A550 - Shoulder Exam
Examination findings of an AC joint injury
- onset: acute - pain characteristics: superior anterior shoulder at the AC joint, anterolateral neck, and anterolateral deltoid - MOI: falling on the point of the shoulder, landing on the AC joint, force applied longitudinally to the clavicle, such as FOOSH - functional assessment: increased pain with overhead motions - inspection: displacement of the clavicle may be obvious, step deformities indicate damage to the cozrococlavicular ligament - palpation: superior displacement of the clavicle that is reduced with manual pressure (piano key sign) - joint and muscle function assessment: a. AROM: pain with elevation of the humerus and during protraction and retraction of the scapula b. PROM: pain produced during elevation of the humerus owing to movement at the AC joint; increased pain with horizontal adduction c. MMT: decreased strength secondary to pain for all muscles having attachment on the acromion or clavicle - joint stability tests: a. stress tests: not applicable b. joint play: joint play movements reveal hypermobility of the AC joint - selective tissue tests: AC traction test, AC compression test - neurological screening: within normal limits - vascular screening: within normal limits - imaging techniques: a. AP radiograph to rule out associated clavicular or scapular fracture (primarily the coracoid process) and/or displacement between the acromion and clavicle b. stress radiographs are rarely required to identify AC joint dislocations - differential diagnosis: distal clavicle fracture, scapular fracture (coracoid), rotator cuff pathology, SLAP lesions - comments: fractures of the distal clavicle may present with the clinical signs and symptoms of an acromioclavicular joint sprain
What does the 180 degrees of GH elevation consist of?
- 120 degrees of GH movement - 60 degrees of scapular rotation
What joints of the shoulder complex are diarthrodial joints?
- AC - SC - GH
What structures can be damaged can be damaged during an AC joint sprain?
- AC ligament - articular surfaces - coracoclavicular ligament (conoid and trapezoid ligaments) - clavicle - acromion - coracoacromial ligament
What does pain in the upper shoulder tell us?
- AC sprain - Trapezius - brachial plexus injury
What tests can you utilize in the clinic to further evaluate the AC joint?
- AC traction test (+ = too much movement or pain) - AC compression test (+ = too much movement or pain)
What are the 4 joints of the shoulder complex?
- Acromioclavicular (AC) Joint - Sternoclavicular (SC) Joint - Glenohumeral (GH) Joint - Scapulothoracic (ST) Joint
What is the preferred image of choice when evaluating acute SC joint dislocations?
- CT scan since it can identify the direction of the dislocation but can also show if any other structures have been compromised - axial views can visualize mediastinal structures and injuries - can differentiate from physeal fractures
What are the MOI for an AC joint sprain?
- FOOSH - blow to superior acromion process
What are some typical mechanisms of traumatic posterior instability?
- FOOSH (axial load with arm adducted and IR) - occurs with arm flexed forward with a posteriorly directed force - seizure and electrocution (don't need to know for test)
What is scapulothoracic rhythm?
- GH and ST articulation must function together - 2:1 ratio (2 GH elevation: 1 ST rotation) - to accomplish 180 degrees of GH elevation
What pathology does a MOI of IR/ER rotation with abduction at the shoulder complex lead us to?
- GH joint dislocation - GH joint subluxation
What are the evaluation tests for a SLAP lesion?
- O'Brien - anterior slide - grind test
What are the joints of the shoulder girdle?
- SC - AC - ST
What structures can be damaged with an SC joint sprain?
- SC joint - articular disc - infraclavicular ligament - SC ligament - costoclavicular ligament
What are the joint of the shoulder complex?
- ST - AC - GH - SC
Describe a type 3 SLAP lesion
- a "bucket-handle" tear of the labrum, where the torn labrum hangs into the joint and causes symptoms of "locking" and "popping" or "clunking" - treatment usually involves removal of the "bucket handle" segment and then repair of any remaining detached, unstable labrum (SLAP repair). This is usually done arthroscopically (key hole) using suture anchors
How do the initial and secondary stages of impingement effect the evolution of the condition?
- a never ending cycle - continuing to use involved muscles continues the condition - inflammation causes impingement and more impingement causes more inflammation
Describe a type 1 SLAP lesion
- a partial tear and degeneration to the superior labrum, where the edges are rough and fray along the free margins, but the labrum is not completely detached - treatment is usually to debrief (clean) the edges - LHBT isn't involved very much
Describe a type 4 SLAP lesion
- a tear of the labrum that extends into the LHBT - treatment is reattachement of the labrum (SLAP repair) and repair of the biceps tear, or a biceps tenodesis. This is done arthroscopically (keyhole) using suture anchors
What tests can you utilize in the clinic to determine the presence of scapular dyskinesis?
- abnormal scapular function should be followed by corrective maneuvers: a. scapular assistance test b. scapular retraction test - tests may identify the role scapular dysfunction plays in the patient's shoulder pathology
How will you manage a patient with signs and symptoms of a possible posterior SC joint dislocation?
- activate EMS/refer for imaging - stabilize - monitor for signs and symptoms of shock or days-near
In which directions can the GH joint dislocate?
- anterior - posterior - inferior
What neurovascular structures may be compromised by fractures of proximal humerus?
- anterior and posterior circumflex humeral arteries - axillary nerve
What are we observing for during the on-field inspection?
