SHOULDER INJURIES

IN ATHLETES
Dr Riafat Mehmood
2. Rotator cuff injuries/tear
Rotator cuff tendinopathy
 Rotator cuff tears refer to partial or full tears of one or a number of the
4 muscles that help move the shoulder and keep the end of the long
bone of the arm within the shallow socket of the shoulder (the “rotator
cuff”).
 Tendinopathy (without complete tear) of the rotator cuff is the most
common cause of shoulder pain. The most commonly torn muscle of
the rotator cuff is the muscle that helps lift the arm away from the
body (the “supraspinatus”).
 Rotator cuff injuries may happen with repetitive overhead use of the
arm, but can also occur after suffering trauma, such as after falling on
an outstretched hand.
 Causes
Rotator cuff tears are often a result of chronic impingement of the
rotator cuff muscles, which may lead to inflammation and tearing.
These injuries can also be a result of a sudden tearing of the tendon
near its attachment to the bone.
 Epidemiology/Etiology
 Rotator cuff tears are the leading cause of shoulder pain and
shoulder-related disability. The pathogenesis of these tears is still
partly unknown.
 caused by degenerative changes, repetitive micro traumas, severe
traumatic injuries, atraumatic injuries and secondary dysfunctions.

 Traumatic injury to the rotator cuff can be caused by falling on an

outstretched hand, by an unexpected force when pushing or pulling, or
during shoulder dislocation.
 Atraumatic causes Normal age-related muscle deterioration and
excessive repetitive motions are examples of
 Extrinsic factors such as subacromial and internal
impingement, tensile overload and repetitive stress can lead to a
higher risk of rotator cuff tears.
 Intrinsic factors such as poor vascularity, alterations in
material properties, matrix composition and aging are also
involved.(level of evidence).
 Smoking and inflammation of the joint capsule (frozen shoulder)
can also lead to a higher risk for a rotator cuff tear. Also, thyroid
pathologies could play a role in rotator cuff tear pathology. But this
relationship needs more research.
 Comorbidities of rotator cuff tears are hormone-related
gynecologic diseases, autoimmune pathologies, rheumatoid
arthritis and type 1 diabetes mellitus.
 the tendons become swollen and hypercellular, the collagen
matrix is disorganized and the tendon weaker, and there is
an increase in vasculature and nerve density.
 Apoptosis (programmed cell death) and associated pathways
are increased in overuse tendinopathy.
 Calcification may occur in any of the rotator cuff tendons but
it is most often seen in the supraspinahls tendon.
 The cause of this calcification is undetermined and it can be
asymptomatic.
 Pain is often severe at rest, with movements, and at night.
 Deposits of calcium may be seen on plain X-ray and on
ultrasound.
 Repetitive throwing motions
 In the late cocking/early acceleration phase, immediately prior to
throwing a ball, a pitcher’s arm is lifted away from the body and externally
rotated. This motion can cause compression of the rotator cuff as well as
the labrum, a ring of tough cartilage that fits in the shoulder socket.
 During the deceleration phase, immediately after the ball’s release, the
shoulder experiences distraction forces that can lead to tensile strength
failure of the rotator cuff.
 SICK (Scapular malposition, inferior medial border prominence,
coracoid pain, and dyskinesis of scapula) is associated with shoulder
injuries, including rotator cuff injuries. SICK, sometimes called SICK
scapula syndrome, is defined by several factors, including poor position
and mechanics of the scapula, and a tight inferior glenohumeral
ligament. Overhead throwing athletes are more prone to SICK
SICK Scapula”
Presentation & Symptoms:
 Pain
 Repetitive overhead activity
 Drooping shoulder on dominant side
Physical Exam:
 Scapular malposition
 Inferior medial border prominence
 Coracoid pain and malposition
 Kinesis abnormalities of scapula
 Can result in impingement type symptoms
 Racquet sports
 Racquet sports include tennis, racquetball, and badminton. Serving the ball requires a
tremendous amount of energy and force, and it accounts for 65% of the swings taken in tennis.
Studies show that tennis players are at an increased risk of rotator cuff tears due to overuse of
the shoulder.
 Baseball /cirket
 developing rotator cuff injuries due to repetitive swings. Any player who throws is at risk for a
shoulder injury, but studies show that pitchers are most likely to injure their rotator cuff due to
the repetitive throwing motion. This also applies to softball pitchers too.
 Swimming
 The repetitive overhead motion can increase your risk of rotator cuff tears, rotator cuff
tendonitis, swimmer’s shoulder, and cartilage tears.
 Football
 Football increases your risk of many different sports injuries, including concussions, knee
injuries, and ankle sprains. Quarterbacks, however, are particularly prone to shoulder injuries.
Because of the repetitive motion of throwing the ball, those who play football are at risk of
shoulder impingement, rotator cuff injuries, and tendinitis. Getting tackled can also lead to
shoulder dislocations.
 Volleyball/baskitball
 Just like tennis and baseball demand a lot from your shoulders, so does volleyball. Serving,
spiking, and blocking can lead to both overuse injuries and acute injuries.
 Clinical features

