Injuries to the Shoulder Region
Injuries to the Shoulder Region
• In this chapter we will discuss the gross anatomy
and arthrology of the articulations of the shoulder
• We will briefly discuss acute and chronic injuries of
the shoulder region which will include:
▫ Acromioclavicular, sternoclavicular, and glenohumeral
joints
• We will review musculotendinous injuries of the
shoulder region related to common mechanisms of
injury such as throwing and swinging
• We will discuss certain injuries in detail such as
impingement syndrome, biceps tendinitis and
contusions of the shoulder

• http://www.youtube.com/watch?v=fpGVidvdlio
A little anatomy 
• The skeleton of the shoulder
consists of bones of the
shoulder girdle and the upper
arm bone (humerus)
• The clavicle and scapula make
up the shoulder girdle
• The head of the humerus
combines with the shallow
glenoid fossa of the scapula to
form the glenohumeral (GH)
joint, also known as the
shoulder joint
• The GH joint is given
additional stability by a
fibrocartilaginous cuplike
structure known as the glenoid
labrum
A little Anatomy 
• Also includes the
acromioclavicular (AC) joint
located between the distal end
of the clavicle and the
acromion of the scapula
• The sternoclavicular (SC) joint
is located between the
proximal end of the clavicle
and the manubrium of the
sternum
• Each joint is held together
with ligaments and joint
capsules that provide stability
while also allowing for
necessary movement
A little Anatomy 
• In nearly all motions the shoulder girdle and the
GH joint work together to move the arm
• Consequently, any limitation from injury to the
shoulder girdle will indirectly affect the GH joint
• The muscles in the shoulder can be divided into
two groups:
▫ Those that act on the shoulder girdle
▫ Those that act on the GH joint
A little Anatomy 
• Muscles of the shoulder girdle
are levator scapulae, trapezius,
rhomboids, subclavius,
pectoralis minor, and serratus
anterior
▫ Collectively contribute to the
movements of the shoulder
girdle
 Which include scapular
retraction and protraction,
upward and downward
scapular rotation, elevation
and depression
A little Anatomy 
• Muscles that act on the GH
joint include the pectoralis
major, latissimus dorsi,
deltoid, teres major,
coracobrachialis and rotator
cuff muscles
• The rotator cuff muscles
include
▫ Supraspinatus, infraspinatus,
teres minor, subscapularis
• Movements normally
attributed to the joint consist
of flexion, extension,
horizontal flexion and
extension, internal and
external rotation, abduction
and adduction
A little Anatomy 
• In athletes a large amount of soft tissue covers
both the shoulder girdle and the GH joint
• As a result, they are somewhat protected from
external blows
• However, even in extremely muscular athletes
both the AC and SC joints lie just under the skin
and are therefore more exposed to injury
Anatomy 
• The blood supply to the entire
upper extremity, including the
shoulder, originates from
branches of the subclavian
artery
• As it passes through the
axillary region it becomes the
axillary artery; it continues
into the upper arm, becoming
the brachial artery, and splits
just distal to the elbow into the
radial and ulnar arteries that
extend into the forearm and
hand
Anatomy 
• Major nerves of the shoulder
and upper extremity originate
from that group known as the
brachial plexus
• Originates from the ventral
primary divisions of the 5th
through the 8th cervical nerves
and the first thoracic nerve
Common Sports Injuries…
• Injuries to the shoulder region are common in
many sports and in some cases are highly sport
specific
• Injuries to both the GH and AC joints are quite
common in wrestling
• Sports that emphasize a throwing or swelling
action often produce injuries caused by overuse
to the muscles of the rotator cuff (infraspinatus,
supraspinatus, teres minor, subscapularis),
which act on the GH joint
Common Sports Injuries…
• The rotator cuff (RC) muscles are extremely
important to the stability of the GH joint
because this large ball-and-socket structure
lacks inherent strength
• Sports such as cycling and skating produce a
large number of fractures of the clavicle brought
about by falls
Common Sports Injuries…
• Injuries of the shoulder region
can be classified as either
acute or chronic
• Sports involving heavy contact
or collisions yield more acute
injuries; those necessitating
repeated movements tend to
produce more chronic injuries
• Activities that have a high
incidence of clavicular injury
include ice hockey, football,
martial arts, lacrosse,
gymnastics, weight lifting,
wrestling, racquetball, squash,
and bicycling
Skeletal Injuries
Fractured Clavicle…
• Most common fracture of the
shoulder region is a fracture of
the clavicle
• Can result from direct blows to
the bone; however, the
majority occur as a result of
falls that transmit the force to
the clavicle either through the
arm or shoulder
• Majority occur about
midshaft; the remainder
involve either the proximal or
distal end of the bone
(American Academy of
Orthopaedic Surgeons
[AAOS], 1991).
