Chapter 22:
The Shoulder Complex
Jennifer Doherty-Restrepo, MS, LAT, ATC
Academic Program Director, Entry-Level ATEP
Florida International University
Acute Care and Injury Prevention
Introduction
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The shoulder is an extremely complicated
region of the body
Joint with a high degree of mobility, but,
not without compromising stability
Involved in a variety of overhead activities
relative to sport
Susceptible to a number of repetitive and
overused type injuries
Functional Anatomy

Great mobility, limited stability
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Round humeral head articulates with flat glenoid
Rotator cuff and long head of the biceps provide
dynamic stability during overhead motion
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Supraspinatus compresses the humeral head
Other rotator cuff muscles depress the humeral head
Integration of the capsule and rotator cuff
Scapula stabilizing muscles also provide dynamic
stability
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Relationship with the other joints of the shoulder
complex and the G-H joint is critical
Functional Anatomy
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Scapulohumeral Rhythm
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Movement of scapula relative to the humerus
Initial 30 degrees of G-H abduction
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30 to 90 degrees of G-H abduction
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Does not incorporate scapular motion
Setting phase
Scapula abducts and upwardly rotates 1 degree for
every 2 degrees of humeral elevation
Above 90 degrees of G-H abduction
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Scapula and humerus move in 1:1 ratio
Prevention of Shoulder Injuries
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Proper physical conditioning is key
Sport-specific conditioning
Strengthen through a full ROM
Warm-up should be used before explosive
arm movements are attempted
Contact and collision sport athletes should
receive proper instruction on falling
Protective equipment
Proper mechanics
Assessment of the Shoulder
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History
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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?
Assessment of the Shoulder
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Observation
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Elevation or depression
of shoulder tips
Position and shape of
clavicle
Position of head and
arms
Acromion process
Biceps and deltoid
symmetry
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Postural assessment
(kyphosis, lordosis,
shoulder)
Scapular elevation and
symmetry
Scapular protraction or
winging
Muscle symmetry
Scapulohumeral rhythm
Palpation: Bony Tissue
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Sternoclavicular joint
Clavicular shaft
Acromioclavicular joint
Coracoid process
Acromion process
Humeral head
Greater and lesser
tuberosity
Bicipital groove
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Spine of scapula
Scapular vertebral
border
Scapular lateral border
Scapular superior angle
Scapular inferior angle
Palpation: Soft Tissue
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Sternoclavicular,
acromioclavicular, and
coracoclavicular
ligaments
Rotator cuff muscles
and tendons
Subacromial bursa
Sternocleidomastoid
Biceps and tendon
Coracoacromial
ligament
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Glenohumeral joint
capsule
Deltoid
Rhomboids
Latissimus dorsi
Serratus Anterior
Levator scapulae
Trapezius
Supraspinatus
Infraspinatus
Teres major and minor
Special Tests
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Active, Passive, and Resistive ROM
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Flexion and extension
Abduction and adduction
Internal and external rotation
Manual Muscle Testing
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Shoulder muscles and scapular stabilizers
RROM and Break tests
Special Tests: SC Joint Instability
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Assesses sternoclavicular joint instability
Athlete in seated position
Apply pressure to the SC joint anteriorly,
superiorly, and inferiorly
Determine stability or pain associated with a
joint sprain
Special Tests: AC Joint Instability
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Assesses acromioclavicular joint instability
Athlete in seated position
Palpate for displacement of acromion and
distal head of clavicle
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Apply pressure in all 4 directions
Determine stability or pain associated with a
joint sprain
Special Tests: GH Joint Instability
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Assesses glenohumeral joint instability
Special tests
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Anterior and Posterior Drawer Tests
Sulcus Test
Clunk Test
Anterior and Posterior Apprehension Tests
Relocation Test
Anterior and Posterior Drawer Tests
Sulcus Test
Clunk Test
Anterior and Posterior
Apprehension Tests
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Anterior Apprehension
Test
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Posterior Apprehension
Test
Relocation Test
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Uses external rotation and posteriorly directed
pressure to allow for increased external rotation
Special Tests: Impingement
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O’Brien Test (Active Compression Test)
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Flexion of GH joint to 90 degrees and
horizontally adduction to 15 degrees
Passively place humerus into full IR and ER
If pain results with internal rotation but decreases
with external rotation and if clicking is present,
possible SLAP lesion
Pain in AC joint may indicate AC joint pathology
Special Tests: Impingement
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Neer’s Test
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Assesses impingement
of soft tissue structures
Positive test is
indicated by pain and
grimace
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Special Tests: Impingement
