Shoulder Injuries

ATHLETIC INJURIES SHOULDER INJURIES

SHOULDER INJURIES • INTRODUCTION – The shoulder is a multi-axial ball and socket joint and has a great degree of movement. – Sport activities, especially those which involved overhead movement place a great deal of stress of this joint. – Shoulder injuries can involve many different types of injuries including; tendonitis, impingement syndrome, tears fractures separations and dislocations.

SHOULDER INJURIES • RELEVANT ANATOMY – Bone – Ligament – Muscle (Rotator Cuff) – Joints • • • •

-Sternoclavicular -Acromioclavicular -Glenohumeral -Scapulothoracic

SHOULDER INJURIES – Rotator Cuff Injuries • Tendinitis, strain, Impingement Syndrome

– Bicipital Tendon • Tear, tendonitis, subluxing long head

– Acromioclavicular Separations – Glenohumeral Subluxations/Dislocations – For each condition, the Mechanism, Signs and Symptoms, Testing procedures and Care will be discussed.

THE JOINTS OF THE SHOULDER

STERNOCLAVICULAR SEPATATIONS

STERNOCLAVICULAR SEPATATIONS

BONY LANDMARKS (ANTERIOR VIEW)

BONY LANDMARKS (POSTERIOR VIEW)

THE ACROMIOCLAVICULAR JOINT

THE CORACOACROMIAL ARCH

LABRAL TEARS

LABRAL TEARS Labral tears can be caused by overuse or trauma. • Two common labral tears are SLAP lesions (Superior Labrum Anterior-Posterior) or Bankart lesions. • SLAP Tears - A SLAP tear is a type of labral tear most commonly seen in overhead throwing athletes such as baseball players and tennis players. The torn labrum seen in a SLAP tear is at the top of the shoulder socket where the biceps tendon attaches to the shoulder. •

TYPES OF LABRAL TEARS • Bankart Lesions - A Bankart lesion is a labral tear that occurs when a shoulder dislocates. When the shoulder comes out of joint, the labrum is torn, and makes the shoulder more susceptible to future dislocations.

RANGE OF MOTION AND THE ROTATOR CUFF MUSCLES – The rotator cuff or S.I.T.S. muscles play an important role in helping provide movement and stability to the glenohumeral joint. – Movements of the shoulder joint include; flexion, extension, abduction, adduction, internal and external rotation, horizintal abduction/and adduction and circumduction. – There are also combined movements of abduction and external rotation and adduction and internal rotation (both tested with the Appley’s Scratch Tests).

RANGE OF MOTION

THE APPLEY’S SCRATCH TESTS Abduction External Rotation

Adduction/Internal Rotation

RANGE OF MOTION • Pain or limitation during movement testing may indicate a variety of conditions or injuries including: – Tendonitis – Acromioclavicaular Problems – A Frozen Shoulder

RANGE OF MOTION •

In abduction, motion occurs at the glenohumeral and scapulothoracic articulation at a ratio of 2:1. • Frozen Shoulder (Adhesive Capsulitis) occurs when there is little glenohumeral movement, only scapulothoracic.

THE ROTATOR CUFF MUSCLES – The rotator cuff muscles are the Supraspinatus, Infraspinatus, Subscapularis and the Teres Minor. – The key role of the supraspinatus is the initiation of abduction, the infraspinatus and teres minor are external rotators and the subscapularis is an internal rotator muscle. – These muscles may develop a tendonitis, a tear, or in the case of the supraspinatus tendon, an impingement.

