Shoulder Injuries

Sternoclavicular Joint Sprain

• Mechanism– Force applied to lateral aspect of shoulder

(travels medially through clavicle)– Force applied anterior or posterior to shoulder– Stretching of SC ligament from direct or

indirect force to joint– Rare-traction force (i.e. uneven bars)

• Signs and symptoms– Point tenderness over SC joint– Pain with active/passive stretch– Loss of function– Pain with protraction/retraction– Dislocations tend to occur anterior or superior

• Although posterior can occur and is a medical emergency

• Signs and Symptoms (cont.)– Inflammation– Hemorrhage– Ecchymosis– Deformity– Instability (with 2nd,3rd degree)

• Special Tests– Active and resistive movements– Passive stress

• Diagnostic Procedure– Refer to ortho– X-Ray

*If posterior emergent

Acromioclavicular Joint Sprain

• Mechanisms– Downward force on point of shoulder with arm

adducted• Blow to acromion process which drives scapula

inferior

– Stretching of AC ligament due to direct or indirect force applied to joint

AC Classification System• I

– Slight partial damage to AC ligament, negative laxity, point tenderness

• II– Rupture AC and partial CC, slight laxity

• III– Complete AC and CC, dislocation distal

clavicle/acromion

• IV, V, VI– AC/CC/tearing deltoid/trap fascia

• Signs and Symptoms– Pain on A/P/RROM

– Loss of function

– Tenderness over AC joint

– Swelling

– Hemorrhage

– Ecchymosis

– Inflammation

– Step deformity

• Signs and Symptoms (cont)– Pain on shoulder abduction– Pain on distraction of AC joint– Abnormal motion of distal clavicle– Deformity– Instability (2nd and 3rd degree)

• Special Tests– Distraction (piano key)– AC Traction/Compression– Pain on Abduction– A/R ROM– Apley’s scratch test

• Diagnostic Procedure– Ortho– X-Ray

Subcoracoid glenohumeral luxation(dislocation)

• Mechanism– Force applied to an abducted, ER arm above 90 deg

• Signs and symptoms– Pain

– Loss of function

– Deformity

– Swelling

– Tenderness on anterior aspect of shoulder

• Special Tests– Check pulse– Check sensation over axillary n.

• Diagnostic Procedure– Refer to ortho– X-ray

Glenohumeral/subglenoid luxation(dislocation)

• Mechanism– Force applied to an abducted arm

• Signs and Symptoms– Pain

– Loss of function

– Marked deformity

– Swelling

– Pt. Tenderness

– Flattened deltoid

• Special Tests– Check pulse at wrist– Check for sensory loss in arm and hand

• Diagnostic Procedure– Refer to ortho– X-ray

Posterior Glenohumeral Luxation(dislocation)

• Mechanism– Fall on outstretched arm

– Blow to the front of the shoulder

• Signs and Symptoms– Pain

– Loss of function

– Marked deformity

– Swelling

– Pt. Tenderness

• Special Tests– Check pulse at wrist– Check sensation of arm/hand

• Diagnostic Procedure– Refer to ortho– X-Ray

Glenohumeral Instability• Result of ligamentous or labral pathology

• Grade of severity is based on joint glide movements

• GH instability has a close relationship with pathological changes in RC

Anterior Glenohumeral Instability

• Mechanism– Acute– Repetitive microtrauma involving ER when GH

joint is abducted to 90 degrees

Signs and symptoms• Sensation of slipping out of place• Increased laxity• Positive apprehension/relocation test• Increased anterior glide• Flattened deltoid• Diffuse pain• Tenderness to anterior GH joint• RC atrophy

Special Tests• Positive Apprehension

• Positive relocation sign

• Sulcus sign

• Glenohumeral translation

Glenoid Labrum tear• Mechanism

– Repetition of shoulder motion– Acute Trauma– Ant. Subluxation of glenohumeral jt.

• Special tests– Clunk test– Resistive ROM– Apprehension test

• Diagnostic– Ortho– MRI

• Signs and symptoms– Pain

– Loss of smooth shoulder motion

– Pop or snap on extended rotation

– Pain with ER at 90 deg of abduction

– Possible positive clunk test

– Pain with forced abduction

– Pain on forced horizontal adduction

– Weakness of RC

Anterior Glenohumeral Subluxation

• Mechanism– Leverage force applied to an abducted and ER

arm

• Signs and Symptoms– Pain– Loss of function– Sensation of shoulder slipping out of place

• Signs and Symptoms (continued)– Obvious deformity before reduction– Spasm– Positive apprehension test– Head of humerus is palpable while slipping

forward

• Special Tests– Apprehension test– Relocation test– Sulcus sign– Glenohumeral translation– Clunk test

