Chapter 11
INJURIES TO THE SHOULDER REGION
Anatomy Review. The shoulder bones consist of the shoulder girdle (clavicle and scapula) and the
humerus. The head of the humerus and the glenoid fossa form the glenohumeral (GH) joint
(shoulder joint), which receives additional support from the glenoid labrum. The shoulder region
also includes the acromioclavicular (AC) joint and the sternoclavicular (SC) joint.
A. Each of these joints is held together by ligaments and joint capsules that provide
stability and allow movement, which is quite limited. Any limitation from injury to
the shoulder indirectly affects
the GH joint. Shoulder girdle muscles are the
levator scapulae, trapezius, rhomboids, subclavius, pectoralis minor, and serratus
anterior. (See Figure 11.4 on page 153 and refer to Time Out 1.1 on page 154.)
B. The muscles that act on the GH joint include the pectoralis major, latissimus dorsi,
deltoid, teres major, rotator cuff muscles, and coracobrachialis. The GH joint can
move in virtually every direction.
C. A large amount of soft tissue covers the shoulder girdle and GH joint, somewhat
protecting these regions from external blows. The AC and SC joints lie just under the
skin and are vulnerable to injury, even in muscular athletes.
D. The blood supply to the upper extremity originates from branches of the subclavian
artery. In the axillary region, the subclavian artery becomes the axillary artery. In the
upper arm, the axillary artery becomes the brachial artery, which splits just distal to
the elbow into the radial and ulnar arteries that extend into the forearm and hand
(refer to Figure 11.6 on page 156).
E. The major nerves of this region come from the group of nerves known as the brachial
plexus (see Figure 11.7 on page 156). The brachial plexus originates from the ventral
primary divisions of the fifth through eighth cervical nerves and the first thoracic
nerve.
I.
Common Sports Injuries. Injuries to the shoulder region frequently occur in many sports.
Injuries to the AC and the GH joints are common in wrestling; throwing and swinging sports
can result in overuse injuries to the rotator cuff muscles that act on the GH joint. Cycling
and skating sports result in a large number of fractures of the clavicle brought about by falls.
Injuries of this region can be either acute or chronic. Sports involving heavy contact or
collisions yield more acute injuries; those requiring repeated movements produce more chronic
injuries.
A. Skeletal Injuries.
1. Fractured Clavicle. Fractured clavicle is the most common fracture of the
region. Such fractures can result from direct blows to the bone, but the majority
are the result of falls that transmit the force to the clavicle either through the
arm or shoulder.
a. Most clavicle fractures occur about mid-shaft.
b. In the adolescent, another type of clavicular fracture can occur that is
known as the greenstick fracture. This type of fracture involves a
cracking, splintering type of injury to immature bone.
c. Clavicle fractures are potentially dangerous, but the majority cause few
complications.
d. Typical signs and symptoms include swelling and/or deformity at the site
of fracture, discoloration at the site, a broken bone end may project
through the skin, and the athlete reports that a snap or pop was heard or
felt. Additionally, the athlete holds the arm on the affected side to relieve
pressure on the shoulder girdle.
e. First aid includes treatment for possible shock, application of a sling and
swathe bandage (see Figure 11.9 on page 156), and application of sterile
dressings on any associated wounds.
f. Arrange for transport to a medical facility.
2. Fractured Scapula. This is a relatively uncommon injury to the shoulder region
that generally results from direct blows to the shoulder region.
a. The signs and symptoms are less clear than for fractures of the clavicle
and include history of severe blow to the shoulder region, followed
immediately by considerable pain and functional loss.
1) An athlete with such a history and symptoms should be referred to
a physician for evaluation.
B. Soft-Tissue Injuries. The GH and AC joints are the most injured in the shoulder region.
1. Acromioclavicular Joint Injuries. The AC joint is located on the lateral superior
surface of the shoulder, just under the skin. This articulation is supported by the
AC ligaments and contains an intra-articular cartilaginous disk. Additional
support is provided by the CC ligament (refer to Figure 11.2 on page 152).
a. The typical mechanism of injury to the AC joint is a downward blow to
the outer end of the clavicle. Another possible mechanism is a fall on an
outstretched arm that transmits the force up the extremity. Both cases
result in varying degrees of ligament damage. The severity of the injury is
graded based on the amount of damage to specific ligaments, but any
injury can be classified into three categories:
1) First degree involves no significant damage; all ligaments are
intact.
2) Second degree involves relatively severe damage (tearing of the
ligaments), but there is no abnormal movement and the clavicle is
in the normal position.
3) Third degree involves complete rupture of AC ligament with an
intact CC ligament (refer to Figure 11.10 on page 157), or
complete rupture of AC and CC ligaments (refer to Figure 11.11
on page 157).
b. Signs and symptoms of first- and second-degree sprains include mild
swelling, point tenderness, and discoloration around the AC joint.
