Injuries/Ailments of the Shoulder

1. Injuries/Ailments of the Shoulder Allyson Howe, M.D. Capt, USAF, MC Primary Care Sports Medicine Fellow

2. SHOULDER • Incidence • Review pertinent anatomy • History and physical exam • Cases with expected exam findings

3. Incidence • Second most common musculoskeletal complaint • Difficult joint to examine • Multidirectional range of motion- UNIQUE! • Shoulder injury can affect nearly every sport as well as impede many daily activities

4. Bones Bony AnatomyAnterior

5. Bony AnatomyPosterior

6. Bony AnatomyJoints and Articulations STATIC STABILIZERS

7. LABRUM

8. Deltoid Rotator cuff Teres major Latissimus dorsi Biceps Pectoralis muscles Clinical Anatomy

9. Rotator Cuff Supraspinatus Infraspinatus teres minor Supscapularis Clinical Anatomy POSTERIOR ANTERIOR

10. Rotator Cuff Supraspinatus Abd Infraspinatus ER teres minor ER Supscapularis IR Clinical Anatomy Depress humeral head against glenoid to allow full abduction

11. Muscular AnatomyPosterior

12. Clinical Anatomy • Bursae • subacromial • subdeltoid • subscapular

13. Functional anatomy • Glenohumeral= ball and socket joint • Very shallow (“golf ball sitting on a tee”) • Inherently unstable • Static stabilizers • glenohumeral ligaments, glenoid labrum and capsule • Dynamic stabilizers • Predominantly rotator cuff muscles • Also scapular rotators (trapezius, levator scapulae, serratus anterior, rhomboids)

14. Clinical ExamHistory • Pain • Acute • Chronic • Weakness • Deformity

15. Clinical ExamHistory • Single event • Repetitive overload • Instability • Does it feel like it’s going to come out? • Catching/Locking • Disability

16. Clinical ExamHistory • Sport/occupation • Frequency • Duration • Previous injury • Previous treatment • Systemic illness • Other joints involved

17. Physical Exam • Inspection • Note deformity, swelling, color changes • Palpation • Bony structures, soft tissue anatomy • Range of Motion • Flexion, Abduction, Internal and External rotation

18. Strength testing Internal/External rotation, Abduction Rotator cuff muscles Special Tests Isolate anatomy Physical Exam

19. Physical ExamInspection • Front & back • Height of shoulder and scapulae • Muscle atrophy, asymmetry

20. Physical ExamPalpation • At rest & with movement • ie. can feel supraspinatus, AC joint • Bony structures • Joints • Soft tissues

21. Physical ExamRange of Motion • Abduction 0-180o

22. Physical ExamRange of Motion • Forward flexion: • 0o – 180o

23. Physical ExamRange of Motion • Extension • 0o – 40 to 60o

24. Physical ExamRange of Motion • Internal rotation • T5 segment • External rotation • 80-90o

25. Physical ExamStrength • Resisted external rotation • Tests infraspinatus, teres minor strength

26. Physical ExamStrength • Resisted internal rotation • Tests subscapularis strength

27. Physical ExamStrength • Empty can test • 45o angle • Steady downward pressure • Tests supraspinatus strength

28. Radiographs

29. Radiographic Anatomy

30. Radiographic Anatomy

31. Case #1 • 22-year-old male rugby player falls onto right shoulder while being tackled • Severe pain on top of right shoulder

32. Case #1 • Notable deformity over superior shoulder • Painful range of motion • Unable to lift right arm above waist • Diagnosis??

33. Acromioclavicular (A-C) Sprain • Damage to A-C joint ligaments • Pain and/or deformity over A-C joint • Graded I-VI • I-III usually treated non-operatively • IV-VI referred to orthopedic surgery

34. Cross-Arm Adduction Test • AC joint pathology • Arm flexed to 90° • Hyperadduct arm across body as far as possible • Pain in AC = (+) test

35. A-C Shear Test • Interlock fingers with hand on distal clavicle and spine of scapula • Pain in A-C joint when hands squeezed together = (+) test

36. Case #2 • 24-year-old male handball player • Fell onto shoulder after being pushed • Intense pain • Hand is tingling and arm feels like it’s hanging • xrays

37. X RAYS DIAGNOSIS???

38. Shoulder Dislocation/Anterior Instability • Humeral head dislocates from glenoid fossa • Almost always anterior • Usually traumatic mechanism with injury to capsule-labrum complex

39. AMBRI Atraumatic Multidirectional Bilateral Rehab Inferior capsular shift TUBS Traumatic Unilateral Bankart Surgery SHOULDER INSTABILITYClassification

40. Shoulder Dislocation/Anterior Instability • Treatment • Reduction of dislocation • Protection & rehab, rehab, rehab • Most will have future dislocations and/or instability • At least 70%!!! (young) • May require surgical tightening/repair of the capsule/labrum complex

41. Sulcus Sign • Inferior instability • Arm relaxed in neutral position, pull downward at elbow • (+) test = sulcus at infra-acromial area • compare to unaffected side

42. Apprehension Test • Anterior and Posterior instability • Shoulder at 90° abducted, slight anterior pressure & External rotation • (+) test = dislocation apprehension • some false (+)

43. Relocation Test • Perform after positive apprehension test • Apply post force over humeral head during external rotation (ER) • (+) test = increased ER tolerance

44. Load & Shift Test • Test for multidirectional instability • Grasp humeral head, slide anteriorly and posteriorly while securing rest of shoulder • (+) if greater than 50% displacement (graded 1-3)

45. Case #3 • 35-year-old male tennis player • Shoulder pain exacerbated by practicing serves • Develops dull, aching pain in right shoulder • Exam?

46. SHOULDER PAINPhysical Exam • Tenderness to palpation anterior shoulder • Pain with abduction starting around 90 degrees • Unable to lift arm past 120 degrees • Pain with forward flexion at 90-120 degrees

47. SHOULDER PAINSPECIAL TESTS • Hawkins • Place arm in passive abduction to 90o • Flex elbow • Internally rotate shoulder

48. SHOULDER PAINSPECIAL TESTS • Neer • PASSIVE • Forced forward flexion of arm with internally rotated shoulder • Test is positive if pain occurs at same point as with active forward flexion

49. SHOULDER PAIN DIAGNOSIS ???

50. Impingement(aggravated by overhead serving) AND hair brushing!