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Shoulder Injury

Rouse High School

Sports Medicine 2

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Pre-Assessment

What are the following bones:

Bone #1

Bone #2

Bone #3

Of the three bones that make up the shoulder which bone do think is most commonly injured. By looking at what do think the is reason?

# 4 - Bone

# 5 - Reason

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Pre-Assessment

The shoulder has a group of four muscles that are important for stabilizing the shoulder. The muscles are usually associated with pitchers in terms of injuries. What is this group of muscles called? #6

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Pre-Assessment

What is the type of injury for the following injuries (sprain, strain, contusion, fracture, dislocation, subluxation).

#7 – “Seperated” Shoulder

#8 – Rotator cuff tear

#9 – Falling on the shoulder and hearing a “pop” on the front of the shoulder.

#10 – Tackling someone with one arm and the shoulder feels like it “shifted”. When looking at it appears deformed.

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Basic Shoulder Anatomy

http://www.youtube.com/watch?v=GOZjgz18eOQ

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Anatomy -Anterior Ligaments

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Anatomy

http://www.youtube.com/watch?v=HhTh7lKd1Sg
Glenohumeral Joint

Ball and socket, synovial joint
Humeral head is larger than glenoid cavity
Glenoid surface is four times smaller than humeral head
Only 25-30% of humeral head is contact with the glenoid
Allows for tremendous amount of motion

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Clavicle

“S” shaped bone
Fractures usually at curve in bone

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Acromioclavicular (AC) Joint

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Sternoclavicular (SC) Joint

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Scapulothoracic Joint

Not a “true” joint
Scapular muscles stabilize the scapula
Scapula doesn’t articulate w/ ribs, but posterior chest wall muscles

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Stability in Shoulder Joint

2 groups of muscles stabilize the shoulder (Dynamic Stabilizers):

Originate on axial skeleton & attach to humerus

Latissimus Dorsi
Pectoralis Major

Originate on scapula & attach to humerus

Rotator Cuff

Suprispinatus
Infraspinatus
Subscapularis
Teres Minor

Deltoid
Teres Major
Coracobrachialis

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Rhomboid Major

Retract scapula

Elevate Scapula

Downward Rotate Scapula

Rhomboid Minor

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Trapezius

Upper

MIddle

Lower

Elevate

Upwardly rotate

retract

depress

Upwardly rotate

Latissimus Dorsi

Adduction

Internal Rotation

Extends humerus

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Biceps Brachii

Flexion

Abduction

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Triceps

Extension

(Long head)

Adduction

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Pectoralis Major

Adduction

Horizontal adduction

Internal Rotation

Flexion

(Clavicular segment)

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Pectoralis Minor

Tilt scapula forward

Inferior angle lifts

Rotates inferior angle medial

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Posterior Deltoid

Extend the humerus

Horizontal abduction

Externally rotate

Middle Deltoid

Abduct Humerus

Anterior Deltoid

Flex the humerus

Horizontal adduction

Internally rotate

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Anatomy - Rotator Cuff Muscles

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Subscapularis

Internal Rotation

Stabilize humeral head

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Supraspinatus

Abduct humerus

External rotation

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Infraspinatus

External Rotation

Horizontal abduction

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Teres Minor

External Rotation

Horizontal abduction

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Bursa

Subacromial

Subdeltoid

Subcoracoid bursitis limits ER

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AC Sprain

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Acromioclavicular sprain

MOI

“Separated Shoulder”
Falling on outstretched arm
Landing on tip of shoulder
Direct blow
https://youtu.be/EIXWemQxqdg

Signs Symptoms

Pain & Swelling over AC
Decreased ROM (Overhead & Across body)
Crossover test
Piano key sign

Vertical movement of the clavicle with palpation

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ACROMIOCLAVICULAR (AC) SPRAIN

Tx:

RICE
Sling

Grade 1 - 3-4 days
Grade 2 - 7-10 days
Grade 3 - 2-3 wks

x-ray if GR 2-3,
sometimes surgery if GR3,
Padding

Prev:

good pads for collision sports

cover acromion/ cap of shoulder

Misc:

GR1 may be mistaken for “Shoulder Pointer”. Acromion/shoulder contusion
Tx the same way
https://www.youtube.com/watch?v=09rydBu_YS0

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STERNOCLAVICULAR (SC) SPRAIN

MOI:

blow to clavicle,
fall on shoulder,
Similar to AC sprain MOI
https://www.youtube.com/watch?v=vWTUZIHB6qg

S/s:

Pain & swelling at SC
Possible deformity if grade 2-3,
Decreased ROM
Posterior dislocation = emergency if airway, nerve, artery impinged

Treatment:

Similar to AC
Immobilize if necessary

Ouch!