http://www.youtube.com/watch?v=7lSX
Gi-7MFg
Fractured Clavicle…
• In the adolescent athlete
another type of clavicular
fracture, commonly known as
a greenstick fracture can occur
• This fracture occurs in
immature bone and involves a
cracking, splintering type of
injury
• Although a fractured clavicle is
potentially dangerous given
the close proximity of the bone
to the major blood vessels and
nerves, the vast majority cause
few complications
Fractured Clavicle…
• Signs and Symptoms:
▫ Swelling and/or deformity of
the clavicle
▫ Discoloration at the site of
the fracture
▫ Possible broken bone end
projecting through the skin
▫ Athlete reporting that a snap
or pop was felt or heard
▫ Athlete holding the arm on
the affected side to relieve
pressure on the shoulder
girdle
Fractured Clavicle…
• Tx:
▫
▫
▫
▫
Treat for possible shock
Carefully apply a sling-and-swathe bandage
Apply sterile dressings to any related wounds
Arrange for transport to a medical facility
Skeletal Injuries
Fractured Scapula
• Much less common fracture
• Unique group of scapular
fractures among professional
football players was described
by Cain and Hamilton (1992)
in the American Journal of
Sports Medicine
• These fractures resulted from
direct blows to the shoulder
region
• The symptoms of this type of
fracture are less clear than
those related to fractures of
the clavicle
Fractured Scapula…
• An athlete with a hx of a severe blow to the shoulder
region, followed immediately by considerable pain
and loss of function, should be referred to a
physician for further evaluation
• Can be identified only by X-ray analysis
• TX
▫ Determined by specific location and extent of the
fracture(s)
▫ Athletes arm will be placed in a sling, and the player
will be removed from sports participation for a period
of 6 weeks
Soft-Tissue Injuries
• A variety of sprains and strains involving any
number of specific ligaments and tendons occur
in this region
• Although any joint can sustain a sprain, the GH
and AC joints are the most commonly injured in
the shoulder region in sports
Acromioclavicular (AC) Joint Injuries…
• This synovial articulation is
supported by the superior and
inferior AC ligaments and
contains an intra-articular
cartilaginous disk as well (Dias
& Gregg, 1991)
• Additional support is provided
by the coracoclavicular (CC)
ligament which comprises the
trapezoid and conoid
ligaments
• The CC ligament is attached
between the superior coracoid
process and the inferior lateral
surface of the clavicle
Acromioclavicular (AC) Joint Injuries…
• Typical mechanism of injury for the AC joint is a
downward blow to the outer end of the clavicle,
which results in the acromion process being driven
inferiorly while the distal clavicle remains in place
• Another mechanism is a fall forward on an
outstretched arm, which then transmits the force up
the extremity and results in the humeral head
driving the acromion superiorly and posteriorly
while the clavicle remains in place (O’Donoghue,
1976)
• Either of these two can result in varying degrees of
ligament damage
Acromioclavicular (AC) Joint Injuries…
• The severity of the injury is
graded based on the amount of
damage to specific ligaments
1. First degree, no significant
damage, all ligaments intact
2. Relatively severe damage
(tearing) of the ligaments.