 The sports person with rotator cuff tendinopathy complains

of pain with overhead activity such as throwing, swimming,
and overhead shots in racquet sports.
 Activities undertaken at less than 90D of abduction are
usually pain-free.
 There may also be a history of associated symptoms of
instability. such as recurrent subluxation or episodes of
"dead arm." Night pain is common.
 On examination,
 there may be tenderness over the supraspinatus tendon proximal to
or at its insertion into the greater tuberosity of the humerus.
 Active movement may reveal a painful arc on abduction between
approximately 70° and 120° . Internal rotation is commonly reduced.
 Rotator cuff strength should be measured with the scapula
adequately stabilized.
 Symptoms can be reproduced with impingement tests as well as with
end-range passive flexion.
 Pain will also occur with resisted contraction of the supraspinatus.
which is best performed with resisted upward movement with the
shoulder joint in 90° of abduction, 30° of horizontal flexion and
internal rotation.
 Diagnostic Procedures

 Many factors are considered in diagnosing rotator cuff tears.

 Subjective history including mechanism of injury, activities
that aggravate or ease pain, current limitations to function
and physical examination findings.
 Additionally, diagnostic imaging is used to make the
diagnosis
Special test
 Tests for subscapularis:
 Lift-off test and Passive Lift Off Test(Subscapularis Weakness)
 Belly Press (Subscapularis Tear)
 Bear Hug Test (Subscapularis Weakness /Tear)

 Tests for Supraspinatus and infraspinatus

 External rotation lag sign: 0° and 90°(supraspinatus and infraspinatus tendons)
 Jobe’s test (Empty Can Test is used to assess the supraspinatus muscle and tendon.)

 Test for Teres minor:

 Hornblower’s Sign
 Outcome Measures

 Disabilities of the Arm, Shoulder and Hand (DASH)

questionnaire is a 30-item questionnaire that looks at the ability of a patient to perform certain
upper extremity activities
 Penn Shoulder Score (PSS)
is a condition- specific self-report measure that first became available in 1999. 34 It is a 100-point
scale that consists of 3 subscales, including pain, satisfaction, and function

 Rotator Cuff Quality of Life Score (RC-QOL)

is a scale designed to evaluate the impact of rotator cuff (RC) disorders on the general quality of
life of patients.
 Treatment

