Chapter 22: The Shoulder Complex
Recurrent Instabilities of the Shoulder
Recurrent shoulder instabilities can occur after acute subluxation or dislocation. the causes of shoulder instabilities may be traumatic (macrotraumatic), atraumatic, micro- traumatic (repetitive use), congenital, or neuromuscula
Bicipital Tenosynovitis
Repetitive overhead athlete - ballistic activity that involves repeated stretching of biceps tendon causing irritation to the tendon and sheath
Sulcus Test
TESTING: Inferior instability (indicative of global instability) POSITION: Grasp humerus, pull down, look at acromion for sulcus (+) TEST: Gap at sulcus and pain
Hawkins-Kennedy Test
The Hawkins-Kennedy test involves horizontal adduction with forced internal rotation of the humerus, which produces impingement (Figure 22-17B). A positive sign is indicated if the patient feels pain and reacts with a grimace.
Clunk Test
The athletic trainer applies downward pressure over the distal forearm. The test is repeated with the humerus externally rotated and the forearm supinated. If pain is present when the humerus is internally rotated but decreases in external rotation, and if there is clicking within the glenohumeral joint, this may indicate an anteroposterior tear in the superior glenoid labrum, (SLAP) lesion. Pain in the acromioclavicular joint with this test may indicate AC joint pathology.
Anterior/Inferior glenohumeral dislocation
The most common mechanism is forced abduction, external rotation, and extension that forces the humeral head out of the glenoid cavity
Drop Arm Test
The patient abducts the arm as far as possible and then slowly lowers it to 90 degrees. From this position, the patient with a torn supraspinatus muscle will be unable to lower the arm farther with control
Glenohumeral Joint Sprain
The posterior capsule can be sprained by a forceful movement of the humerus posteriorly when the arm is flexed. Px and decrease ROM
Windup Phase
First movement until ball leaves gloved hand Lead leg strides forward while both shoulders abduct, externally rotate and horizontally abduct
Clavicular Fractures
Fractures of the clavicle result from a fall on the outstretched arm, a fall on the tip of the shoulder, or a direct impact these are usually greenstick fractures. supports the arm on the injured side and tilts his or her head toward that side, with the chin turned to the opposite side. During inspection the injured clavicle appears slightly lower than the unaffected side
Peripheral Nerve Injuries
Injuries to shoulder nerves commonly stem from blunt trauma or a stretch type of injury. Peripheral nerve injuries can result in muscle weakness.
Tests for Glenohumeral Instability
Load and shift test Anterior drawer test Posterior drawer test Sulcus test Clunk test O'Brien's test Apprehension test Relocation test
Scapular Fractures
MOI: Direct blow; fall on an outstretched arm; direct trauma S/S: pain; point tender; loss of function; possible deformity; swelling; holds arm to the side Tx: Immobilize; ice; refer to MD
Biceps Brachii Ruptures
MOI: powerful concentric/eccentric contraction of the muscle. S/S: snap with sudden intense pain, bulge at the middle of biceps, weakness Tx: sling, surgery
coracoacromial ligament
Makes a connection between the coracoid process and the acromion
Tests for shoulder impingement
Neer's test and Hawkins-Kennedy test
Coracobrachialis origin and insertion
O: Coracoid process I: Middle medial humerus
latissimus dorsi origin and insertion
O: Spinous processes of T7-T12; thoracolumbar fascia; iliac crest; inferior 3 or 4 ribs I: Floor of intertubercular groove of humerus
Rhomboideus major origin and insertion
O: Spinous processes of the seventh cervical and first thoracic vertebrae I: Vertebral border of the scapula, below the spine of the scapula
teres major origin and insertion
O: inferior angle of scapula, I: humerus
teres minor origin and insertion
O: lateral scapula, I: humerus
Pectoralis minor origin and insertion
O: ribs 3-5 I: coracoid process of scapula
Rhomboideus minor origin and insertion
O; Spinous processes of the second through the fifth thoracic vertebrae I;Vertebral border of the scapula, at the base of the spine of the scapula
pectoralis major origin and insertion
O=from medial half of clavicle, from sternum, and from upper six costalcartilages I=CT in humerus
Serratus anterior origin and insertion
O=lateral ribs 1-9, I=vertebral border of anterior surface of scapula
trapezius origin and insertion
O=occipital bone, C1-7, T1-12,; I= Acrominion and spinous process of scapula, clavicle
Levator scapulae origin and insertion
O=transverse process of C1-c4; I= Medial border of scapula superior to spine
Reverse Hill-Sachs Lesion
Occurs on the anteromedial portion of humeral head following posterior shoulder dislocation
deltoid origin and insertion
Origin: Clavicle, acromion and spine of scapula Insertion: Deltoid tuberosity of humerus
Test for Acromioclavicular Joint Instability
Palpate for displacement of acromion and distal head of clavicle Apply pressure in all 4 directions to determine stability
Anterior and Posterior Drawer Tests
Positive anterior and posterior drawer test indicates insufficiency of anterior and posterior joint capsule and labrum, respectively
Scapular Dyskinesis
Abnormal movement of the scapula
Acute Dislocations and Subluxations
Acute Dislocations and Subluxations Shoulder dislocations account for up to 50 percent of all dislocations. Inferior dislocations are ex- tremely rare. Of dislocations caused by direct trauma, 85 to 90 percent recur
Tests for Thoracic Outlet Compression Syndrome
Adson's test Allen test Military brace position test Roo's test
SLAP lesion
An injury to the superior labrum that typically begins posteriorly and extends anteriorly, disrupting the attachment of the long head of the biceps tendon to the superior glenoid tubercle.