There will be no abnormal
movement, and the clavicle
will be in the normal
position
3. Complete rupture of the AC
ligament with an intact CC
ligament; complete rupture
of both the AC and CC
ligaments
Acromioclavicular (AC) joint injuries…
• Signs and Symptoms
▫ With first and second degree sprains there will be mild
swelling with point tenderness and discoloration
around the AC joint
▫ Any movement of the shoulder region will elicit pain
▫ With a third degree sprain there will be significant
deformity in the region of the AC ligament
 In the case of ruptures of both the AC and CC ligaments,
there will be total displacement of the clavicle
▫ The athlete may report having felt a snap or heard a
pop
Acromioclavicular (AC) joint injuries…
• TX:
▫ Immediately apply ice and compression
 Best accomplished by placing a bag of crushed ice
over the AC joint and securing it with an elastic wrap
tied in a figure-eight configuration
▫ Once the ice and compression are in place, apply a
standard sling and swathe bandage
▫ Immediately refer the athlete to a medical facility
for further evaluation
▫ In the event of severe injury, arrange for transport
and treat for shock
Acromioclavicular (AC) joint injuries…
• Long term treatment for AC separations is
dependent on the level of severity of the injury
• In the case of first degree and relatively minor
second degree sprains, rest and immobilization
are normally effective
• Several surgical procedures have been employed
▫ However research indicates that more
conservative, nonsurgical approaches may be just
as effective
Glenohumeral Joint Injuries…
• This articulation consist of a
relatively large humeral head
opposing the rather shallow
glenoid fossa of the scapula
• This bony arrangement is
effective in giving the joint a
greater deal of mobility
• The GH joint is classified as a
spheroidal articulation that
moves within all three planes of
motion: frontal, sagittal, and
transverse
• However, this mobility makes
the GH joint very unstable
• The major soft-tissue structures
of the GH joint include the
capsular ligament and the
coracohumeral ligament
Glenohumeral Joint Injuries…
• Typical mechanism of injury
for the GH joint involves
having the arm abducted and
externally rotated
▫ The anterior portion of the
joint capsule can be stressed
beyond its capacity
▫ If the ligament fails, the head
of the humerus can move
forward and out of place
which leads to an anterior
dislocation
• Depending on the severity, this
injury may be either a
subluxation or a complete
dislocation
• http://www.youtube.com/wat
ch?v=GsaqCQCcJNY
• http://www.youtube.com/wat
ch?v=09ZZbJzeKUA
Glenohumeral Joint Injuries
• Signs and Symptoms:
▫ Deformity of the shoulder joint: the normal contour of
the shoulder is lost, and it appears to slope down
abnormally
▫ The arm of the affected side will appear longer than
normal
▫ The head of the humerus will be palpable with the
axilla
▫ The athlete will be supporting the arm on the affected
side with the opposite arm
▫ The athlete will resist all efforts passively or actively to
move the GH joint
Glenohumeral Joint Injuries…
• TX:
▫ Immediately apply ice and compression
▫ Place a bag of ice on the front and back of the
shoulder joint and secure with an elastic wrap tied
in a figure eight configuration
▫ Apply a standard sling and swathe bandage
▫ Immediately refer the athlete to a medical facility
for further evaluation
▫ Because soft-tissue injury may be extensive, treat
for shock
Glenohumeral Joint Injuries…
• A common complication of GH joint sprains is chronic
GH joint subluxation
• Once sustained, up to 85% to 90% of all traumatic
anterior GH joint dislocations recur (Arnheim, 1987)
• The joint capsule, ligaments, and supporting
musculature are often stretched, leading the joint to
become progressively less stable
• Certain movements, abduction and external rotation, the
joint will pop out and then return to its normal position
• Usually treated conservatively with rest and exercises
that specifically focus on the muscles surrounding the
joint, including the rotator cuff
Sternoclavicular Joint Injuries…
• The SC joint is formed by the
union of the proximal end of
the clavicle and the
manubrium of the sternum
• strengthened by several
ligaments
▫ Joint capsule, anterior and
posterior SC ligaments, the
interclavicular and
costoclavicular ligaments,
and an articular disk located
within the joint
• Although there are fewer
injuries to the SC joint that to
either the AC or GH joints, the
coach should be prepared to
recognize and treat them
correctly
Sternoclavicular Joint Injuries…
• The mechanism of injury for the SC joint involves
and external blow to the shoulder region that results
in a dislocation of the proximal clavicle
• A sprain to the SC joint can range in severity from
minor stretching, with no actual tearing of tissues,
to a complete rupture of ligaments and extensive
soft tissue damage
• Fortunately, anterior/superior dislocations cause
few additional problems and are easily treated
Sternoclavicular Joint Injuries…
• Occuring much less frequently, but potentially
more dangerous, is a posterior SC dislocation
▫ The proximal end of the clavicle is displaced
posteriorly, with the possibility of placing direct
