Chapter 10Chapter 10Shoulder InjuriesShoulder Injuries

Chapter ObjectivesChapter Objectives

• Understand the basic anatomy of Understand the basic anatomy of the shoulder.the shoulder.

• Explain how shoulder injuries occur.Explain how shoulder injuries occur.• Describe the various types of Describe the various types of

injuries to the shoulder.injuries to the shoulder.• Explain treatment procedures fro Explain treatment procedures fro

common shoulder injuries.common shoulder injuries.

AnatomyAnatomy

• BonesBones• HumerusHumerus• ClavicleClavicle• ScapulaScapula

HumerusHumerus

ScapulaScapula

ClavicleClavicle

AnatomyAnatomy• LigamentsLigaments

• Coracoclavicular Coracoclavicular LigamentsLigaments

• TrapezoidTrapezoid• ConoidConoid

• AcromioclaviculAcromioclavicular ligamentar ligament

• CorocoacromialCorocoacromial

MusclesMuscles• Rotator CuffRotator Cuff

• SSubscapularisubscapularis• internal rotator internal rotator

• IInfraspinatusnfraspinatus• external rotator external rotator

• TTeres Minoreres Minor• external rotatorexternal rotator

• SSupraspinatusupraspinatus• primarily an primarily an

abductor of the armabductor of the arm

MusclesMuscles

• DeltoidDeltoid• Attaches to Attaches to

acromion process acromion process and lateral and lateral humerushumerus

• 3 portions3 portions• Anterior, posterior, Anterior, posterior,

and medialand medial

• Abducts, flexes, Abducts, flexes, and extends the and extends the shouldershoulder

MusclesMuscles

• Pectoralis minorPectoralis minor• Pectoralis majorPectoralis major

• Primarily Primarily responsible for responsible for horizontal horizontal adduction and adduction and protractionprotraction

MusclesMuscles• Biceps brachiiBiceps brachii

• 2 heads2 heads• Originates at supraglenoid tubercle and corocoid Originates at supraglenoid tubercle and corocoid

processprocess• Inserts at radiusInserts at radius• Bicep tendon/bicipital grooveBicep tendon/bicipital groove• Held in place by transverse ligamentHeld in place by transverse ligament• Flexes elbow, abducts and supinates forearmFlexes elbow, abducts and supinates forearm

MusclesMuscles• Triceps brachiiTriceps brachii

• 3 heads-long, lateral, and medial3 heads-long, lateral, and medial• Originate posterior humerusOriginate posterior humerus• Insert at ulnaInsert at ulna• Extend elbow, humeral adductionExtend elbow, humeral adduction

JointsJoints

• Acromioclavicular Acromioclavicular (AC) joint(AC) joint• One of most common One of most common

injured areas of injured areas of shouldershoulder

• Consists of acromion Consists of acromion process and distal process and distal clavicleclavicle

• Held together by the Held together by the ac ligamentac ligament

Injured AC jointInjured AC joint

JointsJoints

• Glenohumeral jointGlenohumeral joint• Articulation of the humerus and Articulation of the humerus and

glenoid fossaglenoid fossa• Very susceptible to injury due to fossa Very susceptible to injury due to fossa

being shallowbeing shallow• Humeral head covered with articular Humeral head covered with articular

cartilagecartilage• Capsular ligament surrounds the Capsular ligament surrounds the

entire joint which aids in joint stabilityentire joint which aids in joint stability

Injuries- preventionInjuries- prevention

• Shoulder injury Shoulder injury causescauses• Muscle weaknessMuscle weakness• Postural problemsPostural problems• Nature of the jointNature of the joint

Addressing muscular Addressing muscular weaknessweakness

• Often weak in posterior (back) Often weak in posterior (back) musclesmuscles

• Signs- rounded shoulders, tight Signs- rounded shoulders, tight pectoralis muscles, weak posterior pectoralis muscles, weak posterior shoulder musclesshoulder muscles

