Upper Extremity Injuries and Shoulder Physiology

The Shoulder

Unit 16

Upper Extremity Injuries



Upper extremities are vulnerable to a

variety of injuries depending on the

sport, including:

–

Sprains

–

Strains

–

Dislocations

–

Fractures

Upper Extremity Injuries



Upper extremities are vulnerable to a

variety of injuries depending on the

sport, including:

–

Separations to the thoracic cage, shoulder,

arm, and hand

–

Repetitive motion injuries such as arthritis,

bursitis, tendonitis

Shoulder Complex Physiology



Bones



Muscles



Tendons



Ligaments



Articulations

Bones



Humerus



Scapula



Clavicle

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

Sternoclavicular joint (SC joint)

–

Sternoclavicular ligament



Coracoclavicular joint

–

Coracoclavicular ligament



Acromioclavicular joint (AC joint)

–

Acromioclavicular ligament



Coracoacromial joint

–

Coracoacromial ligament



Glenohumeral joint

–

Glenohumeral ligaments



Scapulothoracic articulation

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FLEXION



Anterior deltoid

–

Primary mover



Biceps brachii

–

Secondary mover

EXTENSION



Posterior deltoid

–

Prim. Mover



Triceps brachii

–

Sec. Mover

ABDUCTION



Supraspinatus

–

1st 5-10 degrees



Middle deltoid

–

Last 90 degrees



Trapezius

–

Assists in movement above 90 degrees

ADDUCTION



Latissimus dorsi



Pectoralis major

HORIZONTAL FLEXION



Pectoralis major



Anterior deltoid

HORIZONTAL EXTENSION



Posterior deltoid



Infraspinatus



Teres minor/major



Rhomboids



Trapezius

–

Stabilizer

CIRCUMDUCTION



Basically all muscles of the shoulder

INTERNAL ROTATION



Subscapularis



Pectoralis major

–

Little help

EXTERNAL ROTATION



Infraspinatus



Teres minor/major



Scapular Elevation



Scapular Depression



Scapular protraction



Scapular retraction



****find muscles that perform these motions

Assessing Shoulder Injuries



H



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S



History

–

What is the cause of pain?

–

Mechanism of injury?

–

Previous history?

–

Location, duration and intensity of pain?

–

Creptitus, numbness, distortion in temperature

–

Weakness or fatigue?

–

What provides relief?



Observation

–

Elevation or depression of shoulder tips

–

Position and shape of clavicle

–

Acromion process

–

Biceps and deltoid symmetry

–

Postural assessment (kyphosis, lordosis,

shoulders)

–

Position of head and arms

–

Scapular elevation and symmetry

–

Scapular protraction or winging

–

Muscle symmetry

–

Scapulohumeral rhythm



Palpation

–

Bony structure palpation should occur bilaterally

and simultaneously if possible

–

Palpate soft tissue structures for point

tenderness, swelling, spasms, lumps, guarding

or trigger points

–

Be sure to palpate anteriorly and posteriorly



Special Tests

–

ROM test for external rotation of the shoulder

–

ROM test for internal rotation of the shoulder

–

Specific ROM tests for the shoulder

including abduction, adduction, flexion, extension,

horizontal adduction, horizontal abduction



Manual muscle tests for the shoulder

–

External rotation strength tests

–

Internal rotation strength test for the shoulder

–

Extension strength test for the shoulder

–

Flexion strength test for the shoulder

–

Abduction and adduction strength tests for the shoulder

–

Empty can test

•

Apprehension test (Crank test)

Apprehension test (Crank test)



Apprehension

test used for

anterior

glenohumeral

instability

–

This motion

should not be

forced

•

 Test for Shoulder Impingement

 Test for Shoulder Impingement

–

Neer’s test and Hawkins-Kennedy test for

impingement used to assess impingement of soft

tissue structures

–

Positive test is indicated by pain and grimace

Test for Supraspinatus

Weakness



Empty Can Test

–

90 degrees of

shoulder flexion,

internal rotation and

30 degrees of

horizontal abduction

–

Downward pressure

is applied

–

Weakness and pain

are assessed

bilaterally

Types of Shoulder Injuries

Fractures



Clavicle, humerus, scapula



Cause: fall on outstretched arm, direct

blow



S/S:  pain, deformity, decreased ROM,

swelling



Perform percussion test, compression

test



Treatment

–

Sling/splint

–

PRICE

–

Physcian/EMS

–

Follow orders



Prevention:

–

Instruct how to fall

–

Proper equipment

Hockey Clavicle Fracture

Dislocations and subluxations



AC, SC, GH jts



Cause:  head of humerus forced/displaced

from glenoid



S/S: pop, dead arm, pain, deformity,

swelling, loss of  ROM/strength



Treatment

–

DO NOT relocated

–

PRICE

–

Check circulation/sensation

–

Physician / x-rays

–

Follow orders



Prevention

–

Strengthen jt

–

Proper equipment

–

Falling

Anterior

Posterior



Posterior



Shoulder dislocation

Shoulder dislocation

-rugby

-rugby



Dwayne Wade

Dwayne Wade



http://www.youtube.com/watch?v=09ZZbJze

http://www.youtube.com/watch?v=09ZZbJze

KUA

KUA



Contusions

–

Cause: direct blow/bony area or muscles

–

S/S:  pain, decreased ROM, r/o other

injuries

–

Treatment: ice, padding, rehab, flexibility

–

Prevention:  proper equipment, mechanics



Myositis ossificans



Sprains

–

Cause: over stretch/tear ligament, capsule



What motions/events would cause this?