- arm posture - gross deformity - can we rule out joint dislocation or bony fracture
What are you going to visualize and palpate for to evaluate for an AC/SC/GH joint dislocation?
- arm posture - palpable gap - noticeable gap - gross deformity
What kind of arm posture should we look for during an on-field inspection?
- arm splinted against torso - arm hanging limply at the side - arm "locked"
What are the important components of a clavicular fracture examination?
- assess vital signs and perform a neuromuscular and lung examination (could have trouble breathing or swallowing, abnormal sensation, mechanical issues, radial pulse, and cap refill) - palpate and observe for visible bulge (tenting skin), bone angulation, or displaced bone edges
What may cause a fracture to the surgical neck of the humerus?
- avascular necrosis - violent contraction of muscles - secondary to GH dislocation
What may cause a fracture to the glenoid neck?
- avulsion - dislocation - subluxation
What may cause a fracture to the glenoid fossa?
- avulsion - labral avulsion - dislocation - subluxation
What may cause a fracture to the lesser tuberosity of the humerus?
- avulsion of subscapularis
What may cause a fracture to the greater tubercle of the humerus?
- avulsion of supraspinatus - avulsion of infrasprinatus - avulsion of teres minor
What nerves are most likely traumatized with a proximal humeral fracture?
- axillary nerve - supra scapular nerve
What is the difference between biceps tendonitis and a subluxing biceps tendon?
- biceps tendinitis: inflammation of the LHBT as it passes through the intertuburcular (bicipital) groove - subluxing LHBT: transverse humeral ligament may be stretched or torn due to forceful extension or forced ER with elbow flexion (leading to subluxing LHBT from bicipital groove)
What different parts of the scapula can become fractured?
- body of scapula - glenoid fossa - glenoid neck - coracoid process
What is a segmental fracture of the mid shaft of the humerus?
- bone is broke in at least 2 pieces, leaving a segment of bone totally separated by the breaks - usually caused by severe trauma
What is a Hill-Sachs lesion?
- bony defect of the posterior humeral head - occurs as the humerus shears over anterior glenoid
Describe a type 2 SLAP lesion
- can be further subdivided into a (anterior), b (posterior), and c (combined anterior-posterior lesions) - the most common type of SLAP tear - the superior labrum is completely torn off the glenoid, due to an injury (often a shoulder dislocation) - leaves a gap between the articular cartilage and the labral attachment to the bone - treatment is reattachment of the labrum (SLAP repair): this is done arthroscopically (key hole) using suture anchors
What is the Apley scratch test?
- can be used as a gross assessment of the athlete's willingness to move the involved extremity and the amount of motion - can be used if joint dislocation or bony fractures have been ruled out - used for shoulder complex ROM
Why is the subacromial bursa often involved with rotator cuff pathology?
- chronic impingement (especially external caused) causes bursa irritation, the bursa becomes inflamed which causes more impingement (damaging cycle) - due to the bursa being in the same/similar space of supraspinatus and has similar mechanisms of injury - bursitis is difficult to differentiate from rotator cuff pain (both tears and bursitis come off as weakness but mechanism is important)
What injuries can result from a FOOSH?
- clavicular fx - AC sprain - SC sprain
What are some typical complaints of patients who have posterior GH instability?
- complain of pain during movements requiring horizontal adduction while loading the posterior joint capsule
If a person has posterior instability, what should the focus be during conservative treatments?
- conservative treatment is the first option: focusses on strength and endurance of infraspinatus muscle - surgery is warranted with clear structural pathology (I.e. posterior labral tear)
What is the conservative management for biceps tendinopathy?
- decrease inflammation with NSAIDs - activity modification - strengthen the rotator cuff and scapular stabilizers
How do you manage a mild/moderate SC joint sprain?
- decrease pain and inflammation ( ice, NSAIDs) - utilize sling to decrease traction of the joint - ROM of cervical spine and upper extremity incorporated initially - strengthen scapular stabilizers once pain and inflammation decrease
What neurovascuar structures are vulnerable to damage with this injury?
- deep brachial artery - brachial artery - ulnar collateral artery - radial artery - radial nerve (due to close contact with the bone)
What signs and symptoms would be present if the axillary nerve is damaged?
- deltoid weakness - paresthesia over mid-deltoid
What vascular examinations do you want to complete during a shoulder complex evaluation?
- distal pulses - capillary refill
What are the evaluation tests for the supraspinatus?
- drop arm test: a positive test is indicated by the inability to control the rate of fall after the humerus reaches 90 degrees of abduction - empty can test: a positive test is indicated by the patient not being able to resist a force
What types of mechanisms would cause overuse injuries to the posterior (infraspinatus/teres minor) rotator cuff muscles?
- eccentric contraction during overhead movement can lead to micro tearing of the posterior rotator cuff muscles - micro tears result as they repetitively slow down the internal rotation of the arm during the end phase of a throw
What are the 2 different categories of shoulder impingement?
- external impingement - internal impingement
What is the MOI for an inferior GH dislocation?
- fairly uncommon - forced abduction with stress applied
What are the movement of the shoulder complex?
- flexion - extension - abduction (for AROM: drop arm test) - internal rotation - external rotation - horizontal abduction - horizontal abduction
Traumatic posterior instability
- following subluxation, similar provocation tests (apprehension and jerk tests) may indicate lingering posterior instability
What is a spiral fracture of the mid shaft of the humerus?