• All predispose athlete to injuryAll predispose athlete to injury• Proper technique in throwing, Proper technique in throwing,

swimming, etc. prevent injuryswimming, etc. prevent injury• Proper padding importantProper padding important

Common shoulder Common shoulder injuriesinjuries

• Acromioclavicular Acromioclavicular ligament sprainligament sprain

• Aka-separated shoulderAka-separated shoulder• most common most common

mechanism of injury mechanism of injury occurs when the athlete occurs when the athlete falls onto the point of the falls onto the point of the shoulder or receives a shoulder or receives a direct blow to the tip of direct blow to the tip of the shoulder or falls on the shoulder or falls on an outstretched arm an outstretched arm

• graded according to the graded according to the degrees  of severity degrees  of severity

AC sprain (cont.)AC sprain (cont.)• Mild (1Mild (1stst degree) degree)

• stretching or slight tearing of the ligament fibers stretching or slight tearing of the ligament fibers • Mild joint tenderness, mild swelling, and little or no Mild joint tenderness, mild swelling, and little or no

disability of the shoulder disability of the shoulder • Moderate (2Moderate (2ndnd degree) degree)

• partial disruption of the supporting ligaments partial disruption of the supporting ligaments • pain and tenderness directly over and around the pain and tenderness directly over and around the

joint, local swelling, and an increase in pain on joint, local swelling, and an increase in pain on forced motion forced motion

• Severe (3Severe (3rdrd degree) degree)• total disruption of one or more of the supporting total disruption of one or more of the supporting

ligaments ligaments • varying degrees of tenderness, swelling, instability, varying degrees of tenderness, swelling, instability,

and an increase in pain with any effort to stress the and an increase in pain with any effort to stress the joint joint

• often exhibit a piano key sign; that is, the clavicle often exhibit a piano key sign; that is, the clavicle can be pushed down but will spring back up when can be pushed down but will spring back up when pressure is released.  pressure is released. 

AC sprain treatmentsAC sprain treatments• PRICEPRICE• Refer if 2Refer if 2ndnd or 3 or 3rdrd degree to r/o fracture degree to r/o fracture• 33rdrd degree may require surgery or degree may require surgery or

harness immobilizationharness immobilization

Glenohumeral ligament Glenohumeral ligament sprainsprain

• sprains of the shoulder joint sprains of the shoulder joint seldom occur unless there is a seldom occur unless there is a subluxation or dislocation subluxation or dislocation

• Vulnerable in abduction and Vulnerable in abduction and external rotationexternal rotation

• Pain with any motionPain with any motion• PRICE and refer to physicianPRICE and refer to physician

Rotator cuff strainRotator cuff strain• Injuries to rotator Injuries to rotator

cuff muscles are cuff muscles are difficult to detect difficult to detect and isolate because and isolate because these muscles, which these muscles, which reinforce the joint reinforce the joint capsule, lie deep in capsule, lie deep in the shoulder the shoulder

• MOI-MOI-• ballistic arm activities ballistic arm activities • forceful concentric forceful concentric

contraction of the contraction of the muscles that muscles that accelerate and accelerate and decelerate limb decelerate limb activities activities

• improper warm ups improper warm ups • muscle fatigue muscle fatigue

Rotator cuff injuries Rotator cuff injuries (cont)(cont)

• Signs and symptomsSigns and symptoms• anterior-lateral shoulder pain anterior-lateral shoulder pain • point tenderness point tenderness • decreased range of motion decreased range of motion • loss of strength consistent with the loss of strength consistent with the

severity of the injury severity of the injury • Pain may radiate down the lateral Pain may radiate down the lateral

arm but usually stops at mid-humerus arm but usually stops at mid-humerus • Pain is often increased at night while Pain is often increased at night while

the individual is lying on the affected the individual is lying on the affected side side

