Forest Pett
Common Injuries to the Upper Extremity
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Upper extremity injuries: account for 20% of injuries in sports medicine
o Repetitive demands of overhead sports: unique chronic injuries for
shoulder/elbow
o Natural tendency to place hand out to break fall: injury scenarios for wrist/elbow
Anatomy:
Shoulder Girdle:
 Shoulder: hypermobile joint, allows for wide ROM for upper extremity
o Increased mobility: puts articulations + associated soft tissues structures at risk for
injury
o Motions: flexion, extension, abduction, adduction, circumduction,
internal/external rotation, and horizontal flexion/extension.
 Shoulder Girdle:
o Composed of 4 bones: sternum, clavicle, scapula, and humerus
o Attaches upper extremity to axial skeleton
o Articulations at SG: sternoclavicular (SC) joint, acromioclavicular (AC) joint,
glenohumeral (GH) joint, and the scapulothoracic (GH) joint.
o Scapula has to be able to move/adjust its position to allow humerus to be properly
positioned for optimal function
o True boney articulations: SC, AC, and GH
o Scapulothoracic articulation: allows scapula to glide on the rib cage.
 SC Joint: stable w/ little mobility. Attaches proximal clavicle to sternum.
o Clavicle: S-shaped bone that articulates distally w/ acromion at the AC joint +
supports shoulder joint by serving as an attachment for the scapula.
o Superficial bone, easily palpated
AC Joint:
 Supported by group of ligaments that attach clavicle to scapula
 Support to AC joint: offered by AC ligament + conoid ligament
 Sight of frequent sprain injuries
 Coracoacromial ligament: doesn’t directly support AC joint.
o Proximity to tendons of rotator cuff cause it to play role in overuse injuries
 Acromion: 1 of 2 unique-shaped projections (other: coracoid) that arise from scapula
 How to find AC joint: follow clavicle distally until you reach bumpy projection of AC
joint.
o This joint can be prominent in those with history of AC joint injury
 Movement/orientation of scapula: critical to proper function of shoulder girdle.
GH Joint:
 Articulates w. scapula at region called the glenoid
o Glenoid: slight concave surface that articulates w/ round head of humerus
o Glenoid labrum: fibrous ring that surrounds glenoid.
o golf ball (humerus) sits on golf tee (glenoid)
 Boney/ligamentous structures provide little static stability
o Shoulder girdle relies on dynamic stability of muscles that support shoulder
o Muscles: act on humerus and help scapula maintain proper position.
o rotator cuff: group of 4 muscles that arise from scapula + insert on humerus
Elbow:
 3 bones make up elbow: distal humerus, proximal radius, and proximal ulna.
 Movements at elbow: flexion/extension
 3 articulations that make up joint: humeroulnar, humeroradial, and radioulnar
 Movements of forearm: pronation and supination
o Movements facilitated by radioulnar and humeroradial joints
 Humeroradial Joint: allows for radial head to spin when forearm is pronated and
supinated.
 Head of radius: held in place by annular ligament.
 Humeroulnar joint: acts like a hinge, allows for flexion and extension.
 Proximal ulna: has significant bony prominence called olecranon process.
o Olecranon process: pointy portion of elbow and common site for
contusions/abrasions
 Elbow supported on each side by medial/lateral collateral ligaments and its boney
configurations
o These elements combine to make elbow stable
 Distal humerus: serves as origin of 2 distinct muscle groups that cross elbow joint and act
on wrist:
o Flexor and extensor groups
o Chronic injury associated w/ throwing sports originates from these muscle groups
o Biceps brachii and triceps brachii muscles act as primary flexors/extensors of
elbow
 Injuries to elbow: complicated by superficial neurovascular structures that pass through
it.
o Ex.: hitting your “funny bone” or ulnar nerve
o Antecubital vein: another common neurovascular structure. Superficial nature
makes it common site for drawing blood.