–

S/S:  pt tender, weak, swelling, instability,

possible deformity, decreased ROM

–

Treatment



PRICE



Physician, follow orders



Rehab

–

Prevention



Proper equipment/technique



Strengthening/stretching



Inspect playing areas



Taping/bracing



Sternoclavicular Sprain

–

Cause of Injury



Indirect force, blunt trauma (may cause

displacement)

–

Signs of Injury



Grade 1 - pain and slight disability



Grade 2 - pain, subluxation w/ deformity,

swelling and point tenderness and decreased

ROM



Grade 3 - gross deformity (dislocation), pain,

swelling, decreased ROM

–

Possibly life-threatening if dislocates posteriorly

–

Care



PRICE, immobilization



Immobilize for 3-5 weeks followed by graded

reconditioning



Acromioclavicular Sprain

–

Cause of Injury



Result of direct blow (from any direction), upward

force from humerus, fall on outstretched arm

–

Signs of Injury



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Care



Ice, stabilization, referral to physician



Grades 1-3 (non-operative) will require 3-4

days (grade 1) and 2 weeks of immobilization (

grade 3) respectively



Aggressive rehab is required w/ all grades

–

Joint mobilizations, flexibility exercises,  &

strengthening should occur immediately

–

Progress as athlete is able to tolerate w/out pain and

swelling

–

Padding and protection may be required until pain-

free ROM returns

Specific tests

–

Sulcus test, apprehension test for sprain of the

anterior capsule

–

Acromioclavicular (AC) sprain test

–

Sternoclavicular (SC) sprain test

Types of Shoulder Injuries



Strains

–

Cause:  overstretching of muscles

–

S/S:  similar to sprains

–

Treatment:  PRICE, physician if necessary,

follow orders, rehab

–

Prevention



Stretching, strengthening

–

Drop arm test-specific test



What do you see?



L clavicle elevation, bruising, left shoulder

higher



What do you think the injury is?



Grade 2 AC sprain, left.  Bull rider



Impingement

–

Cause:  pinching of soft tissue w/overhead

activity; overuse

–

S/S:  pain, weakness, pt tenderness



Hawkins-Kennedy test, winged scapula test

–

Treatment



PRICE, decrease inflam., physician



Strengthen RC, scapular stabilizers

–

Prevention



RC strengthening, proper mechanics

–

Rotator cuff tear



Involves supraspinatus or rupture of other

rotator cuff tendons



Primary mechanism - acute trauma (high

velocity rotation)



Occurs near insertion on greater tuberosity



Full thickness tears usually occur in those

athletes w/ a long history of impingement or

instability (generally does not occur in athlete

under age 40)

–

Signs of Injury



Present with pain with muscle contraction



Tenderness on palpation and loss of strength

due to pain



Loss of function, swelling



With complete tear, impingement and empty

can test are positive

–

Care



RICE for modulation of pain



Progressive strengthening of rotator cuff



Reduce frequency and level of activity initially

with a gradual and progressive increase in

intensity



Shoulder Bursitis

–

Etiology



Chronic inflammatory condition due to trauma

or overuse - subacromial bursa



May develop from direct impact or fall on tip of

shoulder

–

Signs of Injury



Pain w/ motion and tenderness during palpation

in subacromial space; positive impingement

tests

–

Management



Cold packs and NSAID’s to reduce

inflammation



Remove mechanisms precipitating condition



Maintain full ROM to reduce chances of

contractures and adhesions from forming



Bicipital Tenosynovitis

–

Cause of Injury



Repetitive overhead athlete - ballistic activity

that involves repeated stretching of biceps

tendon causing irritation to the tendon and

sheath

–

Signs of Injury



Tenderness over bicipital groove, swelling,

crepitus due to inflammation



Pain when performing overhead activities

–

Care



Rest and ice to treat inflammation



NSAID’s



Gradual program of strengthening and

stretching

Types of Shoulder Injuries



Tendonitis

–

Cause: overuse to tendons



Speed’s test

–

Treatment: PRICE, anti-inflammatory,

rehab, etc

–

Prevention:



Ice post activity, conditioning, mechanics,



Synovitis and bursitis

–

Cause:  inflammation of synovial lining/bursa



Overuse, direct trauma

–

S/S:  pain, crepitus, swelling, decreased

mobility

–

Treatment:  PRICE or heat, stretching pain free

ROM, mechanics, etc

–

Prevention:  mechanics