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Hawkins-Kennedy Test
Assesses impingement
of soft tissue structures
Positive test is
indicated by pain and
grimace
Special Tests: Rotator Cuff
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Drop Arm Test
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Assesses supraspinatus
muscle weakness or
tears
Athlete abducts
shoulder and gradually
lowers to starting
position
Inability to lower arm
slowly and controlled
will indicate torn
supraspinatus
Special Tests: Rotator Cuff
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Empty Can Test
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Place shoulder in
position of 90 degrees
of shoulder flexion, IR,
and 30 degrees of
horizontal abduction
Apply downward
pressure
Assesses supraspinatus
muscle weakness or
tears
Special Tests: Serratus Anterior
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Wall Push-up
Observe for winging scapula
Assesses for serratus anterior weakness
Could indicate injury to long thoracic nerve
Special Tests: Biceps
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Yergason’s Test
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Speed’s Test
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Determines presence of biceps irritation and
possible subluxation of biceps tendon
Determines presence of biceps irritation and
possible subluxation of biceps tendon
Ludington’s Test
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Assesses for possible rupture of biceps
Palpate alternating contractions of each biceps
Special Tests: Thoracic Outlet
Syndrome
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Adson’s Test
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Assesses for anterior scalene syndrome
Compression of subclavian artery by scalenes
Athlete looks toward extended arm and takes a
deep breath
Palpate radial pulse
Disappearance of pulse indicates a positive test
Special Tests: Thoracic Outlet
Syndrome
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Roo’s Test
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Assesses for costoclavicular syndrome
Compression of subclavian artery between clavicle
and first rib
Athlete assumes military brace position and turns
head in opposite direction
Athlete opens and closes hand for 3 minutes Palpate
radial pulse
Test is positive if…
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Pulse disappears
Grip strength decreases
Special Tests: Thoracic Outlet
Syndrome
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Allen’s Test
Assesses for hyperabduction syndrome
Determines if pressure from pectoralis minor
is compressing brachial plexus and
subclavian artery
Specific Injuries
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Clavicular Fractures
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Etiology
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MOI = fall on outstretched arm, fall on tip of
shoulder, or direct impact
Occurs primarily in middle third
Signs and Symptoms
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Athlete supports arm, head tilted towards injured side
with chin turned away
Clavicle may appear lower
Palpation reveals pain, swelling, deformity, and point
tenderness
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Clavicular Fractures (continued)
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Management
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Closed reduction - sling and swathe immediately
Refer for X-ray
Immobilize with brace for 6-8 weeks
After removal of brace, rehabilitation includes:
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Joint mobilizations
Isometric exercises
Use of a sling for 3-4 weeks
May require surgical treatment
Specific Injuries
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Scapular Fractures
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Etiology
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Signs and Symptoms
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MOI = direct impact or force transmitted up through
humerus
Pain during shoulder movement
Swelling and point tenderness
Management
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Sling immediately and refer for X-ray
Use sling for 3 weeks then begin PRE exercises
Specific Injuries
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Fractures of the Humerus
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Etiology
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MOI = direct impact, force transmitted up through
humerus, or fall on outstretched arm
Proximal fractures occur due to direct blow
Dislocations occur due to fall on outstretched arm
Epiphyseal fractures are more common in young
athletes and occur due to direct blow or indirect blow
traveling along long axis of humerus
Specific Injuries
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Fractures of the Humerus (continued)
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Signs and Symptoms
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Pain, swelling, point tenderness, decreased ROM
Management
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Immediate application of splint
Refer for X-ray
Treat for shock
Specific Injuries
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Sternoclavicular Sprain
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Etiology
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MOI = indirect force or blunt trauma
Signs and Symptoms
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Grade 1 - pain and slight disability
Grade 2 - pain, subluxation deformity, swelling, point
tenderness, and decreased ROM
Grade 3 - gross deformity (dislocation), pain, swelling,
and decreased ROM
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Possibly life-threatening if dislocates posteriorly
Specific Injuries
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Sternoclavicular Sprain (continued)
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Management
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RICE
Refer for reduction if necessary
Immobilize for 3-5 weeks
After immobilzation period, begin PRE exercises
Specific Injuries
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Acromioclavicular Sprain
