KIN 188 – Prevention and KIN 188 – Prevention and Care of Athletic InjuriesCare of Athletic Injuries

Shoulder Evaluation and Shoulder Evaluation and InjuriesInjuries

AnatomyAnatomy

Bony AnatomyBony Anatomy

SternumSternum Manubrium, body, xiphoid processManubrium, body, xiphoid process

ClavicleClavicle Sternal (proximal) and acromial (distal) endsSternal (proximal) and acromial (distal) ends Characteristic “s-shape”Characteristic “s-shape”

HumerusHumerus Head, neck, greater/lesser tuberosity, bicipital Head, neck, greater/lesser tuberosity, bicipital

(intertubercular) groove, deltoid tuberosity(intertubercular) groove, deltoid tuberosity Scapula (shoulder blade)Scapula (shoulder blade)

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

Bony AnatomyBony Anatomy

Bony AnatomyBony Anatomy

Right shoulder

blade

ArticulationsArticulations

Sternoclavicular (SC) jointSternoclavicular (SC) joint Proximal clavicle and sternumProximal clavicle and sternum Anterior/posterior SC ligamentsAnterior/posterior SC ligaments

Acromioclavicular (AC) jointAcromioclavicular (AC) joint Distal clavicle and acromion processDistal clavicle and acromion process Superior/inferior AC ligaments, coracoclavicular Superior/inferior AC ligaments, coracoclavicular

ligamentsligaments Glenohumeral (GH) jointGlenohumeral (GH) joint

Head of humerus and glenoid fossa of scapulaHead of humerus and glenoid fossa of scapula Joint capsule is primary ligamentous restraintJoint capsule is primary ligamentous restraint Reinforced by glenoid labrumReinforced by glenoid labrum

Scapulothoracic jointScapulothoracic joint Not a “true” joint, but significant for shoulder ROMNot a “true” joint, but significant for shoulder ROM

ArticulationsArticulations

ArticulationsArticulations

Muscular AnatomyMuscular Anatomy

Muscles acting on the scapulaMuscles acting on the scapula Rhomboid major/minor: retractionRhomboid major/minor: retraction Levator scapulae: elevationLevator scapulae: elevation Serratus anterior: protractionSerratus anterior: protraction Pectoralis major/minor: rotation & tiltPectoralis major/minor: rotation & tilt Trapezius: shoulder shrug & retractionTrapezius: shoulder shrug & retraction Latissimus dorsi: depressionLatissimus dorsi: depression

Muscular AnatomyMuscular Anatomy

Muscles acting on the humerusMuscles acting on the humerus Rotator cuff (SITS)Rotator cuff (SITS)

Supraspinatus, infraspinatus (ER), teres minor (ER), Supraspinatus, infraspinatus (ER), teres minor (ER), subscapularis (IR)subscapularis (IR)

Deltoid :abDeltoid :ab Pectoralis major: adPectoralis major: ad Latissimus dorsi:Latissimus dorsi: Teres major: IRTeres major: IR Long head of triceps brachii: extensorLong head of triceps brachii: extensor Biceps brachii (short/long heads): flexionBiceps brachii (short/long heads): flexion Coracobrachialis: flexionCoracobrachialis: flexion

Neurological AnatomyNeurological Anatomy

Brachial plexus Brachial plexus from cervical spinefrom cervical spine Nerve rootsNerve roots Associated Associated

peripheral nervesperipheral nerves

Vascular AnatomyVascular Anatomy

Subclavian artery Subclavian artery becomes axillary becomes axillary artery becomes artery becomes brachial arterybrachial artery

EvaluationEvaluation

HistoryHistory

Mechanism of injury (etiology)Mechanism of injury (etiology) Direct trauma – contusion, fracture, dislocationDirect trauma – contusion, fracture, dislocation Abduction/external rotation – anterior GH Abduction/external rotation – anterior GH

dislocationdislocation Fall on outstretched arm – dislocations, Fall on outstretched arm – dislocations,

fracturefracture Fall on tip of shoulder – AC sprain, clavicle Fall on tip of shoulder – AC sprain, clavicle

fracture, SC sprainfracture, SC sprain Repetitive overhead movements – tendonitis, Repetitive overhead movements – tendonitis,

impingement syndromes, bursitisimpingement syndromes, bursitis

HistoryHistory

Location of painLocation of pain Localized to shoulder – general shoulder pathologyLocalized to shoulder – general shoulder pathology Radiating pain – neurological involvementRadiating pain – neurological involvement

