Evaluating Shoulder Injuries

7/28/2019 Evaluating Shoulder Injuries

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Morning Report-ish

Shoulders

Adam Ware

PGY-3



18 year old presents after crash on

mountain bike.

• Helmeted mountain bike rider describes this:

– http://www.youtube.com/watch?v=0WzBLmW-

2kc

• Unable to move right shoulder since crash

http://www.youtube.com/watch?v=0WzBLmW-2kc







Physical Exam



Shoulder anatomy



AC Joint Sprain/Separation

• Six classifications of injury:



AC Joint Sprain/Separation

• Physical Exam: –Well-localized swelling & tenderness

over AC joint

–Painful active & passive range of motion

–Crossover testing (scarf sign) increasespain

–Type II, III, V may have high ridingclavicle

–May have tenderness to palpation over clavicle shaft, SC joint & clavicular attachments of trapezius & deltoids



AC joint:

Crossover Test• Patient raises affected

arm to 90°

• Actively adducts armacross body

• Forces acromion into

distal end of clavicle

• Isolates AC joint &

painful if positive



AC Joint Sprain

• Treatment:

–Type I, II, III:

• Conservative treatment

• Ice, Rest, NSAIDS

• Begin ROM exercise as soon as tolerated

–Type IV and higher:

•

May require further intervention



18 year old with shoulder pain

• Skateboarding accident – Fell forward after

jumping from stairs – Like this:

http://www.youtube.com/watch?v=NoPBevhP

blo

• Presented via EMS with pain over mid-clavicle

http://www.youtube.com/watch?v=NoPBevhPblo






Clavicle Fracture



Clavicle Fracture

• Physical Exam:

–Visible & palpable deformity

–Local pain & swelling

–Pain may radiate into trapezius & neck

–Complete neuro exam important to

detect brachial plexus injury



Clavicle Fracture

• Treatment:

–Conservative

–Sling for 2 to 4 weeks

–Displaced fractures may need referral for

further evaluation



Risk Factors for Nonunion of Midshaft Clavicle

Fractures

• Clavicle shortening > 15 –20 mm

• Female sex

• Fracture comminution

• Fracture displacement

• Greater extent of initial trauma

• Older age



16 year old

• Wrestling practice described being thrown

like this:

– http://www.youtube.com/watch?v=Avo88766Ek0

• Unable to move shoulder. No prior history of

shoulder injury.

http://www.youtube.com/watch?v=Avo88766Ek0

http://www.youtube.com/watch?v=Avo88766Ek0



Anterior Shoulder Subluxation/Dislocation

• Dislocation: –Complete separation of articular surfaces

• Subluxation: – Abnormal translation of humeral head on

glenoid without complete separation of articular surfaces

•

Humeral head can dislocate anteriorly,posteriorly or inferiorly

• Anterior dislocation most common




• Mechanism:

–Forced extension, abduction, external rotation

–Direct blow to posterior or posterolateral

shoulder

–Repeated episodes of overuse (subluxation)




• Physical Exam:

– Intense pain

– Arm held in abduction & external rotation

–Humeral head palpable anteriorly

–Unable to completely internally rotate or

abduct the shoulder –Thorough neuro exam (close relation of

axillary nerve)



Anterior Shoulder Dislocation

• Prompt

reduction

• Many differentmethods of

reduction

Traction-

countertraction



Anterior Shoulder Dislocation

• Stimson maneuver

•

Kocher Maneuver – http://www.youtube

.com/watch?v=jD0eAuctHoo

http://www.youtube.com/watch?v=jD0eAuctHoo









• Treatment:

–Sling – few days to 2 weeks

–

Ice –NSAIDS

–Protected range of motion

–Rotator cuff strengthening after acute

pain resolves

–Return to sport when normal strength &

motion regained



12 year old with shoulder pain

• No recent trauma

• Participates as pitcher on competitive baseball

team.

• Physical exam shows pain with passive and

active ROM of shoulder, minimal swelling, and

pain to palpation over proximal humerus.



Little League shoulder

• Stress fracture through the prox humeral physis

• Commonly in throwers

• Overload/overstress injury

• Dx: clinical

• Tx: rest for 4-6wks, followed by rehabilitation

• Return to full activity when full, pain free ROM,

improved stability, normal strength present



Impingement/Rotator cuff tendonitis

• Overuse injury

• Repetitive subacromial

impingement,

compression of rotatorcuff and/or biceps tendon

btw head of humerus and

coraco-acromial arch

• Swimmers, baseball,

volleyball, tennis



Shoulder Impingement Treatment

• Phase 1: pain control

– Ice, NSAIDs, limit overhead activity

• Phase 2: therapeutic exercise

– Strengthen interscapular mm with rowing typeexercise

– Use elastic tubing to strengthen external rotatorsof shoulder

• Phase 3: maintain fitness

– General conditioning, running, cycling



Strengthening exercises

Figure 1. Strengthening inter-scapular

muscles with elastic tubing

Figure 2. Shoulder protraction exercise (balance with one

arm on wobble board or deflated ball)



Strengthening Exercises



PE: Range of Motion

• Flexion/Extension

• Abduction/Adduction

•

Internal/External Rotation



PE: Muscle Testing

Supraspinatus

• Empty Can Test

• 90° abduction

• 30° forward flexion

• Thumbs pointingdownward

• Patient attemptselevation againstexaminer ’s resistance

http://www.aafp.org/afp/971101ap/salfig2c.jpg



PE: Muscle testingSubscapularis

• “Lift-off test”

• Internally rotate shoulder

• Dorsum of hand against

lower back• Patient attempts to push

away examiner ’s hand

• Modified: Place hand on

abdomen and resistinternal rotation



PE: Muscle Testing

Infraspinatus/Teres Minor • Patient’s arms

adducted at sides

• Elbows flexed to 90°• Patient attempts

external rotation

against examiner ’sresistance



Impingement Signs:

Neer ’s Test

• Scapula stabilized

• Arm fully pronated

• Examiner bringsshoulder into maximalforward flexion

•

Pain

subacromialimpingement

Evaluating Shoulder Injuries

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