Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Shoulder and Upper Arm
Pathologies
Chapter 16
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Anatomy

Bony anatomy



Manubrium
 Jugular notch
 Clavicular notch
Clavicle
Scapula
 Subscapular fossa
 Vertebral border
 Inferior and superior angle
 Scapular spine
 Supraspinous fossa
 Acromion process
 Coracoid process
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Anatomy

Bony anatomy

Humerus


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
Humeral head
Bicipital groove
Greater tuberosity
Lesser tuberosity
Surgical neck
Deltoid tuberosity
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Anatomy

Joints of the shoulder complex

Glenohumeral joint (GH)
 Acromioclavicular joint (AC)
 Sternoclavicular joint (SC)
 Scapulothoracic articulation
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Anatomy
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Anatomy

Bursa of the shoulder complex
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Subacromial bursa
 Above
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

supraspinatus tendon
Buffers tendons contact with acromion process and the
coracoacromial ligament
Inflammed bursa can lead to RTC impingement
Subdeltoid bursa
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Examination of Shoulder Injuries
Past medical history

Previous history
 AC or GH injury can alter
biomechanics
 Cervical spine pathology
 Can radiate pain to upper
extremity
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History of the present
condition
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
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Location of the pain
Onset
Activity and injury mechanism
Symptoms
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Examination of Shoulder Injuries

Inspection

Functional assessment
 Pain
in follow-through
 Pain in cocked position
 Pain in deceleration
 Loss of control and/or velocity
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Examination of Shoulder Injuries

Inspection

Anterior shoulders
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Level of the shoulders
Position of the head
Position of the arm
Contour of the clavicles
Symmetry of the deltoid
muscle group
Anterior humerus and
biceps brachii muscle
group
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Examination of Shoulder Injuries

Inspection

Posterior structures
 Alignment
of the vertebral column
 Position of the scapula

Sprengel’s deformity — congenitally undescended scapula
 Muscle
development
 Position of the humerus
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Examination of Shoulder Injuries

Palpation of the anterior shoulder
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Jugular notch
Sternoclavicular joint
Clavicular shaft
Acromion process and AC joint
Coracoid process
Humeral head
Greater tuberosity
Lesser tuberosity
Bicipital grove
Humeral shaft
Pectoralis major
Pectoralis minor
Coracobrachialis
Deltoid group
Biceps brachii
Long head of the biceps
Short head of the biceps
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Examination of Shoulder Injuries

Palpation of the posterior shoulder
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Spine of the scapula
Superior angle
Inferior angle
Infraspinatus
Teres minor
Supraspinatus
Teres major
Rhomboid major
Rhomboid minor
Levator scapulae
Trapezius
Latissimus dorsi
Posterior deltoid
Triceps brachii
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Examination of Shoulder Injuries

Joint and muscle function assessment

Active range of motion (AROM)
 Flexion
and extension
 Abduction and adduction
 Internal and external rotation
 Horizontal adduction and abduction

Manual muscle testing (MMT)
 Scapular movements
 Passive range of motion (PROM)
 Same
motions as AROM
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Examination of Shoulder Injuries

Joint stability tests




Sternoclavicular joint play
Test for acromioclavicular
joint laxity
Test for glenohumeral joint
laxity
Neurologic testing


Upper quarter screen
Referred pain from visceral
organs
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Pathologies of the Shoulder and
Related Special Tests

Acromioclavicular joint
pathology



“Separated shoulder”
MOI: FOOSH, blow to
superior acromion
process
Classification of sprains
depends on structures
involved, degree of
instability, and direction of
displaced clavicle
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Pathologies of the Shoulder and
Related Special Tests

Glenohumeral instability

Anterior instability
 Posterior instability
 Inferior instability
 Multidirectional instability
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Pathologies of the Shoulder and
Related Special Tests

Rotator cuff pathology



Impingement syndrome
Rotator cuff tendinopathy
Subacromial bursitis
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Pathologies of the Shoulder and
Related Special Tests

Biceps tendon pathology

Bicipital tendinopathy


Causes
 RTC dysfunction
 Impingement
Superior labrum anterior to posterior lesions (SLAP
lesions)

Tears of the superior aspect of the glenoid labrum that extend
anteriorly and posteriorly to the biceps insertion
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
On-Field Examination of Shoulder Injuries
On-field history
On-field inspection


Location of pain
 Upper shoulder
 AC sprain
 Trapezius
 Brachial plexus injury
 MOI
 Internal or external rotation (with
abduction)
 GH joint discloation or
subluxation
 FOOSH
 Clavicular fracture, AC sprain,
SC sprain
Copyright © 2010. F.A. Davis Company
Arm posture
 Arm splinted against torso
 Arm hanging limply at the side
 Arm “locked”
 Gross deformity
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
On-Field Examination of Shoulder Injuries
On-field palpation





Position of the humeral head
AC joint alignment
Clavicle
Sternoclavicular joint
Humerus
Copyright © 2010. F.A. Davis Company
Additional on-field tests

If joint dislocation or bony
fracture have been ruled out
 Apley’s scratch test (see Box
13–3) can be used as a gross
assessment of the athlete’s
willingness to move the
involved extremity and the
amount of motion
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Initial Management of On-Field Shoulder
Injuries

Scapular fracture





Body of the scapula
Glenoid fossa
Glenoid neck
Coracoid process
Management



Immobilize the arm on the affected side in a comfortable position
Athlete then is transported
GH dislocation also needs a radiographic evaluation to rule out a
secondary fracture to the glenoid or coracoid process
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
On-Field Examination of Shoulder Injuries

Clavicular fracture
 Immobilization using a sling or triangular bandage
 Transport for definitive diagnosis
 Sternoclavicular joint injuries
 Neurologic and vascular examination of the extremity and carotid
artery
 Involved arm is immobilized
 Athlete is immediately transported to an emergency medical facility
 Acromioclavicular joint injuries
 Immobilize in a position that lessens the displacement between the
clavicle and the acromial process
 Protect joint with additional padding during activity
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Glenohumeral dislocations
Monitor the distal pulses, check for circulation in the fingertips,
and perform a sensory screen
Arm is fixed in the position it has assumed
Reductions of GH dislocations should only be performed by those
who are trained to do so
Forced reduction of the humeral head may damage the glenoid
fossa, the coracoid process, or the neurovascular structures in
the area. Following reduction, assess distal pulse and active
range of motion, avoiding external rotation and abduction.
Stabilize the shoulder using a sling, and refer the athlete for
further examination.
Humeral fractures
Splint in position found using moldable splint or vacuum splint
Leave wrist and fingers exposed to check circulation
Transport
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company
Evaluation of Orthopedic and Athletic Injuries, 3rd Edition
Copyright © 2010. F.A. Davis Company