Common Injuries to the Shoulder:
 Acute shoulder girdle injuries: common MOI are overuse
 Chronic shoulder girdle injuries: common MOI is sport specific motions
o Ex.: a wrestler who is pounded into mat on the point of the shoulder could injure
the AC joint
o Ex.: baseball pitcher w. poor mechanics/weak rotator cuff is susceptible to
tendonitis or impingement problems.
Fractures and Injuries to Bone:
 Clavicle: commonly fractured in active participants.
o MOI: direct blow, indirect forces from fall on the point of shoulder, or a FOOSH
o commonly fractures in the middle third of the bone
o Injury may present w/ obvious deformity and pain for the patient. Obvious
deformity for all fractures isn’t true, thus a patient who has point tenderness over
the bone should be referred for a radiograph.
o Treatment of clavicle fracture: treated w/ sling or a figure-of-8 brace for 4-8
weeks.
o Surgical fixation required if: fracture is on most lateral aspect of bone or the ends
of the fracture site threaten to penetrate the skin.
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Scapula and Humerus: other locations for fracture in shoulder region
o MOI: Direct blows and FOOSH
o Fractures of Humerus: occur most frequently through the surgical neck of the
humerus (area just below the humeral head) and the mid shaft.
 Avulsion fractures of the greater tubercle (insertion of supraspinatus) and
lesser tubercle (insertion of the subscapularis) sometimes occur.
o Soft tissue covering humerus makes palpation of bone difficult
 Pain, deformity, and loss of function are common signs of fracture
o Fractures to humerus can lead to the impact of the long-term use of the GH joint.
o If fractured: AT has to immobilize and transport patient for immediate evaluation.
o Stress fractures: uncommon, overhead throwers most susceptible
Soft Tissue Injuries
Sprains, Subluxations, and Dislocations:
 Sprains at shoulder girdle: include injuries to the SC, AC, and GH joints
 Sprain to SC joint: results from indirect force transmitted along the clavicle to the
ligaments that support the articulation between the sternum and proximal clavicle.
o less common than sprain to AC joint
o occur in sports where forces are applied to point of the shoulder
o SC sprains are tender to palpation and may have deformity at proximal clavicle
Uncommon situation: proximal clavicle can become separated from the sternum.
If it is displaced backwards (posterior), it can interfere w/ the subclavian artery
and vein and create a life-threatening situation.
 AC joint sprain: often referred to as a “separation” of the shoulder.
o Degree of injury and resulting deformity of the AC joint: correlates w/ which
ligaments have been injured and the amount of damage to each.
o Patients w/ AC sprain: usually have observable deformity on the top of the
shoulder due to selling or the distal clavicle riding higher than normal.
o Painful, pain increases w/ movement, particularly w/ horizontal abduction
(bringing arm across the body). Swelling at joint can occur.
o AT may be able to: depress the distal clavicle and note the amount of movement.
o Degrees: 1st: least severe, 3rd: involves a complete disruption of the ligaments
securing the acromion and distal clavicle.
o Treatment: patients should follow PRICE with protection in the form of a sling
 Physician should evaluate to rule out fracture/determine severity of injury.
GH Joint:
 Allows for wide ROM at shoulder
 Glenoid portion of scapula provides great mobility at expense of stability
 Ligaments supporting GH: Capsular (or GH ligament), Coracohumeral and inferior GH
ligaments.
o Consistent w/ the joint capsule and the tension on each ligament changes depends
on the position of the arm.
 Excessive stress on GH joint can cause ligaments to be sprained.
 Most vulnerable: when arm is abducted and externally rotated
o if forced beyond limits in this position, the capsular ligament can fail and the
humerus will slide in an anterior and inferior direction and out of the socket of the
glenoid, resulting in dislocation.

Hill-Sachs Lesion: boney lesion that can occur from compression of the posterior
humeral head against the anterior rim of the glenoid.
o can occur w/ single dislocation or w/ recurrent dislocations
o symptoms: patients have significant pain while joint is dislocated. Contour of
deltoid may look flat and arm will hang near the side. Round humeral head may
be palpable in axilla (armpit).
o Care: immobilize patient and take to a physician for reduction of the joint and
radiograph.
o Subluxation: If GH joint only partially slides out of position
Muscle-Tendon Injuries: often sports specific
 Classified: 1st thru 3rd degree
 Symptoms: pain, stiffness in muscle group, discomfort with activity, and weakness,
 Overhand sports: common sports specific activities that often involve strain and overuse
problems with rotator cuff muscle group.
