Chapter 22: The Shoulder Complex

Return to Activity

-Based on pre established criteria -Must be based on sound understanding of healing process -Objective measures of strength and functional performance testing

Flexibility

-Codman's pendulum exercises and sawing motions should begin early -Progress to active assisted ROM in pain free range (cardinal planes) -Should be performed in conjunction with rotator cuff and scapula strengthening exercises

Functional Progressions

-Incorporation of sports specific skills -Strengthening that involves PNF patters (resembles throwing) -Gradual and progressive increase in angular velocities

General Body Conditioning

-Maintain cardiovascular endurance through cycling, running, and walking

Neuromuscular Control

-Must regain appropriate firing sequence for specific muscles -Biofeedback can be used to regain control -Proprioception -Closed kinetic chain exercises will be required in gymnasts, wrestlers, and weight lifters ---Emphasize co contraction muscle activity -OKC and CKC are necessary in complete rehab plan

Rotator Cuff Tear

-Occurs near insertion on greater tuberosity -Partial or complete thickness tear -Full thickness tears usually occur in those athletes with a long history (generally does not occur in athletes under age 40) -Primary mechanism: acute trauma or impingement -Involve supraspinatus or rupture of other rotator cuff tendons

O'Brien Test (Active Compression Test)

-Patient flexes GH joint to 90 degrees and horizontally adducted 15 degrees from the sagittal plane -Downward pressure is applied with humerus fully internally rotated and externally rotated -If pain with internal rotation but decreases with external rotation and there is clicking=SLAP lesion -Pain in AC joint may indicate AC joint pathology

Palpation

-Sternoclavicular joint -Clavicular shaft -Acromioclavicular joint -Coracoid process -Acromion process -Humeral head -Greater and lesser tuberosity -Bicipital groove -Spine of scapula -Scapular vertebral border -Scapular lateral border -Scapular superior angle -Scapular inferior angle -Glenohumeral joint capsule -Deltoid -Rhomboids -Sternoclavicular, acromioclavicular, and coracoclavicular ligaments -Rotator cuff muscles and tendons -Subacromial bursa -Sternocleidomastoid -Biceps and tendon -Coracoacromial ligament -Infraspinatus -Latissimus dorsi -Serratus Anterior -Levator scapulae -Trapezius -Supraspinatus -Teres major and minor

Shoulder Joint Mobilization

-Used to re establish appropriate joint arthrokinematics -Used with joint capsule tightness

Immobilization

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

Neer's Test and Hawkins-Kennedy Test

-impingement used to assess impingement of soft tissue structures -Positive test is indicated by pain and grimace

Tests for Thoracic Outlet Compression Syndrome

1. Anterior Scalene Syndrome (Adson's Test) -Compression of subclavian artery by scaleness is assessed -Disappearance of pulse when patient turns toward extended arm and takes breath indicates a positive test 2. Hyperabduction Syndrome Test (Allen Test) -Used to assess if pressure from pectoralis minor is compressing brachuial plexus and subclavian artery.

Observation

1. Elevation or depression of shoulder tips 2. Position and shape of clavicle 3. Acromion process 4. Biceps and deltoid symmetry 5. Postural assessment (kyphosis, lordosis, shoulders) 6. Position of head and arms 7. Scapular elevation and symmetry 8. Scapular protraction or winging 9. Muscle symmetry 10. Scapulohumeral rhythm

Active and Passive Range of Motion

1. Flexion, extension 2. Abduction and adduction 3. Internal and external rotation

Tests for Glenohumeral Instability

1. Glenohumeral Translation-anterior and posterior stability -Translation of 1 cm or greater is an indication of GH ligament instability and inadequacy of glenoid lip 2. Anterior and posterior drawer tests -Positive anterior and posterior drawer test indicates insufficiency of anterior and posterior joint capsule and labrum, respectively. 3. Sulcus Test

Functional Anatomy

1. Great degree of mobility with limited stability 2. Integration of the capsule and rotator cuff 3. The scapula stabilizing muscles and the relationship with the other joints of the shoulder complex and the glenohumeral joint is critical 4. Scapulohumeral Rhythm

Rehabilitation of the Shoulder Complex

1. Immobilization 2. General Body Conditioning 3. Mobilization 4. Flexibility 5. Scapular Strengthening Exercises 6. Strengthening Exercises 7. Neuromuscular Control 8. Plyometric Exercises 9. Functional Progressions 10. Return to Activity

Scapulohumeral rhythm

1. Movement of scapula relative to the humerus 2. Initial 30 degrees of glenohumeral abduction does not incorporate scapular motion (setting phase) 3. After the initial 30 degrees of abduction, there is a 2:1 ratio between glenohumeral and scapulothoracic joint motion

