Injuries to the Shoulder Region

Injuries to the Shoulder Region• In this chapter we will discuss the gross anatomy and

arthrology of the articulations of the shoulder• We will briefly discuss acute and chronic injuries of

the shoulder region which will include:▫Acromioclavicular, sternoclavicular, and glenohumeral

joints• We will review musculotendinous injuries of the

shoulder region related to common mechanisms of injury such as throwing and swinging

• We will discuss certain injuries in detail such as impingement syndrome, biceps tendinitis and contusions of the shoulder

•http://www.youtube.com/watch?v=fpGVid

vdlio

A little anatomy • The skeleton of the shoulder

consists of bones of the shoulder girdle and the upper arm bone (humerus)

• The clavicle and scapula make up the shoulder girdle

• The head of the humerus combines with the shallow glenoid fossa of the scapula to form the glenohumeral (GH) joint, also known as the shoulder joint

• The GH joint is given additional stability by a fibrocartilaginous cuplike structure known as the glenoid labrum

A little Anatomy • Also includes the

acromioclavicular (AC) joint located between the distal end of the clavicle and the acromion of the scapula

• The sternoclavicular (SC) joint is located between the proximal end of the clavicle and the manubrium of the sternum

• Each joint is held together with ligaments and joint capsules that provide stability while also allowing for necessary movement

A little Anatomy

•In nearly all motions the shoulder girdle and the GH joint work together to move the arm

•Consequently, any limitation from injury to the shoulder girdle will indirectly affect the GH joint

•The muscles in the shoulder can be divided into two groups: ▫Those that act on the shoulder girdle▫Those that act on the GH joint

A little Anatomy • Muscles of the shoulder

girdle are levator scapulae, trapezius, rhomboids, subclavius, pectoralis minor, and serratus anterior▫ Collectively contribute to

the movements of the shoulder girdle Which include scapular

retraction and protraction, upward and downward scapular rotation, elevation and depression

A little Anatomy • Muscles that act on the GH

joint include the pectoralis major, latissimus dorsi, deltoid, teres major, coracobrachialis and rotator cuff muscles

• The rotator cuff muscles include▫ Supraspinatus,

infraspinatus, teres minor, subscapularis

• Movements normally attributed to the joint consist of flexion, extension, horizontal flexion and extension, internal and external rotation, abduction and adduction

A little Anatomy •In athletes a large amount of soft tissue

covers both the shoulder girdle and the GH joint

•As a result, they are somewhat protected from external blows

•However, even in extremely muscular athletes both the AC and SC joints lie just under the skin and are therefore more exposed to injury

Anatomy • The blood supply to the

entire upper extremity, including the shoulder, originates from branches of the subclavian artery

• As it passes through the axillary region it becomes the axillary artery; it continues into the upper arm, becoming the brachial artery, and splits just distal to the elbow into the radial and ulnar arteries that extend into the forearm and hand

Anatomy • Major nerves of the

shoulder and upper extremity originate from that group known as the brachial plexus

• Originates from the ventral primary divisions of the 5th through the 8th cervical nerves and the first thoracic nerve

Common Sports Injuries…•Injuries to the shoulder region are common

in many sports and in some cases are highly sport specific

•Injuries to both the GH and AC joints are quite common in wrestling

•Sports that emphasize a throwing or swelling action often produce injuries caused by overuse to the muscles of the rotator cuff (infraspinatus, supraspinatus, teres minor, subscapularis), which act on the GH joint

Common Sports Injuries…•The rotator cuff (RC) muscles are

extremely important to the stability of the GH joint because this large ball-and-socket structure lacks inherent strength

•Sports such as cycling and skating produce a large number of fractures of the clavicle brought about by falls

Common Sports Injuries…• Injuries of the shoulder region

can be classified as either acute or chronic

• Sports involving heavy contact or collisions yield more acute injuries; those necessitating repeated movements tend to produce more chronic injuries

• Activities that have a high incidence of clavicular injury include ice hockey, football, martial arts, lacrosse, gymnastics, weight lifting, wrestling, racquetball, squash, and bicycling

Skeletal InjuriesFractured Clavicle…

• Most common fracture of the shoulder region is a fracture of the clavicle

• Can result from direct blows to the bone; however, the majority occur as a result of falls that transmit the force to the clavicle either through the arm or shoulder