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Clavicular Fracture

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Clavicular Fracture

Etiology

Frequent
MOI
Location – mid third
Greenstick - youths

Signs and Symptoms

Pt tenderness
Swelling
Deformity

Treatment

Sling
Refer to Dr. for X-ray

Treat for shock
Immobilized

Prognosis

6-8 Weeks
Contact sports longer
Surgery - rare

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Shoulder Disclocation/Subluxation

https://www.youtube.com/watch?v=IiHkhL4FfVg

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Dislocations / Subluxations

MOI:

Anterior dislocation/subluxation - most common
Humeral head ends up in axilla
MOI

Abduction with ER
Fall on arm / hand or…
Blow to posterior shoulder especially if arm is horizontally extended

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Dislocations / Subluxations

S/s:

Pain with a “pop”
Deformity = flattened shoulder cap
Palpate humeral head in axilla
If impinges on artery/nerve will have numbness, tingling, decreased pulse,

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Dislocations / Subluxations

Tx:

RICE, immob, refer to Dr.
Only trained people reduce a shoulder
X-ray first time occurrence to rule out fx,
Immobilize
Rehab per doctor
Emphasize rotator cuff.
brace?

Prev:

strong

Misc:

high recurrence rate,

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Apprehension Test

Anterior Apprehension/Relocation³

Athlete's Position Supine with the shoulder located on the edge of the table. A.T.'s Position The athletic trainer stands at the side of the athlete, and then proceeds to abduct the shoulder to 90 degrees and supports the humerus. The elbow is then passively flexed. Execution & Rationale The athletic trainer slowly externally rotates the shoulder, producing tension on the glenohumeral ligamentous complex. This mimics a common mechanism of instability. This test is positive if... The athlete elicits apprehension and pain, at which point the test should be terminated. This shows that the capsuloligamentous structures of the glenohumeral joint have been damaged. RELOCATION TEST At the first sign of apprehension, the athletic trainer provides a posterior force on the glenohumeral joint. This effectively "relocates" the humeral head in optimal contact with the glenoid. This test is positive if the pain and apprehension is reduced.

