Transcript Chapter 22: The Shoulder Complex

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
Introduction
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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
Functional Anatomy
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Great mobility, limited stability
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Round humeral head articulates with flat glenoid
Rotator cuff and long head of the biceps provide
dynamic stability during overhead motion
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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
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Relationship with the other joints of the shoulder
complex and the G-H joint is critical
Prevention of Shoulder Injuries
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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
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Clavicular Fractures
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Etiology
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MOI = fall on outstretched arm, fall on tip of
shoulder, or direct impact
Occurs primarily in middle third
Signs and Symptoms
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Athlete supports arm, head tilted towards injured side
with chin turned away
Clavicle may appear lower
Palpation reveals pain, swelling, deformity, and point
tenderness
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Clavicular Fractures (continued)
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Management
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Closed reduction - sling and swathe immediately
Refer for X-ray
Immobilize with brace for 6-8 weeks
After removal of brace, rehabilitation includes:
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Joint mobilizations
Isometric exercises
Use of a sling for 3-4 weeks
May require surgical treatment
Specific Injuries
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Scapular Fractures
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Etiology
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Signs and Symptoms
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MOI = direct impact or force transmitted up through
humerus
Pain during shoulder movement
Swelling and point tenderness
Management
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Sling immediately and refer for X-ray
Use sling for 3 weeks then begin PRE exercises
Specific Injuries
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Fractures of the Humerus
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Etiology
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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
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Fractures of the Humerus (continued)
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Signs and Symptoms
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Pain, swelling, point tenderness, decreased ROM
Management
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Immediate application of splint
Refer for X-ray
Treat for shock
Specific Injuries
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Acromioclavicular Sprain
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Etiology
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MOI = direct blow (from any direction) or upward
force from the humerus
Graded from 1 - 6 according to severity of injury
Signs and Symptoms
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Grade 1 - point tenderness, pain with movement
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No disruption of AC joint
Grade 2 - tear or rupture of AC ligament, pain, point
tenderness, and decreased ROM (abd/add)
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Partial displacement of lateral end of clavicle
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Acromioclavicular Sprain (continued)
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Signs and Symptoms
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Grade 3 - rupture of AC and CC ligaments
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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
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Acromioclavicular Sprain (continued)
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Management
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Ice, sling and swathe
Referral to physician
Grades 1 – 3: non-operative treatment
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1 - 2 weeks of immobilization
Grades 4 – 6: surgery required
Aggressive rehab is required for all AC sprains
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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
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A: Grade 1
B: Grade 2
C: Grade 3
D: Grade 4
E: Grade 5
F: Grade 6
Specific Injuries
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Glenohumeral Joint Sprain
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Etiology
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MOI = forced abduction and/or external rotation; or a
direct blow
Signs and Symptoms
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Pain during movement
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Especially when re-creating the MOI
Decreased ROM
Point tenderness
Specific Injuries
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Glenohumeral Joint Sprain (continued)
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Management
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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
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Acute Subluxations and Dislocations
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Etiology
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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
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Acute Subluxations and Dislocations
(continued)
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Signs and Symptoms
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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
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Acute Subluxations and Dislocations
(continued)
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Management
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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
Specific Injuries
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Shoulder Impingement Syndrome
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Etiology
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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
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Laxity and inflammation
Postural mal-alignments
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Kyphosis and/or rounded shoulders
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Shoulder Impingement Syndrome (continued)
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Signs and Symptoms
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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
Specific Injuries
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Rotator cuff tear
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Etiology
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Occurs near insertion on greater tuberosity
Involve supraspinatus or rupture of other rotator cuff
tendons
Partial or complete thickness tear
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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
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Pain and weakness with shoulder ABD and IR
Point tenderness
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Rotator cuff tear (continued)
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Management
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NSAID’s and analgesics
Modalities
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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
Specific Injuries
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Thoracic Outlet Compression
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Etiology
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Compression of brachial plexus, subclavian artery and
vein
Due to
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1) decreased space between clavicle and first rib,
2) scalene compression,
3) compression by pectoralis minor, or
4) presence of cervical rib
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Thoracic Outlet Compression (continued)
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Signs and Symptoms
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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
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Conservative treatment - correct anatomical condition
through stretching (pec minor and scalenes) and
strengthening (trapezius, rhomboids, serratus anterior,
erector spinae)
Specific Injuries
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Biceps Brachii Rupture
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Etiology
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Generally occurs near origin of muscle at bicipital
groove
MOI = powerful contraction
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Biceps Brachii Rupture (continued)
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Signs and Symptoms
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Audible snap with sudden and intense pain
Protruding bulge may appear near middle of biceps
Weakness with elbow flexion and supination
Management
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Ice for hemorrhaging
Immobilize with a sling and refer to physician
Athletes will require surgery
Specific Injuries
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Bicipital Tenosynovitis
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Etiology
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Ballistic activity involves repeated stretching of biceps
tendon causing irritation to the tendon and sheath
MOI = repetitive overhead activities
Signs and Symptoms
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Point tenderness over bicipital groove
Swelling, crepitus due to inflammation
Pain when performing overhead activities
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Bicipital Tenosynovitis (continued)
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Management
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Rest, ice, and ultrasound to treat inflammation
NSAID’s
Gradual program of strengthening and stretching
Specific Injuries
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Contusion of Upper Arm
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Etiology
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Signs and Symptoms
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MOI = Direct blow
Transitory paralysis and decreased ROM
Management
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RICE for at least 24 hours
Provide protection to prevent repeated episodes that
could cause myositis ossificans
Maintain ROM
Rehabilitation of the Shoulder
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Immobilization
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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
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Maintain cardiovascular endurance through
cycling, running, and walking