Test for Acromioclavicular Joint Intability

1. Palpate for displacement of acromion and distal head of clavicle 2. Apply pressure in all 4 directions to determine stability

Prevention of Shoulder Injuries

1. Proper physical conditioning is key 2. Develop body and specific regions relative to activities 3. Strengthen through a full ROM 4. Warm up should be used before explosive arm movements are attempted 5. Contract and collision sport athletes should receive proper instruction on falling 6. Protective equipment 7. Mechanics versus overuse injuries

Mobility and Stability

1. Round humeral head that articulates with a flat glenoid 2. Rotator cuff and long head of the biceps provide dynamic stability 3. Supraspinatus compresses the head while the other rotator cuff muscles depress the humeral head during overhead motion

History

1. What is the cause of pain? 2. Mechanism of injury? 3. Previous injury? 4. Location, duration, and intensity of pain? 5. Crepitus, numbness, distortion in temperature? 6. Weakness or fatigue? 7. What provides relief?

Empty Can Test

90 degrees of shoulder flexion, internal rotation, and 30 degrees of horizontal abduction Downward pressure is applied Weakness and pain are assessed bilaterally for supraspinatus

Subjective Shoulder Scale Assessment

American Shoulder and Elbow Surgeons (ASES) Subjective Shoulder Scale -Patient derived assessment and physician derived objective assessment -Used for outcomes assessment in patients with shoulder instability, rotator cuff disease, and GH arthritis -Pain rated on ordinal scale (0-10) -Function is rated ordinal scale (0-10) based on 10 questions (ie ability to put on a coat, combing hair, etc)

Costoclavicular Syndrome Test (Roo's Test)

Compression of artery between clavicle and first rib Positive if after opening and closing hands for 3 minutes, strength or circulation decreases Also positive if while in military brace position, head is turned in opposite direction and pulse disappears

Scapular Dyskinesis

Etiology -Abnormal movement of the scapula -SICK scapula ---Scapular malposition ---Inferior medial scapular winging ---Coracoid tenderness ---Kinesis abnormalities of the scapula -Occurs due to repetitive use, often in overhead athletes -Changes are detrimental to normal function and increase risk of injury Signs and Symptoms -Affected shoulder tends to be held lower and is rolled forward (slouched) -Prominent inferior scapular border due to tight pectoralis major/minor, weak serratus anterior and lower portion of trapezius -Posterior tipping may contribute to functional narrowing of subacromial space, leading to pain when shoulder is abducted and externally rotated -Winging becomes more pronounced with fatigue and may contribute to impingement and cuff injury Management -Strengthening scapula stabilizers -Stretching of the posterior capsule and pectoralis major, coracobrachialis, and short head of biceps -Throwing athletes should avoid throwing until scapular positioning improves

Peripheral Nerve Injuries

Etiology -Blunt trauma or stretch type injury Signs and Symptoms -Constant pain, muscle weakness, and paralysis or atrophy Management -RICE -Transient muscle weakness may occur with quick resolution -If muscle wasting or atrophy occurs referral to physician if necessary

Shoulder Bursitis

Etiology -Chronic inflammatory condition due to trauma or overuse-subacromial bursa -Fibrosis, fluid build up resulting in constant inflammation Signs and Symptoms -Pain with motion and tenderness during palpation in subarcomial space; positive impingement tests Management -Cold, ultrasound, and NSAID's to reduce inflammation -Remove mechanisms precipitating condition -Maintain full ROM to reduce chances of contractures and adhesions from forming

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 pec. minor, or 4) presence of cervical rib Signs and Symptoms -Paresthesia and 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)

Adhesive Capsulitis (Frozen Shoulder)

Etiology -Contracted and thickened joint capsule with little synovial fluid -Chronic inflammation with contracted inelastic rotator cuff muscles -Generalized pain with motions (active and passive) resulting in resistance of movement Signs and Symptoms -Pain in all directions both with active and passive motion Management -Aggressive joint mobilizations and stretching of tight musculature -Electric stim for pain and ultrasound for deep heating

Contusion of the Upper Arm

Etiology -Direct blows Signs and Symptoms -Transitory paralysis and inability to use extensor muscles of forearm (if radial nerve impacted) Management -RICE for at least 24 hours -Provide protection to contused area to prevent repeated episodes that could cause myositis ossificans -Maintain ROM

Clavicular Fractures

Etiology -Fall on out stretched arm, fall on tip of shoulder, or direct impact -Occur primarily in middle third (greenstick fracture often occurs in young patients) Signs and Symptoms -Generally presents with supporting of arm, headtilted towards injured side with chin turned away -Clavicle may appear lower -Palpation reveals pain, swelling, deformity, and point tenderness Management -closed reduction: sling and swathe immobilize with figure 8 brace for 6-8 weeks -May require surgical treatment -Removal of brace should be followed with joint mobes, isometrics, and use of a sling for 3-4 weeks