Rotator cuff injuries Rotator cuff injuries (cont)(cont)

• TreatmentTreatment• PRICEPRICE• Gentle strengthening and flexibility Gentle strengthening and flexibility

exercisesexercises• See handout for examplesSee handout for examples

Impingement sydromeImpingement sydrome

• common injury involving the soft common injury involving the soft tissues of the shoulder comprising of tissues of the shoulder comprising of the subacromial space (often involves the subacromial space (often involves the supraspinatus and biceps)the supraspinatus and biceps)

• Usually result of repetitive overhead Usually result of repetitive overhead types of movementtypes of movement

• TreatmentTreatment• Modified activityModified activity• Strengthening posterior shoulder musclesStrengthening posterior shoulder muscles• Improving flexibility (especially in pecs)Improving flexibility (especially in pecs)

Bicipital tendinitisBicipital tendinitis• Common with Common with

overhead activities overhead activities (swimming, (swimming, throwing, etc)throwing, etc)

• Tendon becomes Tendon becomes irritated in bicipital irritated in bicipital groovegroove

• May feel crepitis May feel crepitis (grinding)(grinding)

• Rest and Rest and immobilization may immobilization may be requiredbe required

• Treat with Treat with Ultrasound and N-Ultrasound and N-SAIDSSAIDS

Bicep tendon ruptureBicep tendon rupture

• Caused by direct blow or severe Caused by direct blow or severe contracture forcescontracture forces

• Athlete will have inability to flex Athlete will have inability to flex the elbowthe elbow

• Noticeable deformity as bicep Noticeable deformity as bicep muscle will roll up under skinmuscle will roll up under skin

• Treat- ice, immobilized, refer to Treat- ice, immobilized, refer to physicianphysician

• Surgical repair necessarySurgical repair necessary

Clavicular fractureClavicular fracture• Most often Most often

fractures occur in fractures occur in distal 1/3 of bonedistal 1/3 of bone

• Usually caused by Usually caused by direct blow or direct blow or falling on the tip of falling on the tip of the shoulderthe shoulder

• Restrict motion Restrict motion with sling and icewith sling and ice

• Refer for x-rayRefer for x-ray• Most fractures Most fractures

take 6 weeks to take 6 weeks to healheal

Humeral fractureHumeral fracture

• Not difficult to find if fractured at Not difficult to find if fractured at midshaftmidshaft

• Shoulder can sometimes hide humeral Shoulder can sometimes hide humeral head fractureshead fractures

• Pain on all sides of bone when palpated Pain on all sides of bone when palpated (around circumference) is good (around circumference) is good indicator of fractureindicator of fracture

• Splint and refer for immediate care Splint and refer for immediate care • Check pulse before and after splinting Check pulse before and after splinting

to check circulationto check circulation

Epiphysis injuryEpiphysis injury

• Can be caused byCan be caused by• Blow to humeral headBlow to humeral head• Falling on elbow and driving humerus Falling on elbow and driving humerus

into glenoid fossainto glenoid fossa• Signs/symptoms-same as humeral fxSigns/symptoms-same as humeral fx• Treat with ice, splint, slingTreat with ice, splint, sling• Refer, can cause growth impairmentRefer, can cause growth impairment• Young pitchers prone to epiphyseal Young pitchers prone to epiphyseal

injury from excessive throwinginjury from excessive throwing

Avulsion fractureAvulsion fracture

• Can accompany a glenohumeral or Can accompany a glenohumeral or AC sprainAC sprain

• Capsular ligament pulls away from Capsular ligament pulls away from scapula when humerous dislocates scapula when humerous dislocates from glenoid fossafrom glenoid fossa

• Only revealed or ruled out by x-rayOnly revealed or ruled out by x-ray• Treat with splint and iceTreat with splint and ice