 Medications (anti-inflammatory and acetaminophen) are the

mainstay of initial treatment to help manage pain symptoms
 Rest, with or without a sling, may also provide relief in
a newly-injured shoulder
 Exercises to increase strength and improve range of
motion are recommended
 Surgery may be recommended, especially for
complete tears in young or active patients
Physical Therapy Management
 During examination and rehabilitation, it is important to isolate
the individual rotator cuff muscles as much as possible. This
because the rotator cuff muscles can become fatigued, injured or
atrophied individually. Physical therapy has a beneficial effect
when it’s part of a treatment programmed.
 Reducing pain and muscle tension in the scapular and neck area
in order to promote the motility of the scapula. This to ensure the
correct position of the glenoid. The muscles targeted are the
M. pectoralis minor, upper trapezius and M. levator scapulae.
 - Improving the wrong humeral head position in order to restore
scapulo-humeral mobility.
- Strengthen the muscles that stabilize and move the shoulder,
the upper part of the M. serratus anterior and the intact rotator
cuff muscles.
 Both nonoperative rehabilitation and postoperative
rehabilitation of the rotator cuff involves the following
principles.
 Reduction of overload and total arm rehabilitation
 - There should be no compensatory actions in the upper
extremity.
- It is advised to quickly use the elbow, forearm and wrist in
order to strengthen them. Especially during long
immobilization.
 - Mobilization of the scapulothoracic joint and submaximal
strengthening of the scapular stabilizers are indicated. The
injured tissues should not be inappropriately stressed or
loaded.
 A technique which is used early in the rehabilitation phase is the
scapular protraction and retraction resistance exercise.
 It involves a side-lying position and specific hand placement to resist
scapular protraction and retraction without stress applied on the
glenohumeral joint. This exercise begins at low resistance. The
glenohumeral joint must be in slight abduction and forward flexion
during scapular motion.

 Restoration of normal joint arthrokinematics

 - Posterior capsular mobilization and stretching techniques are often

indicated and applied to improve internal rotation ROM.

 Promotion of muscular strength balance and local muscular endurance

 EXAMPLES OF OPEN CHAIN EXERCISES
 Side-lying external rotation
 Shoulder extension
 Prone horizontal abduction
 90/90 external rotation
3.Glenoid labrum injuries
SLAP Lesion
 A SLAP tear or SLAP lesion is an injury to the glenoid labrum
(fibrocartilaginous rim attached around the margin of the glenoid
cavity).
 Tears of the superior labrum near to the origin of the long head of
biceps were first described among throwing athletes label of
‘SLAP’, an abbreviation for superior labrum anterior and posterior,

 labrum is the primary attachment site for the shoulder capsule and
glenohumeral1igaments.
 superior aspect of the glenoid labrum attachment site for the
tendon of the long head of the biceps muscle.
 Injuries to the glenoid labrum are divided into superior labrum
anterior to posterior (SLAP) and non-SLAP lesions, and further
into stable and unstable lesions
 A total of four types of superior labral lesions
involving the biceps anchor have been
identified.
 Type I concerns degenerative fraying with no
detachment of the biceps insertion.
 Type II is the most common type and
represents a detachment of the superior
labrum and biceps from the glenoid rim.
 Type III represents a bucket-handle tear of the
labrum with an intact biceps tendon insertion
to the bone.
 type IV lesions, the least common type
represents an intra-substance tear of the
biceps tendon with a bucket-handle tear of the
superior aspect of the labrum
 The Type II SLAP lesions have been further divided into
three subtypes depending on whether the detachment
of the labrum involves the anterior aspect of the labrum
alone, the posterior aspect alone, or both aspects.

 Type V: a Bankart lesion that extends superiorly to

include a Type II SLAP lesion.
 Type VI: an unstable flap tear of the labrum in
conjunction with a biceps tendon separation.
 Type VII: a superior labrum and biceps tendon
separation that extends anteriorly, inferior to the middle
glenohumeral ligament.
 Epidemiology/Aetiology
 There are a lot of different mechanisms of injury that can
result in a SLAP lesion. The following causes have been
found:
 repetitive throwing,
 hyperextension,
 a fall on an outstretched arm,
 heavy lifting,
 direct trauma.
 Clinical Presentation
 The most common complaint in patients that present with
SLAP lesions is pain. Pain is typically intermittent and often
associated with overhead movements
 sensations of painful clicking and/or popping with shoulder
movement
 loss of glenohumeral internal rotation range of motion
 pain with overhead motions
 loss of rotator cuff muscular strength and endurance
 loss of scapular stabiliser muscle strength and endurance
 inability to lie on the affected shoulder
Special test
1.Biceps load test

