SOFT TISSUE INJURIES OF THE SHOULDER

Entity Notes Epidemiology Pathophysio- History PE Diagnostics Nonsurgical Surgical

logy treatment treatment
Shoulder • Three stages of • Common in Repetitive • Associated with a painful arc
impinge- impingement: throwing sports motion from an (with abduction of the arm in the
ment 1) edema and and swimmers abducted and range of 60 to 120º).
hemorrhage along externally • Hawkin’s maneuver: arm flexed,
supraspinatus insertion rotated slightly abducted and internally
(12 to 25 years of age, position to an rotated
typically reversible) internally • Neer’s sign: arm in full flexion at
2) fibrosis, thickening of rotated flexed 90º, internally rotated while resisting
CA ligament, bony position.  flexion. (These two are not so
changes of acromion tuberosity of the specific to impingement however.)
3) Partial or complete humerus comes • Also associated with tendonitis of
cuff tears: >40 y of age under arch of supraspinatus and biceps tendons
the acromion or and degenerative changes in rotator
along cuff.
coracoacromial
ligament
Bicipital • Biceps: elbow flextion • Associated • Tendon noted • From • Yergason’s • Consider it in
tendonitis and supination of the with overhead to be swollen, subluxation of test: palpation young, active
forearm + in abduction activities stenotic at the the tendon: the of the tendon individuals
of arm in ER position transverse patient can and pain
ligament, and report a produced with
frequently “snapping resisted
hemorrhagic. sensation” supination while
• Adhesions • Symptoms can the elbow is
may develop in range from flexed and held
the area with discomfort and against the trunk
ongoing inflam weakness to a • Speed’s test:
• If the TL is lax painful snap resistance of
or ruptured the forward flexion
biceps tendon with the elbow
can sublux. extended and
• Rupture of the supinated
tendon most • Subluxation of
commonly the tendon can
affects the be palpated
proximal portion
of the long head
Rotator • Tears can be • Traumatic can • There is an • Pain at the site • Painful arc • Diagnostic
cuff traumatic or happen at any area of the cuff along the • Drop arm test ultrasound (least
tendonitis degenerative age but more with less tuberosity (pain on sensitive, can
and tears common in older vascularization, • Night pain lowering the arm miss incomplete
people which may • Exacerbation  Patient drops tears),
• In people contribute to of symptoms arm rapidly) arthrography
>60y, there is a some of the with lying on that • Muscle (can
54% incidence changes noted shoulder at night strength: done demonstrate
 of tears in • As we age, • Pain along the to isolate extravasations
asymptomatic cuff thins and lateral aspect of supraspinatus, of contrast in
individuals becomes frayed. the arm toward performed along partial-thickness
insertion of the plane of scapula tears) and MRI
deltoid (30% ant to (T2 more
• Pain with frontal plane) sensitive for full-
overhead with arm in IR: thickness tears
activities full thickness than partial)
tear 
significant
weakness.
Partial tears 
mild to no
weakness.
Adhesive • Typically painful to • Prolonged • Can be • Suspect the • multiplanar • Codman’s or pendulum exercises
capsulitis treat and has prolonged immobilization idiopathic or diagnosis if loss of range, may help with range in pain-free
or frozen recovery course, up to after 1 of 3 Ts: assoc with there is most affected zone (SEE BELOW)
shoulder 2 y. significant risk internal progressive loss ER and
factor derangement of range and Abduction
• Higher risk: (trauma, diffuse pain
Middle aged tendonitis, tears) despite
women, DM BUT can still conservative
patients occur even treatment • Joint mobilization ± UTZ
without any of measures • NSAID trial
these • IA or subacromial injection of
anesthetic and steroid may help
• Distention of capsule can be
attempted but requires large
volumes to be injected (25 to 35 mL:
typical jt capacity), probably less
painful if with initial infusion of
lidocaine, 3-5mL
SOFT TISSUE INJURIES OF THE SHOULDER
Two primary factors make the shoulder joint particularly susceptible to soft-tissue injuries. First, the surrounding soft tissues constitute the main support system for the upper extremity.
Second, the small glenoid fossa allows for a large range of motion that often permits hypermobility, thereby straining the soft tissues and stressing the joint. Injuries of the shoulder can
be broadly classified as those that result from more acute processes, such as direct trauma, and those that occur from more repetitive tasks, such as bursitis and tendonitis. Overall,
shoulder injuries are so common that they are second only to back injuries in disability costs. Understanding the complex anatomy and kinesiology of the shoulder is essential for
accurate diagnosis and appropriate treatment.
Anatomy of the Shoulder
The shoulder is composed of many joints, including the scapulothoracic joint, which is considered a functional joint. The glenohumeral joint is a synovial joint lined by the glenoid
labrum, which provides a large contact surface to the glenoid fossa. Despite the large labrum, the humeral head comes into contact with only about one third of the glenoid fossa at
any one time (25). The capsule of the glenohumeral joint is divided into three functional bands that are considered ligaments, aptly named the superior (SGHL), middle (MGHL), and
inferior glenohumeral (IGHL) ligaments. Additional support is provided by the coracohumeral ligament (CHL) originating on the coracoid and inserting into the greater and lesser
tuberosities. The acromioclavicular (AC) joint is another synovial joint made up of the distal aspect of the clavicle and the acromion and is supported by the coracoacromial ligament,
the AC ligament, and the coracoclavicular ligament (composed of two smaller ligaments: the conoid and the trapezoid). Motion at the AC joint requires not only translation but also
rotation for smooth movement of the shoulder. The last synovial joint involved in the shoulder is the sternoclavicular joint. The joint is bordered by the medial aspect of the clavicle and
the manubrium of the sternum. There are four ligaments surrounding the joint: the anterior and posterior sternoclavicular ligaments, the costoclavicular ligament, and the interclavicular
ligament.
The muscles of the shoulder and shoulder girdle can be divided into two major groups: those that stabilize the scapula and those that attach to the humerus. The stabilizers include the
trapezius, levator scapula, rhomboids, serratus anterior, and pectoralis minor. These muscles allow for the stability of the shoulder girdle and provide a foundation for movement and
force generation that is passed along the trunk into the arm for functional use. The muscles that attach to the humerus include the rotator cuff muscles (supraspinatus, infraspinatus,
teres minor, and subscapularis), deltoid, teres major, pectoralis major, coracobrachialis, biceps brachii, and latissimus dorsi. These muscles provide the arm with most of its motion.
Kinesiology of the Shoulder
Range of motion of the shoulder is accomplished by glenohumeral and scapulothoracic motion. The first 30 degrees of abduction is initiated by the deltoid muscle followed by a 2:1
ratio of movement, with the glenohumeral joint responsible for 120 degrees and the scapulothoracic motion supplying the additional 60 degrees (26). The humerus, however, needs to
be in an externally rotated position to be able to obtain full abduction; otherwise, the tuberosity on the humerus impinges on the undersurface of the acromion. The muscles noted
previously can be divided into functional groups. For example, internal rotation is accomplished by the subscapularis, latissimus, anterior fiber of the deltoid, pectoralis major, and teres
major. External rotators include the infraspinatus, teres minor, and posterior fibers of the deltoid. Abductors include the deltoid, supraspinatus, trapezius, and serratus anterior.
Adduction is accomplished by the subscapularis, infraspinatus, teres minor, pectoralis, latissimus dorsi, and teres major. Flexion of the arm involves the pectoralis major, biceps
brachii, and anterior deltoid. Extension is accomplished by posterior deltoid, teres major, and latissimus dorsi. Some muscles may contribute to motion based on the initial position of
the humerus. For example, if the humerus is in a flexed position, the pectoralis may assist in early extension to the neutral plane.