• Diagnostic Procedure– Refer to ortho

Bankhart Lesion

• Inferior GH ligament may be avulsed along with a portion of the labrum

• Complains of pain/crepitus as humeral head moves against anterior labrum during GH glide testing

Hills-Sach Lesion

• Common finding associated with anterior GH dislocation

• Small defect in posterior humeral head’s articular cartilage

• Caused by impact of humeral head on glenoid fossa as humerus attempts to relocate

Superior Labrum Anteroposterior Lesions

• Known as SLAP lesions

• Tear in superior glenoid labrum located near the attachment of the long head of biceps brachii tendon

Rotator Cuff Impingement• Mechanisms

– Decreased space in subacromial arch– Structures beneath are impinged between

acromion and humeral head• Chronic microtrauma

• Vascular impairment

• Partial tear RC- altered mechanics

• Anatomic variation of arch

• Signs and Symptoms– Increase in pain from IR to ER– Snapping sensation– Loss of function– Pain with overhead activity– Painful arc– Pain on superolateral aspect of shoulder

• Signs and Symptoms (cont.)– Pain on active abduction between 70 and 130

degree– Pain on extreme forward flexion with forearm

supinated– Pain on internal rotation with arm abducted at

90 and forearm pronated

• Special tests– Impingement test (Neer and Hawkins)– Forward Flexion test– Empty can test– RROM

• Diagnostic Procedure– Ortho

Rotator Cuff Tendinitis/Strain

• Mechanisms– Trauma due to excessive forcible contraction or

stretching– Muscle fatigue– Overuse– Slow onset– Decrease muscle balance between IR and ER– Capsular laxity– Poor vascularization of tendons– Supraspinatus most commonly injured

• Symptoms and Signs– Pain with A/P/RROM– Loss of function– Snapping– Tenderness– Spasm– Swelling– Ecchymosis

• Signs and Symptoms– Pt. Tenderness over RC tendons– Inflammation– Hematoma formation– Muscle defect– Pain on abduction/ER/ and flexion of shoulder

• Special Test– Apley’s scratch – Impingement– Drop Arm– Forward Flexion– Empty can

*Refer to Ortho

Tenosynovitis of Shoulder• Mechanism

– Overuse– Direct or repeated trauma– Poor throwing techniques

• Signs and symptoms– Pain on A/P/RROM– Loss of function– Tenderness– Swelling– Thickening of tendon

• Special Tests– A/P/RROM

• Diagnostic Procedure– Refer to ortho

Bicep Tendon Pathology• Biceps Tendinitis

• Luxation of bicep tendon

• Long Head of biceps rupture

Bicep tendinitis• Mechanism

– Irritation of biceps tendon in the groove– Rotator cuff dysfunction– Repeated microtrauma– Overuse– Degenerative changes– impingement

• Signs and symptoms– Pain on P/A/RROM

– Loss of function

– Overuse activity

– Tenderness

– Errythema

– Swelling

– Inflammation

– Crepitus

• Special Tests– A/P/RROM– RC muscle test

• Diagnostic Procedure– Physician if symptoms persist

Luxation of biceps tendon• Mechanism

– Inadequate muscle development– Overuse in throwing– Tearing of transverse humeral ligament– Shallow bicipital groove of humerus– Faulty mechanics

• Signs and Symptoms– Pain in anterior aspect of shoulder– Loss of shoulder function– Snapping sensation followed by dull ache in

arm or arm feeling dead– Tenderness over bicipital groove– Inflammation

• Special Tests– Yergason– Speed’s– Ludington

• Diagnostic Procedure– Refer to physician

Long head of biceps rupture• Mechanism

– Violent contraction against resistance

• Symptoms/signs– Pain

– Loss of function

– Sensation of something rolling up arm

– Protruding bulge in biceps

– Tenderness along long head

– Loss of strength

• Special Tests– Ludington’s test

• Diagnostic Procedure– Refer to ortho

• Contusion of biceps– Mechanism

• Direct Trauma

– Signs and Symptoms• Pain• Loss of elbow flexion and extension• Transitory paralysis• Pt. Tenderness• Ecchymosis• Hematoma Formation• Inflammation

• Special Tests– A/P/RROM

• Diagnostic Procedures– Refer if symptoms persist

Exostosis/Myositis Ossificans

• Mechanism– Repeated trauma (humerus)

• Signs and Symptoms– Pain– Point tenderness– Possible paresthesia– Swelling– Loss of Function

Proximal Humerus Epiphyseal Plate Injury

• Mechanism– Direct trauma– Indirect trauma traveling along length of

humerus

• Signs and Symptoms– Sudden pain– Tenderness– Deformity– Rapid Swelling– Possible bony deviations– Crepitus– Ecchymosis