2.O’Brien test

3.Speeds Test
 Medical Management
 Type I: are treated with debridement. Straightforward
arthroscopic shaving, without damaging the biceps anchor,
is enough for the surgical treatment of this type of lesion.
 Type II: can be treated with arthroscopic fixation of the
superior labrum to establish biceps anchor stability.
 Type III: can easily be debrided by an arthroscopic shaver.
There is no need to repair this type of injury. After the
resection of the free fragment, a pain free shoulder can be
established.
 Type IV: can be repaired with multiple sutures.
 Physical Therapy Management
 clinical recommendations regarding the rehabilitation of patients with SLAP
lesions.
 forward flexion in a side-lying position
 prone extension
 seated rowing
 serratus punch (protraction with the elbow extended)
 knee push-up plus
 forward flexion in external rotation and forearm supination
 full can (elevation in the scapular plane in external rotation
 internal rotation in 20° of abduction ,external rotation in 20° of abduction
 internal rotation in 90° of abduction ,external rotation in 90° of abduction
 internal rotation diagonal ,external rotation diagonal
DISLOCATION OF THE GLENOHUMERAL JOINT
 The shoulder dislocation (more accurately termed
a glenohumeral joint dislocation) involves separation of
the humerus from the glenoid of the scapula at
the glenohumeral joint.
1. anterior shoulder dislocation (95% of shoulder dislocations)
2. posterior shoulder dislocation
3. inferior shoulder dislocation
 younger: 20-30 years (male to female ratio of 9:1)
 older: 60-80 years (female to male ratio of 3:1
 Clinical presentation

 Patients present with severe pain and restriction of movement

of the shoulder.
 The majority of people who present with a shoulder dislocation
do so after trauma, e.g. sporting trauma, assault, falls.
 It is useful to determine whether the dislocation is
acute, chronic or recurrent.
 Increased incidence in patients who have had a previous
shoulder injury, and particularly in those who have
dislocated previously.
 The process of dislocation is massively disruptive to the
labrum, joint capsule, supporting ligaments, and muscles.
 This is particularly true of anterior dislocations where
there can be an injury to the anterior capsule, anterior
labrum, or biceps tendon, or a combination.
 TYPE OF DISLOCATION

 Shoulder dislocations are usually divided according

to the direction in which the humerus exits the joint:
 anterior >95%
 subcoracoid (majority)
 subglenoid (1/3)
 subclavicular (rare)
 posterior 2-4%
 inferior (luxatio erecta) <1%
 Radiographic features
 A shoulder x-ray series is sufficient in almost all cases to make the diagnosis,
although CT and MR are often required to assess for the presence of subtle
fractures of the glenoid rim or ligamentous/ tendinous injuries respectively.
 Report checklist
 In addition to reporting the presence of a dislocation a number of features and
associated findings should be sought and commented upon:
 direction of dislocation
 associated fractures/injuries
 Hill-Sachs defect
 bony Bankart lesion
 proximal humeral fracture
 clavicular fracture
 acromioclavicular joint disruption
 acromial fracture
 Treatment and prognosis
 The only treatment option for a dislocated shoulder is a prompt
reduction. This is usually performed in the Emergency Department
following sedation and appropriate analgesia. A number of techniques
can be used to reduce the shoulder.
 The ease of reduction is dependent on the age and build of the patient
(younger, heavily built guys will be more difficult to reduce) and the time
that the joint has been dislocated (the longer it has been out, the more
difficult it is to get back in).
 Rest is required following dislocation, so immobilization is required:
 three weeks for younger patients (<30 years old, who have a very high
rate of recurrence)
 7-10 days in older patients. During this time gentle active motion should
be carried out to preserve range of motion .
 As a general rule, the shorter the duration of dislocation the fewer
complications (size of Hill-Sachs defect, neurovascular compromise,
etc.).
 Early arthroscopy, labral repair and debridement may be of use,
especially in young patients with anterior dislocation in which there is a
high (up to 85%) rate of recurrence.
 Shoulder dislocations can also be associated with large rotator cuff
tears in the older ages groups.
 The incidence starts to increase around age 40 and is especially high
in patients above the age of 60 .
 The major morbidity associated with untreated massive rotator cuff
tears in this age group requires a clinician to ensure actively that these
injuries are not missed.
 This can be done by clinical examination, looking for weakness in the
rotator cuff muscles or radiologically with ultrasound or MRI.
 Best outcomes are achieved with early surgical repair of the rotator cuff
 ANTERIOR SHOULDER DISLOCATION

