Chapter 22: The Shoulder Complex

Jennifer Doherty-Restrepo, MS, LAT, ATC

Academic Program Director, Entry-Level ATEP

Florida International University

Acute Care and Injury Prevention

The shoulder is an extremely complicated region of the body

Joint with a high degree of mobility, but, not without compromising stability

Involved in a variety of overhead activities relative to sport

Susceptible to a number of repetitive and overused type injuries

Introduction

Functional Anatomy Great mobility, limited stability

Round humeral head articulates with flat glenoid Rotator cuff and long head of the biceps provide dynamic

stability during overhead motion Supraspinatus compresses the humeral head Other rotator cuff muscles depress the humeral head Integration

of the capsule and rotator cuff

Scapula stabilizing muscles also provide dynamic stability Relationship with the other joints of the shoulder complex and

the G-H joint is critical

Prevention of Shoulder Injuries Proper physical conditioning is key Sport-specific conditioning Strengthen through a full ROM Warm-up should be used before explosive arm

movements are attempted Contact and collision sport athletes should receive

proper instruction on falling Protective equipment Proper mechanics

Specific Injuries Clavicular Fractures

Etiology MOI = fall on outstretched arm, fall on tip of shoulder, or

direct impact Occurs primarily in middle third

Signs and Symptoms Athlete supports arm, head tilted towards injured side with

chin turned away Clavicle may appear lower Palpation reveals pain, swelling, deformity, and point

tenderness

Clavicular Fractures (continued) Management

Closed reduction - sling and swathe immediately Refer for X-ray Immobilize with brace for 6-8 weeks After removal of brace, rehabilitation includes:

Joint mobilizations Isometric exercises Use of a sling for 3-4 weeks

May require surgical treatment

Scapular Fractures Etiology

MOI = direct impact or force transmitted up through humerus

Signs and Symptoms Pain during shoulder movement Swelling and point tenderness

Management Sling immediately and refer for X-ray Use sling for 3 weeks then begin PRE exercises

Specific Injuries

Fractures of the Humerus Etiology

MOI = direct impact, force transmitted up through humerus, or fall on outstretched arm

Proximal fractures occur due to direct blow Dislocations occur due to fall on outstretched arm Epiphyseal fractures are more common in young

athletes and occur due to direct blow or indirect blow traveling along long axis of humerus

Specific Injuries

Fractures of the Humerus (continued) Signs and Symptoms

Pain, swelling, point tenderness, decreased ROM Management

Immediate application of splint Refer for X-ray Treat for shock

Specific Injuries

Acromioclavicular Sprain Etiology

MOI = direct blow (from any direction) or upward force from the humerus

Graded from 1 - 6 according to severity of injury

Signs and Symptoms Grade 1 - point tenderness, pain with movement

No disruption of AC joint

Grade 2 - tear or rupture of AC ligament, pain, point tenderness, and decreased ROM (abd/add) Partial displacement of lateral end of clavicle

Specific Injuries

Acromioclavicular Sprain (continued) Signs and Symptoms

Grade 3 - rupture of AC and CC ligaments AC joint separation

Grade 4 - posterior dislocation of clavicle Grade 5 – rupture of AC and CC ligaments, tearing of

deltoid and trapezius attachments, gross deformity, severe pain, decreased ROM

Grade 6 - displacement of clavicle behind the coracobrachialis

Acromioclavicular Sprain (continued) Management

Ice, sling and swathe Referral to physician Grades 1 – 3: non-operative treatment

1 - 2 weeks of immobilization Grades 4 – 6: surgery required Aggressive rehab is required for all AC sprains

Joint mobilizations, flexibility exercises, and PRE exercises should occur immediately

Progress as tolerated – no pain and no additional swelling Padding and protection may be required until pain-free ROM

returns

A: Grade 1 B: Grade 2 C: Grade 3 D: Grade 4 E: Grade 5 F: Grade 6

Glenohumeral Joint Sprain Etiology

MOI = forced abduction and/or external rotation; or a direct blow

Signs and Symptoms Pain during movement

Especially when re-creating the MOI Decreased ROM Point tenderness

Specific Injuries

Glenohumeral Joint Sprain (continued) Management

RICE for 24-48 hours Sling After hemorrhaging subsides, modalities may be

utilized along with PROM and AROM exercises to regain full ROM

When full ROM achieved without pain, PRE exercises can be initiated

Must be aware of potential development of chronic conditions (instability)

