SHOULDER ASSESSMENT. BONY PALPATIONS Shoulder Complex.
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Transcript of SHOULDER ASSESSMENT. BONY PALPATIONS Shoulder Complex.
SHOULDER ASSESSMENT
BONY PALPATIONS
Shoulder Complex
Scapulothoracic Articulation
Not a true anatomical joint
Resting position of scapula is:
Superior angle is level with spinous process T2
Inferior angle level with spinous process T7
Medial border of scapula is 5-6 cm or three fingers width from spinous processes
SHOULDER LIGAMENTS
STERNOCLAVICULAR LIGAMENTS
Motions @ Sternoclavicular Joint
SC Joint acts like ball and socket joint
Motions at joint: Elevation- Depression Rotation : upward-downward Rotation: forward-downward;
backward-upward
AC Joint Characteristics Synovial joint
Keeps glenoid fossa continually facing the humeral head
Articular disc between acromion and distal clavicular head
Capsule – lax to allow for complex shoulder motion
AC Joint Superior and
inferior acromioclavicular lig. Strengthen upper
aspect of joint Limits approx.
90% of anterior-posterior translation
Coracoclavicular Ligament .: Limits 80% of
superior translation of the clavicle- acts as a tie bar to hold clavicle down
Maintains a constant relationship of the scapula on the clavicle
Coracoacromial ligament Forms roof over humeral
head Prevents upward
displacement of humeral head and protects underlying structures
Sharp lateral edge may impinge on bursa and supraspinatus tendon
Superior Transverse Ligament
Bridges lesser scapular notch Provides a passage for suprascapular
nerve
Glenohumeral Joint Synovial Joint: humeral head articulates
with glenoid cavity Humeral head points medially,
backward and tilts upward Glenoid is ½ as long and 1/3 as wide as
the humeral head Contact area is limited Surface area of humeral head is 3-4
times larger than the fossa
Glenohumeral Capsule
GLENOHUMERAL AND CORACOHUMERAL LIGAMENTS
Coracohumeral Lig.- One of the most important ligament structures
1. Blends with rotator cuff, fills space b/t subscapularis and supraspinatus
MaintainsGH relationship
Involved with frozen shoulder
GLENOHUMERAL LIGAMENTS
Glenoid labrum Rim of cartilaginous
tissue attached around margin of glenoid fossa
Serves as attachment for ligaments
Deepens articular cavity
Increases glenoid contact with humeral head & serves “chock block” function
Glenoid Fossa with Rotator Cuff Muscles
Muscles of Shoulder
Shoulder Bursae 1. Subacromial or Subdeltoid
bursa 2. B/t coracoid &
glenohumeral Jt. Capsule 3. Summit of the acromion 4. B/t infraspinatus & joint
capsule 5. B/t teres major & long
head biceps 6. B/t subscapularis & Joint
capsule 7. Tendinous insertion of
latissimus dorsi 8. Behind the
coracobrachialis muscle
Blood Supply to Shoulder Complex
Blood Supply
Neurovascular Bundle
Brachial Plexus
Upper Extremity Dermatomes
Posterior Dermatomes
1st Phase Scapulohumeral Rhythm
Phase I:
Humerus: 30 degrees Abduction
Scapula: Minimal movement
Clavicle: 0-15 degree elevation
2nd Phase Scapulohumeral Rhythm
Phase II: Humerus: 40
degrees Abduction
Scapula:20 degree rotation
Clavicle: 30-36 degree elevation
3rd Phase Scapulohumeral Rhythm
Phase III: Humerus: 60 degrees
Abduction 90 degree lateral rotation
Scapula:30 degree rotation
Clavicle: 30-50 degree posterior rotation
up to 30 degree elevation
Biceps tendon mobility Biceps tendon
does not move in the bicipital groove during movement
Humeral head moves over the fixed tendon
Shoulder Patterns: Closed packed position= 90
degrees abduction and external rotation
Open packed position= arm down by side up to 20-25 degrees abduction
Clavicle Fractures Most common Fx. Results :
Fall on out stretched arm
Fall on tip of shoulder Direct impact
Occurs most often in junction of middle and outer thirds of clavicle
X-ray of Clavicle Fracture
Signs and Symptoms of Clavicle Fractures Athlete supporting arm held in
tight to body with head tilted toward injury
On inspection , injured clavicle appears slightly lower than unaffected side
Palpation reveals swelling, point tenderness, mild deformity
Management of Fx. Clavicle Apply a sling and swathe bandage or
figure 8 harness Obtain x-rays Nearly all are treated with closed
