kin 191 b – shoulder injuries

KIN 191B – Advanced Assessment of Upper Extremity Injuries

Shoulder Injuries

Shoulder Pathologies

• Sternoclavicular (SC) joint injuries• Acromioclavicular (AC) joint injuries• Glenohumeral (GH) joint injuries• Rotator cuff injuries• Biceps tendon injuries• Thoracic outlet syndrome• Fractures

Sternoclavicular Joint Injuries

• Common etiology is via longitudinal force application (fall on outstretched arm, etc.) to distal clavicle

• Most common direction of dislocation is anterior – potential concerns if posterior

Sternoclavicular Joint Injuries

• Signs/symptoms include point tenderness, crepitus, displacement, pain/limitation to ROM especially during 0-90 degrees of abduction (SC axis of movement)

• Ligamentous tests evaluate for abnormal glide/motion at SC joint (multidirectional)

• Usually managed conservatively (immobilized) and then PRE as tolerated

Acromioclavicular Joint Injuries

• Horizontal stability (A/P) from AC ligaments and vertical stability (superior) from coracoclavicular ligaments

• Common mechanisms include:– Landing on outstretched arm– Landing on or direct blow to acromion process

(“tip of shoulder”)– Force on distal clavicle when scapula is fixed


• Signs/symptoms include point tenderness, displacement (step-off), pain/limitation to ROM, especially at 90+ degrees of abduction (AC axis of movement) – horizontal adduction (cross arm test) is good evaluative and return to play test)


• AC sprain classifications– Grade I – point tenderness, no displacement (AC

ligament microtrauma)– Grade II – some laxity and step-off present (AC

ligament ruptured and some damage to CC ligament)

– Grade III – significant laxity and step-off (rupture of AC and CC ligaments)

AC Sprain Classifications


• Ligamentous stress tests include “piano key” test (step-off at distal clavicle), AC traction test (vertical instability), AC compression test (horizontal instability)

• Usually managed conservatively (immobilized) although some grade II/III sprains managed surgically

Glenohumeral Joint Injuries

• Can be due to ligamentous and/or labral pathology, capsular instability (“freaks”), or muscular weakness

• Normal GH function is delicate balance between static and dynamic stabilizers of structurally unstable joint


• Severity of injury classified as with previous ligamentous injury discussion– Grade I – microtrauma– Grade II – partial tear– Grade III – complete rupture

• Grades then contribute to differing amounts of humeral head displacement on glenoid relative to nature of ligamentous injury

GH Injury Management

• If sublux/dislocate prior to age 30, >90% likelihood of recurrent episodes, so typically repair surgically

• If occurs after age 30, can decide between surgical and conservative management– Conservative management must focus on

strengthening dynamic stabilizers since static stabilizers have been compromised


• Anterior instability

• Posterior instability

• Inferior instability

• Multidirectional instability

Anterior GH Instability

• Primary etiology is abduction and external rotation – can also result from P-A forces

• Signs/symptoms generally include generalized pain/tenderness in shoulder, limited/painful ER ROM, pain/weakness to ER, anterior glide/translation of humerus on glenoid, flattened deltoid contour

Anterior GH Dislocation

Anterior GH Instability

• Bankart lesion– Inferior GH ligament avulsed with/without

corresponding portion of glenoid labrum

• Hill-Sachs lesion– Defect in posterior humeral head from impact on

glenoid fossa as humerus attempts to reduce

Bankart Lesion

Hill-Sachs Lesion

Anterior GH Special Tests

• Apprehension sign/test– Abduction/external rotation (90/90) position from supine

position– Positive if pain and/or apprehension

• Relocation test– Apprehension test secondary to manual A-P force to

humeral head– Positive if pain with apprehension and no pain with

relocation• Anterior GH glide/translation/drawer– May be done supine, side laying, sitting

Apprehension/Relocation Tests

Posterior GH Instability

• Much less common than anterior instability• Primary etiology is posterior force application with

shoulder flexed and internally rotated – usually cumulative trauma that presents with a single event

• Signs/symptoms include generalized shoulder pain/tenderness, limited/painful IR, weakness/pain to IR, posterior glide/translation of humerus on glenoid