• Majority occur about midshaft; the remainder involve either the proximal or distal end of the bone (American Academy of Orthopaedic Surgeons [AAOS], 1991).

http://www.youtube.com/watch?v=7lSXGi-7MFg

Fractured Clavicle…• In the adolescent athlete

another type of clavicular fracture, commonly known as a greenstick fracture can occur

• This fracture occurs in immature bone and involves a cracking, splintering type of injury

• Although a fractured clavicle is potentially dangerous given the close proximity of the bone to the major blood vessels and nerves, the vast majority cause few complications

Fractured Clavicle…• Signs and Symptoms:

▫ Swelling and/or deformity of the clavicle

▫ Discoloration at the site of the fracture

▫ Possible broken bone end projecting through the skin

▫ Athlete reporting that a snap or pop was felt or heard

▫ Athlete holding the arm on the affected side to relieve pressure on the shoulder girdle

Fractured Clavicle…•Tx:

▫Treat for possible shock▫Carefully apply a sling-and-swathe bandage ▫Apply sterile dressings to any related

wounds▫Arrange for transport to a medical facility

Skeletal InjuriesFractured Scapula

• Much less common fracture

• Unique group of scapular fractures among professional football players was described by Cain and Hamilton (1992) in the American Journal of Sports Medicine

• These fractures resulted from direct blows to the shoulder region

• The symptoms of this type of fracture are less clear than those related to fractures of the clavicle

Fractured Scapula…• An athlete with a hx of a severe blow to the

shoulder region, followed immediately by considerable pain and loss of function, should be referred to a physician for further evaluation

• Can be identified only by X-ray analysis• TX

▫Determined by specific location and extent of the fracture(s)

▫Athletes arm will be placed in a sling, and the player will be removed from sports participation for a period of 6 weeks

Soft-Tissue Injuries•A variety of sprains and strains involving

any number of specific ligaments and tendons occur in this region

•Although any joint can sustain a sprain, the GH and AC joints are the most commonly injured in the shoulder region in sports

Acromioclavicular (AC) Joint Injuries…• This synovial articulation

is supported by the superior and inferior AC ligaments and contains an intra-articular cartilaginous disk as well (Dias & Gregg, 1991)

• Additional support is provided by the coracoclavicular (CC) ligament which comprises the trapezoid and conoid ligaments

• The CC ligament is attached between the superior coracoid process and the inferior lateral surface of the clavicle

Acromioclavicular (AC) Joint Injuries…• Typical mechanism of injury for the AC joint is a

downward blow to the outer end of the clavicle, which results in the acromion process being driven inferiorly while the distal clavicle remains in place

• Another mechanism is a fall forward on an outstretched arm, which then transmits the force up the extremity and results in the humeral head driving the acromion superiorly and posteriorly while the clavicle remains in place (O’Donoghue, 1976)

• Either of these two can result in varying degrees of ligament damage

Acromioclavicular (AC) Joint Injuries…• The severity of the injury is

graded based on the amount of damage to specific ligaments

1. First degree, no significant damage, all ligaments intact

2. Relatively severe damage (tearing) of the ligaments. There will be no abnormal movement, and the clavicle will be in the normal position

3. Complete rupture of the AC ligament with an intact CC ligament; complete rupture of both the AC and CC ligaments

Acromioclavicular (AC) joint injuries…

• Signs and Symptoms▫With first and second degree sprains there will be

mild swelling with point tenderness and discoloration around the AC joint

▫Any movement of the shoulder region will elicit pain▫With a third degree sprain there will be significant

deformity in the region of the AC ligament In the case of ruptures of both the AC and CC

ligaments, there will be total displacement of the clavicle

▫The athlete may report having felt a snap or heard a pop

Acromioclavicular (AC) joint injuries…•TX:

▫Immediately apply ice and compression Best accomplished by placing a bag of crushed

ice over the AC joint and securing it with an elastic wrap tied in a figure-eight configuration

▫Once the ice and compression are in place, apply a standard sling and swathe bandage

▫Immediately refer the athlete to a medical facility for further evaluation

▫In the event of severe injury, arrange for transport and treat for shock

Acromioclavicular (AC) joint injuries…•Long term treatment for AC separations is

dependent on the level of severity of the injury

•In the case of first degree and relatively minor second degree sprains, rest and immobilization are normally effective