- fracture line that wraps around the shaft of the bone that looks like a corkscrew - usually caused by falls, accidents, and sports related injury when bone is twisted with great force (football tackle)
What are the most important conditions to rule out during on-field evaluation of injuries to the shoulder complex?
- fractures to the clavicle, scapula, or humerus - dislocations at the SC, AC, or GH joints
What intervention strategies are often utilized for MDI?
- generally managed conservatively - focus on strengthening scapular stabilizers and rotator cuff musculature
When will an SC joint injury require surgery?
- generally, closed reduction is done under anesthesia - at the discretion of the Ortho surgeon
What are the static stabilizers of the GH joint?
- glenohumeral ligaments - GH joint capsule - GH labrum - coracohumeral ligament
How will early conservative management of the SC joint injury change relative to the diagnosed grade?
- grade 1: 5-10 days in a sling - grade 2: 2-3 weeks in a sling (anterior instability) or in a figure-8 brace (posterior instability) - grade 3: 3-4 weeks in a sling (anterior instability) or in a figure-8 brace (posterior instability)
What different parts of the proximal humerus can become fractured?
- greater tuberosity - lesser tuberosity - surgical neck
When do you need to refer a patient with an SC joint injury?
- if they have obvious swelling and deformity at the joint and difficulty swallowing or breathing or a more prominent clavicle distally - if any possible posterior dislocation, active EMS
How will you manage an AC joint injury/dislocation?
- immobilize in a position that lessens the displacement between the clavicle and the acromial process - protect joint with additional padding during activity
What does management of a scapular fracture consist of?
- immobilize the arm on the affected side in a comfortable position - athlete is then transported - if it's a GH dislocation, you need a radiograph evaluation to rule out a secondary glenoid or coracoid process fx
What is the initial management of a completely displaced clavicular fracture?
- immobilize using a figure 8 brace and sling (conservative management) - analgesics - transport for definitive diagnosis - may opt to have plate fixation instead of conservative management
What is initial management of non-displaced or minimally displaced clavicular fracture?
- immobilize using a sling or triangular bandage - analgesics - elbow ROM - transport for definitive diagnosis
What are conservative treatment intervention strategies for internal impingement?
- improve scapular control - reduce GIRD (stretch posterior structures)
What are the primary static restraints to inferior GH translation?
- in neutral position, superior GH ligament - with humerus adducted to 45-90 degrees (neutral rotation), inferior GH ligament
What is a Bankart lesion?
- inferior GH ligament avulses from labrum causing a tear - anterioinferior labrum may also avulse from glenoid (bony bankart lesion)
What structures can become injured with an inferior GH dislocation?
- inferior glenohumeral ligament - superior glenohumeral ligament - coracohumeral ligament
What is the primary cause of supraspinatus irritation?
- irregularly shaped acromion - spur formation on acromion - os acromiale
What structures are important to remember to palpate during a shoulder complex examination?
- jugular notch - sternoclavicular joint - clavicular shaft - acromion process - acromioclavicular joint - Coracoid process - humeral head - greater tuberosity - lesser tuberosity - bicipital groove - humeral shaft - pectoralis major and minor - coracobrachialis - deltoid muscle group - biceps brachii (LH and SH) - spine of the scapula - superior angle of the scapula - interior angle of the scapula - rotator cuff (SITS) - teres major - rhomboid major and minor - lavatory scapulae - trapezius (upper, middle, and lower) - latissimus dorsi - triceps brachii
Why do clavicular fractures typically occur in the middle of the clavicle?
- lacks ligamentous attachments - thinnest bone segment
What causes GH instability?
- ligament laxity - labral pathology - GH capsular instability - muscle weakness
What are some important components of the on-field history?
- location of pain - MOI - FOOSH
What are the mechanisms for an SC joint sprain?
- longitudinal force of the clavicle - FOOSH - hit on lateral portion of the shoulder - traction forces
What are some secondary causes of supraspinatus irritation?
- loss of humeral head depression or stabilization (loss of inferior glide and scapular rotation) - poor posture (rounded shoulders) - repetitive overhead movement - GH instability - supraspinatus hypertrophy - scapular dyskinesis
What muscles are often weak when it comes to scapular dyskinesis?
- lower and middle trapezius - serrates anterior - supraspinatus - infraspinatus - teres minor - subscapularis
What are less likely MOIs of proximal humeral fractures?
- may occur secondary to GH dislocation - violent contraction of muscles that attach to the proximal humerus
What are the anterior stabilizers of the GH joint?
- middle GH ligament - anterior band of inferior ligament
Damage to what anatomical structures can lead to anterior GH instability specifically?
- middle GH ligament - anterior band of inferior ligament - superior GH ligament - rotator cuff tears or weakness - dysfunction of the long head of the biceps tendon
What structures can become injured with a posterior GH dislocation?
- middle glenohumeral ligament - posterior joint capsule
What are the main examination findings for a proximal humeral fracture?
- moderate to severe shoulder pain - holding effected arm adducted against their side - swelling and ecchymosis shortly after injury - gross deformity may occur (more typical with an associated dislocation) - focal tenderness over proximal humerus
How will you manage a GH joint injury/dislocation?
- monitor the distal pulses, check for circulation in the fingertips (cap refill), and perform a sensory screen - arm is fixed in the position it has assumed
What is the MOI for an anterior GH dislocation?