• YERGASON’S TEST - (+) Test: weakness or pain indicates supraspinatus tear or

- Indication: Tests stability of biceps tendon in the bicipital groove suprascapular nerve neuropathy
- Procedure: Flex elbow held by one hand and pronate forearm while
holding wrist with the other hand. Externally rotate the arm as the • APPREHENSION TEST
patient resists and pull down on the elbow - Indication: test for chronic shoulder dislocation
- (+) Test: Pain is felt over the bicipital groove area, bicipital tendon - Procedure: Abduct and externally rotate the shoulder dislocatable
may pop out from the bicipital groove - (+) Test: Look of apprehension and/or patient resists further motion
• SPEED’S TEST: • SULCUS SIGN
- Indication: test for biceps muscle or tendon pathology - Indications: shoulder instability, or loss of muscle control due to
- Procedure: examiner resists shoulder flexion to 80-90 degrees by nerve injury
the patient - Procedure: examiner grasps patient’s forearm below the elbow and
- (+) Test: Pain at bicipital groove, especially when arm is supinated pulls down on the neutral arm
• EMPTY CAN TEST - (+) Test: dimple/sulcus/groove appears between humeral head &
- Indication: Tests for supraspinatus strength and impingement acromion
- Procedure: the patient is positioned sitting with arms straight out, • SCAPULAR WINGING
0
elbows locked, thumbs down, and arm at 30 (in scapular plane). - Weakness of the serratus anterior (ask the patient to do forward
The patient should attempt to abduct his arms against the push) or trapezius (side push)
examiner's resistance - Maybe seen during inspection