sternoclavicular joint
Articulation between the clavicle and the sternum
scapulohumeral rhythm
As the humerus elevates to 30 degrees, there is no movement of the scapula. This phase is referred to as the setting phase, during which a stable base is being established on the thoracic wall. After the setting phase, there is a 2:1 ratio of glenohumeral to scapulothoracic movement
brachial plexus
C5-C8, T1
Shoulder Bursitis
Chronic inflammatory condition due to trauma or overuse
Adhesive Capsulitis (Frozen Shoulder)
Decreased passive and active range of motion More stiffness than pain it involves a contracted and thickened joint capsule that is tight around the humeral head, with little synovial fluid
Tests for Supraspinatus Muscle Weakness
Drop Arm Test Empty Can Test
deceleration phase of throwing
During this phase, the external rotators of the rotator cuff contract eccentrically to decelerate the humerus. The rhomboids con- tract eccentrically to decelerate the scapula.
follow through phase
End of motion when athlete is in a balanced position
glenohumeral joint
The synovial ball-and-socket joint of the shoulder
Yergason's Test
This test involves keeping the elbow at 90 degrees with the forearm pronated while the athlete attempts to actively supinate against the resistance of the athletic trainer as the humerus is also being pulled downward
Thoracic Outlet Compression Syndromes
Thoracic outlet compression syndromes involve compression of the brachial plexus, subclavian artery, and subclavian vein (neurovascular bundle) Test: the anterior scalene syndrome test, the hyperabduction syndrome test, the military brace position test, and the costoclavicular syndrome test.
Shoulder Impingement
When the space between the bone on top of the shoulder (acromion) and the tendons of the rotator cuff rub against each other during arm elevation. compression of the supraspinatus tendon, the subacromial bursa, and the long head of the bi- ceps tendon, all of which are located under the cora- coacromial arch
Roo's Test
While the patient is in a sitting position, both arms are abducted to 90 degrees and externally rotated The patient opens and closes the hands and fingers, making fists for 3 minutes. Loss of strength in the hands or loss of sensation
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 w/ a joint sprain
Apprehension Test and Relocation Test
With the arm abducted 90 degrees, the shoulder is slowly and gently externally rotated as far as the patient will allow. The patient with a history of anterior glenohumeral instability will show great apprehension, reflected by a facial grimace before an endpoint can be reached. Posterior instability also can be determined through an apprehension maneuver. With the patient in a supine position, the shoulder is flexed to 90 degrees and internally rotated while a force is applied through the long axis of the humerus The relocation test is done with the patient lying supine, the shoulder at 90 degrees and the elbow at 90 degrees. As the shoulder is externally rotated, pressure is applied posteriorly to stabilize the humeral head, which allows for a greater degree of external rotation than does the apprehension test43 The test is positive if apprehension or pain is relieved with this maneuver.
