KIN 257 Prevention and Care of Athletic Injuries

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KIN 257 – Prevention and Care of Athletic Injuries Shoulder Anatomy, Evaluation and Injuries

KIN 257 – Prevention and Care of Athletic Injuries Shoulder Anatomy, Evaluation and Injuries

Anatomy

Anatomy

Bony Anatomy n Sternum n n Clavicle n n n Sternal (proximal) and acromial

Bony Anatomy n Sternum n n Clavicle n n n Sternal (proximal) and acromial (distal) ends Characteristic “s-shape” Humerus n n Manubrium, body, xiphoid process Head, neck, greater/lesser tuberosity, bicipital (intertubercular) groove, deltoid tuberosity Scapula n Vertebral (medial)/axillary (lateral)/superior borders, inferior/superior angles, coracoid/acromion processes, spine, glenoid/supraspinous/infraspinous/subscapular fossas

Bony Anatomy

Bony Anatomy

Bony Anatomy

Bony Anatomy

Articulations n Sternoclavicular (SC) joint n n n Acromioclavicular (AC) joint n n n

Articulations n Sternoclavicular (SC) joint n n n Acromioclavicular (AC) joint n n n Distal clavicle and acromion process Superior/inferior AC ligaments, coracoclavicular ligaments Glenohumeral (GH) joint n n Proximal clavicle and sternum Anterior/posterior SC ligaments Head of humerus and glenoid fossa of scapula Joint capsule is primary ligamentous restraint Reinforced by glenoid labrum Scapulothoracic joint n Not a “true” joint, but significant for shoulder ROM

Articulations

Articulations

Articulations

Articulations

Muscular Anatomy n Muscles acting on the scapula Rhomboid major/minor n Levator scapulae n

Muscular Anatomy n Muscles acting on the scapula Rhomboid major/minor n Levator scapulae n Serratus anterior n Pectoralis major/minor n Trapezius n Latissimus dorsi n

Muscular Anatomy n Muscles acting on the humerus n Rotator cuff (SITS) n n

Muscular Anatomy n Muscles acting on the humerus n Rotator cuff (SITS) n n n n Supraspinatus, infraspinatus, teres minor, subscapularis Deltoid Pectoralis major Latissimus dorsi Teres major Long head of triceps brachii Biceps brachii (short/long heads) Coracobrachialis

Neurological Anatomy n Brachial plexus from cervical spine n n Nerve roots Associated peripheral

Neurological Anatomy n Brachial plexus from cervical spine n n Nerve roots Associated peripheral nerves

Vascular Anatomy n Subclavian artery becomes axillary artery becomes brachial artery

Vascular Anatomy n Subclavian artery becomes axillary artery becomes brachial artery

Evaluation

Evaluation

History n Mechanism of injury (etiology) n n n Direct trauma – contusion, fracture,

History n Mechanism of injury (etiology) n n n Direct trauma – contusion, fracture, dislocation Abduction/external rotation – anterior GH dislocation Fall on outstretched arm – dislocations, fracture Fall on tip of shoulder – AC sprain, clavicle fracture, SC sprain Repetitive overhead movements – tendonitis, impingement syndromes, bursitis

History n Location of pain n n Localized to shoulder – general shoulder pathology

History n Location of pain n n Localized to shoulder – general shoulder pathology Radiating pain – neurological involvement n Unusual sounds/sensations n History of previous injury n n Residual weakness from neck/shoulder injury Biomechanical changes from prior injury can result in increased risk of overuse injuries

History n Change in activity n n Acute/gradual onset of symptoms n n Macrotraumatic

History n Change in activity n n Acute/gradual onset of symptoms n n Macrotraumatic vs. microtruamatic Characterize pain n n Intensity, duration, frequency, surface change, equipment change Location (point with 1 finger) Dull, sharp, burning, throbbing, etc. Rate on scale (1 -10) What increases or decreases? Treatment, medication, evaluation to date

Inspection/Observation n General posture n n Anterior n n Level of shoulders, clavicle contour,

Inspection/Observation n General posture n n Anterior n n Level of shoulders, clavicle contour, deltoid contour, biceps brachii contour Lateral n n Head position, arm splinted to side, “dead arm”, deformity with dislocations Deltoid, acromion process, humerus position Posterior n Vertebral alignment (scoliosis), level of scapulae, muscle tone

Palpation – Anterior Structures n n n n SC joint Clavicle Acromion AC joint

Palpation – Anterior Structures n n n n SC joint Clavicle Acromion AC joint Coracoid process Humeral head Greater tuberosity n n n n Lesser tuberosity Bicipital groove Humeral shaft Pectoralis major Coracobrachialis Deltoid Biceps brachii

Palpation – Posterior Structures n n Spine of scapula Superior angle Inferior angle Rotator

Palpation – Posterior Structures n n Spine of scapula Superior angle Inferior angle Rotator cuff n n Subscapularis Supraspinatus Infraspinatus Teres minor n n n n Teres major Rhomboids Levator scapulae Trapezius Latissimus dorsi Posterior deltoid Triceps brachii