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Etiology
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MOI = direct blow (from any direction) or upward
force from the humerus
Graded from 1 - 6 according to severity of injury
Signs and Symptoms
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Grade 1 - point tenderness, pain with movement
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No disruption of AC joint
Grade 2 - tear or rupture of AC ligament, pain, point
tenderness, and decreased ROM (abd/add)
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Partial displacement of lateral end of clavicle
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Acromioclavicular Sprain (continued)
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Signs and Symptoms
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Grade 3 - rupture of AC and CC ligaments
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AC joint separation
Grade 4 - posterior dislocation of clavicle
Grade 5 – rupture of AC and CC ligaments, tearing of
deltoid and trapezius attachments, gross deformity,
severe pain, decreased ROM
Grade 6 - displacement of clavicle behind the
coracobrachialis
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Acromioclavicular Sprain (continued)
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Management
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Ice, sling and swathe
Referral to physician
Grades 1 – 3: non-operative treatment
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1 - 2 weeks of immobilization
Grades 4 – 6: surgery required
Aggressive rehab is required for all AC sprains
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Joint mobilizations, flexibility exercises, and PRE exercises should
occur immediately
Progress as tolerated – no pain and no additional swelling
Padding and protection may be required until pain-free ROM returns
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A: Grade 1
B: Grade 2
C: Grade 3
D: Grade 4
E: Grade 5
F: Grade 6
Specific Injuries
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Glenohumeral Joint Sprain
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Etiology
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MOI = forced abduction and/or external rotation; or a
direct blow
Signs and Symptoms
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Pain during movement
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Especially when re-creating the MOI
Decreased ROM
Point tenderness
Specific Injuries
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Glenohumeral Joint Sprain (continued)
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Management
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RICE for 24-48 hours
Sling
After hemorrhaging subsides, modalities may be
utilized along with PROM and AROM exercises to
regain full ROM
When full ROM achieved without pain, PRE exercises
can be initiated
Must be aware of potential development of chronic
conditions (instability)
Specific Injuries
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Acute Subluxations and Dislocations
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Etiology
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Subluxation = excessive translation of humeral head
without complete separation from joint
Anterior dislocation = results from an anterior force
on the shoulder with forced ABD and ER
Posterior dislocation = results from forced ADD and
IR, or, falling on an extended and internally rotated
shoulder
Specific Injuries
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Acute Subluxations and Dislocations
(continued)
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Signs and Symptoms
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Anterior dislocation - flattened deltoid; prominent
humeral head in axilla; arm carried in slight ABD and
ER rotation; moderate pain and disability
Posterior dislocation - severe pain and disability; arm
carried in ADD and IR; prominent acromion and
coracoid process; limited ER and elevation
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Acute Subluxations and Dislocations
(continued)
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Management
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Sling and swathe and refer for reduction
Immobilize for 3 weeks following reduction
Perform isometrics while in sling
After immobilization period, begin PRE exercises as
pain allows
Protective bracing when return to play
Possible Complications of Shoulder
Dislocations
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Bankart lesion
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Hill Sachs lesion
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Permanent anterior defect of labrum
Caused by compression of cancellous bone against anterior
glenoid rim creating a divot in the humeral head
SLAP lesion
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Defect in superior labrum that begins posteriorly and extends
anteriorly impacting attachment of long head of biceps on
labrum
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Brachial nerves and vessels may be compromised
Rotator cuff injuries
Fractures
Bicipital tendon subluxation
Transverse ligament rupture
Specific Injuries
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Chronic Recurrent Instabilities
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Etiology
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MOI = traumatic, microtraumatic (repetitive overuse),
atraumatic, congenital, and neuromuscular
As supporting tissue become more lax, mobility
increases
Results in damage to other soft tissue structures
Specific Injuries
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Chronic Recurrent Instabilities (continued)
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Signs and Symptoms
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Anterior - may have clicking or pain; complain of
dead arm during cocking phase (when throwing); pain
posteriorly; possible impingement; positive
apprehension test
Posterior - possible impingement; loss IR;
crepitation; increased laxity; pain anteriorly and
posteriorly
Multidirectional - inferior laxity; positive sulcus
sign; pain and clicking with arm at side; possible signs