Unusual sounds/sensationsUnusual sounds/sensations

History of previous injuryHistory of previous injury Residual weakness from neck/shoulder injuryResidual weakness from neck/shoulder injury Biomechanical changes from prior injury can result Biomechanical changes from prior injury can result

in increased risk of overuse injuries in increased risk of overuse injuries (compensations and modified technique can (compensations and modified technique can change tissue use)change tissue use)

HistoryHistory

Change in activityChange in activity Intensity, duration, frequency, surface change, footwear Intensity, duration, frequency, surface change, footwear

changechange

Acute/gradual onset of symptomsAcute/gradual onset of symptoms Macrotraumatic vs. microtruamaticMacrotraumatic vs. microtruamatic

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

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

Inspection/ObservationInspection/Observation

General postureGeneral posture Head position, arm splinted to side, “dead arm”, deformity Head position, arm splinted to side, “dead arm”, deformity

with dislocations with dislocations

AnteriorAnterior Level of shoulders, clavicle contour, deltoid contour, biceps Level of shoulders, clavicle contour, deltoid contour, biceps

brachii contourbrachii contour

LateralLateral Deltoid, acromion process, humerus positionDeltoid, acromion process, humerus position

PosteriorPosterior Vertebral alignment (scoliosis), level of scapulae, muscle toneVertebral alignment (scoliosis), level of scapulae, muscle tone

Palpation – Anterior Palpation – Anterior StructuresStructures

SC jointSC joint ClavicleClavicle AcromionAcromion AC jointAC joint Coracoid processCoracoid process Humeral headHumeral head Greater tuberosityGreater tuberosity

Lesser tuberosityLesser tuberosity Bicipital grooveBicipital groove Humeral shaftHumeral shaft Pectoralis majorPectoralis major CoracobrachialisCoracobrachialis DeltoidDeltoid Biceps brachiiBiceps brachii

Palpation – Posterior Palpation – Posterior StructuresStructures

Spine of scapulaSpine of scapula Superior angleSuperior angle Inferior angleInferior angle Rotator cuffRotator cuff

SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres minorTeres minor

Teres majorTeres major RhomboidsRhomboids Levator scapulaeLevator scapulae TrapeziusTrapezius Latissimus dorsiLatissimus dorsi Posterior deltoidPosterior deltoid Triceps brachiiTriceps brachii

Special TestsSpecial Tests

ROMROM Active – patient/athlete moves jointActive – patient/athlete moves joint Passive – clinician moves joint, evaluates end Passive – clinician moves joint, evaluates end

feelfeel Resistive – proximal stabilization and distal Resistive – proximal stabilization and distal

application of resistance (“break” test vs. application of resistance (“break” test vs. resistance through ROM)resistance through ROM)

NeurovascularNeurovascular

Special testsSpecial tests

Range of MotionRange of Motion

Flexion (~180 degrees)Flexion (~180 degrees) Biceps brachii, coracobrachialis, anterior and middle deltoid, Biceps brachii, coracobrachialis, anterior and middle deltoid,

pectoralis major (clavicular head)pectoralis major (clavicular head)

Extension (~60 degrees)Extension (~60 degrees) Posterior deltoid, latissimus dorsi, teres major, triceps brachii Posterior deltoid, latissimus dorsi, teres major, triceps brachii

(long head)(long head)

Abduction (~180 degrees)Abduction (~180 degrees) Deltoid, supraspinatus, biceps brachiiDeltoid, supraspinatus, biceps brachii

Adduction (~45 degrees)Adduction (~45 degrees) Pectoralis major, latissimus dorsi, teres major, Pectoralis major, latissimus dorsi, teres major,

coracobrachialis, triceps brachiicoracobrachialis, triceps brachii

Range of MotionRange of Motion

Internal rotation (~70-80 degrees at 90/90)Internal rotation (~70-80 degrees at 90/90) Subscapularis, pectoralis major, latissimus dorsi, teres Subscapularis, pectoralis major, latissimus dorsi, teres

major, anterior deltoidmajor, anterior deltoid

External rotation (~80-90 degrees at 90/90)External rotation (~80-90 degrees at 90/90) Infraspinatus, teres minor, supraspinatus, posterior Infraspinatus, teres minor, supraspinatus, posterior

deltoiddeltoid

Horizontal abduction (~45 degrees at 90)Horizontal abduction (~45 degrees at 90) Posterior deltoid, infraspinatus, teres minorPosterior deltoid, infraspinatus, teres minor

