Chapter 15 Shoulder and Upper Arm Pathologies Copyright

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Chapter 15 Shoulder and Upper Arm Pathologies Copyright © 2015. F. A. Davis Company

Chapter 15 Shoulder and Upper Arm Pathologies Copyright © 2015. F. A. Davis Company

Clinical Anatomy § Bony anatomy § Manubrium § Jugular notch § Clavicle § Scapula

Clinical Anatomy § Bony anatomy § Manubrium § Jugular notch § Clavicle § Scapula § Subscapular fossa § Vertebral border § Inferior and superior angle § Scapular spine § Supraspinous fossa § Acromion process § Coracoid process Copyright © 2015. F. A. Davis Company

Clinical Anatomy Copyright © 2015. F. A. Davis Company

Clinical Anatomy Copyright © 2015. F. A. Davis Company

Clinical Anatomy § Bony anatomy § Humerus § § § § Humeral head Anatomical

Clinical Anatomy § Bony anatomy § Humerus § § § § Humeral head Anatomical neck Bicipital groove Greater tuberosity Lesser tuberosity Surgical neck Deltoid tuberosity Copyright © 2015. F. A. Davis Company

Clinical Anatomy § Bony anatomy of the scapula Copyright © 2015. F. A. Davis

Clinical Anatomy § Bony anatomy of the scapula Copyright © 2015. F. A. Davis Company

Clinical Anatomy § Joints of the shoulder complex § § Glenohumeral joint (GH) Acromioclavicular

Clinical Anatomy § Joints of the shoulder complex § § Glenohumeral joint (GH) Acromioclavicular joint (AC) Sternoclavicular joint (SC) Scapulothoracic articulation Copyright © 2015. F. A. Davis Company

Clinical Anatomy Copyright © 2015. F. A. Davis Company

Clinical Anatomy Copyright © 2015. F. A. Davis Company

Clinical Anatomy Copyright © 2015. F. A. Davis Company

Clinical Anatomy Copyright © 2015. F. A. Davis Company

Clinical Anatomy § Scapulothoracic rhythm § GH and scapulothoracic articulation must function together. §

Clinical Anatomy § Scapulothoracic rhythm § GH and scapulothoracic articulation must function together. § 2: 1 ratio (GH elevation: STA rotation) § To accomplish 180 of GH elevation § 120 from GH movement and 60 from scapular rotation Copyright © 2015. F. A. Davis Company

Clinical Anatomy § Bursa of the shoulder complex § Subacromial bursa § Above supraspinatus

Clinical Anatomy § Bursa of the shoulder complex § Subacromial bursa § Above supraspinatus tendon § Buffers tendons’ contact with acromion process and the coracoacromial ligament § Inflamed bursa can lead to RTC impingement. § Subdeltoid bursa Copyright © 2015. F. A. Davis Company

Clinical Examination of Shoulder Injuries Past medical history § Previous history § AC or

Clinical Examination of Shoulder Injuries Past medical history § Previous history § AC or GH injury can alter biomechanics. § Cervical spine pathology § Can radiate pain to upper extremity Copyright © 2015. F. A. Davis Company History of the present condition § § Location of the pain Onset Activity and injury mechanism Symptoms

Clinical Examination of Shoulder Injuries § Inspection § Functional assessment § Pain in follow-through

Clinical Examination of Shoulder Injuries § Inspection § Functional assessment § Pain in follow-through § Pain in cocked position § Pain in deceleration § Loss of control or velocity Copyright © 2015. F. A. Davis Company

Clinical Examination of Shoulder Injuries § Inspection § Anterior shoulders § § § Level

Clinical Examination of Shoulder Injuries § Inspection § Anterior shoulders § § § Level of the shoulders Position of the head Position of the arm Contour of the clavicles Symmetry of the deltoid muscle group § Anterior humerus and biceps brachii muscle group Copyright © 2015. F. A. Davis Company

Clinical Examination of Shoulder Injuries Fracture of left clavicle Copyright © 2015. F. A.