- most common dislocation direction - arm abducted and externally rotated
What are the dynamic stabilizers of the GH joint?
- muscles that cross the GH joint (ex. rotator cuff)
When managing for an SC joint injury, why is it important to know if the patient is younger than 25 years old?
- need to rule out growth plate injuries in patients 25 years and younger - rule out dislocations
How will you manage an SC joint injury/dislocation?
- neurological and vascular examination of the the extremity and carotid artery - involved arm is immobilized - athlete is immediately transported to an emergency medical facility
Intervention strategies of anterior GH instability?
- non-traumatic: typically managed conservatively, unless clear tear of static or dynamic stabilizers is present; brief period of immobilization to manage pain; gradual strengthening program focused on anterior stabilizers and scapular stabilizers - traumatic: high risk of repeated anterior dislocations (80-90% recurrance rate); surgery often focuses on repair of bankart lesion
What is the MOI for a posterior GH dislocation?
- occurs with arm flexed forward with a posteriorly directed force - often spontaneously reduces
Examination findings of an SC joint injury
- onset: acute - pain: limited to SC joint area - other symptoms: pressure on underlying neurovascular network that can cause paresthesia in the upper extremity; pressure on the trachea and esophagus impedes swallowing and breathing - mechanism: indirect force applied to the joint through the clavicle, such as FOOSH, or anteriorly or posteriorly directed forces exerted on the anterolateral or posterolateral shoulder - functional assessment: pain is increased with any shoulder motion that causes movement at the SC joint - inspection: dislocations are marked by displacement of the clavicular head anteriorly, superiorly, or posteriorly; first and second degree sprains may present with localized swelling over the joint; discoloration may not be present; the patient's neck may be tilted toward the involved joint; venous congestion of the involved arm, neck, and head may occur with posterior dislocation - palpation: obvious joint displacement may be felt, although this finding is often obscured by swelling; pain at the SC joint - joint and muscle function assessment: for first and second degree sprains, pain is elicited at any point after 90 degrees of elevation, after which the ligamentous structures are maximally taut; pain may be elicited during scapular protraction and retraction a. AROM: increased pain with flexion and abduction b. PROM: increased pain with flexion, abduction, and horizontal adduction c. MMT: isometric testing should not be painful - selective tissue tests: none - neurological screening: within normal limits - vascular screening: increased pain during early phases of elevation - imaging techniques: a. anterior/posterior radiographs may be inconclusive; an oblique (serendipity) view will help visualize the displacement b. CT is the imaging of choice - differential diagnosis: proximal clavicle fracture, sternal fracture, first rib fracture, medial clavicle epiphyseal injury, pneumothorax - comments: posterior SC dislocations are considered medical emergencies because of the potential threat to the underlying neurovascular structures, the esophagus, and the trachea; fractures of the medial one-third of the clavicle can produce a pseudoqislocation; the medial end of the clavicle is the last long bone epiphysis to close
Examination findings of scapular dyskinesis
- onset: gradual, identified during examination of other pathology - pain: localized over coracoid process, pec minor, superior and medial borders of the scapula, AC joint, posterolateral joint line or subacromial space, also possibly including upper trapezius and posterior cervical musculature (secondary to trap spasming) - risk factors: patient may describe a recent increase in overhead activity; may also be associated with other pathologies - functional assessment: poor shoulder function during overhead activity with an associated loss of strength, power, or endurance - inspection: thoracic kyphosis, cervical lordosis, and/or scoliosis; dominant side scapula may be positioned lower and more protracted than the non dominant arm at rest - palpation: may present with pain over coracoid process, pectoralis minor, superior and medial borders of scapula, posterolateral GH joint or subacromial space, upper trapezius, and posterior cervical region - joint and muscle function assessment: a. AROM: dysfunctional motion, position, or stability of the scapula observed during arm elevation or lowering b. MMT: decreased strength in lower and middle trapezius, serrates anterior; decrease in strength in rotator cuff secondary to the scapula failing to provide a stable base. scapular retraction test may be positive c. PROM: GH internal rotation deficit (GIRD) may be present in overhead throwers - joint stability tests: a. stress tests: not applicable b. joint play: joint play movements may reveal hypermobsility of the AC, SC, or GH joint - selective tissue tests: tests for rotator cuff impingement (subacromial or internal) or AC or labral pathology may be positive; scapular assistance test may be positive - neurological screening: within normal limits - vascular screening: symptoms resembling thoracic outlet syndrome may be reported - imaging techniques: within normal limits; typically, only suspicion of concurrent pathology warrants referral of these patients to a physician - differential diagnosis: cervical radiculopathy, supra scapular nerve syndrome, thoracic outlet syndrome, brachial plexus neuropathy/long thoracic nerve play
Examination findings of subacromial impingement