Humerus Fracture• Mechanism

– Direct trauma

– Fall on an outstretched arm

• Signs and Symptoms– Sudden pain

– Loss of function

– Tenderness

– Deformity

– Rapid Swelling

Axillary N. Injury• Mechanism

– Direct trauma to lateral arm

– 2nd to anterior dislocated arm

• Signs and symptoms– Loss of shoulder abduction

– Tenderness

– Loss of function of deltoid/biceps

– Dermatome numbness in area of middle Deltoid

• Special Tests– A/RROM for Deltoid– Sensation testing for Deltoid

• Diagnostic Procedures– Neurologist

Subacromion Bursitis• Mechanism

– Direct Trauma– Overuse– Fall on an outstretched hand– RC impingement (i.e. stress from throwing)

• Signs and Symptoms– Similar to RC impingement– Pain(at night/ ache with rest)– Loss of function– Tenderness– Redness, swelling, inflammation– Pain on rotation and/or abduction>80 deg

• Special Tests– Appley’s Scratch test– Resistive movements

• Diagnostic– Refer to physician

Subdeltoid bursitis• Mechanism

– Direct Trauma– Fall on outstretched hand– Overuse

• Signs and Symptoms– Pain– Loss of function– Tenderness(under deltoid)– Redness, swelling, inflammation– Pain and/or weakness on abduction

• Special Tests– Apley’s scratch test– Resistive movement tests

• Diagnostic– Refer to physician

Clavicle Contusion• Mechanisms

– Direct trauma to clavicle

• Symptoms– Pain – Loss of Function– Transitory paralysis– Point tenderness– Inflammation

• Special Tests– Distraction Test (rule out AC sprain)

• Diagnostic Procedure– Refer to orthopedic surgeon– XRay

Deltoid Contusion• Mechanism

– Direct Trauma

• Symptoms– Pain– Loss of function– Point tenderness– Transitory paralysis– Weakness on shoulder abduction

Long Thoracic N. Contusion (Winging Scapula)

Mechanism– Indirect trauma to lat. Thoracic wall or shoulder– Overuse of shoulder– Prolonged traction (i.e. cycling)

Signs and symptoms– Scapular winging (scapula protrudes posteriorly)– Dull ache around shoulder girdle– Decrease motion with shoulder movement

• Special Tests– Scapula protraction test

• Pushing against a wall will cause winging effect

• Diagnostic Procedure– Physician– EMG study (Electromyography)

Thoracic Outlet Syndrome• Mechanism

– Pressure on medial cord of brachial plexus, subclavian artery a/o subclavian vein (neurmuscular bundle)

– Cervical rib– Pect minor/scalene tightness– Pressure on neurovascular bundle as it runs

between clavicle and first rib

Signs and Symptoms• Neurological

– C8-T1 medial because of closeness to 1t rib, ulnar n, occasionally median n.

• Vascular– Vein-swelling– Artery-decreased blood flow

• Tests– Adson’s– Allen– Costoclavicular (military brace)

Clavicle Fracture• Fracture collar bone

• Mechanisms– Fall on outstretched arm– Direct contact

• Signs and Symptoms– Sudden pain– Tenderness(direct /indirect)– Loss of shoulder function– Deformity(rapid swelling/bony deviation)– Head tilt towards side of fracture– Crepitus

• Signs and symptoms (cont.)– False joint motion– Delayed ecchymosis– Head tilted toward side of fracture– Rounded shoulder– Athlete may be supporting affected elbow with

opposite hand

*Refer to ortho/X-ray

Scapula Fracture• Mechanism

– Direct trauma

– Indirect trauma from fall (on shoulder or arm)

• Signs and Symptoms– Sudden pain

– Loss of function

– Tenderness (direct/indirect)

– Possible crepitus

• Signs and Symptoms (cont.)– Rapid Swelling– Bony deviations– Crepitus– False Joint Motion– Delayed Ecchymosis

*Refer to ortho/X-Ray

Proximal humerus Epiphyseal plate Injury

• Mechanisms– Direct trauma– Indirect along shaft

• Signs and symptoms– Pain– Loss of function– Deformity– Swelling– Crepitus– False joint

Blocker’s Extosis• Myositis Ossificans• Mechanisms

– Repetitive trauma to humerus

• Signs and symptoms– Pain

– Pt. Tenderness

– Bony prominence

– Swelling

– Loss of function-elbow flexion/extension

Humerus Fracture• Mechanism

– Direct trauma from fall/external force

• Signs and Symptoms– Pain– Loss of function– Deformity- shortened humerus– Swelling– False joint motion

Triceps strain• Mechanism

– Excessive forcible contraction or stretching– Muscle fatigue

• Signs and symptoms

• Tests