•Several surgical procedures have been employed▫However research indicates that more

conservative, nonsurgical approaches may be just as effective

Glenohumeral Joint Injuries…• This articulation consist of a

relatively large humeral head opposing the rather shallow glenoid fossa of the scapula

• This bony arrangement is effective in giving the joint a greater deal of mobility

• The GH joint is classified as a spheroidal articulation that moves within all three planes of motion: frontal, sagittal, and transverse

• However, this mobility makes the GH joint very unstable

• The major soft-tissue structures of the GH joint include the capsular ligament and the coracohumeral ligament

Glenohumeral Joint Injuries…• Typical mechanism of injury

for the GH joint involves having the arm abducted and externally rotated▫ The anterior portion of the

joint capsule can be stressed beyond its capacity

▫ If the ligament fails, the head of the humerus can move forward and out of place which leads to an anterior dislocation

• Depending on the severity, this injury may be either a subluxation or a complete dislocation

• http://www.youtube.com/watch?v=GsaqCQCcJNY

• http://www.youtube.com/watch?v=09ZZbJzeKUA

Glenohumeral Joint Injuries• Signs and Symptoms:

▫Deformity of the shoulder joint: the normal contour of the shoulder is lost, and it appears to slope down abnormally

▫The arm of the affected side will appear longer than normal

▫The head of the humerus will be palpable with the axilla

▫The athlete will be supporting the arm on the affected side with the opposite arm

▫The athlete will resist all efforts passively or actively to move the GH joint

Glenohumeral Joint Injuries…•TX:

▫Immediately apply ice and compression▫Place a bag of ice on the front and back of

the shoulder joint and secure with an elastic wrap tied in a figure eight configuration

▫Apply a standard sling and swathe bandage ▫Immediately refer the athlete to a medical

facility for further evaluation▫Because soft-tissue injury may be

extensive, treat for shock

Glenohumeral Joint Injuries…• A common complication of GH joint sprains is chronic

GH joint subluxation• Once sustained, up to 85% to 90% of all traumatic

anterior GH joint dislocations recur (Arnheim, 1987)• The joint capsule, ligaments, and supporting

musculature are often stretched, leading the joint to become progressively less stable

• Certain movements, abduction and external rotation, the joint will pop out and then return to its normal position

• Usually treated conservatively with rest and exercises that specifically focus on the muscles surrounding the joint, including the rotator cuff

Sternoclavicular Joint Injuries…• The SC joint is formed by

the union of the proximal end of the clavicle and the manubrium of the sternum

• strengthened by several ligaments▫ Joint capsule, anterior and

posterior SC ligaments, the interclavicular and costoclavicular ligaments, and an articular disk located within the joint

• Although there are fewer injuries to the SC joint that to either the AC or GH joints, the coach should be prepared to recognize and treat them correctly

Sternoclavicular Joint Injuries…• The mechanism of injury for the SC joint

involves and external blow to the shoulder region that results in a dislocation of the proximal clavicle

• A sprain to the SC joint can range in severity from minor stretching, with no actual tearing of tissues, to a complete rupture of ligaments and extensive soft tissue damage

• Fortunately, anterior/superior dislocations cause few additional problems and are easily treated

Sternoclavicular Joint Injuries…•Occuring much less frequently, but

potentially more dangerous, is a posterior SC dislocation▫The proximal end of the clavicle is

displaced posteriorly, with the possibility of placing direct pressure on soft-tissue structures in the region such as blood vessels or even the esophagus and trachea (AAOS, 1991)

Sternoclavicular Joint Injuries…• Signs and Symptoms:

▫In most cases (2nd and 3rd degree sprains) there will be gross deformity present at the SC joint

▫Swelling will be immediate▫Movement of the entire shoulder girdle will be

limited owing to pain within the SC joint▫Having heard a snapping sound or may have

experienced a tearing sensation at the SC joint▫Note the body position of the athlete, because in

this injury the arm may be held close to the body and the head/neck may be tilted/flexed toward the injured shoulder

Sternoclavicular Joint Injuries…•TX:

▫Apply ice and compression▫Take care not to put pressure over the

airway when wrapping▫Place the arm of the affected shoulder in a

standard sling-and-swathe▫In cases of severe soft-tissue damage, treat

the athlete for shock

Sternoclavicular Joint Injuries…• Medical tx for the majority

of SC joint sprains is conservative, that is, reduction of the dislocation if present followed by 2 to 3 weeks of support with a sling-and-swathe bandage