- onset: insidious - pain characteristics: beneath the acromion and radiating to the lateral arm; pain during overhead movements in plane of scapula (may be relieved when applying inferior gliding force to humerus) - other symptoms: the patient may complain of popping and clicking, depending on involvement of bursa and rotator cuff musculature - mechanism: repetitive overhead motion impinging the rotator cuff muscles (especially the supraspinatus) and LHBT between the humeral head and coracoacromial arch - risk factors: rotator cuff weakness (atrophy of infraspinatus and supraspinatus); increased anterior laxity, irregularly shaped acromion (curved or hooked), subacriomial spurs, scapular dyskinesis - functional assessment: increased pain with overhead motions; may be coupled with compensatory scapulothoracic movement, with early and excessive scapular elevation and/or decreased posterior tilting during arm-raising maneuvers - inspection: the shoulder may be postured for comfort by holding the arm in slight abduction; a forward shoulder posture where the scapula rests in a protracted position and the humerus is internally rotated is frequently associated with impingement - palpation: tenderness exists beneath the acromion process, over the supraspinatus insertion at the greater tuberosity and over the bicipital groove - joint and muscle function assessment: a. AROM: active abduction in an arc of motion from about 70 - 120 degrees results in pain b. PROM: increased pain at the end-range of elevation; pectorals minor tightness is often associated with impingement c. MMT: pain and/or weakness with elevation in plane of scapula (empty can or full can test) and external rotation - joint stability tests: a. stress tests: a complete ligamentous and capsular screen is necessary to rule out GH and AC laxity b. joint play: GH hypermobsility and/or hypo mobility may be present; decreased thoracic spine mobility - selective tissue tests: the neer and Hawkins impingement tests are usually painful - neurological screening: within normal limits - vascular screening: within normal limits - imaging techniques: radiographs to rule out the primary cause of impingement, including a hooked acromion or osteophyte (little broken piece of bone) - differential diagnosis: labral tears, SLAP lesions, rotator cuff tendinopathy, subacromial bursitis, long head of biceps tendinopathy - comments: impingement may occur secondary to GH instability in younger patients; the degenerative response caused by rotator cuff impingement, if untreated, can lead to rotator cuff tears; temporary relief of symptoms associated with an injection of anesthetic into the subacromial space is indicative of impingement
Examination findings of rotator cuff tendinopathy
- onset: insidious or acute - pain characteristics: deep within the shoulder beneath the acromion process; pain usually radiates into the lateral arm - other symptoms: clicking during certain GH motions - mechanism: a. insidious: chronic impingement or degeneration of the rotator cuff tendons over time due to aging; a single traumatic episode could cause the final rupture of a weakened tendon b. acute: dynamic overloading of the tendon - risk factors: subacromial impingement, internal impingement, acromion changes, repetitive overhead motion, repetitive eccentric loading, scapular dyskinesis - functional assessment: pain during overhead motions; during elevation, the scapula may excessively protract, elevate, or anteriorly tip - inspection: in chronic cases, atrophy of the infraspinatus and/or spuraspinatus - palpation: tenderness in the subacromial space and at the insertion of the supraspinatus tendon into the greater tuberosity - joint and muscle function assessment: a. AROM: painful between 70 degrees and 120 degrees of elevation, especially in abduction b. PROM: decreased pain compared with AROM, except in positions of impingement c. MMT: pain and/or weakness with abduction, internal rotation, external rotation, and elevation in the plane of the scapula - joint stability tests: a. stress tests: tests to rule out GH and AC laxity and impingement b. joint play: joint play to assess for hyper- or hypo- mobility - selective tissue tests: drop arm test and impingement tests may be positive - neurological screening: within normal limits - vascular screening: within normal limits - imaging techniques: a. standard radiographic series consists of scapular plane AP, internal rotation, external rotation, and transscapular and axillary views to rule out rotator cuff tears and bony abnormalities. A subacromial space of less than 7 mm is indicative of a full thickness cuff tear b. MRI has a sensitivity of 0.95 and specificity of 0.95 in identifying rotator cuff tears, degeneration, and partial thickness tears c. MR arthrography, ultrasonography - differential diagnosis: AC joint degeneration, subacromial impingement, internal impingement, labral tear, long head of the biceps tendinopathy, capsulitis - comments: a history of rotator cuff tendinopathy often precedes a rotator cuff tear
Who is more prone to GIRD?
- overhead throwers - baseball pitchers (due to extreme external rotation required from sport)
Signs and symptoms of internal impingement that may help your evaluation of this condition
- pain in posterior shoulder during activity - loss of control and velocity with overhead throwers - restricted posterior joint play - restricted horizontal adduction - restricted internal rotation
Examination findings of SLAP lesions
- pain not typically noted at rest
How can we best evaluate when shoulder pads or other equipment that might make the initial evaluation difficult are present?
- palpation under the shoulder pads - removal of the shoulder pads
How would you expect signs and symptoms to differ between partial thickness tears and full thickness tears?
- partial thickness tears: short, longitudinal lesions that are not through the entire tendon (don't tear whole tendon) - full thickness tears: tears through the entire tendon with severe dysfunction and atrophy upon inspection
How do you analyze scapular movement?
- patient maximally flexes GH joint - patient holds a 3-5 lb. weight and raises arms into forward flexion to maximum elevation (repeat 5 times) - prominence of any aspect of the medial border and/or excessive shrugging on symptomatic side marks presence of dyskinesis
What are the signs and symptoms of a posterior GH dislocation?
- patient's arm adducted and internally rotated - coracoid process may be more prominent since the humeral head is moved posteriorly - humeral head may be palpable posteriorly - pain - swelling - unwillingness to move the arm
What are some signs and symptoms of an anterior GH dislocation?
- patient's arm slightly abducted and supported - acromion process more prominent - flattened deltoid - pain - unwillingness to move - impaired sensation and motor function
Why is GIRD typically associated with internal shoulder impingement?