and symptoms associated with anterior and posterior
instability
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Chronic Recurrent Instabilities (continued)
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Management
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Conservative treatment involves extensive
strengthening of the rotator cuff and scapula
stabilizers
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Avoid joint mobilizations and ROM exercises
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Should be pursued before surgery is considered
Various braces can be used to limit motion
Surgical stabilization may be required to improve
function and comfort
Specific Injuries
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Shoulder Impingement Syndrome
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Etiology
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Mechanical compression of supraspinatus tendon,
subacromial bursa, and long head of biceps tendon
due to decreased space under coracoacromial arch
MOI = overhead repetitive activities
Exacerbating factors
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Laxity and inflammation
Postural mal-alignments
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Kyphosis and/or rounded shoulders
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Shoulder Impingement Syndrome (continued)
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Signs and Symptoms
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Diffuse pain
Increased pain with palpation of subacromial space
Decreased strength of external rotators compared to
internal rotators
Tightness in posterior and inferior capsule
Positive impingement and empty can tests
Neer’s progressive stages of shoulder
impingement…
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Stage I
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Result of supraspinatus or biceps tendon
injury
Presents with point tenderness; pain with ABD
and resisted supination with external rotation;
edema; thickening of rotator cuff and bursa
Occurs in athletes < 25 years old
Neer’s progressive stages of shoulder
impingement…
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Stage II
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Permanent thickening and fibrosis of
supraspinatus and biceps tendon
Presents with aching during activity that
worsens at night
May experience restricted arm motion
Neer’s progressive stages of shoulder
impingement…
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Stage III
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History of shoulder problems and pain
Tendon defect (less than 3/8 of an inch) or
possible muscle tear
Permanent scar tissue and thickening of rotator
cuff
Occurs in athletes 25 - 40 years old
Neer’s progressive stages of shoulder
impingement…
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Stage IV
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Infraspinatus and supraspinatus atrophy
Presents with pain during ABD, limited
AROM and PROM, weak RROM
Tendon defect (greater than 3/8 of an inch)
Clavicle degeneration
Specific Injuries
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Rotator cuff tear
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Etiology
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Occurs near insertion on greater tuberosity
Involve supraspinatus or rupture of other rotator cuff
tendons
Partial or complete thickness tear
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Full thickness tears usually occur in athletes with a long
history of rotator cuff pathology
Generally does not occur in athlete under age 40
MOI = acute trauma or impingement
Signs and Symptoms
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Pain and weakness with shoulder ABD and IR
Point tenderness
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Rotator cuff tear (continued)
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Management
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NSAID’s and analgesics
Modalities
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Electrical stimulation for pain
Ultrasound for inflammation
Restore appropriate mechanics by strengthening
rotator cuff to depress and compress humeral head to
restore subacromial space
Severe cases may require rest, immobilization, and
surgery
Specific Injuries
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Shoulder Bursitis
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Etiology
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Chronic inflammatory condition resulting from
fibrosis or fluid build-up
MOI = direct trauma or overuse
Usually occurs in the subacromial bursa
Signs and Symptoms
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Pain with motion, pain during palpation of
subacromial space
Positive impingement tests
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Shoulder Bursitis
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Management
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Reduce inflammation
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Cold, ultrasound, NSAID’s
Remove mechanisms precipitating condition
Maintain full ROM to reduce the risk of contractures
and adhesions forming
Specific Injuries
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Frozen Shoulder (Adhesive Capsulitis)
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Etiology
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Contracted and thickened joint capsule with little
synovial fluid
Chronic inflammation resulting in contracted, inelastic
rotator cuff muscles
Signs and Symptoms
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Pain in all directions both with AROM and PROM
Patient resists moving the shoulder due to pain
Specific Injuries
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Frozen Shoulder (continued)
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Management
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Aggressive joint mobilizations
Stretching of tight musculature
Electrical stimulation for pain control
Ultrasound for deep heating
Specific Injuries
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Thoracic Outlet Compression