reduction Keep immobilized for 6-8 weeks Open reduction:
Vascular complications, displaced epiphysis in skeletally immatue pt., Fx. Ends threaten skin, near AC joint
Scapular Fractures
Rare in sports Cause: direct contact
with force directed through humerus to scapula
Locations: body, glenoid, acromion, coracoid
X-ray Fracture of Scapula Body
Signs and Symptoms of Scapular Fractures Pain and tenderness around back of the
shoulder Athlete typically holds arm securely at
the side and avoids any attempt to move humerus
Diagnostic Test: X-ray
Treatment: Nonoperative Treatment: Sling and early ROM with in 1 week
Fractures of Proximal Humeral
Cause: direct blow, a dislocation or the impact received from FOOSH injury
Can be mistaken for shoulder dislocation
Can occur at anatomical neck, tuberosity or surgical neck
Most occur at surgical neck
Humeral Shaft Fractures
Humeral Shaft Fractures Cause: direct blow or Foosh Injury Type: comminuted or transverse fractures Signs & Symptoms: Severe pain, swelling,
deformity Complication: radial nerve involvement- loss
of wrist and finger extension and sensation over the back of dorsal surface- within 6 months radial nerve should be fine
Treatment: Nonoperative- x-ray views followed by splints and pressure wrap and casting with sling for 1st week
Sternoclavicular Sprains & Dislocations
Relatively uncommon in sports
Cause: indirect force transmitted through the humerus and down shaft of clavicle
Medial end of clavicle can be displaced upward and forward or slightly anteriorly
Sternoclavicular Sprains and Dislocations
3 Classification of Injury: 1st Degree: little pain or disability, pt.
Tenderness, no jt. Deformity 2nd Degree: displays subluxation of SCJ with visible
deformity, pain, swelling, pt. Tenderness, inability to abduct the shoulder FROM or horizontally abduct arm = ligamentous instability
3rd Degree: Complete Dislocation with gross displacement of clavicle at sternal junction, swelling, loss of function= rupture SCL and Costoclavicular Lig
Danger: Posterior Dislocation – pressure placed on blood vessels, esophagus and or trachea causing life- or death situation
Management of Sternoclavicular Sprains and Dislocations
Treatment: RICE, immobilization, emergency care for breathing
X-ray Physician reduction Immobilization 3-6
weeks Recurrence is very
high in these injuries
Acromioclavicular Sprain/Separation
Commonly caused by falling directly onto the tip of acromion
Common in hockey, rugby, football, equestrian accidents and martial arts
Injuries are classified into 6 types based on the severity of injury and degree of clavicular separation
AC Pathology
AC Separation
Acromioclavicular Treatment 1st and 2nd degrees are treated
conservatively with ice & ROM exercise and immobilization
3rd – 6th – could require operative intervention in cases where intra-articular disc is damaged and or interarticular fx occur
Operative : place a k-wire around clavicle to hold it down – 12 weeks post surgery rehab and immobilization
AC Joint Harness
Glenohumeral Dislocations Most common are anterior displaced
with arm abducted and externally rotated
Capsule can remain in tact or be severely damaged as head of humerus in forced out ot glenoid fossa in anterior inferior direction
Secondary labrum injuries – Bankhart Lesion and /or Hill-Sachs Lesions
Glenohumeral Dislocation
Anterior Glenohumeral Dislocation
Signs & Symptoms: Flattened Deltoid
contour Palpation of axilla
reveals prominence of humeral head
Athlete carries affected arm in slight abduction and external rotation
Severe Pain with initial dislocation
Tingling and numbness extends down the arm into hand
Bankhart Lesion
X-Ray finding of Bankhart Lesions
Hill-Sachs Lesion
Small articular Cartilage defect on the humeral head caused by the impact of humeral head on the glenoid fossa as the humerus dislocates
Hill-Sachs Lesion
Anterior Dislocation Reduction
Posterior Glenohumeral Dislocation
Fairly rare and only account for 1-4 % of all shoulder dislocations
Mechanism of injury: a forced adduction and internal rotation of the shoulder usually directed to anterior compartment or a fall on an extended and internally rotated arm