Clinical Examination of Shoulder Injuries Fracture of left clavicle Copyright © 2015. F. A. Davis Company

Clinical Examination of Shoulder Injuries Anterior GH dislocation Copyright © 2015. F. A. Davis

Clinical Examination of Shoulder Injuries Anterior GH dislocation Copyright © 2015. F. A. Davis Company

Clinical Examination of Shoulder Injuries § Inspection § Posterior structures § Alignment of the

Clinical Examination of Shoulder Injuries § Inspection § Posterior structures § Alignment of the vertebral column § Position of the scapula § Sprengel deformity—congenitally undescended scapula § Muscle development § Position of the humerus Copyright © 2015. F. A. Davis Company

Clinical Examination of Shoulder Injuries § Palpation of the anterior shoulder 1. 2. 3.

Clinical Examination of Shoulder Injuries § Palpation of the anterior shoulder 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Jugular notch Sternoclavicular joint Clavicular shaft Acromion process and AC joint Coracoid process Humeral head Greater tuberosity Lesser tuberosity Bicipital groove Humeral shaft Pectoralis major Pectoralis minor Coracobrachialis Deltoid group Biceps brachii Long head of the biceps Short head of the biceps Copyright © 2015. F. A. Davis Company

Clinical Examination of Shoulder Injuries § Palpation of the posterior shoulder 1. 2. 3.

Clinical Examination of Shoulder Injuries § Palpation of the posterior shoulder 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Spine of the scapula Superior angle Infraspinatus Teres minor Supraspinatus Teres major Rhomboid minor Levator scapulae Trapezius Latissimus dorsi Posterior deltoid Triceps brachii Copyright © 2015. F. A. Davis Company

Clinical Examination of Shoulder Injuries § Joint and muscle function assessment § Active range

Clinical Examination of Shoulder Injuries § Joint and muscle function assessment § Active range of motion (AROM) § Flexion and extension § Abduction and adduction § Internal and external rotation § Horizontal adduction and abduction § Manual muscle testing (MMT) § Scapular movements § Passive range of motion (PROM) § Same motions as AROM Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Drop Arm Test for Rotator Cuff Tendinopathy Copyright © 2015. F.

Selective Tissue Test: Drop Arm Test for Rotator Cuff Tendinopathy Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Gerber Lift. Off Test for Subscapularis Pathology Copyright © 2015. F.

Selective Tissue Test: Gerber Lift. Off Test for Subscapularis Pathology Copyright © 2015. F. A. Davis Company

Clinical Examination of Shoulder Injuries § Joint stability tests § Sternoclavicular joint play §

Clinical Examination of Shoulder Injuries § Joint stability tests § Sternoclavicular joint play § Test for acromioclavicular joint laxity § Test for glenohumeral joint laxity § Neurological testing § Upper quarter screen § Referred pain from visceral organs Copyright © 2015. F. A. Davis Company

Pathologies of the Shoulder and Related Special Tests § Sternoclavicular joint sprains § MOI:

Pathologies of the Shoulder and Related Special Tests § Sternoclavicular joint sprains § MOI: Longitudinal force on the clavicle § FOOSH, hit on lateral portion of shoulder, or traction forces § Signs and symptoms § Pain with protraction, retraction, and joint play § Posterior dislocations = medical emergency! § Threat to subclavian artery and vein, trachea, and esophagus Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Pathologies of the Shoulder and Related Special Tests § Acromioclavicular joint pathology § “Separated

Pathologies of the Shoulder and Related Special Tests § Acromioclavicular joint pathology § “Separated shoulder” § MOI: FOOSH, blow to superior acromion process § Classification of sprains depends on structures involved, degree of instability, and direction of displaced clavicle. Copyright © 2015. F. A. Davis Company

Classification System for Acromioclavicular Joint Sprains Copyright © 2015. F. A. Davis Company

Classification System for Acromioclavicular Joint Sprains Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Acromioclavicular Traction Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Acromioclavicular Traction Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Acromioclavicular Compression Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Acromioclavicular Compression Test Copyright © 2015. F. A. Davis Company

Pathologies of the Shoulder and Related Special Tests § Glenohumeral instability § § Anterior

Pathologies of the Shoulder and Related Special Tests § Glenohumeral instability § § Anterior instability Posterior instability Inferior instability Multidirectional instability Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Apprehension Test for Anterior Glenohumeral Laxity Copyright © 2015. F. A.