Rotator Cuff: responsible for providing dynamic stability to the GH joint.
 Unstable GH joint: rotator cuff must work harder to hold humerus in place.
o In this situation: muscles of the rotator cuff are susceptible to overload and
strain injuries (muscle tendon strains and tendonitis).
 Throwing motion: requires rapid acceleration and deceleration of upper arm.
o Deceleration phase: when the rotator cuff must contract while being
lengthened. Contraction called an eccentric contraction.
o Eccentric contraction: associated w/ muscle strain injury and tendonitis.
o Relation in between laxity in GH joint and overuse injuries of the rotator cuff
 Impingement syndrome: (shoulder injury)
o Syndrome: a collection of symptoms
o Tendons of the rotator cuff slide beneath the acromial arch. Space beneath the
acromion must be sufficient to allow movement of the tendons of the rotator
cuff, as well as the subcromial bursae and the ligaments that support the AC
joint.
o Occurs: if any of the above structures are inflamed. Space may be
compromised and cause pain for patient w/ movements.
o Most impingement injuries are chronic, acute impingement can occur when
head of humerus is jammed up against the acromial arch.
 Can occur w/ FOOSH
o Space further compromised: when humerus is internally rotated and flexed.
o Symptoms: pain felt deep in shoulder joint and describe an increase in pain w/
abduction and internal rotation of the humerus.
o Treatment: decreasing inflammation and pain while addressing issues that
promote inflammation.
o Promotions of inflammation: biomechanical corrections in technique,
improving strength, and maintaining flexibility. Arthroscopic surgery
sometimes recommended to release the coracoacromial ligament and smooth
underside of the acromion.
 Bicep Tendon: common location for tendonitis and inflammation. Tendon of long
head of bicep brachii helps depress and stabilize the head of humerus during
abduction.
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Originates: from area above glenoid
Passes below the subacromial arch and can play role in impingement
Chronic Injury: has gradual onset and is found in overhead sport athletes.
Tendon held in place via transverse humeral ligament
 Ligament can become injured acutely and cause the tendon to sublux
out of bicipital groove
Other Soft Tissue Injuries:
 Contusions: most common soft tissue injuries
 Shoulder frequently hit in contact sports
 Large deltoid muscle provides protection for GH joint
o Other joints of shoulder girdle are exposed and susceptible to contusion
 MOI for contusion: direct blows from other players/balls
o Ecchymosis and edema are common
 Treatment: if severe they may require support (sling) to allow adequate rest and healing
 Shoulder Pointer: fall on the point of the shoulder that contuses the AC joint
o Treatment: ice and compression to decrease inflammation
 Significant contusions: can cause bleeding and pooling of blood in muscle tissue
o If untreated: secondary formation of calcium can occur (myositis ossificans).
Common Injuries to the Elbow:
Fractures and Injuries to Bone:
 Bones that make up elbow joint are subject to fracture
 Fracture to upper arm and elbow more seen in pediatric patient when compared to adults
 Common fracture areas: proximal ulna, radial head, medial epicondyle, and
supracondylar fractures of the humerus.
 MOI: direct blows, FOOSH, and fractures secondary to dislocation.
 Triad of fractures in young athletes: can occur with a fall in full extension combined w/ a
valgus force.
o Triad: fracture of olecranon process, compression of the radial neck, and avulsion
of the medial epicondyle.