Specific Injuries

Acute Subluxations and Dislocations Etiology

Subluxation = excessive translation of humeral head without complete separation from joint

Anterior dislocation = results from an anterior force on the shoulder with forced ABD and ER

Posterior dislocation = results from forced ADD and IR, or, falling on an extended and internally rotated shoulder

Specific Injuries

Acute Subluxations and Dislocations (continued) Signs and Symptoms

Anterior dislocation - flattened deltoid; prominent humeral head in axilla; arm carried in slight ABD and ER rotation; moderate pain and disability

Posterior dislocation - severe pain and disability; arm carried in ADD and IR; prominent acromion and coracoid process; limited ER and elevation

Specific Injuries

Acute Subluxations and Dislocations (continued) Management

Sling and swathe and refer for reduction Immobilize for 3 weeks following reduction Perform isometrics while in sling After immobilization period, begin PRE exercises as

pain allows Protective bracing when return to play

Shoulder Impingement Syndrome Etiology

Mechanical compression of supraspinatus tendon, subacromial bursa, and long head of biceps tendon due to decreased space under coracoacromial arch

MOI = overhead repetitive activities Exacerbating factors

Laxity and inflammation Postural mal-alignments

Kyphosis and/or rounded shoulders

Specific Injuries

Shoulder Impingement Syndrome (continued) Signs and Symptoms

Diffuse pain Increased pain with palpation of subacromial space Decreased strength of external rotators compared to

internal rotators Tightness in posterior and inferior capsule Positive impingement and empty can tests

Rotator cuff tear Etiology

Occurs near insertion on greater tuberosity Involve supraspinatus or rupture of other rotator cuff

tendons Partial or complete thickness tear

Full thickness tears usually occur in athletes with a long history of rotator cuff pathology

Generally does not occur in athlete under age 40 MOI = acute trauma or impingement

Signs and Symptoms Pain and weakness with shoulder ABD and IR Point tenderness

Specific Injuries

Rotator cuff tear (continued) Management

NSAID’s and analgesics Modalities

Electrical stimulation for pain Ultrasound for inflammation

Restore appropriate mechanics by strengthening rotator cuff to depress and compress humeral head to restore subacromial space

Severe cases may require rest, immobilization, and surgery

Thoracic Outlet Compression Etiology

Compression of brachial plexus, subclavian artery and vein

Due to 1) decreased space between clavicle and first rib, 2) scalene compression, 3) compression by pectoralis minor, or 4) presence of cervical rib

Specific Injuries

Thoracic Outlet Compression (continued) Signs and Symptoms

Paresthesia, pain, sensation of cold, impaired circulation, muscle weakness, muscle atrophy, and radial nerve palsy

Positive anterior scalene test, costoclavicular test, and hyperabduction test

Management Conservative treatment - correct anatomical condition

through stretching (pec minor and scalenes) and strengthening (trapezius, rhomboids, serratus anterior, erector spinae)

Specific Injuries Biceps Brachii Rupture

Etiology Generally occurs near origin of muscle at bicipital groove MOI = powerful contraction

Biceps Brachii Rupture (continued) Signs and Symptoms

Audible snap with sudden and intense pain Protruding bulge may appear near middle of biceps Weakness with elbow flexion and supination

Management Ice for hemorrhaging Immobilize with a sling and refer to physician Athletes will require surgery

Bicipital Tenosynovitis Etiology

Ballistic activity involves repeated stretching of biceps tendon causing irritation to the tendon and sheath

MOI = repetitive overhead activities

Signs and Symptoms Point tenderness over bicipital groove Swelling, crepitus due to inflammation Pain when performing overhead activities

Specific Injuries

Bicipital Tenosynovitis (continued) Management

Rest, ice, and ultrasound to treat inflammation NSAID’s Gradual program of strengthening and stretching

Contusion of Upper Arm Etiology

MOI = Direct blow

Signs and Symptoms Transitory paralysis and decreased ROM

Management RICE for at least 24 hours Provide protection to prevent repeated episodes that could

cause myositis ossificans Maintain ROM

Specific Injuries

Rehabilitation of the Shoulder Immobilization

Will vary depending on injury Time in brace or splint are injury specific Isometrics can be performed ROM and strengthening are dictated by healing

General Body Conditioning Maintain cardiovascular endurance through

cycling, running, and walking