Kin 188 Shoulder Evaluation And Injuries

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  • Kin 188 Shoulder Evaluation And Injuries

    1. 1. KIN 188 – Prevention and Care of Athletic Injuries Shoulder Evaluation and Injuries
    2. 2. Anatomy
    3. 3. Bony Anatomy <ul><li>Sternum </li></ul><ul><ul><li>Manubrium, body, xiphoid process </li></ul></ul><ul><li>Clavicle </li></ul><ul><ul><li>Sternal (proximal) and acromial (distal) ends </li></ul></ul><ul><ul><li>Characteristic “s-shape” </li></ul></ul><ul><li>Humerus </li></ul><ul><ul><li>Head, neck, greater/lesser tuberosity, bicipital (intertubercular) groove, deltoid tuberosity </li></ul></ul><ul><li>Scapula (shoulder blade) </li></ul><ul><ul><li>Vertebral (medial)/axillary (lateral)/superior borders, inferior/superior angles, coracoid/acromion processes, spine, glenoid/supraspinous/infraspinous/subscapular fossas </li></ul></ul>
    4. 4. Bony Anatomy
    5. 5. Bony Anatomy Right shoulder blade
    6. 6. Articulations <ul><li>Sternoclavicular (SC) joint </li></ul><ul><ul><li>Proximal clavicle and sternum </li></ul></ul><ul><ul><li>Anterior/posterior SC ligaments </li></ul></ul><ul><li>Acromioclavicular (AC) joint </li></ul><ul><ul><li>Distal clavicle and acromion process </li></ul></ul><ul><ul><li>Superior/inferior AC ligaments, coracoclavicular ligaments </li></ul></ul><ul><li>Glenohumeral (GH) joint </li></ul><ul><ul><li>Head of humerus and glenoid fossa of scapula </li></ul></ul><ul><ul><li>Joint capsule is primary ligamentous restraint </li></ul></ul><ul><ul><li>Reinforced by glenoid labrum </li></ul></ul><ul><li>Scapulothoracic joint </li></ul><ul><ul><li>Not a “true” joint, but significant for shoulder ROM </li></ul></ul>
    7. 7. Articulations
    8. 8. Articulations
    9. 9. Muscular Anatomy <ul><li>Muscles acting on the scapula </li></ul><ul><ul><li>Rhomboid major/minor: retraction </li></ul></ul><ul><ul><li>Levator scapulae: elevation </li></ul></ul><ul><ul><li>Serratus anterior: protraction </li></ul></ul><ul><ul><li>Pectoralis major/minor: rotation & tilt </li></ul></ul><ul><ul><li>Trapezius: shoulder shrug & retraction </li></ul></ul><ul><ul><li>Latissimus dorsi: depression </li></ul></ul>
    10. 10. Muscular Anatomy <ul><li>Muscles acting on the humerus </li></ul><ul><ul><li>Rotator cuff (SITS) </li></ul></ul><ul><ul><ul><li>Supraspinatus, infraspinatus (ER), teres minor (ER), subscapularis (IR) </li></ul></ul></ul><ul><ul><li>Deltoid :ab </li></ul></ul><ul><ul><li>Pectoralis major: ad </li></ul></ul><ul><ul><li>Latissimus dorsi: </li></ul></ul><ul><ul><li>Teres major: IR </li></ul></ul><ul><ul><li>Long head of triceps brachii: extensor </li></ul></ul><ul><ul><li>Biceps brachii (short/long heads): flexion </li></ul></ul><ul><ul><li>Coracobrachialis: flexion </li></ul></ul>
    11. 11. Neurological Anatomy <ul><li>Brachial plexus from cervical spine </li></ul><ul><ul><li>Nerve roots </li></ul></ul><ul><ul><li>Associated peripheral nerves </li></ul></ul>
    12. 12. Vascular Anatomy <ul><li>Subclavian artery becomes axillary artery becomes brachial artery </li></ul>
    13. 13. Evaluation
    14. 14. History <ul><li>Mechanism of injury (etiology) </li></ul><ul><ul><li>Direct trauma – contusion, fracture, dislocation </li></ul></ul><ul><ul><li>Abduction/external rotation – anterior GH dislocation </li></ul></ul><ul><ul><li>Fall on outstretched arm – dislocations, fracture </li></ul></ul><ul><ul><li>Fall on tip of shoulder – AC sprain, clavicle fracture, SC sprain </li></ul></ul><ul><ul><li>Repetitive overhead movements – tendonitis, impingement syndromes, bursitis </li></ul></ul>
    15. 15. History <ul><li>Location of pain </li></ul><ul><ul><li>Localized to shoulder – general shoulder pathology </li></ul></ul><ul><ul><li>Radiating pain – neurological involvement </li></ul></ul><ul><li>Unusual sounds/sensations </li></ul><ul><li>History of previous injury </li></ul><ul><ul><li>Residual weakness from neck/shoulder injury </li></ul></ul><ul><ul><li>Biomechanical changes from prior injury can result in increased risk of overuse injuries (compensations and modified technique can change tissue use) </li></ul></ul>