1) Any movement of the shoulder region will be painful.
2) In a third-degree sprain, there is considerable deformity in the
region of the AC ligament. If both the AC and CC ligaments have
ruptured, there will be total displacement of the clavicle.
3) The athlete may report having felt a snap or heard a pop.
c. First aid involves immediate application of ice and compression using a
bag of crushed ice over the AC joint and securing it with an elastic
bandage wrapped in a figure-eight configuration.
1) After the ice and compression is in place, apply a standard slingand-swathe bandage.
2) Refer immediately to a medical doctor. In the event of severe
injury, arrange for transport and treat for shock.
d. Non-surgical approaches to treatment may be just as effective as surgical
ones.
2. Glenohumeral Joint Injuries. This joint consists of the relatively large humeral
head opposing the shallow glenoid fossa of the scapula. The GH joint has a
great deal of mobility but is unstable. Major soft-tissue structures of the GH
joint include the capsular ligament and the coracohumeral ligament.
a. The typical mechanism of injury to the GH joint is having the arm
abducted and externally rotated. This mechanism stresses the GH joint
capsule and associated ligaments beyond their capacity.
b. The most common type of GH joint dislocation is known as the anterior
dislocation, which may be a subluxation or complete dislocation.
c. Signs and symptoms include shoulder joint deformity, the normal contour
of the shoulder is lost and it slopes down; abnormally long arm on
affected side; the humeral head will be palpable with the axilla.
1) The athlete will support the arm on the affected side; the affected
arm will be slightly abducted at the shoulder and flexed at the
elbow.
2) The athlete will resist all efforts to passively or actively move the
GH joint.
d. In cases of subluxation, the GH joint may appear normal, however,
movement will be painful and the joint may be point tender.
e. First aid care includes immediate application of ice and compression with
a rolled towel placed in the axilla. Place the bag of crushed ice on the
front and back of the shoulder joint and secure with an elastic wrap in a
figure-eight configuration.
1) After the ice and compression is in place, apply a standard slingand-swathe bandage.
2) Refer immediately to a medical doctor. In the event of severe
injury, arrange for transport and treat for shock.
f. GH joint injuries can become chronic; 85% to 90% of all traumatic
anterior GH injuries recur. In severe cases, surgical reconstructive
procedures may be needed.
3. Sternoclavicular Joint Injuries. The SC joint is formed by the union of the
proximal end of the clavicle and the manubrium of the sternum. The SC joint is
supported by several ligaments (see Figure 11.3 on page 152) that include the
joint capsule, the SC ligaments, the interclavicular and costoclavicular
ligaments, and an articular disk within the joint.
a. Injuries to the SC joint are far fewer than to either the AC or GH joints. A
sprain to the SC joint may range in severity from minor (no ligament
tearing) to a complete rupture of all supporting ligaments.
b. The mechanism of injury involves an external blow to the shoulder
resulting in a dislocation of the proximal clavicle, most commonly with
the bone moving anteriorly and superiorly. Such dislocations cause few
additional problems and are easily treated.
1) A rare but potentially dangerous form of this injury is a posterior
SC dislocation, which can put pressure on soft-tissue structures in
the region, such as blood vessels or even the esophagus and/or
trachea.
c. Signs and symptoms include gross deformity of the SC joint (second- and
third-degree sprains), swelling, limited movement of the shoulder due to
pain within the SC joint.
1) The athlete will often report a snapping sound or experiencing a
tearing sensation at the SC joint.
2) The athlete typically holds the arm on the affected side close to
the body and the head/neck region may be tilted or flexed toward
the injured shoulder.
d. First aid care includes application of ice and compression achieved with a
bag of crushed ice secured by an elastic wrap in a figure-eight
configuration. Do not put pressure over the airway when wrapping the
shoulder.
1) Place the arm of the affected shoulder in a standard sling-andswathe bandage.
2) In cases of severe soft-tissue damage, treat for shock.
e. Treatment of most SC joint injuries is conservative. Eventually, a sound
rehabilitation exercise program prescribed by a sports medicine
professional will be helpful.
4. Strains of the Shoulder Region. Any muscles of the shoulder region can suffer
a strain. Perhaps the most common strain involves the rotator cuff.
a. Rotator Cuff. The muscles of the rotator cuff contribute to abduction
and rotation of the GH joint.
1) The throwing process has been described as a five-phase process
of windup, cocking, acceleration, release, and follow-through.
2) The cocking phase involves pulling the throwing arm into an
abducted and externally rotated position at the GH joint,
incorporating a concentric contraction of several rotator cuff
muscles.