GH Dislocation

Posterior GH Special Tests

• Posterior apprehension test– 90/90 position, scapula stabilized by the table, posterior

(A-P) force applied to proximal humerus• Test for posterior instability in the plane of the

scapula– Abducted to 90, horizontally adducted to 30 (plane of

scapula), posterior (A-P) translation to proximal humerus• Posterior GH glide/translation/drawer– May be done supine, side laying, sitting

Posterior Apprehension Test

Inferior GH Instability

• Signs/symptoms include anterior shoulder pain/tenderness, limited/painful ROM, weakness/pain to IR/ER, increased GH glide in all directions

• Essentially becomes indicator for multidirectional GH instability – rarely if ever present in isolation

Inferior GH Special Test

• Sulcus sign– In “neutral” position, distraction (inferior) force

applied to humerus– Positive if sulcus (“divot”) appreciated beneath

the acromion process – indicative of multidirctional GH instability

– If sulcus sign positive at 90 degrees of flexion, more indicative of inferior GH instability

Sulcus Sign

Rotator Cuff Injuries

• Impingement syndrome

• Rotator cuff tendonitis

• Subacromial bursitis

Impingement Syndrome

• Impingement and inflammation of rotator cuff tendons in subacromial space essentially represent vicious cycle (cause and effect)

• Caused by reduction in space beneath coracoacromial arch– RTC tendons (supraspinatus), long head of biceps

brachii tendon, subacromial bursa

Impingement


• Most commonly caused by anatomical changes/abnormalities that compromise those tissues (anomaly, scarring, etc.)

• Fatigue/weakness from overuse can impinge under acromion since humeral head depression is affected

• Also may have problems if scapular motion (rhythm) is compromised (weakness, muscle imbalances, biomechanical issues)


• Signs/symptoms dominated by limitations/pain/weakness to shoulder motions (esp. IR/ER) above 90 degrees, also may have localized tenderness/pain

• Often present with painful arc of motion between ~45-120 degrees of flexion and/or abduction

Painful Arc

Impingement Tests

• Neer test– Performed standing or sitting, shoulder passively

flexed and internally rotated– Positive if pain with motion, esp. at end range

• Hawkins-Kennedy test– Performed standing or sitting, shoulder in 90/90

position (scapular plane is best), shoulder passively internally rotated

– Positive if pain with motion, esp. at end range

Impingement Tests

Rotator Cuff Tendonitis

• Anatomically predisposed to injury– Poor vascular supply to tendons in subacromial space –

“wringing out” with rotation movement– Shape and location of acromion process also can

compromise• Type I – flat• Type II – gently curved• Type III – “beaked” or hooked – high likelihood of contributing to

rotator cuff pathology• Type IV – inferior spurs off acromion – almost certain to

experience rotator cuff pathology

Types of Acromion Processes

Rotator Cuff Tendonitis

• Classification of rotator cuff tendonitis– Grade I (mild) – pain after activity only– Grade II (moderate) – pain during and after activity– Grade III (severe) – pain with ADLs

• Signs/symptoms include tenderness to subacromial area, greater tuberosity, biceps tendon, pain/weakness/limitation to abduction, IR, ER ROMs

Rotator Cuff Tears

• Arise secondary to inflammatory conditions and associated microtrauma – may occur from single event, but typically overuse and cumulative conditions

• Partial-thickness tears– Short, longitudinal lesions in superficial or midsubstance of

tendons

• Full-thickness tears– Complete disruption of tendinous structure and funtion

Rotator Cuff Tear

Rotator Cuff Tests

• Drop arm test– Positive if individual unable to control adduction of GH

joint from abducted position– Indicative of at least partial rotator cuff tears

• Empty can test– Shoulder abducted to 90 in scapular plane with thumb

down, resistance applied (“isolates” supraspinatus)– Positive if weakness and/or pain elicited– “Full can” modification – better for exercise

Rotator Cuff Tests

Subacromial Bursitis

• Often occurs concurrently with rotator cuff tendonitis/tears – all present as impingement syndromes

• Difficult to isolate one condition vs. another clinically – requires advanced evaluative techniques