• Very rare that surgical correction is needed

• Obviously a sound program of rehabilitation exercises prescribed by a competent sports medicine professional will be helpful in getting the athlete back into action

Strains of the Shoulder Region…•A large number of muscles attach to the

bones of the shoulder girdle, any one of which can suffer a strain

•Certain sports produce very specific injuries to the shoulder

•The most common strain involves the muscles of the rotator cuff

Rotator Cuff Injuries…• The muscles of the rotator

cuff serve a variety of purposes, including stabilization of the humeral head in the glenoid fossa as well as abduction and internal and external rotation of the GH joint▫ The muscles consist of

subscapularis, supraspinatus, infraspinatus, and teres minor

Rotator Cuff Injuries…

•To better understand the mechanism one must review and understand the kinesiology of the overhand throw and/or swing

•Throwing has been described as a five-phase process involving:▫Windup▫Cocking▫Acceleration▫Release▫Follow-through

Rotator Cuff InjuriesFive phase of throwing

1. Wind-up requires putting the entire body in to the best position to generate throwing forces

2. Cocking involves pulling the throwing arm into an abducted and externally rotated position at the GH joint• Incorporates a concentric contraction (occurs when a

muscle shortens and there is movement at the joint accompanied by contraction against resistance)

3. Acceleration phase involves a sudden reversal of cocking: the arm s moved rapidly into internal rotation, horizontal flexion, and adduction of the GH joint via concentric contractions of muscles such as the pectoralis major, anterior deltoid, teres major, lattissmus dorsi and triceps

Rotator Cuff InjuriesThe phases of throwing

4. Release phase is the shortest in the throwing cycle and involves timing the release at the point of maximum velocity

5. The follow-through requires that the entire upper extremity be decelerated immediately after the release

Rotator Cuff Injuries…• It is critical to note that several muscles of the

rotator cuff are actively contracting eccentrically in an effort to slow the arm down

• The vast majority of strains to the rotator cuff occur during the follow-through phase, specifically during the eccentric phase of the contraction

• This problem is made worse when the muscles of the rotator cuff are significantly weaker than those muscles involved in the acceleration phase▫This problem can be eliminated with a proper

designed conditioning program aimed at strengthening the muscles of the rotator cuff

Rotator Cuff Injuries…•Strains = overuse•Develop slowly over many weeks or

months•Proper warm-up of the throwing and/or

swinging arm ca help reduce the stress on the musculature of the shoulder girdle

Rotator Cuff Injuries…• Signs and Symptoms:

▫ Pain within the shoulder, especially during the follow-through phase of a throw or swing

▫ Difficulty in bringing the arm up and back during the cocking phase of a throw or swing

▫ Pain and stiffness within the shoulder region 12 to 24 hours after a practice or competition that involved throwing or swinging

▫ Point tenderness around the region of the humeral head that appears to be deep within the deltoid muscle

▫ Rotator cuff injuries can also mimic many others common to the shoulder region, including bursitis and tendinitis

Rotator Cuff Injuries…• TX:

▫ Overuse injuries are difficult to treat effectively without a thorough medical evaluation

▫ The application of ice and compression may prove helpful in reducing the pain and loss of function associated with the injury

▫ Athlete will report repeated episodes of symptoms spanning many weeks or even months

▫ Medical referral for a complete evaluation is essential

• http://www.youtube.com/watch?v=64VhamtSdss

Glenohumeral Joint-Related Impingement Syndrome•To impinge means to be forced “upon or

against something”•A syndrome is defined as “a number of

symptoms occurring together and characterizing a specific disease”

•Hence, an impingement syndrome of the shoulder occurs when a soft-tissue structure such as a bursa or tendon is squeezed between moving joint structures, resulting in irritation and pain

Glenohumeral Joint-Related Impingement Syndrome• In the case of the GH

joint, the most common impingement occurs to the tendon of the supraspinatus muscle as it passes across the top of the joint

• The region located directly beneath the acromion process is known as the subacromial space

• The floor of the subacromial space is the GH joint capsule

• The ceiling comprises the acromion process and the coracoacromial ligament

Glenohumeral Joint-Related Impingement Syndrome•Any condition, whether related to sports

or congenital, that decreases the size of the subacromial space may result in the development of an impingement syndrome