3) During the follow-through phase, several rotator cuff muscles are
contracting eccentrically to slow the arm down; this is when most
rotator strains occur.
4) Strains to the rotator cuff are normally the result of overuse and
develop slowly over a period of weeks or months.
5) Athletes involved in throwing or swinging sports should have a
properly designed rotator cuff conditioning program and should
warm up the throwing arm properly.
6) Errors in the execution of a throw or swing can contribute to an
overuse injury. Teaching correct technique reduces the chances of
such injuries.
7) Signs and symptoms of injury include pain within the shoulder,
especially during the follow-through phase; difficulty in bringing
the arm up and back during the cocking phase; pain and stiffness
within the shoulder region 12 to 24 hours after throwing or
swinging; and point tenderness around the region of the humeral
head that appears to be deep in the deltoid muscle.
8) First aid care must take into consideration that overuse injuries are
difficult to treat effectively without a thorough medical
evaluation. When symptoms occur, the application of ice and
compression may be helpful. In most cases, the athlete will report
repeated bouts of symptoms for weeks, even months. Therefore,
medical referral is necessary.
b. Glenohumeral Joint-Related Impingement Syndrome. A syndrome is
defined as “a number of symptoms occurring together and characterizing
a specific disease.” Impingement syndrome of the shoulder occurs when a
soft-tissue structure such as a bursa or tendon is squeezed between
moving joint structures, resulting in irritation and pain.
1) In cases affecting the GH joint, the most common impingement
occurs to the tendon of the supraspinatus muscle as it passes
across the top of the joint en route to its insertion.
2) Any condition that decreases the size of the subacromial space
may result in an impingement syndrome. (Refer to Figure 11.16
on page 163 for an illustration of the anatomy of this region.)
3) Athletes in sports that require an emphasis on arm movements
above the shoulder are at a higher risk of impingement syndrome
than athletes in sports that do not require such movements.
4) Signs and symptoms include pain when the GH joint is abducted
and externally rotated in conjunction with loss of strength, pain
whenever the arm is abducted beyond 80° to 90°, nocturnal pain,
and pain felt deep within the shoulder.
5) First aid care is not needed, as they tend to develop over a long
time period. Any athlete complaining of the above signs and
symptoms should be referred for a complete medical evaluation.
6) Treatment consists of rest, anti-inflammatory drugs, and physical
therapy. In severe cases, surgery may be indicated.
c. Biceps Tendon Problems. The GH joint includes the tendon of the long
head of the biceps brachii muscle. The tendon passes into the joint
capsule and is surrounded by the synovium of the GH joint. The tendon
of the short head of the biceps brachii muscle derives from the coracoid
process, but the tendon remains separate from the GH joint.
1) The tendon of the long head of the biceps brachii can suffer an
impingement syndrome if it is compressed within the subacromial
space.
2) The symptoms are similar to those of impingement of the
supraspinatus tendon.
3) Athletes who are at risk for this injury include those involved in
sports that place an emphasis on repetitive overhead movements
with the arms.
4) Another problem related to the long head tendon of the biceps
brachii is tendinitis that may lead to a subluxation of the tendon
from the bicipital groove. This develops slowly over a period of
weeks or months. As the tendon enlarges as a result of
inflammation, it becomes less stable in the groove, where it is held
by the transverse humeral ligament.
5) In chronic cases, a sudden violent force such as is generated by
throwing may cause the tendon to subluxate out of the groove,
stretching and tearing the ligament.
6) Signs and symptoms of biceps tendon problems include painful
abduction of the shoulder joint; pain in the shoulder joint when the
athlete supinates the forearm against resistance; and the athlete
may note a popping or snapping sensation when flexing and
supinating the forearm against resistance.
7) First aid care is not a concern because such injuries develop over
time and fall into the category of a chronic injury. If the athlete
should subluxate the biceps tendon from the bicipital groove,
immediate application of ice and compression is recommended.
Long-term care includes rest, anti-inflammatories, and gradually
progressive rehabilitation exercise. If symptoms persist, surgery
may be necessary.
d. Contusions of the Shoulder Region. External blows to the shoulder region
often happen in many sports. The GH joint is well protected by muscles
that cross the joint, while the nearby AC joint is totally exposed to
external blows. If the athlete sustains a contusion to the joint the result
can be an extremely painful condition known as a shoulder pointer.
1) Signs and symptoms include history of a recent blow to the
shoulder, associated with pain and decreased ROM; spasm if
muscle tissue is involved; and discoloration and swelling,
especially over bony areas such as the AC joint.
2) First aid care includes immediate application of ice and
compression. In cases of severe pain, apply an arm sling to relieve
stress on the shoulder region.
3) If significant swelling persists for more than 72 hours, refer the
athlete to a physician. In some cases the AC ligament may have
sustained a sprain.