Acute Shoulder injuries
Physical activity injuries
26/01/10
Janis Leach
Objectives
Recap of anatomy of the shoulder
Identify key clinical features and
mechanisms of injury to the shoulder joint.
Complete an assessment of the area
Read through literature on assessment
procedures
Clinical perspective
Numerous structures can cause shoulder
pain. It is helpful if the problem can be
narrowed down to one or more of the
following 5 categories of shoulder pain:
– Rotator cuff muscles
– Instability
– Stiffness
– AC joint
– Referred pain
Common causes of shoulder pain
Rotator cuff injury
Glenohumeral dislocation / instability
Glenoid labral tears
Clavicle fracture
AC joint sprain
Rotator cuff injuries
Rotator cuff injury:
Common cause of shoulder pain and
impingement. The tendons become swollen and
weak
Clinical features:
– Pain with overhead activity. Activities at less than 90
degrees abduction – pain-free.
– Tenderness over supraspinatus tendon at it’s insertion
onto greater tuberosity.
– Painful arc between 70-120 degrees abduction.
– Pain with resisted contraction of supraspinatus.
Rotator cuff strains / tears
Minor strains:
– generally present with sudden onset of pain or
‘twinge’ in shoulder area.
– Some limitation of function
– Respond quickly to rest, stretching and soft tissue
therapy.
Complete and partial tears:
–
–
–
–
Common in older athletes
Pain during activity
Inability to sleep on affected shoulder
Weakness on supraspinatus tests
Dislocation of glenohumeral joint
Anterior dislocation (most common):
One of the most common traumatic sports
injuries.
Results from arm being forced into excessive
abduction and external rotation.
Most anterior dislocations damage the
attachment of the labrum to the anterior glenoid
margin (Bankart lesion)
May also be an associated fracture of anterior
glenoid rim, disruption of glenohumeral
ligaments or a compression fracture of humeral
head (Hill-Sachs lesion)
Anterior dislocation cont.
Anterior dislocation cont.
History:
Acute trauma – either direct or indirect.
Sudden onset of pain
Patient may describe a feeling of ‘popping out’.
Examination reveals:
– Prominent humeral head below acromion
– Loss of smooth contour compared with non-injured
side.
– Occasional damage to axillary nerve = impaired
sensation on lateral aspect of shoulder.
Labrum injuries
Labrum is primary attachment site for shoulder
capsule and GH ligaments. The superior aspect
of labrum serves as attachment site for tendon
of long head of biceps muscle.
Injuries to labrum are divided into superior
labrum anterior to posterior (SLAP)
SLAP lesions are injuries that extend from
anterior of biceps tendon to posterior of biceps
tendon.
Labrum injuries
Glenoid labral tears
Labrum injuries
Mechanism of injury:
– Repetitive overhead throwing
– Excessive inferior traction (catching a heavy object).
Clinical features:
– Poorly localized pain in shoulder aggravated by
overhead and behind the back arm motions.
– Popping, catching or grinding may be present.
– Tenderness over anterior aspect of shoulder.
– Pain on resisted biceps contraction.
Clavicle fracture
Common fracture in sporting activities.
Mechanism of injury:
– Fall onto the point of the shoulder (i.e. horse riding or cycling)
OR
– Direct contact with opponents in sports such as football / rugby.
Most common fracture site – middle third of clavicle.
Lateral end displaces inferiorly and medial end displaces
superiorly.
Clinical features:
– Very painful
– Localised tenderness, deformity, swelling.
Clavicle fracture
Clavicle fracture
Management:
Provide pain relief
Almost always heal in 4-6 weeks.
The ends often overlap and clavicle is shortened
causing a number of functional problems.
– A figure of 8 bandage prevents this shortening rather
than sling.
– Surgery may be required if the clavicle has
compromised the skin.
Acromioclavicular joint injuries
AC joint injuries cont.
Another common injury in athletes who fall
onto point of shoulder.
Clinical features:
– Localised tenderness
– Pain on movement, especially horizontal
adduction.
– Palpable step deformity – visual in more
severe injury.
AC joint injury management
Follow the general principles of management of
ligamentous injuries:
– Initially ice is applied to minimise degree of damage
and pain relief.
– Injured limb should be immobilised in a sling for up to
2-3 days in type 1 injuries or up to six weeks in
severe type 2 or type 3 injuries.
– Isometric strengthening exercises can commence
once pain permits.
– Tape can be applied to AC joint to provide protection
on return to sport.
Review
Normal shoulder function is essential for
many popular sports and shoulder
dysfunction causes significant impairment
of everyday quality of life.
The shoulder is a challenging region for
sports medicine practitioners. A sound
background knowledge in the functional
anatomy is essential in the treatment and
management of shoulder injuries.
Assessment of Shoulder
Observation
Palpation
– Suprasternal notch
– Sternoclavicular joint
– Clavicle
– Acromion
– Acromioclavicular joint
– Head of the humerus
– Spine of the scapula
ROM
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation
Horizontal abduction
Horizontal adduction
Depression
Elevation
Scapula Retraction
Scapula Protraction
Special tests
Apprehension test for dislocation
Apley scratch
Scapula winging
Empty can test
Lift off test
Drop arm test
AC compression
Apprehension test for dislocation
Apley scratch
Loss ROM – rotator cuff injury
Scapula winging
Weak Serratus Anterior muscle
Damage to Long thoracic nerve
– Assessed by wall press up
Empty can test
Supraspinatus injury
Lift off test
Subscapularis
Drop arm test
Supraspinatus
Passively abduct patient’s shoulder
Arm lowered slowly to the waist
Patient may lower the arm until the final part of the
movement as deltoid will work at first
AC compression
AC joint dysfunction
Cross over test – forward elevation to 90 degrees,
followed by active horizontal adduction
Labral tears – clunk sign
– The patient's arm is rotated and loaded (force
applied) from extension through to forward
flexion. A clunk sound or clicking can indicate
a labral tear.
Practical
Work in pairs to assess the shoulder
Use your notes and discuss the procedures with
each other