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Pitching Phases

Fundamentals of Throwing �Almost all sports involve some form of an overhead throw. While each has its own fundamental technique, they all have certain phases. These phases are the following: Wind-up, Cocking, Acceleration, Release and Deceleration, and the Follow-through.^{2,4,8,15,32,45} These phases all stress the ligaments and musculature of the glenohumeral joint in different ways, at different times in the motion. The following is an analysis of a common overhead throw. The Wind-up - Sometimes known as the Preparation phase, the wind-up is the beginning of any throw.⁴ Upon initiation, the shoulder is shifted in a posterior direction. This posterior shifting can cause pathology at the posterior glenoid labrum. This is due to the repetitive stress on the humeral head by the posterior labrum. As a result, the humeral head may roughen and become scarred.⁸ During this phase, the long head of the biceps stretches due to its attachment on the superior glenoid labrum.⁸ The wind-up lasts about a second, ending when the ball leaves the gloved hand. The Cocking Phase - During the end of the cocking phase, the shoulder is abducted to ninety degrees and externally rotated to varying amounts larger than ninety degrees.^{2,4,8,15,32,45} It is not unusual for a veteran thrower to possess more than fifteen degrees of added external rotation in the throwing shoulder.⁸ This is also accompanied by approximately thirty degrees of horizontal abduction.⁸ This motion is brought about by a combination of the deltoid and rotator cuff musculature. The deltoid muscles provide a majority of the gross movement, with the rotator cuff holding the humeral head in the glenoid. As the athlete assumes this position, a significant amount of tensile force is present in the anterior joint capsule and musculature.⁸ This is especially true in the rotator cuff. The cocking phase is terminated when the ball is brought forward, leading to the acceleration phase.⁴ Acceleration Phase - The acceleration phase occurs as the ball is brought forward.^4,45 This movement is facilitated by the once stretched anterior structures contracting, using active and passive tension.⁸ All leg and trunk movements of the body relay additional kinetic energy to the shoulder and ultimately the ball.³² The anterior structures are also aided by the firing of the internal rotators.⁸ Angular velocities up to 9,189 degrees per second have been recorded during this phase.² �As the shoulder is brought forward, some control of horizontal adduction must be present in order to control the pitch. The supraspinatus, infraspinatus, and teres minor are responsible for this by eccentrically contracting.^4,8,32 If not well controlled, injuries to the anterior labrum or humeral head may occur. This is due to the humeral head being allowed to pass over the anterior lip of the glenoid. Possible reasons for the excessive migration of the humeral head are poor conditioning of the rotator cuff, or a lax posterior capsule.^4,8,32 The acceleration phase ends when the ball is released.⁴ The Release and Deceleration Phase -The release and deceleration phase occurs from ball release and lasts until the shoulder is maximally rotated internally.⁴ As a general rule, deceleration forces are twice as great, yet last half as long.^4,45 Deceleration is primarily a function of the posterior rotator cuff muscles.³² They slow down the humerus as it internally rotates and keeps the humeral head controlled in the glenoid fossa. Jobe and colleagues have reported forces of up to three hundred pounds being resisted by the posterior rotator cuff as it decelerates the arm. Lesions of the rotator cuff or labral tears, such as a SLAP lesion, frequently occur at this phase.⁸ The Follow-through - The follow-through involves the body moving forward with the shoulder and arm. This further reduces the distraction forces on the posterior rotator cuff.⁴

Home

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Rotator Cuff Tendinitis

http://www.youtube.com/watch?v=bgv8tmWzmnI

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ROTATOR CUFF TENDINITS/ TEAR

MOI:

Supraspinatus is most common
Partial or full thickness

Partial more common (2x).
Most full tears occur in people over 40 w/ long HX of shoulder problems.

Usually caused

Acute trauma - Tears
Impingement - Tendinitis
Repetitive micro-trauma (pitching)

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Rotator Cuff Tendonitis

S/s:

Tendonitis = normal s/s
Tear

Pain, usually no obvious defect decreased function
May feel pop if acute
Chronic they will have history of shoulder pain
Weakness of muscle,

+ drop arm, + empty can

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Rotator Cuff Injury

Tx:

Rehab vs. Surgery,
Emphasizing rotator cuff
Gradual return to activity

Prev:

good rotator cuff program to prevent problems

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Shoulder Impingement

http://www.youtube.com/watch?v=6RbDkz737oA

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IMPINGEMENT SYNDROME

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IMPINGEMENT SYNDROME

MOI:

Compression

Supraspinatus tendon
Subacromial bursa
Long head of biceps tendon.

Decreased space under the arch
Overuse or repetitive trauma that irritates the structures & causes inflammation.
Most common in overhead sports.

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IMPINGEMENT SYNDROME

Signs and Symptoms

Diffuse pain around the AC area,
Pain increases w/ overhead activities
Stage I = ache after activity
Stage II = ache with activity, increases at night
Stage III = pain with all activity and atrophy

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Impingement

TX:

RICE, STP,
Rotator Cuff Program.
Core strengthening
Modify activity
Gradual return to activity,
Injection (bursa relief)
Surgery

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SLAP Tear/Lesion

SLAP

Superior Labrum, Anterior to Posterior
Pulls Labrum away from Glenoid near attachment of the Biceps Tendon
Tear from 9 o’clock to 3 o’clock
Associated with unstable shoulder (GH)

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SLAP Tear/Lesion

MOI

Similar to subluxation/dislocation

S & S

Pain - along upper GH joint line
Feeling - weak & popping sensation
Reduced biceps & RC strength

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SLAP Tear/Lesion

Tx

Strengthen RC but limit bicep exercises early on
Refer to orthopedic
Surgery?? Not always indicated