Signs & Symptoms: severe pain and disability – Arm is fixed in adduction and internal rotation, deltoid muscle is flattened, acromion and coracoid processes are more prominent than normal and the head of the humerus may be posterior. Head is usually dislodged in the posterior rotator cuff musculature
Usually reduced spontaneously
Posterior Dislocation Management
Same as with Anterior Dislocations
Recurrent Dislocations and Subluxations Cause capsule to stretch out allowing
for multiple reoccurrences Athlete complains of arm feeling like it
is “Going Dead”- commonly referred to as Dead Arm Syndrome
These need to be repaired with Bristow Repair or Bankhart procedure to prevent Multidirectional shoulder instability (MSI)
Subacromion Bursitis
Shoulder Subacromion Bursitis Typically an overuse syndrome Occurs most often to subacromion
bursa Occurs to as: Swimmer, baseball,
and tennis players MOI: same as impingement , not
isolated but a multifaceted problem accompany impingement, rotator cuff problems
Signs and Symptoms:
Unable to move shoulder in abduction, rotation
Muscle atrophy occurring due to disuse Can be sudden or insidious onset Inability to sleep at night Point tenderness on the anterior and lateral
edges of the acromion process Painful arch between 70-120 degrees Assessment: Pain on passive and active
motion in the same direction
Management of Bursitis
RICE immediately Deep heat with ultrasound and/or hot
packs NSAIDs and activity modification Injections but must be compliant for 2
weeks Avoid Frozen shoulder
Neurovascular Bundle
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome
Signs and Symptoms: Parenthesis and pain in side or back of neck extending
across the shoulder down the medial are to the ulnar aspect of hand
Sensation of cold – caused by arterial involvement- usually symptoms occur very rapidly after exercise or activity using hand
Impaired circulation could lead to gangrene of the fingers
Weakness of muscle leading to decreased grip strength Muscle atrophy Radial nerve palsy
Orthopedic Test Used to Assess TOS
Adison’s Test- Test for costioclavicular encroachment
Allen’s Test- Stretch the scalenes
Military Press Test- Hyper abduction places pect minor on stretch
Roos’s Test- Combination
Management of TOS Conservative approach should be taken with
early and mild cases: works in 50%-80% of cases
Sling support and tension reduction Anti-inflammatory medication Exercise to strengthen trapezius, serratus
anterior, and erector muscles of the spine to counter act pull of pect minor
Postural correction- especially in cases of drooped or forward tilted shoulder: emphasize stretch the anterior muscles and strengthening posterior muscles
Brachial Plexus Injury Etiology: Transient
neurapraxia resulting from stretching or compression of the BP
Neurapraxia involves a disruption in normal function of a peripheral nerve without any degenerative changes
Common terms: stinger, burner, or pinched nerve
Brachial Plexus Injuries Mechanism of injury: neck is forced laterally to
the opposite side while the shoulder is depressed as occurs with a shoulder blocking football Or compresses the brachial plexus when the neck
extended , compressed and rotated toward the affected side
S&S: burning sensation, numbness, tingling and pain extending from shoulder down to the hand with some loss of function of arm and hand
Symptoms rarely last for more than several days Neck ROM is normal Repeated BP injuries may result in neuritis,
muscular atrophy and perm ant damage
Management of Brachial Plexus Injuries
Push the shoulder pads up off the shoulder
Ask athlete to move fingers and arm around to get sensation back – hold ice in hand
After symptoms have completely resolve , the athlete may return to full activity
Fit shoulder pads with a cervical roll to limit neck ROM during impact
Biceps Tendon Pathology
Bicipital Tendonitis: Occurs to long head
of Biceps as it lies in the tubular sheath in the bicipital groove
Causes: repetitive motion of the shoulder
Assess with: Speeds Test
Biceps Tendon Tendonitis
Subluxation of Biceps Tendon
Cause: Tear of Transverse Humeral Lig.