Glenohumeral Joint Sprain

Etiology -Forced abduction and/or external rotation or a direct blow Signs and Symptoms -Pain during movement especially when recreating MOI -Decreased ROM and pain with palpation Management -RICE for 24-48 hours; sling -After hemorrhaging subsides, cryotherapy, ultrasound, and massage can be used along with passive and active exercise to regain full ROM -When full ROM achieved without pain, resistance exercises can be initiated -Must be aware of potential development of chronic conditions

Fractures of the Humerus

Etiology -Humeral shaft fractures ---Occur as a result of a direct blow, or fall on outstretched arm -Proximal fractures occur due to direct blow, dislocation, fall on outstretched arm ---May pose danger to nerve and blood supply -Epiphyseal fractures are more common in young patients ---Occurs due to direct blow or indirect blow traveling along long axis of humerus Signs and Symptoms -Pain, swelling, point tenderness, decreased ROM Management -Immediate application of splint, treat for shock and refer ---Humeral fractures: remove from activity for 3-4 months ---Proximal fractures: incapacitation 2-6 months ---Epiphyseal fracture: quick healing 3 weeks

Sternoclavicular Sprain

Etiology -Indirect force, blunt trauma (may cause displacement) Signs and Symptoms -Grade 1: pain and slight disability -Grade 2: pain, subluxation with deformity, swelling and point tenderness, and decreased ROM ---Possibly life threatening if dislocates posteriorly Management -RICE, reduction if necessary -Immobilization for 3-5 weeks followed by graded reconditioning

Shoulder Impingement

Etiology -Mechanical compression of supraspinatus tendon, subocromial bursa and long head of biceps tendon due to decreased space under coracoacromial arch -Seen in over head repetitive activities -Exacerbating factors: laxity and inflammation, postural mal alignments ---Kyphotic posture, rounded shoulders Signs and Symptoms -Diffuse pain, pain on palpation of subacromial space -In overhead athletes clinicians may see increased GH external rotation (ERG) and decreased internal rotation (GIRD) -Positive impingement and empty can tests Management -Analgesics, electrical stimulation for pain, NSAID's and ultrasound for inflammation -Restore appropriate mechanisms and strengthen rotator cuff to depress and compress humeral head to restore space -Strengthen lower extremity and trunk to reduce stress on shoulder -Stage 3 and 4 cases may require immobilization and rest and potentially surgery

Bicipital Tensosynovitis

Etiology -Repetitive, overhead, ballistic activity that involves repeated stretching of biceps tendon causing irritation to the tendon and sheath Signs and Symptoms -Tenderness over bicipital groove, swelling, crepitus due to inflammation -Pain when performing overhead activities Management -Rest, ice, and ultrasound to treat inflammation -NSAID's -Gradual program of strengthening and stretching

Biceps Brachii Rupture

Etiology -Result of a powerful contraction -Generally occurs near origin of muscle at bicipital groove Signs and Symptoms -Patient hears a resounding snap and feels sudden and intense pain -Protruding bulge may appear near middle of biceps -Definite weakness with elbow flexion and supination Management -Ice for hemorrhaging, place arm in sling, and refer to physician -Patient will require surgery -Older individual may not require surgery as brachialis serves as primary elbow flexor and most can function without biceps

Acromioclavicular Sprain

Etiology -Result of direct blow (from any direction), upward force from humerus -Can be graded from 1-6 depending on severity Signs and Symptoms -Grade 1: point tenderness and pain with movement; no disruption of AC joint -Grade 2: tear or rupture of AC ligament, partial displacement of lateral end of clavicle; pain, point tenderness and decreased ROM (abduction/adduction) -Grade 3: rupture of AC and CC ligaments -Grade 4: posterior separation of clavicle -Grade 5: loss 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 Management -Ice, stabilization, referral to physician -Grades 1-3 (non operative) will require 3-4 days and 2 weeks of immobilization respectively -Grades 4-6 will require surgery -Aggressive rehab is required will all grades ---Joint mobilizations, flexibility exercises, and strengthening shoulder occur immediately ---Progress as patient is able to tolerate without pain and swelling ---Padding and protection may be required until pain free ROM returns

Scapular Fracture

Etiology -Result of direct impact or force transmitted up through humerus Signs and Symptoms -Pain during shoulder movement as well as swelling and point tenderness Management -Sling immediately and follow up with X ray -Use sling for 3 weeks with overhead strengthening beginning at week 1