 Overuse injuries secondary to throwing can occur to boney structures of the elbow
 Posterior elbow impingement: condition involving the repeated contact between the
medial olecranon process and the olecranon fossa.
o Common among overhead throwers
o Overhead motions place the elbow under stress through a valgus extension
overload (i.e., rapidly moving from a valgus position to an extended position)
o Seen in football linemen who force the elbow into extension during pass
protection
o Symptoms: show decreases in throwing performance and have posteromedial
elbow pain.
o On exam: may have loss of extension and pain w/ valgus stress. Crepitus may be
present. Sever cases locking can occur (inability to move joint).
o Treatment: x-ray needed to determine health of joint surfaces and to look for
osteophytes and loose bodies in the joint.
o Ulnar collateral ligament has resulting instability because of repetitive valgus
stress.
o Stress fracture to the tip of the olecranon: can occur w/ same MOI
o Treatment (of elbow impingement): rest and gradual return to throwing w. an
emphasis on proper mechanics. Period of rehab w/ ROM and strength exercises.
 Surgical intervention: repairing ulnar collateral ligament to gain added
elbow stability to assist baseball players.
Soft Tissue Injuries
Sprains, Subluxations, and dislocations:
 Collateral ligaments: support and protect the elbow from excessive varus and valgus
stress.
o Subject to sprain injury: graded 1st thru 3rd degree
 MOI for sprains of elbow ligaments: FOOSH combined w/ a varus or valgus force,
hyperextension, or repetitive overload on the medial aspect of the elbow.
 Sprain injuries: produce pain, joint laxity w/ activity or on examination, and (severe
cases) loss of function.
 Treatment: rest and rehab (for sprains at elbow)
o 3rd degree: may require surgery depending on desired outcome
 Immediate Care: PRICE w/ protection in form of sling
 Dislocations of Elbow: occur when the humeroulnar joint is separated
o MOI: FOOSH w/ elbow extended
o Elbow dislocates posteriorly, causing the olecranon process to sit behind the distal
humerus. May have complications to neurovascular structures.
o Immediate Care: splint w/ ice and gentle compression. Transport for medical
attention immediately, may need to be treated for shock.
Muscle-Tendon Injuries:
 Musculotendinous Injuries at elbow: medial and lateral epicondylitis.
 Medial epicondyle: serves as origin for muscles that flex the wrist
 Lateral epicondyle: serves as origin for the muscles that extend the wrist.
 Medial Epicondylitis: commonly known as golfers elbow and is less common than LE.
o Common in activities that require pronation of the forearm and strong flexion of
the wrist.
o Injuries are inflammation of muscle groups that originate at the epicondyles.
 Better described as tendinosis or epicondylosis that represents a condition
of the tendon rather than a description of inflammation.
o Medial epicondyle must be treated w/ care due to close proximity to ulnar nerve.
Any patient w/ medial elbow pain should be examined for neurovascular
involvement.
 Lateral Epicondylitis: commonly known as tennis elbow.
o Caused by strong forceful eccentric contractions of the extensor muscle group.
 Any repetitive activity that involves wrist extension can induce this
o Symptoms: have pain, swelling over epicondyle, and active extension of the wrist
or reproduction of an eccentric contraction will be painful.
 Treatment: decrease aggravating activities, use ice and anti-inflammatory medications for
local symptoms, and promote flexibility and strength to tolerate loads placed in muscles.
o Use of counter force brace will decrease loads on extensor muscles.
o Slow progressive treatment plan
Other Soft Tissue Injuries:
 Contusions at elbow occur: due to prominence of olecranon on the proximal ulna.

Acute injury associated w/ contusion of olecranon: the development of olecranon bursitis.
o Causes the bursa to swell and creates deformity to elbow.
o Swelling: impairs ROM and size of olecranon bursa may interfere w/ clothing or
protective equipment.
o Olecranon bursa is susceptible to infection
 “hitting your funny bone”: contusion to the medial or posterior aspect of elbow can
irritate the ulnar nerve
Neurovascular Injuries:
 Neuropraxia: mildest form of nerve injury.
o Includes injuries: that do not disrupt the integrity of the nerve tissue.
o MOI: Friction, compression, contusion, and tension (or combinations). Nerve
tissue can also be damaged by stretch mechanisms secondary to trauma like
fracture or dislocation.
 With this trauma, the AT must asses neurovascular function by = testing
muscle strength, sensation, and reflexes
 3 of the main peripheral nerves of upper extremity cross elbow joint: ulnar, median, and
radial nerve.