    16. 16. History <ul><li>Change in activity </li></ul><ul><ul><li>Intensity, duration, frequency, surface change, footwear change </li></ul></ul><ul><li>Acute/gradual onset of symptoms </li></ul><ul><ul><li>Macrotraumatic vs. microtruamatic </li></ul></ul><ul><li>Characterize pain </li></ul><ul><ul><li>Location (point with 1 finger) </li></ul></ul><ul><ul><li>Dull, sharp, burning, throbbing, etc. </li></ul></ul><ul><ul><li>Rate on scale (1-10) </li></ul></ul><ul><ul><li>What increases or decreases? </li></ul></ul><ul><li>Treatment, medication, evaluation to date </li></ul>
    17. 17. Inspection/Observation <ul><li>General posture </li></ul><ul><ul><li>Head position, arm splinted to side, “dead arm”, deformity with dislocations </li></ul></ul><ul><li>Anterior </li></ul><ul><ul><li>Level of shoulders, clavicle contour, deltoid contour, biceps brachii contour </li></ul></ul><ul><li>Lateral </li></ul><ul><ul><li>Deltoid, acromion process, humerus position </li></ul></ul><ul><li>Posterior </li></ul><ul><ul><li>Vertebral alignment (scoliosis), level of scapulae, muscle tone </li></ul></ul>
    18. 18. Palpation – Anterior Structures <ul><li>SC joint </li></ul><ul><li>Clavicle </li></ul><ul><li>Acromion </li></ul><ul><li>AC joint </li></ul><ul><li>Coracoid process </li></ul><ul><li>Humeral head </li></ul><ul><li>Greater tuberosity </li></ul><ul><li>Lesser tuberosity </li></ul><ul><li>Bicipital groove </li></ul><ul><li>Humeral shaft </li></ul><ul><li>Pectoralis major </li></ul><ul><li>Coracobrachialis </li></ul><ul><li>Deltoid </li></ul><ul><li>Biceps brachii </li></ul>
    19. 19. Palpation – Posterior Structures <ul><li>Spine of scapula </li></ul><ul><li>Superior angle </li></ul><ul><li>Inferior angle </li></ul><ul><li>Rotator cuff </li></ul><ul><ul><li>Subscapularis </li></ul></ul><ul><ul><li>Supraspinatus </li></ul></ul><ul><ul><li>Infraspinatus </li></ul></ul><ul><ul><li>Teres minor </li></ul></ul><ul><li>Teres major </li></ul><ul><li>Rhomboids </li></ul><ul><li>Levator scapulae </li></ul><ul><li>Trapezius </li></ul><ul><li>Latissimus dorsi </li></ul><ul><li>Posterior deltoid </li></ul><ul><li>Triceps brachii </li></ul>
    20. 20. Special Tests <ul><li>ROM </li></ul><ul><ul><li>Active – patient/athlete moves joint </li></ul></ul><ul><ul><li>Passive – clinician moves joint, evaluates end feel </li></ul></ul><ul><ul><li>Resistive – proximal stabilization and distal application of resistance (“break” test vs. resistance through ROM) </li></ul></ul><ul><li>Neurovascular </li></ul><ul><li>Special tests </li></ul>
    21. 21. Range of Motion <ul><li>Flexion (~180 degrees) </li></ul><ul><ul><li>Biceps brachii, coracobrachialis, anterior and middle deltoid, pectoralis major (clavicular head) </li></ul></ul><ul><li>Extension (~60 degrees) </li></ul><ul><ul><li>Posterior deltoid, latissimus dorsi, teres major, triceps brachii (long head) </li></ul></ul><ul><li>Abduction (~180 degrees) </li></ul><ul><ul><li>Deltoid, supraspinatus, biceps brachii </li></ul></ul><ul><li>Adduction (~45 degrees) </li></ul><ul><ul><li>Pectoralis major, latissimus dorsi, teres major, coracobrachialis, triceps brachii </li></ul></ul>
    22. 22. Range of Motion <ul><li>Internal rotation (~70-80 degrees at 90/90) </li></ul><ul><ul><li>Subscapularis, pectoralis major, latissimus dorsi, teres major, anterior deltoid </li></ul></ul><ul><li>External rotation (~80-90 degrees at 90/90) </li></ul><ul><ul><li>Infraspinatus, teres minor, supraspinatus, posterior deltoid </li></ul></ul><ul><li>Horizontal abduction (~45 degrees at 90) </li></ul><ul><ul><li>Posterior deltoid, infraspinatus, teres minor </li></ul></ul><ul><li>Horizontal adduction (~120 degrees at 90) </li></ul><ul><ul><li>Pectoralis major, anterior deltoid </li></ul></ul>