Horizontal adduction (~120 degrees at 90)Horizontal adduction (~120 degrees at 90) Pectoralis major, anterior deltoidPectoralis major, anterior deltoid

Range of MotionRange of Motion

Scapular protraction (shoulder blades apart)Scapular protraction (shoulder blades apart) Serratus anterior, pectoralis minorSerratus anterior, pectoralis minor

Scapular retractionScapular retraction Trapezius, rhomboids, levator scapulaeTrapezius, rhomboids, levator scapulae

Scapular elevation (shrugs)Scapular elevation (shrugs) Upper trapezius, levator scapulae, rhomboidsUpper trapezius, levator scapulae, rhomboids

Scapular depression (back to normal from shrug)Scapular depression (back to normal from shrug) Lower trapezius, pectoralis minor, subclaviusLower trapezius, pectoralis minor, subclavius

Scapular downward rotation (AD)Scapular downward rotation (AD) Rhomboids, pectoralis minorRhomboids, pectoralis minor

Scapular upward rotation (AB)Scapular upward rotation (AB) Trapezius, serratus anteriorTrapezius, serratus anterior

NeurovascularNeurovascular

Neurological evalationNeurological evalation Nerve root level and peripheral nerve sensory Nerve root level and peripheral nerve sensory

and motor distributionsand motor distributions

Vascular evaluationVascular evaluation Skin temperature/colorSkin temperature/color Capillary refillCapillary refill Radial pulseRadial pulse Brachial pulseBrachial pulse Axillary pulseAxillary pulse

Special TestsSpecial Tests

Anterior/posterior translation – SC jointAnterior/posterior translation – SC joint

““Piano key” test – AC jointPiano key” test – AC joint

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

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

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

Sulcus test – GH joint (inferior)Sulcus test – GH joint (inferior)

Special TestsSpecial Tests

Neer test – rotator cuff impingementNeer test – rotator cuff impingement

Hawkins-Kennedy test – rotator cuff impingementHawkins-Kennedy test – rotator cuff impingement

Yergason’s test – biceps tendon instabilityYergason’s test – biceps tendon instability

Speed’s test – biceps tendon irritationSpeed’s test – biceps tendon irritation

Empty can test – supraspinatus impingementEmpty can test – supraspinatus impingement

Drop arm test – rotator cuff tearDrop arm test – rotator 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 Most common direction of displacement is anteriordisplacement is anterior

Significant potential concerns if Significant potential concerns if posterior (carotid artery, esophagus, posterior (carotid artery, esophagus, other important structures)other important structures)

AC Joint InjuriesAC Joint Injuries

Horizontal stability from superior/inferior Horizontal stability from superior/inferior AC ligamentsAC ligaments

Vertical stability from coracoclavicular Vertical stability from coracoclavicular ligamentsligaments

If “step-off” is present, indicates complete If “step-off” is present, indicates complete tear of AC ligaments and at least partial tear of AC ligaments and at least partial tear of coracoclavicular ligamentstear of coracoclavicular ligaments

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 – surgeryrecurrence – surgery

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

Rotator Cuff InjuriesRotator Cuff Injuries

Impingement syndromesImpingement syndromes ““Pinching” of tendons under acromion Pinching” of tendons under acromion

processprocess

TendonitisTendonitis Poor blood supply, “wrung out” with rotationPoor blood supply, “wrung out” with rotation

Rotator cuff tearsRotator cuff tears Usually from cumulative effectsUsually from cumulative effects

Biceps Tendon InjuriesBiceps Tendon Injuries

TendonitisTendonitis Secondary to biomechanical issues and/or Secondary to biomechanical issues and/or

repetitive overuse movementsrepetitive overuse movements

Biceps tendon ruptureBiceps tendon rupture Can occur to long head from glenoid rim, short Can occur to long head from glenoid rim, short

head from coracoid process or distal tendon head from coracoid process or distal tendon from radius at elbowfrom radius at elbow

Typically has resultant deformityTypically has resultant deformity

FracturesFractures

ScapulaScapula Rarely suffers bony injuryRarely suffers bony injury If so, processes most If so, processes most

common sitecommon site

ClavicleClavicle Commonly fractured in Commonly fractured in

middle 1/3middle 1/3

HumerusHumerus Head often injured with Head often injured with

GH dislocationsGH dislocations Shaft rarely injured unless Shaft rarely injured unless

severe forcessevere forces