Glenohumeral Glenohumeral dislocations and dislocations and

subluxationssubluxations• Head of Head of

humerous is out humerous is out of the socketof the socket

• Sublux- head was Sublux- head was out, then back inout, then back in

• Cause-excessive Cause-excessive abduction and abduction and external rotationexternal rotation

Glenohumeral Glenohumeral dislocations and dislocations and

subluxationssubluxations• Dislocation can cause tear of the Dislocation can cause tear of the

capsular ligamentcapsular ligament• Anterior dislocation most commonAnterior dislocation most common• Deformity usually seen at deltoid Deformity usually seen at deltoid

muscle (shoulder flat)muscle (shoulder flat)• X-ray needed to determine extent X-ray needed to determine extent

of injuryof injury

Glenohumeral Glenohumeral dislocations and dislocations and

subluxationssubluxations• Dislocations and subluxations need Dislocations and subluxations need

to strengthen adductors and to strengthen adductors and internal rotatorsinternal rotators

• Can wear restrictive harnessCan wear restrictive harness• Surgery sometimes required to Surgery sometimes required to

repair capsular ligamentrepair capsular ligament

Adhesive capsulitisAdhesive capsulitis• frozen shoulderfrozen shoulder• inflammation about inflammation about

the rotator cuff and the rotator cuff and capsular area that capsular area that can result in dense can result in dense adhesions and adhesions and capsular capsular contractures causing contractures causing restriction of motion restriction of motion and pain and pain

• exact cause remains exact cause remains unknown unknown

• The main feature is a The main feature is a lack of passive range lack of passive range of motion of motion

Brachial plexus injuryBrachial plexus injury• normally involves normally involves

the cervical spine, the cervical spine, but the symptoms but the symptoms are exhibited in are exhibited in the shoulder and the shoulder and upper extremity upper extremity

• Usually caused by Usually caused by forced rotation or forced rotation or lateral flexion lateral flexion

• Is a stretching or Is a stretching or pinching of pinching of brachial plexusbrachial plexus

Brachial plexus injuryBrachial plexus injury• result in transitory result in transitory

paralysis of the armparalysis of the arm• numbness or a numbness or a

burning sensations burning sensations radiating down the radiating down the arm and sometimes arm and sometimes into the hand into the hand

• Weakness or Weakness or numbness lasting numbness lasting more than an hour more than an hour should be referred should be referred to a physician to a physician

Thoracic Outlet Thoracic Outlet Syndrome Syndrome

• a group of symptoms resulting a group of symptoms resulting from compression of the thoracic from compression of the thoracic neurovascular bundle neurovascular bundle

• .  This neurovascular bundle .  This neurovascular bundle emerges from the thorax though emerges from the thorax though an outlet or triangle formed by the an outlet or triangle formed by the scalene muscles and the first rib scalene muscles and the first rib

• Narrowing of the outlet can cause Narrowing of the outlet can cause a variety of symptomsa variety of symptoms

Thoracic Outlet Thoracic Outlet SyndromeSyndrome

• Possible causesPossible causes• hypertrophy of one of the scalene hypertrophy of one of the scalene

musclesmuscles• shape of the first rib shape of the first rib • scar tissue formation around the scar tissue formation around the

nerve roots nerve roots • cervical ribs cervical ribs • excess callus formation as a result of excess callus formation as a result of

a fractured clavicle a fractured clavicle • hyperabduction or stretching of the hyperabduction or stretching of the

brachial plexus brachial plexus

Thoracic Outlet Thoracic Outlet SyndromeSyndrome

• Symptoms Symptoms • aching pain across the shoulder aching pain across the shoulder • pain in the side of the neck and down pain in the side of the neck and down

the armthe arm• sensation of weakness, heaviness, and sensation of weakness, heaviness, and

easily fatigability when using the armeasily fatigability when using the arm

• Athletes exhibiting TOS often have Athletes exhibiting TOS often have a history of trauma to the head, a history of trauma to the head, neck, or shoulder area neck, or shoulder area