 One of the most common traumatic sports injuries is acute

dislocation of the glenohumeral joint
 Anterior shoulder dislocation is by far the commonest type
of dislocation and usually results from forced abduction,
external rotation and extension.
 Predisposing factors
 flattened, shallow anterior/anteroinferior glenoid bony contour:
 may predispose to recurrent dislocations
 Radiographic features

 Anterior dislocations can be further divided according to

where the humeral head comes to lie:
 subcoracoid: most common
 subglenoid
 subclavicular
 intrathoracic: very rare
 In anterior dislocations, the humeral head comes to lie
anterior, medial and somewhat inferior to its normal location
and glenoid fossa.
 Treatment and prognosis
 Anterior shoulder dislocations are usually managed
with closed reduction and a period of immobilization (e.g. 6
weeks) to allow adequate capsular healing, although whether
this significantly changes the likelihood of recurrent
dislocation is not certain .
 The key to successful healing and normal eventual function
is a structured course of physical therapy aimed at reducing
muscle wasting and maintaining mobility.
 The emphasis, especially early on, is on isometric exercises,
in which the glenohumeral joint remains immobilized
 Surgical repair is not required for dislocation as such, but
rather to treat complications and associated injuries which
include:
 shoulder instability due to damage to the inferior
glenohumeral ligament (IGHL)
 Hill-Sachs defect
 Bankart lesion or other anterior glenolabral injuries
 damage to the axillary artery, or brachial plexus
 intraarticular loose body
 Posterior shoulder dislocation
 Mechanism
 Typically the humeral head is forced posteriorly in internal
rotation while the arm is abducted . In adults, convulsive
disorders are the most common cause.
 Occasionally, they can be the result of strength imbalance
within the rotator cuff muscles. Posterior dislocations may
even go unnoticed, especially in elderly patients
 Radiographic features
 Plain film series usually suffices in making the diagnosis, although
cross-sectional imaging (CT or MRI) is often used to assess the
presence and extent of articular surface injury (reverse Hill-Sachs
defect), glenoid injury (reverse Bankart lesion) or ligamentous injury.

 Reporting checklist
 In addition to stating that a posterior dislocation is present, any
evidence of proximal humeral fractures or glenoid fractures should
be sought and commented on
 Treatment and prognosis
 When a posterior dislocation presents to the emergency department,
unlike anterior shoulder dislocations which are relatively easily reduced,
posterior dislocations are more problematic and attempts at closed
reduction should only be performed in consultation with a treating
orthopedic surgeon .
 Additionally, if the shoulder has been dislocated for ≥3 weeks
(particularly common in debilitated elderly patients) or if the anterior
humeral articular injury (reverse Hill-Sachs defect) involves >20% of
the articular surface, then the closed reduction is contraindicated .
 Fortunately, neurovascular compromise is uncommon, but associated
glenolabral and capsular injuries can lead to posterior shoulder
instability
 Inferior shoulder dislocation