- patients with GIRD have a tight posterior inferior GH ligament - results in superior translation of humeral head during GH elevation
What specific signs and symptoms will you need to evaluate for to rule out a posterior dislocation?
- pooling of blood into shoulder or neck - coughing/shortness of breath - difficulty swallowing - parenthesia - more prominent clavicle
What signs and symptoms will a patient with a posterior SC joint dislocation often present with?
- pooling of blood into the shoulder or neck - coughing/shortness of breath - difficulty swallowing - more prominent clavicle
What other things might we test/observe during an on-field shoulder evaluation?
- position of the humeral head - AC joint alignment - clavicle - SC joint - humerus
List 3 proposed causes of GIRD?
- posterior capsule tightness (posterior side of the inferior GH ligament) —> repetitive cocking that occurs with overhead throwing motions - rotator cuff tightness (infraspinatus and teres minor) - bony abnormality (humeral retroversion/decreased anteversion) —> caused by beginning overhead throwing at a young age
When is immediate referral warranted?
- posterior fracture - signs of neurovasuclar compromise, open wounds, or skin tenting
Damage to what anatomical structures can lead to posterior GH instability?
- posterior side of the inferior GH ligament - posterior joint capsule - infraspinatus - teres minor
What is severity of tears of the rotator cuff based on?
- presence of tearing - tear may result in macro- or micro- trauma
How do you protect a non-emergent acute SC joint injury?
- protect the arm with a sling (holds the weight of the arm) and a swathe (minimizes humeral head and scapular movement) - should be send for imaging the same day
What are the 3 major roles of the scapula?
- provide a mobile and stable base for the humerus - adjusts the glenoid and acromion to avoid impingement - transfer kinetic energy
What are the 3 different ways in which the clavicle becomes displaced following a fracture?
- proximal segment - distal segment - overlap (shortening)
What other diagnostic instruments may also be used when evaluating acute SC joint dislocations? Why?
- radiograph: due to the close association between SC dislocation and sternum or clavicle fractures - angiogram: if any vascular occlusion is suspected, to visualize blood flow through vascular structures to determine if it is present - ultrasound, to identify the presence of an SC dislocation and damage to SC ligaments
What are the primary complaints of patients who have a Hill-Sachs lesion?
- rarely symptomatic - mechanical sounds (popping/locking/clicking) - possible deep shoulder pain
When should GH joint reductions be performed?
- reductions should only be performed by those who are trained to do so - following reduction, assess distal pulse and AROM, avoiding ER and abduction - stabilize the shoulder using a sling - refer the athlete for further examination
What is initial management of an AC joint sprain?
- refer hypermobile AC joints for imaging (fractures of distal clavicle may mimic AC dislocation) - grade 1 and 2 AC sprains treated conservatively with immobilization of arm (if needed for pain control) - grade 2 or higher AC sprains may require surgery, however outcomes similar to conservative ROM and strengthening management
What type of actives cause non traumatic posterior instability?
- repetitive forces that force the humeral head posteriorly (I.e. blocking) - forces that distract the posterior GH structures (I.e. follow through of overhead throw) - weakness or fatigue of subscapularis and infraspinatus
What causes anterior GH instability?
- repetitive overload (non traumatic) - following an acute dislocation/subluxation (traumatic)
What must happen in order to keep the humeral head centered within the glenoid fossa during movement?
- requires mobility, stability, and neuromuscular control to keep the humeral head centered within the glenoid fossa - upward rotation of scapula (scapulothoracic rhythm)
How do you begin an assessment for scapular dyskinesis?
- resting posture --> side to side asymmetry (check for prominent inferomedial or medial border) - analyze scapular movement while patient maximally flexes GH joint
What are conservative intervention strategies of subacromial impingement?
- restore scapular kinematics - improve thoracic extension mobility - targeted stretching (pec minor/major) - strengthen rotator cuff musculature
What causes non traumatic anterior instability?
- results form repetitive shoulder movements that cause anterior shear force across the GH joint (I.e. overhead throwing -- late cocking phase and early acceleration) - static stabilizers fatigue and begin to stretch - dynamic stabilizers must compensate but eventually fatigue as throwing continues - symptoms of weakness and instability result - exam tests are designed to provoke or alleviate pain and/or the sensation of instability
What are the movements of the scapular muscles?
- retraction and downward rotation - retraction - protraction and upward rotation - depression and retraction - elevation
What structures from the boundaries of the subacromial space?
- roof: acromion, coracoacromial ligament - anterior: coracoid process - floor: humeral head, superior glenoid, end of supraspinous fossa
What are the most common causes of biceps tendon pathologies?
- rotator cuff dysfunction - overuse of the biceps brachii - subacromial impingement
What shoulder injuries are often associated with/cause scapular dyskinesis?
- rotator cuff injuries - GH instability - AC joint injury - adhesive capsulitis
Describe how scapular dyskinesis causes supraspinatus irritation
- scapula must upwardly rotate and posteriorly tilt during GH elevation to avoid impingement - middle and lower trapezius activation may be delayed causing excessive scapular elevation and anterior tilt - pectoralis minor/major may be tight
What is a comminuted fracture of the mid shaft of the humerus?
- shaft of the bone is broken in more than 2 pieces - trauma (car accident, fall from great height, great impact)
Define partial thickness tears of the rotator cuff
- short, longitudinal lesions - not through the entire tendon
What are the primary complaints of patients who have a bankart lesion?