Subacromial Bursitis

Management of Impingement Syndromes

• Conservative management focuses initially on rest, NSAIDs, modalities to control sx

• Then must focus on flexibility and strengthening of rotator cuff muscles and scapular stabilizers

• Surgical intervention can include debriding subacromial space or resection of C-A ligament/distal clavicle

Biceps Tendon Injuries

• Bicipital tendonitis

• SLAP lesions

Bicipital Tendonitis

• May occur secondary to rotator cuff injury, overuse of biceps and/or impingement

• May involve transverse humeral ligament injury which causes instability of long head of biceps tendon in bicipital groove

Biceps Tendon Tests

• Yergason’s test– Evaluates for biceps

tendonitis and instability– Arm at side, elbow at 90,

resistance to ER and supination – often also includes elbow flexion

– Positive if pain and/or “snapping” in bicipital groove

Biceps Tendon Tests

• Speed’s test– Evaluative for biceps tendonitis– Resistance to shoulder flexion with elbow extended and

forearm supinated– Positive if painful in bicipital groove

• Ludington’s test– Evaluative for long head of biceps brachii rupture– Hands on head, patient applies downward force to top of

head while clinician palpates tendon for tension– Positive if no tension is present and/or with pain

Biceps Tendon Tests

SLAP Lesions

• S – superior• L – labrum• A – anterior to• P – posterior• Represent tears in glenoid labrum near

attachment of long head of biceps tendon• Often associated with deceleration during

throwing, but not consistent in presentation

SLAP Lesions

• Classifications of SLAP lesions– Type I – labrum frayed near biceps attachment– Type II – labrum avulsed from glenoid with

associated tear of biceps tendon– Type III – non-displaced bucket-handle tear of

labrum with no biceps involvement– Type IV – bucket-handle tear of labrum with

associated tear of biceps tendon

Types of SLAP Lesions

SLAP Lesions

• Active compression (O’Brien) test– Shoulder flexed 90 and horizontally add 15– Resistance applied with shoulder IR, then ER– Positive if pain/clicking with IR, but absent with ER

• May also evaluate with MRI/CT• Most SLAP lesions identified at surgery – may

be debrided or repaired

Thoracic Outlet Syndrome

• Pressure on brachial plexus and/or subclavian artery/vein from:– Presence of cervical rib– Impingement between clavicle and 1st rib– Compression between pec minor and rib cage– Tightness in anterior and middle scalenes

Thoracic Outlet Anatomy


• Cervical rib is outgrowth of C7 vertebrae, only ~10% with cervical rib suffer TOS

• Other compressions are due to anatomical location and influenced by poor posture, forward shoulders, wearing a backpack

• Increased risk with repetitive overhead activities (throwing, swimming, etc.)


• Signs and symptoms:– Neurological – numbness, paresthesia, pain

(especially in C8 and T1 distributions)– Arterial – cool, pale skin, cyanosis to UE– Venous – edema in UE, swollen/prominent veins,

thrombophlebitis (blood clots)

Thoracic Outlet Syndrome Tests

• Adson’s test– Attempts to stretch neurovascular bundle and compress

under anterior scalene– Patient sits with shoulder abd to ~30 and ER, elbow ext,

forearm supinated, clinician palpates for radial pulse– Clinician ER and extends patient’s shoulder and neck is ext

and rotated toward involved side, patient instructed to hold breath

– Positive if radial pulse disappears/diminishes with maneuver – many false positive results

Adson’s Test

Thoracic Outlet Syndrome Tests

• Allen test– Evaluates for TOS from pec minor origin– Patient sits with shoulder in 90/90, clinician

palpates for radial pulse– Clinician horizontally abd and ER shoulder, patient

turns head toward opposite shoulder– Positive if radial pulse disappears/diminishes with

maneuver – many false positive results

Allen Test

Fractures• Scapula– rare occurrences, can involve body but most common to

processes, can be from direct trauma or associated with avulsion/dislocation

• Clavicle– most common in central 1/3 at curvatures, can be from

direct trauma or fall on outstretched arm• Humerus– humeral head fractures associated with GH dislocation,

humeral shaft fractures rare and usually from trauma, some with rotational force

Fractures

kin 191 b – shoulder injuries

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