Kin 188 Shoulder Evaluation And Injuries

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