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Prevention and Care of Prevention and Care of Athletic InjuriesAthletic Injuries
Shoulder Evaluation and InjuriesShoulder Evaluation and Injuries
www.fisiokinesiterapia.biz
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