Selective Tissue Test: Apprehension Test for Anterior Glenohumeral Laxity Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Relocation and Anterior Release Tests for Anterior Glenohumeral Laxity Copyright ©

Selective Tissue Test: Relocation and Anterior Release Tests for Anterior Glenohumeral Laxity Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Posterior Apprehension Test for Glenohumeral Laxity Copyright © 2015. F. A.

Selective Tissue Test: Posterior Apprehension Test for Glenohumeral Laxity Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Jerk (Posterior Stress) Test for Labral Tears Copyright © 2015. F.

Selective Tissue Test: Jerk (Posterior Stress) Test for Labral Tears Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Sulcus Sign for Inferior Glenohumeral Laxity Copyright © 2015. F. A.

Selective Tissue Test: Sulcus Sign for Inferior Glenohumeral Laxity Copyright © 2015. F. A. Davis Company

Pathologies of the Shoulder and Related Special Tests § Rotator cuff pathology § Impingement

Pathologies of the Shoulder and Related Special Tests § Rotator cuff pathology § Impingement syndrome § Rotator cuff tendinopathy § Subacromial bursitis Copyright © 2015. F. A. Davis Company

Types of Impingement Force Source Primary subacromial impingement • Irregularly shaped acromion • Spur

Types of Impingement Force Source Primary subacromial impingement • Irregularly shaped acromion • Spur formation on acromion • Os acromiale Secondary subacromial impingement • Loss of humeral head depression or stabilization • Poor posture • Repetitive overhead movement • Scapular dyskinesis • GH instability • Supraspinatus hypertrophy Internal impingement • Glenohumeral internal rotation deficit (GIRD) • GH instability • High volume of throwing or other repetitive overhead activity • Occupation requiring repetitive overhead activity Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Neer Impingement Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Neer Impingement Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Hawkins (Kennedy-Hawkins) Impingement Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Hawkins (Kennedy-Hawkins) Impingement Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Empty Can Test for Supraspinatus Pathology Copyright © 2015. F. A.

Selective Tissue Test: Empty Can Test for Supraspinatus Pathology Copyright © 2015. F. A. Davis Company

Pathologies of the Shoulder and Related Special Tests § Biceps tendon pathology § Bicipital

Pathologies of the Shoulder and Related Special Tests § Biceps tendon pathology § Bicipital tendinopathy § Causes § RTC dysfunction § Impingement § Superior labrum anterior to posterior lesions (SLAP lesions) § Tears of the superior aspect of the glenoid labrum that extend anteriorly and posteriorly to the biceps insertion Copyright © 2015. F. A. Davis Company

Classification of SLAP Lesions Type Pathology I Degenerative fraying of the labrum near the

Classification of SLAP Lesions Type Pathology I Degenerative fraying of the labrum near the insertion of the LHBT II Avulsion of the glenoid labrum with an associated tear of the LHBT Type II SLAP lesions have been further classified relative to the detachment of the labrum: • Isolated to the anterior aspect • Isolated to the posterior aspect • Appearing in both aspects III A bucket-handle tear of the labrum with displacement of the fragment; no involvement of the LHBT IV Bucket-handle tear of the labrum with associated tearing of the LHBT = long head of the biceps tendon; SLAP = superior labrum anterior to posterior Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Yergason Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Yergason Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Speed Test for Long Head of the Biceps Brachii Tendinopathy Copyright

Selective Tissue Test: Speed Test for Long Head of the Biceps Brachii Tendinopathy Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Active Compression Test (O’Brien Test) Copyright © 2015. F. A. Davis

Selective Tissue Test: Active Compression Test (O’Brien Test) Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Anterior Slide Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Anterior Slide Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Anterior Slide Test Compression-Rotation (Grind) Test Copyright © 2015. F. A.