Test : Yeagerson’s Test
Rupture of Biceps Tendon
Signs & Symptoms of Rupture Biceps Tendon
Maybe indistinguishable from impingement syndrome
Pain n the glenohumeral joint itself Pain on active and resistive supination and
flexion of forearm No pain with passive ROM Most common ruptures : near or in bicipital
groove Orthopedic Test: Resistive and Active ROM Ludington Test
Glenoid Labrum Lesions Lesions occur with
shoulder dislocations and traumatic subluxation
Labrum can be detached from the glenoid rim: frank tear
Long head of biceps is typically involved in superior tear or SLAP lesions
2 Classic Types of Lesions SLAP = Superior Lesion Anterior to
Posterior – 10 – 2 o’clock
Bankhart Lesion – 4-6 o’clock on the rim of the labrum
4 Classifications of Lesions
Rotator Cuff Impingement Syndrome
Referred to as: Swimmer’s Shoulder, Thrower’s Shoulder, or Painful Arch Syndrome
Anatomy: impingement occurs to supraspinatus muscle at anterior edge of acromion and coracoacrominal ligament
Etiology : repeated use of arm aoe the horizontal plane causes a reductionof space for the supraspinatus muscle to pass under the acromion
Rotator Cuff Impingement
Causes of Rotator Cuff Impingement
1. Shape of the acromion
The contact pattern of the rotator cuff on the undersurface of the acromion
Contact can be determined by the shape of the acromion
Causes of Rotator Cuff Impingement
2. Instability of Glenohumeral Joint- if capsule is laxed or dynamic stabilizers are inadequate, the humeral head will displace excessive which can cause secondary impingement
Causes of Rotator Cuff Impingement 3. Scapular hypermobility: When
the scapula glides excessively laterally (protraction) during arm elevation causing the glenoid fossa to “open up” which may contribute to excessive movement of the humeral head anteriorly and superiorly – Inadequate scapular stability
Scapulohumeral Force Couple
Orthopedic Test to Assess RC Impingement
Kennedy-Hawkins Test Cross-Over Test Neer’s Test O’Brian Test
3 stages of RC Impingement
Stage I: Reversible Damage Injury to supraspinatus or Long head Biceps
Aching after activity Pt. tenderness high over supraspinatus at
greater tuberosity of humerus Pain with abduction = Painful arch Positive impingement sign
Biceps Tendon: Pt. tender over biceps tendon, pain at biceps tendon with straight arm flexion (Speed’s Test), pain resisted supination & ER
Stage II RC Impingement
Lesions are impossible to reverse, can take years
Fibrotic symptoms set in: Aching during activity , worse at night Some restricted ROM No obvious muscle defect Muscle fiber separation Permanent thicken of RC and Acromial bursa
Stage III RC Impingement Long history of shoulder problems Shoulder pain during activity with
increased pain at night Muscle defect of1cm or less Possible parrtial muscle tear Permanent thickening of rotator cuff and
subacromial bursa with scar tissue Complaint of weakness in everyday
endeavors
Stage IV RC Impingement Obvious infraspinous and supraspinous
strophy Complete tear of rotator cuff with severe to
minimal pain Tenderness over greater tuberosity, anterior
acromion, AC Jt. Very painful Arch Muscle defect greater than 1cm Limited active and full passive ROM Possible degeneration of clavicle Positive impingement sign
Treatment for RC Impingement
Stage I & II: Change mechanic of raising arm above
head= changing swimming stroke or throwing motion
Ice after workout and avoid heat Ultrasound Rest Steroid injection to decrease inflammation Stretch rotator cuff
Treatment Stage III Conservative Emphasis placed on ROM and
Strengthening external rotators
Stage III & IV Surgical Treatment
Anterior Acromoplasty: Involves resection the coracoacrominal ligament and shaving under surfaces of the acromion without disrupting the deltoid muscle
Rotator Cuff Tears Most common tears= supraspinatus Most often fails near its periphery , near
the attachment at greater tubeorsity – described as: Partial thickness tears – involves superficial
surface Full thickness tears – extends through the
articular surface to bursal surface
Rotator Cuff Tears Described as acute or
chronic and partial and full thickness
Classified by size of tear Can be torn is single
traumatic event or failure can occur over a longer period of time and present in an insidious manner
Overhead Athletes Generally have partial
articular –side tear Acute tears usually
found in athletes younger than 40 Commonly recall a single
traumtic event and present with shoulder pain, weakness, and a positive shrug sign (shrugging shoulder with an attempted abduction of the arm)
Older Athletes Tend to have
chronic, full thickness tears
Management of Rotator Cuff Tears
Arthroscopic evaluation necessary: Some have intact cuff with marked
thickened, inflammed , and fibrotic subacromial bursa – arthroscopic subacromial decompression is indicated
Partial RCT are debrided and the instability is corrected. Tears involving less than 50% of the tendon thickness can be debrided arthoscopically , while larger tear may require repair
Signs and Symptoms of Rotator Cuff Tears
Pain with shoulder elevation and abduction and external rotation
Night pain , inability to lay on shoulder Weakness, and diminished function Shoulder muscular atrophy
Orthopedic Test: Drop Arm I and II; Empty Can Test, Pain on Active motion in one direction and pain on passive ROM in opposite direction
Adhesive Capsulitis Referred to a “Frozen Shoulder” Exhibits a classical capsular pattern with loss
of active and passive ROM due to adhesions in the capsule
Glenohumeral joint capsule becomes inflammed , thickened, and excessively scarred with adhesion forming to humeral head
Common in 50-60 yr. old women Higher incidence in pt. with diabetes mellitus
Three Stages of Adhesive Capsulitis
Stage I= painful phase, gradual onset diffuse pain, worse at night, last 2-9 months
Stage II= Stiffening phase – last 4-12 months- significant loss of ROM especially overhead movements and reaching into back pocket
Stage III= Thawing phase- Gradual regaining of ROM
Orthopedic Test - None