- shoulder pain - feelings of instability as the head of the humerus moves against the anterior labrum during GH joint play assessments, load and shift, and external rotation assessment
What does the management of of mid shaft humeral fractures consist of?
- splint in the position they are found in using a moldable splint or vacuum splint
Which joint provides the only true articulation connecting the upper limb to the axial skeleton?
- sternoclavicular (SC) joint
What are the joint play assessments of the shoulder complex?
- sternoclavicular joint - acromioclavicular joint - Glenohumeral joint
What typically contributes to the development of internal shoulder impingement?
- strongly associated with glenohumeral internal rotation deficit (GIRD) and anterior instability
What are the secondary contributors of the anterior GH joint?
- superior GH ligament - rotator cuff muscles - LHBT
What anatomical structures are located within the subacromial space and thus susceptible to impingement?
- supraspinatus tendon - infraspinatus tendon - subacromial bursa - superior GH capsule - labrum - long head of the biceps tendon
What signs and symptoms would be present if the supra scapular nerve is damaged?
- supraspinatus weakness - infraspinatus weakness
Why is it sometimes difficult to visually observe an SC joint dislocation? What does this mean about your management of this condition?
- swelling occludes ability to determine direction of dislocation - refer all patients with suspected SC dislocation if you can't determine which direction it's dislocated in
Define full thickness tears of the rotator cuff
- tear through the entire tendon - severe dysfunction and atrophy visible upon inspection
What is an oblique fracture of the mid shaft of the humerus?
- the fracture is a straight line on an angle through width of the shaft of the bone - usually caused by landing on arm at an angle during a fall or getting hit suddenly from an angle (car accident)
How do the different classifications of SLAP lesions help dictate the types of signs and symptoms the patient may have?
- the more tearing, the more mechanical sounds like popping and clicking you will hear as well as feel along with locking
What is a transverse fracture of the mid shaft of the humerus?
- the straight fracture line is perpendicular to the shaft of the bone - usually caused by a blow transmitting a large amount of force directly perpendicular to the bone
What are the various types of fractures that may occur at the mid shaft of the humerus?
- transverse - oblique - spiral - comminuted - segmental
What is os acromiale?
- unfused osseous union at acromion - 8% prevalence
How should palpation under the shoulder pads be performed?
- unlatch shoulder pad straps - palpate under cantilever or through the neck opening - gentle palpation to begin with
How should removal of shoulder pads be performed?
- unlatch shoulder pad straps - remove uninjured arm - slide shirt and pads up over the head - drop shirt down over injured arm (if shirt is too tight, cut it off)
What are the evaluation tests for biceps tendinopathy?
- yergason test - speed test - Ludingtons (biceps dance)
Can an SC joint injury be a medical emergency? When?
- yes, posterior dislocations are medical emergencies - with a posterior dislocation, there is a threat to the subclavian artery and vein, trachea, and esophagus
What is a piano key sign?
- you push on clavicle, it pushes down towards the acromion and see it pop back up - true sign is on intact clavicle with AC joint sprain and lifts at lateral end of clavicle - can also be done with clavicular fracture where you see it lift in shaft of bone midclavicle
What is the rotator interval? How is it related to anterior GH instability?
-a potential area of capsular weakness that leads to anterior instability - a weakened region of anterior GH joint formed by a space between supraspinatus and subscapularis
What is the least common MOI of clavicular fx?
6% from FOOSH
Where do clavicular fractures typically occur?
69% of fractures occur in the middle of the clavicle (at the junction between the 2 curves)
What is the second most common MOI of clavicular fx?
7% from blunt trauma to the clavicle
What is the most common MOI of clavicular fx?
87% caused by fall onto shoulder
For non-emergent SC joint injuries, how do you help a patient protect their injury?
Apply a sling and a swathe
What is the preferred image of choice when evaluating acute SC joint dislocations?
CT scan becuase it can identify the direction of dislocation, shows fractures, and can identify if any other structures have been compromised
What is the surgical management for biceps tendinopathy?
Chronic LHBT pain and dysfunction may benefit from surgically repositioning the tendon
What is surgical management of a rotator cuff tendinopathy?
Depending on the tear size, the surgeon has to decide between arthroscopic surgery or full-open repair
Why is it inaccurate to diagnose GIRD as simply a "10-15 degree loss of IR compared bilaterally"?
GIRD is defined as excess ER and lacking IR - having some more movement in ER is normal (such as 110 ER and 70 IR) - having a larger amount of ER and very limited IR (such as 135 ER and 45 IR) is indicative of GIRD and abnormal
What are the evaluation tests for subscapularis?
Gerber lift off test: a positive is indicated by the patient's inability to lift the back of their hand off of t he small of their back
What does GIRD stand for?
Glenohumeral Internal Rotation Deficit (loss of IR)
When is conservative management of an SC joint injury acceptable?
Grade 1 and 2 sprains
What type of SC dislocation is considered a medical emergency?
Posterior SC dislocation
When do you need to refer a patient with an SC joint injury?
Posterior dislocation or swelling that occludes the ability to determine the direction of SC dislocation
What is the general prognosis for SC joint injuries?
Prognosis is generally favorable for anterior and fair for posterior
When will you need to refer a patient with a suspected SC joint injury for imaging?
Suspected fracture or dislocation (or too much swelling present)
what are the different classifications of a SLAP lesion?