Selective Tissue Test: Anterior Slide Test Compression-Rotation (Grind) Test Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

Copyright © 2015. F. A. Davis Company

On-Field Examination of Shoulder Injuries § Equipment considerations § Palpation under the shoulder pads

On-Field Examination of Shoulder Injuries § Equipment considerations § Palpation under the shoulder pads § Unlatch shoulder pad straps § Palpate under cantilever or through neck opening § Palpation should be gentle to begin. § Removal of the shoulder pads § Unlatch shoulder pad straps § Remove uninjured arm § Slide shirt and shoulder pads up over head § If shirt is too tight, cut it off. § Drop it down over injured arm Copyright © 2015. F. A. Davis Company

On-Field Examination of Shoulder Injuries Copyright © 2015. F. A. Davis Company

On-Field Examination of Shoulder Injuries Copyright © 2015. F. A. Davis Company

On-Field Examination of Shoulder Injuries On-field history On-field inspection § § § Location of

On-Field Examination of Shoulder Injuries On-field history On-field inspection § § § Location of pain § Upper shoulder § AC sprain § Trapezius § Brachial plexus injury MOI § Internal or external rotation (with abduction) § GH joint dislocation or subluxation § FOOSH § Clavicular fracture, AC sprain, SC sprain Copyright © 2015. F. A. Davis Company § Arm posture § Arm splinted against torso § Arm hanging limply at the side § Arm “locked” Gross deformity

On-Field Examination of Shoulder Injuries On-field palpation Additional on-field tests § If joint dislocation

On-Field Examination of Shoulder Injuries On-field palpation Additional on-field tests § If joint dislocation or bony fracture have been ruled out § Apley scratch test can be used as a gross assessment of the athlete’s willingness to move the involved extremity and the amount of motion § § § Copyright © 2015. F. A. Davis Company Position of the humeral head AC joint alignment Clavicle Sternoclavicular joint Humerus

Initial Management of On-Field Shoulder Injuries § Scapular fracture § § Body of the

Initial Management of On-Field Shoulder Injuries § Scapular fracture § § Body of the scapula Glenoid fossa Glenoid neck Coracoid process § Management § Immobilize the arm on the affected side in a comfortable position § Athlete then is transported. § GH dislocation also needs a radiographic evaluation to rule out a secondary fracture to the glenoid or coracoid process. Copyright © 2015. F. A. Davis Company

On-Field Examination of Shoulder Injuries § Clavicular injuries § Clavicular fracture § Immobilization using

On-Field Examination of Shoulder Injuries § Clavicular injuries § Clavicular fracture § Immobilization using a sling or triangular bandage § Transport for definitive diagnosis Copyright © 2015. F. A. Davis Company

On-Field Examination of Shoulder Injuries § Sternoclavicular joint injuries § Neurological and vascular examination

On-Field Examination of Shoulder Injuries § Sternoclavicular joint injuries § Neurological and vascular examination of the extremity and carotid artery § Involved arm is immobilized. § Athlete is immediately transported to an emergency medical facility. Copyright © 2015. F. A. Davis Company

On-Field Examination of Shoulder Injuries § Acromioclavicular joint injuries § Immobilize in a position

On-Field Examination of Shoulder Injuries § Acromioclavicular joint injuries § Immobilize in a position that lessens the displacement between the clavicle and the acromial process § Protect joint with additional padding during activity Copyright © 2015. F. A. Davis Company

On-Field Examination of Shoulder Injuries § Glenohumeral dislocations § Monitor the distal pulses, check

On-Field Examination of Shoulder Injuries § Glenohumeral dislocations § Monitor the distal pulses, check for circulation in the fingertips, and perform a sensory screen § Arm is fixed in the position it has assumed. § Reductions of GH dislocations should only be performed by those who are trained to do so. Copyright © 2015. F. A. Davis Company

On-Field Examination of Shoulder Injuries § Glenohumeral dislocations (cont. ) § Forced reduction of

On-Field Examination of Shoulder Injuries § Glenohumeral dislocations (cont. ) § Forced reduction of the humeral head may damage the glenoid fossa, the coracoid process, or the neurovascular structures in the area. Following reduction, assess distal pulse and active range of motion, avoiding external rotation and abduction. Stabilize the shoulder using a sling, and refer the athlete for further examination. Copyright © 2015. F. A. Davis Company

On-Field Examination of Shoulder Injuries § Humeral fractures § Splint in position found using

On-Field Examination of Shoulder Injuries § Humeral fractures § Splint in position found using moldable splint or vacuum splint § Leave wrist and fingers exposed to check circulation § Transport Copyright © 2015. F. A. Davis Company