pressure on soft-tissue structures in the region
such as blood vessels or even the esophagus and
trachea (AAOS, 1991)
Sternoclavicular Joint Injuries…
• Signs and Symptoms:
▫ In most cases (2nd and 3rd degree sprains) there will be
gross deformity present at the SC joint
▫ Swelling will be immediate
▫ Movement of the entire shoulder girdle will be limited
owing to pain within the SC joint
▫ Having heard a snapping sound or may have
experienced a tearing sensation at the SC joint
▫ Note the body position of the athlete, because in this
injury the arm may be held close to the body and the
head/neck may be tilted/flexed toward the injured
shoulder
Sternoclavicular Joint Injuries…
• TX:
▫ Apply ice and compression
▫ Take care not to put pressure over the airway
when wrapping
▫ Place the arm of the affected shoulder in a
standard sling-and-swathe
▫ In cases of severe soft-tissue damage, treat the
athlete for shock
Sternoclavicular Joint Injuries…
• Medical tx for the majority of
SC joint sprains is
conservative, that is, reduction
of the dislocation if present
followed by 2 to 3 weeks of
support with a sling-andswathe bandage
• Very rare that surgical
correction is needed
• Obviously a sound program of
rehabilitation exercises
prescribed by a competent
sports medicine professional
will be helpful in getting the
athlete back into action
Strains of the Shoulder Region…
• A large number of muscles attach to the bones of
the shoulder girdle, any one of which can suffer
a strain
• Certain sports produce very specific injuries to
the shoulder
• The most common strain involves the muscles of
the rotator cuff
Rotator Cuff Injuries…
• The muscles of the rotator cuff
serve a variety of purposes,
including stabilization of the
humeral head in the glenoid
fossa as well as abduction and
internal and external rotation
of the GH joint
▫ The muscles consist of
subscapularis, supraspinatus,
infraspinatus, and teres
minor
Rotator Cuff Injuries…
• To better understand the mechanism one must
review and understand the kinesiology of the
overhand throw and/or swing
• Throwing has been described as a five-phase
process involving:
▫
▫
▫
▫
▫
Windup
Cocking
Acceleration
Release
Follow-through
Rotator Cuff Injuries
Five phase of throwing
1. Wind-up requires putting the entire body in to the best position to generate
throwing forces
2. Cocking involves pulling the throwing arm into an abducted and externally
rotated position at the GH joint
• Incorporates a concentric contraction (occurs when a muscle
shortens and there is movement at the joint accompanied by contraction
against resistance)
3. Acceleration phase involves a sudden reversal of cocking: the arm s moved
rapidly into internal rotation, horizontal flexion, and adduction of the GH
joint via concentric contractions of muscles such as the pectoralis major,
anterior deltoid, teres major, lattissmus dorsi and triceps
Rotator Cuff Injuries
The phases of throwing
4. Release phase is the shortest in the throwing cycle and involves timing the
release at the point of maximum velocity
5. The follow-through requires that the entire upper extremity be decelerated
immediately after the release
Rotator Cuff Injuries…
• It is critical to note that several muscles of the
rotator cuff are actively contracting eccentrically in
an effort to slow the arm down
• The vast majority of strains to the rotator cuff occur
during the follow-through phase, specifically during
the eccentric phase of the contraction
• This problem is made worse when the muscles of the
rotator cuff are significantly weaker than those
muscles involved in the acceleration phase
▫ This problem can be eliminated with a proper
designed conditioning program aimed at
strengthening the muscles of the rotator cuff
Rotator Cuff Injuries…
• Strains = overuse
• Develop slowly over many weeks or months
• Proper warm-up of the throwing and/or
swinging arm ca help reduce the stress on the
musculature of the shoulder girdle
Rotator Cuff Injuries…
• Signs and Symptoms:
▫ Pain within the shoulder,
especially during the followthrough phase of a throw or
swing
▫ Difficulty in bringing the arm
up and back during the cocking
phase of a throw or swing
▫ Pain and stiffness within the
shoulder region 12 to 24 hours
after a practice or competition
that involved throwing or
swinging
▫ Point tenderness around the
region of the humeral head
that appears to be deep within
the deltoid muscle
▫ Rotator cuff injuries can also
mimic many others common to
the shoulder region, including
bursitis and tendinitis
Rotator Cuff Injuries…
• TX:
▫ Overuse injuries are difficult
to treat effectively without a
thorough medical evaluation
▫ The application of ice and
compression may prove
helpful in reducing the pain
and loss of function
associated with the injury
▫ Athlete will report repeated
episodes of symptoms
spanning many weeks or even
months
▫ Medical referral for a
complete evaluation is
essential
• http://www.youtube.com/wat
ch?v=64VhamtSdss
Glenohumeral Joint-Related
Impingement Syndrome
• To impinge means to be forced “upon or against
something”
• A syndrome is defined as “a number of
symptoms occurring together and characterizing
a specific disease”
• Hence, an 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
Glenohumeral Joint-Related
Impingement Syndrome