 It is caused by either of the following mechanisms:

 sudden forceful arm hyper abduction
 less commonly, direct loading force on a fully abducted arm,
with an extended elbow and pronated forearm.
 The humeral head is forced against the acromion, usually
with resultant inferior glenohumeral capsule rupture
and rotator cuff disruption.
 Radiographic features

 The humeral head is displaced directly below and slightly

medial to the glenoid fossa, with the arm often in marked
abduction (luxatio erecta).
 An inferior dislocation can mimic a subcategory of
glenohumeral dislocation known as subglenoid anterior
dislocation, where the humeral head rests directly inferior to
the glenoid in the AP and lateral projections . It is
distinguished from the latter by the humeral shaft's position
parallel to the scapular spine.
 MRI is performed post-reduction. Common findings
include :
 rotator cuff tears
 injuries to the glenoid labrum
 injuries to both the anterior and posterior band of
the inferior glenohumeral ligament (IGHL)
 bone bruises or impaction fractures (Hill-Sachs defect)
at the superolateral aspect of the humeral head.

 Complications
 Inferior dislocations have a high complication rate, with
secondary osseous, soft tissue, vascular, neurological,
tendon, and ligament injuries
SHOULDER INSTABILITY
 Classification of Shoulder Instability
 Stanmore Triangle
 This classification helps the therapist to correctly diagnose the
instability and prioritize the treatment.
 There are three main subgroups in this classification:
 Polar 1: Shoulder instability is directly related to trauma. There
is evidence of a structural deficit in the GH joint
 Polar 2: There is evidence of structural deficit and atraumatic
instability
 Polar 3: No evidence of structural defects. Muscle patterning is
present.
 BASED ON THE DIRECTION OF SHOULDER
INSTABILITY

 ANTERIOR INSTABILITY

 POSTERIOR INSTABILITY

 MULTIDIRECTIONAL INSTABILITY
(ATRAUMATIC)
 TRAUMATIC UNIDIRECTIONAL INSTABILITY

 ACQUIRED SPORT-SPECIFIC INSTABILITY

 ATRAUMATIC
 ANTERIOR INSTABILITY
 There occurs translation of the humeral head in the anterior. direction It is the
most common form of shoulder instability.
 POSTERIOR INSTABILITY
 It accounts for 2 to 5 % of instability cases. Usually, the athletic population is
affected by this type of instability who participate in an overhead
activity. Structural issues like posterior glenoid erosion and glenoid retroversion
or deficiency of rotator interval can predispose patients to posterior instability.
 MULTIDIRECTIONAL INSTABILITY (ATRAUMATIC)
 There is a combination of anterior /posterior/inferior instability at the GH joint.
In many cases, this type of instability is because of generalized laxity
throughout the body. Another cause is repetitive trauma during extremes of
motion.
 Mainly the pain is during the mid ranges of shoulder ROM which indicates main
role of altered muscle activation. Inappropriate position of the scapula can also
 Traumatic Unidirectional Instability with Bankart lesion
(TUBS)

 ANTERIOR DISLOCATION
 This is the commonest sports injury in which acute anterior dislocation of
GH joint occurs. The arm is forced into excessive abduction and external
rotation. It damages the anterior part of the labrum (Bankart lesion).
 The patient presentation is arm adduction and internally rotated with loss
of deltoid contour. Posterior sulcus/glenohumeral void is observed. The
humeral head is palpated anteriorly. Radiographs are used to confirm the
diagnosis and rule out other bone injuries.
 One of the three following criteria has to be fulfilled in order to prescribe
the Xray :
 Age>40, first time dislocation, traumatic mechanism of injury
POSTERIOR DISLOCATION.