THE ROTATOR CUFF MUSCLES

THE ROTATOR CUFF MUSCLES • There are a number of tests designed to test and isolate the various rotator cuff muscles. • These include: – The Codman’s Drop Arm Test (General Test) – The Empty Can Test (Supraspinatus) – Tests for External Rotation (Infra/Teres) – Hornblower’s sign/test (Teres Minor) – Tests for Internal Rotation (Subscapularis) – Lift Off Sign (Subscapularis)

TEARS IN THE ROTATOR CUFF Drop-Arm (Codman’s) Test

THE EMPTY CAN TEST (Supraspinatus)

THE SUBSCAPULARIS MUSCLE (Resited Internal Rotation/Lift Off Sign)

EXTERNAL ROTATION (Infraspinatus/Teres Minor)

HORNBLOWER’S TEST/SIGN (Teres Minor)

MUSCLE IMBALANCE CONCEPT

IMPINGEMENT SYNDROME Impingement syndrome is a common overuse condition with overhead sporting activity. • The etiology involves three structures, the supraspinatus tendon, the long head of the biceps and the subdeltoid/subacromial bursa occupying a confined area under the coracoacromial arch. • With repeated overhead activity, the greater tuberosity of the humerus impinges and inflames these structures leading to pain and inflammation with any overhead activity. •

IMPINGEMENT SYNDROME

IMPINGEMENT SYNDROME NEER’S TEST

HAWKINS KENNEDY TEST

THE LONG HEAD OF THE BICEPS – The long head of the biceps along with the rotator cuff function to provide dynamicstability in the shoulder. – Because it plays a key role in glenohumeral stabilization, the bicipital tendon is frequently involved in shoulder injuries. – The long head of the biceps may be; develop a tendonitis, TEAR, or tear the supporting ligament and sublux out of the bicipital groove.

LONG HEAD OF BICEPS

SPEED’S TEST FOR A LONG HEAD BICEPS TENDONITIS

SUBLUXING LONG HEAD OF BICEPS TENDON

DIFFERENT SHAPES OF THE BICIPITAL GROOVE

YERGASON’S TEST FOR A SUBLUXING LONG HEAD

ACROMIOCLAVICULAR SEPARATIONS/SPRAINS – The Acromioclavicular or AC joint is located at the distal clavicle and articulates with the acromion process of the scapula. – This is a weak joint, held together by ligaments and a joint capsule. – When there is damage to one or more of these supporting ligaments the clavicle ‘separates’ or dislocates, creating a step or piano key deformity. – Graded as 1 – 3rd (based on number of ligaments torn) 4-6 degrees depending on the position of the clavicle (Rockwood’s classification).

ACROMIOCLAVICULAR SEPARATIONS/SPRAINS • There is also a fibrocartligeous disk present which separates the two bones of the acromion and clavicle. • The two main supporting ligaments are the acromioclavicular (AC Ligament) and the coraco-clavicular ligament, which is made up of the conoid and trapezoid ligaments.

THE ACROMIOCLAVICULAR JOINT

ACROMIOCLAVICULAR SEPARATION

ACROMIOCLAVICULAR SEPARATIONS/SPRAINS • Specific tests for this injury involve opening or ‘gapping’ the AC joint. • Orthopaedic tests for this injury include: – The Traction test – The Crossbody, Crossover, Horizontal Abduction test – The Shear test

A.C. LIGAMENT TESTS (Traction Test)

A.C. LIGAMENT TESTS (Cross Over, Cross Body, Horizontal Abduction Test)

THE SHEAR TEST

SHOULDER DISLOCATIONS – Shoulder dislocations account for up to 50% of all the dislocations in the body. – Due to the fact that the shoulder has a great degree of movement and that it relies on the surrounding musculature for support, shoulder dislocations are a common shoulder injury. – The most common type of dislocation is an Anterior dislocation.

ANTERIOR GLENOHUMERAL DISLOCATION

SHOULDER DISLOCATIONS – An anterior-inferior dislocation may result from direct impact or a forced abduction and external rotation. – With this type of dislocation, the head of the humerus is forced out of the glenoid fossa anteriorly and inferiorly. – There is a high risk of fracture and possible neurovascular injury.

SULCUS SIGN FROM SHOULDER INSTABILITY

DISLOCATIONS OF THE SHOULDER