•The most common causes of GH joint-related impingment syndromes are “automatic variations in the coracoacromial arch” that cause damage to the structures found in the subacromial space

Glenohumeral Joint-Related Impingement Syndrome•Athletes who participate in sports placing

an emphasis on arm movements above the shoulder level demonstrate a higher rate of impingement problems when compared with athletes who take part in sorts not emphasizing such movements

•A survey of athletes in sports requiring arm motions found the high-risk sports to include volleyball, badminton, basketball, gymnastics, squash, swimming, table tennis, tennis, and track and field events

Glenohumeral Joint-Related Impingement Syndrome• Signs and Symptoms:

▫ Pain when the GH joint is abducted and externally rotated in conjunction with loss of strength

▫ Pain whenever the arm is abducted beyond 80 to 90 degrees

▫ Nocturnal pain▫ Pain felt deep within the

shoulder

Glenohumeral Joint-Related Impingement Syndrome• TX:

▫Any athlete complaining of the signs and symptoms listed should be referred for a complete medical evaluation

▫Rest, anti-inflammatory drugs, and physical therapy▫If these fail, surgery to correct the problem may be

prescribed This can be done arthroscopy Involves procedures such as removal of bone spurs

from beneath the acromion process, release of the coracoacromial ligament or a resectioning of a portion of the undersurface of the acromion process

Biceps Tendon Injuries…• The anatomy of the GH

joint includes the tendon of the long head of the biceps brachii muscle

• The tendon passes into the joint capsule and is surrounded by a specialized portion of the synovium of the joint

• As the tendon continues through the joint, it runs across the superior surface of the humeral head

Biceps Tendon Injuries…• The tendon of the long

head of the biceps brachii originates from the supraglenoid tubercle

• The short head of the biceps brachii derives from the nearby coracoid process

• This tendon remains anatomically separate from the GH joint

• The tendon of the long head of the biceps brachii is located directly beneath the acromion process; therefore, it can suffer a type of impingemenet similar to that seen in the supraspinatus tendon

Biceps Tendon Injuries•Athletes at risk for this injury include those

involved in sports that place an emphasis on repetitive overhead movements with the arms

•Another problem related to the long head tendon of the biceps brachii is tendinitis, which may lead to a subluxation of the tendon from the bicipital groove

•In most cases, tendinitis will develop slowly over a period of weeks or months

•As the tendon enlarges as a result of the inflammation, it becomes less stable in the groove

Biceps Tendon Injuries…• In chronic cases, a sudden

violent force such as is commonly generated in throwing may cause the tendon to subluxate out of the groove, thereby stretching and tearing the ligament

• The athlete will notice significant symptoms if the tendon subluxates from the bicipital groove

Biceps Tendon Injuries…• Signs and Symptoms:

▫ Painful abduction of the shoulder joint similar to that seen in impingement problems

▫ Pain in the shoulder joint when the athlete supinates the forearm against any resistance

▫ When actively flexing and supinating the forearm against resistance, the athlete may note a popping or snapping sensation as the tendon of the long head of the biceps brachii subluxates

• TX:▫ Not a practical concern

because they generally develop over time and fall into the category of a chronic injury

▫ Immediate application of ice and compression

▫ Long-term care for this injury includes rest, anti-inflammatories, and gradually progressive exercise rehabilitation

▫ If symptoms persist and the tendon continues to subluxate from the bicipital groove, then surgery may be an option

Contusions of the Shoulder Region• External blows around the shoulder region are a

common occurrence in a variety of sports• The GH joint is well protected by muscles

crossing over the joint, such as the deltoid• The nearby AC joint, however, is exposed and

quite vulnerable to external blows• If the athlete sustains a contusion to this joint,

the result can be an extremely painful condition known as a shoulder pointer (contusion and subsequent hematoma in the region of the AC joint)

Contusions to the Shoulder Region• Signs and Symptoms

▫ History of a recent blow to the shoulder, with pain and dec ROM

▫ Spasm if muscle tissue is involved▫ Discoloration and swelling,

especially over bony regions such as the AC joint

• TX:▫ Immediately apply ice and

compression directly over the area

▫ In case of severe pain, arm sling to relieve stress on the shoulder region

▫ If significant swelling persist for more than 72 hours in the AC joint, refer the athlete to a physician