Special Tests n ROM n n n Active – patient/athlete moves joint Passive –

Special Tests n ROM n n n Active – patient/athlete moves joint Passive – clinician moves joint, evaluates end feel Resistive – proximal stabilization and distal application of resistance (“break” test vs. resistance through ROM) n Neurovascular n Stress tests

Range of Motion n Flexion (~180 degrees) n n Extension (~60 degrees) n n

Range of Motion n Flexion (~180 degrees) n n Extension (~60 degrees) n n Posterior deltoid, latissimus dorsi, teres major, triceps brachii (long head) Abduction (~180 degrees) n n Biceps brachii, coracobrachialis, anterior and middle deltoid, pectoralis major (clavicular head) Deltoid, supraspinatus, biceps brachii Adduction (~45 degrees) n Pectoralis major, latissimus dorsi, teres major, coracobrachialis, triceps brachii

Range of Motion n Internal rotation (~70 -80 degrees at 90/90) n n External

Range of Motion n Internal rotation (~70 -80 degrees at 90/90) n n External rotation (~80 -90 degrees at 90/90) n n Infraspinatus, teres minor, supraspinatus, posterior deltoid Horizontal abduction (~45 degrees at 90) n n Subscapularis, pectoralis major, latissimus dorsi, teres major, anterior deltoid Posterior deltoid, infraspinatus, teres minor Horizontal adduction (~120 degrees at 90) n Pectoralis major, anterior deltoid

Range of Motion n Scapular protraction n n Scapular retraction n n Lower trapezius,

Range of Motion n Scapular protraction n n Scapular retraction n n Lower trapezius, pectoralis minor, subclavius Scapular downward rotation n n Upper trapezius, levator scapulae, rhomboids Scapular depression n n Trapezius, rhomboids, levator scapulae Scapular elevation n n Serratus anterior, pectoralis minor Rhomboids, pectoralis minor Scapular upward rotation n Trapezius, serratus anterior

Neurovascular n Neurological evalation n n Nerve root level and peripheral nerve sensory and

Neurovascular n Neurological evalation n n Nerve root level and peripheral nerve sensory and motor distributions Vascular evaluation n n Skin temperature/color Capillary refill Radial pulse Brachial pulse Axillary pulse

Stress Tests n Anterior/posterior translation – SC joint n “Piano key” test – AC

Stress Tests n Anterior/posterior translation – SC joint n “Piano key” test – AC joint n Apprehension test – GH joint (anterior) n Relocation test – GH joint (anterior) n Anterior/posterior glide tests – GH joint n Sulcus test – GH joint (inferior)

Stress Tests n Neer test – rotator cuff impingement n Hawkins-Kennedy test – rotator

Stress Tests n Neer test – rotator cuff impingement n Hawkins-Kennedy test – rotator cuff impingement n Yergason’s test – biceps tendon instability n Speed’s test – biceps tendon irritation n Empty can test – supraspinatus impingement n Drop arm test – rotator cuff tear

Injuries

Injuries

Injuries n SC joint injuries n AC joint injuries n GH joint injuries n

Injuries n SC joint injuries n AC joint injuries n GH joint injuries n Rotator cuff injuries n Biceps tendon injuries n Fractures

SC Joint Injuries n n Most common direction of displacement is anterior Significant potential

SC Joint Injuries n n Most common direction of displacement is anterior Significant potential concerns if posterior

SC Joint Injuries

SC Joint Injuries

AC Joint Injuries n n n Horizontal stability from superior/inferior AC ligaments Vertical stability

AC Joint Injuries n n n Horizontal stability from superior/inferior AC ligaments Vertical stability from coracoclavicular ligaments If “step-off” is present, indicates complete tear of AC ligaments and at least partial tear of coracoclavicular ligaments

AC Joint Injuries

AC Joint Injuries

GH Joint Injuries n n n Anterior much more common than posterior If occurs

GH Joint Injuries n n n Anterior much more common than posterior If occurs before age 30, >90% chance of recurrence – surgery If after age 30 – choose between surgery/rehab

Rotator Cuff Injuries n Impingement syndromes n n Tendinopathy n n “Pinching” of tendons

Rotator Cuff Injuries n Impingement syndromes n n Tendinopathy n n “Pinching” of tendons under acromion process Poor blood supply, “wrung out” with rotation Rotator cuff tears n Usually from cumulative effects

Rotator Cuff Tendinopathy

Rotator Cuff Tendinopathy

Rotator Cuff Tear

Rotator Cuff Tear

Biceps Tendon Injuries n Tendinopathy n n Secondary to biomechanical issues and/or repetitive overuse

Biceps Tendon Injuries n Tendinopathy n n Secondary to biomechanical issues and/or repetitive overuse movements Biceps tendon rupture n n Can occur to long head from glenoid rim, short head from coracoid process or distal tendon from radius at elbow Typically has resultant deformity

Biceps Tendon Rupture

Biceps Tendon Rupture

Fractures n Scapula n n n Clavicle n n Rarely suffers bony injury If

Fractures n Scapula n n n Clavicle n n Rarely suffers bony injury If so, processes most common site Commonly fractured in middle 1/3 Humerus n n Head often injured with GH dislocations Shaft rarely injured unless severe forces