Types 1, 2, 3, and 4
Will the athlete be able to return to their sport and perform at a high level after an SC injury?
Yes, - grade 1: 7-10 days - grade 2: 4-8 weeks - grade 3: 8-12 weeks (anterior) or 12-14 weeks (posterior)
What is the definition of scapular dyskinesia?
abnormality or impairment of voluntary movement
What is conservative management of a rotator cuff tendinopathy?
activity modification and strengthening of scapular musculature and rotator cuff strength progression
What are surgical intervention strategies of subacromial impingement?
aimed at altering the shape of the acromion
How can a Bankart lesion and a Hill-Sachs lesion occur simultaneously?
anterior shoulder dislocation
What are dynamic GH joint supports?
augment passive restraints and provide coordinated movement of GH joint
What may cause a fracture to the body of the scapula?
avulsion
What may cause a fracture to the coracoid process?
avulsion
What is the classification of the GH joint?
ball-and-socket
How is GH instability categorized/graded?
based on joint play movements (how much the humeral head displaces relative to glenoid fossa)
Where is internal shoulder impingement located?
between the humeral head and the glenoid
What is the definition of multidirectional instability (MDI)?
combination fo 2 or more unidirectional instabilities
How do we classify AC joint injuries?
depends on the structures involved, degree of instability, and direction of displaced clavicle
Describe the secondary stage of impingement (the damaging cycle)
enlarged tendons further decrease subacromial space and increase chance of impinging structures
How can conservative management of MDI make the patient's condition worse?
focusing exercises to improve only one instability direction may make MDI worse
What is the classification of the AC joint?
gliding joint
Why is it clinically significant that the SC joint is the only true articulation connecting the upper limb to the axial skeleton?
if one of the SC joint ligaments is sprained or the clavicle is fractured, muscular tissue is all that is holding the arm to the thorax (patient will naturally feel the need to splint)
What nerve has the potential to become impinged/damaged with an anterior dislocation? What signs and symptoms may be present if that nerve is damaged?
impaired sensation and motor function if the axillary nerve is involved
Where is external shoulder impingement located?
in the subacromial space
How is it related to external impingement of the shoulder?
increased mobility of unfused section increases impingement risk
How does a distal segment clavicle fx displace?
inferiorly due to the weight of the arm
Describe the initial stage of impingement (the damaging cycle)
inflammation of the rotator cuff tendons (supraspinatus/infraspinatus)
Why do first time GH dislocations often become recurrent?
laxity in supporting structures
How do we evaluate for MDI?
may be congenital, presenting with generalized hyper laxity without a history of trauma (patients typically participate in overhead activities that impose repetitive micro trauma)
Why should we be cautious with forced reduction of the humeral head?
may cause damage to the glenoid fossa, the coracoid process, or the neuromuscular structures in the area
What structures are most commonly involved with internal impingement?
most common form involved the underside of the supraspinatus and infraspinatus tendons pressing against the glenoid
What direction does the inferior angle of the scapula move with upward rotation of the scapula?
moves laterally
What direction does the inferior angle of the scapula move with downward rotation of the scapula?
moves medially
Is there correlation between MOI and which third of the clavicle is fractured?
no
What is the classification of the ST joint?
not a true synovial joint
What are key points to the initial on-field evaluation of injuries to the shoulder complex?
observation and palpation
What group of people are proximal humeral fractures most common in?
older adults
What are the signs and symptoms of an SC joint sprain?
pain with protraction, retraction, and joint play
How does scapular dyskinesia apply to the shoulder complex?
poor scapular function due to poor motion, position, and/or stability
What tests can be done to determine if lingering instability is present after a posterior dislocation or subluxation?
posterior apprehension
What are passive GH joint supports?
provide stability, limit extreme motion, align humeral head during movement
What is the most common displacement of the clavicle after fracture?
proximal displacement
What are the primary dynamic stabilizers/restrains to inferior GH translation?
rotator cuff musculature (SITS)
What is the classification of the SC joint?
saddle type (functions as a ball-and-socket
What is the common term for an AC joint sprain?
separated shoulder
What equipment might make this initial evaluation difficult?
shoulder pads
What is the goal of surgical treatment of internal impingement?
stabilization to reduce migration of humeral head
What structures can become injured during an anterior GH dislocation?
stresses anterior and inferior ligaments
How does an overlap (shortening) clavicle fx displace?
subscapularis and pectorals (maj/min) internally rotate and pull the arm towards the chest
How does a proximal segment clavicle fx displace?
superiorly due to pull of the sternocleidomastoid (SCM)
Which of the rotator cuff muscles is most susceptible to overuse injuries? Why?
supraspinatus because it is the most commonly impinged on
Describe type 1 anatomical variation of the acromion
the acromion is flat (normal)
Describe type 4 anatomical variation of the acromion
the acromion process has spurs projecting off its inferior surface and has the highest potential for causing rotator cuff pathology
Describe type 2 anatomical variation of the acromion
the acromion process is gently curved, with the potential to compress the underlying tissues
Describe type 3 anatomical variation of the acromion
the acromion process is sharply "beaked" or hooked and has a higher potential to cause rotator cuff pathology
Why are the rotator cuff tendons so susceptible to overuse injuries?
they have poor vascularization
What is the goal of an instability evaluation?
to perform unidirectional assessments and add results together to identify if MDI is present
How does the scapula move as the humerus elevates?
upward rotation