 Ulnar nerve: commonly irritated w/ injuries involving medial aspect of elbow (i.e.,
sprains, medial epicondylitis, fractures.)
 Ulnar neuritis: entrapment of ulnar nerve found distal to medial epicondyle where nerve
enters the forearm.
o Can be found secondary to elbow instability, bone spurs, and thickening of the
synovium.
o Vulnerable to stress: during valgus overload of elbow common w/ overhead
sports.
 Median Nerve: located toward middle of forearm. Can be compressed under the pronator
teres muscle.
o Pronator teres syndrome: Above injury. Can cause numbness, pain, and
discomfort.
 Radial nerve can become entrapped and injured if compressed by the supinator
musculature in the forearm.
o If rest, activity modification, and symptomatic care do not alleviate symptoms,
surgical release of entrapped nerve is done.
Considerations for the Skeletally Immature Patient:
 6 ossification center around elbow: these growth areas usually fuse or close in
adolescents anywhere from 14 and 16 years of age.
o In growing athletes: these un-fused areas are common sites of injury (esp.
overhead sports).
 When repetitions of multidirectional mechanical forces at the elbow result in boney
and/or soft tissue injury they can result in specific injuries not seen skeletally mature
athlete.
 Little League Elbow: spectrum of boney changes at the elbow caused by medial stress
and lateral compression to elbow.
Three injuries below are examples of age dependant conditions in elbow:
 Medial Epicondylar Apophysitis: develops due to repetitive stress to the medial
epicondyle of the humerus at the origin of the flexor and pronator muscles.
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o Ex. of a traction apophysitis
o Called “little league elbow”
o Symptoms: progressively worsening medial elbow pain brought on by pitching or
throwing. Pain occurs during late cocking and early acceleration phases of
pitching when maximum valgus stress occurs at elbow.
Olecranon Apophysitis: occurs at insertion of the triceps tendon at the olecranon
apophysis.
o Pain at this posterior region: caused by rapid and repetitive acceleration and
deceleration during throwing/pitching
o Symptoms: posterior elbow pain and decreased ROM, and may or may not have
swelling. Posterior elbow will be tendor to palpation, and activating the triceps
against resistance will be painful.
o Treatment: activity modification, ROM, strength and proper mechanics. If it
doesn’t respond, surgical repair necessary.
Osteochondritis Dissecans: focal injury to subchondral bone and can result in
degeneration of overlying articular cartilage.
o In immature pitcher/thrower: cause of lateral elbow pain
o OCD in elbow: caused by repetitive stress and lateral compression to
humeroradial joint.
o Thought of as: repeatedly banging together the joint surfaces of the radial head
and distal humerus.
o Symptoms: gradual onset lateral elbow pain that is worse w/ activity and better w/
rest. Patients tender to touch over anterior and lateral aspect of the elbow. May
have Crepitus or swelling.
 Advanced cases: patients will have loss of ROM in extension of the elbow
or rotation of the forearm.
o MRI may be needed to fully evaluate status of injury
o Treatment of OCD lesion in elbow: dictated by the stability of the OCD lesion.
 Stable lesions: treated w/ activity modification and careful monitoring.
 Unstable lesions: may require surgery to remove loose bodies, repair
fragments, and address joint surface repairs if possible.
o OCD lesions that don’t heal properly may suffer lifelong pain and loss of motion
Colles’ Fracture: a fracture to the upper extremity that pushes the wrist back over the
fracture and creates a silver fork deformity (colles’ fracture).
o Common for FOOSH
o May involve just the radius or the ulna as well.
o Patient experience severe pain
o Treatment: Splinting, compression, and elevation followed by referral.
 Ice used for pain but discontinued if there is concern about blood supply
or nerve damage.
 Monitor patient for shock
Scaphoid: a bone in the 1st row of carpal bones that articulates w/ the distal radius.
o Frequently injured in FOOSH mechanism
o Pain w/ palpation by pressing into snuffbox is reason for referral to physician.
o