Acute Subluxation and Dislocations

Etiology -Subluxation involves excessive translation of humeral head without complete separation from joint -Anterior dislocation is the result of an anterior force on the shoulder, forced abduction and external rotation -Posterior dislocation occurs due to the forced adduction and internal rotation or falling on an extended and internally rotated shoulder Signs and Symptoms -Anterior inferior dislocation: flattened deltoid, prominent humeral head in axilla; arm carried in slight abduction and external rotation; moderate pain and disability -Posterior dislocation: severe pain and disability; arm carried in adduction and internal rotation; prominent acromion and coracoid process; limited external rotation and elevation Management -RICE and reduction by a physician -Perform isometrics while in sling -Immobilization following reduction for 3 weeks -Progress to resistance exercises as pain allows -Return to activity when patient has regained 20% of body weight when tested for internal and external rotation -Protective bracing Possible Complications of Shoulder Dislocations -Bankart Lesion: permanent anterior defect of labrum -Hill Sachs Lesion: caused by compression of cancellous bone against anterior glenoid rim creating a divot in the humeral head -SLAP Lesion: defect in superior labrum that begins posteriorly and extends anteriorly impacting attachment of long head of biceps on labrum -Brachial nerves and vessels may be compromised -Rotator cuff injuries -Fractures -Bicipital tendon subluxation and transverse ligament rupture

Chronic Recurrent Instabilities of the Shoulder

Etiology -Traumatic, atraumatic, microtraumatic (repetitive use), congenital and neuromuscular -As supporting tissue become more lax, mobility increases resulting in damage to other soft tissue structures Signs and Symptoms -Anterior: may have clicking or pain; complain of dead arm during cocking phase (when throwing); pain posteriorly; possible impingement; positive apprehension test -Posterior: possible impingement, loss of internal rotation; crepitation, increased laxity; pain anteriorly and posteriorly -Multidirectional: inferior laxity; positive sulcus sign; pain and clicking with arm at side; possible signs and symptoms associated with anterior and posterior instability Management -Conservative treatment involves extensive strengthening (rotator cuff and scapula stabilizers) ---The internal and external rotators along with the biceps should be strengthened -Avoid joint mobilizations and flexibility exercises -Various hardness and restraints can be used to limit motion -Surgical stabilization may be required to improve function and comfort -Strengthening should be continued for a reasonable time before surgery is opted for

Assessment of the Shoulder Complex

History Observation Palpation Special Tests

Integration of capsule and rotator cuff

Muscle contractions dynamically control the capsule

Muscle Testing

Muscle of the shoulder and those that serve as scapula stabilizers

Neer's Progressive Stages of Shoulder Impingement

Stage 1: result of supraspinatus or biceps tendon injury presenting with point tenderness, pain with abduction and resisted supination with external rotation; edema, thickening of rotator cuff and bursa (occurs in patients < 25 years old) Stage 2: permanent thickening and fibrosis of supraspinatus and bicpes tendon; presenting with aching during activity that worsens at night; may experience restricted arm motion Stage 3: history of shoulder problems and pain, tendon defect (3/8") or possible muscle tear and permanent scar tissue and thickening of rotator cuff (patients 25-40 years old) Stage 4: infraspinatus and supraspinatus wasting, pain during adduction, tendon defect greater than 3/8", limited active and full passive ROM, weak resistive ROM and clavicle degeneration

Drop Arm Test

Used to determine tears of rotator cuff (primarily the supraspinatus) Patient abducts shoulder and gradually lowers to starting position Inability to lower arm slowly and controlled will indicate torn supraspinatus

Military Brace Position

Used to identify costoclavicular compression of subclavian artery Shouders are retracted with arm extended 30 degrees Head is then rotated to opposite shoulder Test is positive if pulse disappears

Throwing Mechanics

Windup Phase -First movement until ball leaves gloved hand -Lead leg strides forward while both shoulders abduct, externally rotated, and horizontally abduct Cocking Phase -Hands separate (achieve max, external rotation) while lead foot comes in contact with ground Acceleration -Max, external rotation until ball release (humerus adducts, horizontally adducts, and internally rotates) -Scapula elevates, abducts, and rotates upward Deceleration Phase -Point from ball release until max shoulder internal rotation -Eccentric contraction of external rotators to decelerate humerus while rhomboids decelerate scapula Follow Through Phase -End of motion while athlete is in a balanced position

Test for Sternoclavicular Joint Instability

With patient seated, pressure is applied to the SC joint anteriorly, superiorly, and inferiorly to determine stability or pain associated with a joint sprain

Test for Biceps Irritation

Yergason's test and Speed's test utilized to determine pain and possible subluxation of biceps tendon Ludington's test used to assess possible rupture of biceps (feel for contraction while alternating contractions of each biceps)