O'Brien Test
With the patient sitting, the glenohumeral joint is flexed to 90 degrees and horizontally adducted 15 degrees from the sagittal plane. The humerus is fully internally rotated with the forearm pronated. The athletic trainer applies downward pressure over the distal forearm. The test is repeated with the humerus externally rotated and the forearm supinated. (SLAP) lesion.
axilla
armpit (axillary)
scapulothoracic joint
articulation between the anterior scapula and the thoracic wall
Load and Shift Test
athletic trainer places one hand over the shoulder to stabilize the scapula With the other hand, he or she grasps the humeral head between the thumb and index finger. A stress load is applied and translation of the humerus is assessed in both an anterior and a pos- terior direction. glenohumeral instability
Subluxations of the shoulder
brief transient occurrence in which the humeral head quickly returns to its normal position relative to the glenoid. Subluxation can occur anteriorly, posteriorly, or inferiorly.
subacromial bursa
bursa that protects the supraspinatus muscle tendon and superior end of the humerus from rubbing against the acromion of the scapula
Sternoclavicular Sprain
cause: indirect force sign: pain, deformity, care: PRICE, immobilize If the clavicle is displaced posteriorly, pressure may be placed on the blood vessels, esophagus, or trachea, causing a life-or-death situation.
coracoclavicular ligament
conoid and trapezoid ligaments.
glenohumeral internalrotation deficit (GIRD)
decreased internal rotation both the empty can test and the drop arm test may increase pain.
glenoid labrum
fibrocartilage ring that deepens glenoid cavity
Neer's Test
forced flexion of the humerus in the overhead position may cause impingement of soft-tissue structures between the humeral head and the coracoacromial arch
Acromioclavicular Sprain
he mechanism of an acromioclavicular sprain is most often a direct impact to the tip of the shoulder fall on an outstretched arm.
acceleration phase of throwing
humerus abducts, horizontally abducts, internal rotation, scapula elevates, abducts and rotates upward
infraspinatus origin and insertion
origin: infraspinous fossa of scapula insertion: greater tubercle of humerus
subscapularis origin and insertion
origin: subscapular fossa insertion: lesser tubercle of humerus
supraspinatus origin and insertion
origin: supraspinous fossa of scapula insertion: greater tubercle of humerus
Empty Can Test
patient bring the arm into 90 degrees of for-ward flexion and 30 degrees of horizontal abduction. the arm is internally rotated as far as possible, thumb pointing downward. The athletic trainer then applies a downward pressure. Weakness and pain can be detected in this position
Adson's Test
patient seated on a stool, with one hand resting on the thigh. The athlete's radial pulse is taken, first with the arm relaxed and then extended, while the patient elevates the chin, turns the face toward the extended hand, and holds the breath. A positive test is one in which the pulse is depressed or stopped completely in the testing position
Speed's Test
patient's elbow extended, the forearm supinated, and resistance applied as the humerus elevates to 60 degrees
Bankart lesion
permanent anterior defect of labrum
hillsachs lesion
posterior lateral aspect of the humeral head the anterior glenoid rim that creates a divot in the humeral head.
scapulothoracic joint allows for what movements?
scapular elevation, depression, protraction, retraction, abduction, and adduction.
cocking phase
the hands separate and ends when maximum external rotation of the humerus has occurred. During this phase, the lead foot comes in contact with the ground.
acromioclavicular joint
the joint where the acromion and the clavicle meet
Allen test
the patient's radial pulse is taken while the shoulder is extended horizontally and rotated laterally. The patient is asked to rotate the head away from the affected arm. If the pulse disappears, the test is positive
Throwing Mechanics
windup, cocking, acceleration, deceleration, follow-through
Contusions of the Upper Arm
• Etiology: common in contact sports; repeated contusion can lead to blocker's exostosis (myositis ossificans - calcifications or bone fragments occur in a muscle) • Signs/Symptoms: radial nerve can be contused (transitory paralysis and inability to use extensor muscles of forearm) • Management: RICE, protect contused area, maintain ROM with stretching of muscle
Fractures of the Humerus
• Fractures of the surgical neck • Mostly impacted - one fragment being driven into the spongy bone of another fragment • Transverse fracture of the shaft of the humerus - usually due to direct blow to the arm. Proximal fragment is pulled laterally • Spiral fracture of the humeral shaft - due to falling on the outstretched hand • Intercondylar fracture of the humerus - due to severe fall on flexed elbow. Olecranon driven like a wedge between medial/lateral parts of the condyle, separating one or both from the humeral shaft • Nerve contact o Surgical neck - axillary o Radial groove - radial o Distal end - median nerve o Medial epicondyle - ulnar
