuryIf so, processes most common If so, processes most common sitesite

ClavicleClavicleCommonly fractured in middle Commonly fractured in middle 1/31/3

HumerusHumerusHead often injured with GH Head often injured with GH dislocationsdislocationsShaft rarely injured unless Shaft rarely injured unless severe forcessevere forces