    23. 23. Range of Motion <ul><li>Scapular protraction (shoulder blades apart) </li></ul><ul><ul><li>Serratus anterior, pectoralis minor </li></ul></ul><ul><li>Scapular retraction </li></ul><ul><ul><li>Trapezius, rhomboids, levator scapulae </li></ul></ul><ul><li>Scapular elevation (shrugs) </li></ul><ul><ul><li>Upper trapezius, levator scapulae, rhomboids </li></ul></ul><ul><li>Scapular depression (back to normal from shrug) </li></ul><ul><ul><li>Lower trapezius, pectoralis minor, subclavius </li></ul></ul><ul><li>Scapular downward rotation (AD) </li></ul><ul><ul><li>Rhomboids, pectoralis minor </li></ul></ul><ul><li>Scapular upward rotation (AB) </li></ul><ul><ul><li>Trapezius, serratus anterior </li></ul></ul>
    24. 24. Neurovascular <ul><li>Neurological evalation </li></ul><ul><ul><li>Nerve root level and peripheral nerve sensory and motor distributions </li></ul></ul><ul><li>Vascular evaluation </li></ul><ul><ul><li>Skin temperature/color </li></ul></ul><ul><ul><li>Capillary refill </li></ul></ul><ul><ul><li>Radial pulse </li></ul></ul><ul><ul><li>Brachial pulse </li></ul></ul><ul><ul><li>Axillary pulse </li></ul></ul>
    25. 25. Special Tests <ul><li>Anterior/posterior translation – SC joint </li></ul><ul><li>“ Piano key” test – AC joint </li></ul><ul><li>Apprehension test – GH joint (anterior) </li></ul><ul><li>Relocation test – GH joint (anterior) </li></ul><ul><li>Anterior/posterior glide tests – GH joint </li></ul><ul><li>Sulcus test – GH joint (inferior) </li></ul>
    26. 26. Special Tests <ul><li>Neer test – rotator cuff impingement </li></ul><ul><li>Hawkins-Kennedy test – rotator cuff impingement </li></ul><ul><li>Yergason’s test – biceps tendon instability </li></ul><ul><li>Speed’s test – biceps tendon irritation </li></ul><ul><li>Empty can test – supraspinatus impingement </li></ul><ul><li>Drop arm test – rotator cuff tear </li></ul>
    27. 27. Injuries
    28. 28. Injuries <ul><li>SC joint injuries </li></ul><ul><li>AC joint injuries </li></ul><ul><li>GH joint injuries </li></ul><ul><li>Rotator cuff injuries </li></ul><ul><li>Biceps tendon injuries </li></ul><ul><li>Fractures </li></ul>
    29. 29. SC Joint Injuries <ul><li>Most common direction of displacement is anterior </li></ul><ul><li>Significant potential concerns if posterior (carotid artery, esophagus, other important structures) </li></ul>
    30. 30. AC Joint Injuries <ul><li>Horizontal stability from superior/inferior AC ligaments </li></ul><ul><li>Vertical stability from coracoclavicular ligaments </li></ul><ul><li>If “step-off” is present, indicates complete tear of AC ligaments and at least partial tear of coracoclavicular ligaments </li></ul>
    31. 31. AC Joint Injuries
    32. 32. GH Joint Injuries <ul><li>Anterior much more common than posterior </li></ul><ul><li>If occurs before age 30, >90% chance of recurrence – surgery </li></ul><ul><li>If after age 30 – choose between surgery/rehab </li></ul>
    33. 33. Rotator Cuff Injuries <ul><li>Impingement syndromes </li></ul><ul><ul><li>“ Pinching” of tendons under acromion process </li></ul></ul><ul><li>Tendonitis </li></ul><ul><ul><li>Poor blood supply, “wrung out” with rotation </li></ul></ul><ul><li>Rotator cuff tears </li></ul><ul><ul><li>Usually from cumulative effects </li></ul></ul>
    34. 34. Biceps Tendon Injuries <ul><li>Tendonitis </li></ul><ul><ul><li>Secondary to biomechanical issues and/or repetitive overuse movements </li></ul></ul><ul><li>Biceps tendon rupture </li></ul><ul><ul><li>Can occur to long head from glenoid rim, short head from coracoid process or distal tendon from radius at elbow </li></ul></ul><ul><ul><li>Typically has resultant deformity </li></ul></ul>
    35. 35. Fractures <ul><li>Scapula </li></ul><ul><ul><li>Rarely suffers bony injury </li></ul></ul><ul><ul><li>If so, processes most common site </li></ul></ul><ul><li>Clavicle </li></ul><ul><ul><li>Commonly fractured in middle 1/3 </li></ul></ul><ul><li>Humerus </li></ul><ul><ul><li>Head often injured with GH dislocations </li></ul></ul><ul><ul><li>Shaft rarely injured unless severe forces </li></ul></ul>

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