Etiology
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Compression of brachial plexus, subclavian artery and
vein
Due to
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1) decreased space between clavicle and first rib,
2) scalene compression,
3) compression by pectoralis minor, or
4) presence of cervical rib
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Thoracic Outlet Compression (continued)

Signs and Symptoms
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Paresthesia, pain, sensation of cold, impaired
circulation, muscle weakness, muscle atrophy, and
radial nerve palsy
Positive anterior scalene test, costoclavicular test, and
hyperabduction test
Management

Conservative treatment - correct anatomical condition
through stretching (pec minor and scalenes) and
strengthening (trapezius, rhomboids, serratus anterior,
erector spinae)
Specific Injuries

Biceps Brachii Rupture

Etiology
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Generally occurs near origin of muscle at bicipital
groove
MOI = powerful contraction

Biceps Brachii Rupture (continued)

Signs and Symptoms
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Audible snap with sudden and intense pain
Protruding bulge may appear near middle of biceps
Weakness with elbow flexion and supination
Management
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Ice for hemorrhaging
Immobilize with a sling and refer to physician
Athletes will require surgery
Specific Injuries

Bicipital Tenosynovitis

Etiology

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
Ballistic activity involves repeated stretching of biceps
tendon causing irritation to the tendon and sheath
MOI = repetitive overhead activities
Signs and Symptoms

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
Point tenderness over bicipital groove
Swelling, crepitus due to inflammation
Pain when performing overhead activities

Bicipital Tenosynovitis (continued)

Management



Rest, ice, and ultrasound to treat inflammation
NSAID’s
Gradual program of strengthening and stretching
Specific Injuries

Contusion of Upper Arm

Etiology


Signs and Symptoms


MOI = Direct blow
Transitory paralysis and decreased ROM
Management

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
RICE for at least 24 hours
Provide protection to prevent repeated episodes that
could cause myositis ossificans
Maintain ROM
Specific Injuries

Peripheral Nerve Injuries

Etiology
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
Signs and Symptoms


MOI = blunt trauma or overstretching-type injuries
Constant pain, muscle weakness, paralysis, or atrophy
Management

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
RICE
Transient muscle weakness may occur
If muscle atrophy occurs, referral to a physician is
necessary
Rehabilitation of the Shoulder

Immobilization

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
Will vary depending on injury
Time in brace or splint are injury specific
Isometrics can be performed
ROM and strengthening are dictated by healing
General Body Conditioning

Maintain cardiovascular endurance through
cycling, running, and walking
Rehabilitation of the Shoulder

Joint Mobilizations


Used to re-establish appropriate joint
arthrokinematics
Used if joint capsule tightness is present
Rehabilitation of the Shoulder

Flexibility


Codman’s pendulum exercises should begin early
Progress to Active Assisted ROM in pain free
range

Cardinal planes
Rehabilitation of the Shoulder

Strengthening Exercises

Should include rotator cuff and scapula stabilizers
Rehabilitation of the Shoulder

Neuromuscular Control




Must regain appropriate firing sequence for
specific muscles (scapulohumeral rhythm)
Biofeedback can be used to regain control
Proprioception
Closed kinetic chain exercises will be required in
gymnasts, wrestlers, and weight lifters

Emphasize co-contraction muscle activity
Rehabilitation of the Shoulder

Functional Progressions


Incorporation of sports specific skills
Strengthening that involves PNF patterns


Throwing motion
Return to Activity



Based on pre-established criteria
Functional performance testing
Objective measures of strength and performance