• In the case of the GH joint, the
most common impingement
occurs to the tendon of the
supraspinatus muscle as it
passes across the top of the
joint
• The region located directly
beneath the acromion process
is known as the subacromial
space
• The floor of the subacromial
space is the GH joint capsule
• The ceiling comprises the
acromion process and the
coracoacromial ligament
Glenohumeral Joint-Related
Impingement Syndrome
• Any condition, whether related to sports or
congenital, that decreases the size of the
subacromial space may result in the
development of an impingement syndrome
• The most common causes of GH joint-related
impingment syndromes are “automatic
variations in the coracoacromial arch” that cause
damage to the structures found in the
subacromial space
Glenohumeral Joint-Related
Impingement Syndrome
• Athletes who participate in sports placing an
emphasis on arm movements above the shoulder
level demonstrate a higher rate of impingement
problems when compared with athletes who take
part in sorts not emphasizing such movements
• A survey of athletes in sports requiring arm
motions found the high-risk sports to include
volleyball, badminton, basketball, gymnastics,
squash, swimming, table tennis, tennis, and
track and field events
Glenohumeral Joint-Related
Impingement Syndrome
• Signs and Symptoms:
▫ 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
degrees
▫ Nocturnal pain
▫ Pain felt deep within the
shoulder
Glenohumeral Joint-Related
Impingement Syndrome
• TX:
▫ Any athlete complaining of the signs and symptoms
listed should be referred for a complete medical
evaluation
▫ Rest, anti-inflammatory drugs, and physical therapy
▫ If these fail, surgery to correct the problem may be
prescribed
 This can be done arthroscopy
 Involves procedures such as removal of bone spurs from
beneath the acromion process, release of the
coracoacromial ligament or a resectioning of a portion of
the undersurface of the acromion process
Biceps Tendon Injuries…
• The anatomy of 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 a specialized
portion of the synovium of the
joint
• As the tendon continues
through the joint, it runs
across the superior surface of
the humeral head
Biceps Tendon Injuries…
• The tendon of the long head of
the biceps brachii originates
from the supraglenoid tubercle
• The short head of the biceps
brachii derives from the
nearby coracoid process
• This tendon remains
anatomically separate from the
GH joint
• The tendon of the long head of
the biceps brachii is located
directly beneath the acromion
process; therefore, it can suffer
a type of impingemenet
similar to that seen in the
supraspinatus tendon
Biceps Tendon Injuries
• Athletes at risk for this injury include those
involved in sports that place an emphasis on
repetitive overhead movements with the arms
• Another problem related to the long head tendon
of the biceps brachii is tendinitis, which may
lead to a subluxation of the tendon from the
bicipital groove
• In most cases, tendinitis will develop slowly over
a period of weeks or months
• As the tendon enlarges as a result of the
inflammation, it becomes less stable in the
groove
Biceps Tendon Injuries…
• In chronic cases, a sudden
violent force such as is
commonly generated in
throwing may cause the
tendon to subluxate out of the
groove, thereby stretching and
tearing the ligament
• The athlete will notice
significant symptoms if the
tendon subluxates from the
bicipital groove
Biceps Tendon Injuries…
• Signs and Symptoms:
▫ Painful abduction of the
shoulder joint similar to that
seen in impingement problems
▫ Pain in the shoulder joint when
the athlete supinates the
forearm against any resistance
▫ When actively flexing and
supinating the forearm against
resistance, the athlete may note
a popping or snapping
sensation as the tendon of the
long head of the biceps brachii
subluxates
• TX:
▫ Not a practical concern because
they generally develop over
time and fall into the category
of a chronic injury
▫ Immediate application of ice
and compression
▫ Long-term care for this injury
includes rest, antiinflammatories, and gradually
progressive exercise
rehabilitation
▫ If symptoms persist and the
tendon continues to subluxate
from the bicipital groove, then
surgery may be an option
Contusions of the Shoulder Region
• External blows around the shoulder region are a
common occurrence in a variety of sports
• The GH joint is well protected by muscles crossing
over the joint, such as the deltoid
• The nearby AC joint, however, is exposed and quite
vulnerable to external blows
• If the athlete sustains a contusion to this joint, the
result can be an extremely painful condition known
as a shoulder pointer (contusion and subsequent
hematoma in the region of the AC joint)
Contusions to the Shoulder Region
• Signs and Symptoms
▫ History of a recent blow to the
shoulder, with pain and dec ROM
▫ Spasm if muscle tissue is involved
▫ Discoloration and swelling,
especially over bony regions such
as the AC joint
• TX:
▫ Immediately apply ice and
compression directly over the area
▫ In case of severe pain, arm sling to
relieve stress on the shoulder
region
▫ If significant swelling persist for
more than 72 hours in the AC joint,
refer the athlete to a physician