It is less common than an anterior dislocation. The

cause is a fall on the outstretched hand or a direct
blow on the shoulder in internal rotation of
adduction. The Cardinal sign is limited external
rotation. An X-ray of lateral view or axillary view is
necessary for diagnosis.
 ACQUIRED SPORT-SPECIFIC INSTABILITY

This type is commonly seen in overhead athletes when the

anterior capsule has become lax due to overuse. This is also
known as an acquired instability overuse syndrome. Clinical
features are recurrent shoulder pain while throwing, sudden
inability to throw or smash and a feels like 'dead arm', GIRD
/scapular dyskinesia /signs of labral pathology are also seen.
Apprehension /relocation tests are positive.
This condition can turn into impingement due to abnormal
translation of humeral head.
 ATRAUMATIC

 Abnormal position or motion of the shoulder joint that leads to pain,

subluxation, dislocation and functional impairment.
 Atraumatic (non-traumatic) shoulder instability is a subclassification of
glenohumeral joint instability, encompassing those for whom trauma is
not considered the primary etiology.

 Two main types of atraumatic instabilities:

 Congenital instabilities;
 Laxity of structures in the shoulder which may be present since birth.
 Chronic recurrent instabilities
 May be seen after surgery for shoulder dislocation, due to glenoid rim
lesions.
 Over time, microtrauma can lead to instability of the glenohumeral joint.
 Clinically Relevant Anatomy
 Glenohumeral stability depends on the combination of
various factors that can be grouped into:
 Capsulo-ligamentary or static stabilizers
 Musculotendinous or dynamic stabilizers
 Clinical Presentation
 Possible signs and symptoms of chronic/recurrent instability
 Anterior Instability
 Clicking
 Pain
 Complain of the dead arm with throwing
 Pain posteriorly
 Possible subacromial or internal impingement signs
 The patient may have a positive apprehension test, relocation test,
and/or anterior release test
 Increased joint accessory motion particularly in the anterior direction
POSTERIOR INSTABILITY
 Possible subacromial or internal impingement
 Glenohumeral internal rotation deficit (GIRD) may be present
 Pain
 Clicking
 Increased joint accessory motion particularly in the posterior direction
MULTIDIRECTIONAL INSTABILITY
 Antero-inferior laxity most commonly presents with global shoulder pain, cannot
pinpoint to a specific location
 May have a positive sulcus sign, apprehension/relocation test, anterior release tests
 Secondary rotator cuff impingement can be seen with microtraumatic events caused
during participation in sports such as gymnastics, swimming and weight training
 Increased joint accessory motion in multiple planes
 Red flags

 Trauma, pain and weakness (indicates rotator cuff

tear)
 Swelling/mass (Indicates tumor/malignancy)
 Fever or any systemic illness
 Unreduced dislocation
 Infected joint
 SUBJECTIVE HISTORY
 May have history of: trauma with or without a
previous dislocation; lax joints (consider elbow, knee,
thumb hyperextension, use Beighton scale to
evaluate hypermobility)
 Activities of daily living may be difficult to complete
 Global pain around shoulder
 PHYSICAL EXAMINATION
 Screen cervical spine and thoracic spine
 Observation/Palpation
 Long head of biceps, supraspinatus tendon, AC joint, SC joint, spine,
1st rib, other regional muscles
 Posture
 Asymmetry
 Scapular winging
 Atrophy
Active ROM
 Glenohumeral flexion, extension, abduction, adduction,
rotation - internal & external, scaption
 Look for apprehensive behavior
Passive ROM
 May have pain and/or stiffness
 Apprehension will be present
Functional Testing
 Hand to posterior neck
 Hand to scapula
 Hand to opposite scapula
Joint Accessory Motion Testing
 Increased mobility in the direction of the instability (anterior,
posterior, multidirectional)
SPECIAL TESTS

 Possibly sulcus sign,

 apprehension/relocation
 anterior release tests depending on suspected form
of instability
 Load and Shift Test
 MEDICAL MANAGEMENT

 Medical management will hinge on the specifics of the patient

presentation including the mechanism of injury, severity, patient goals,
etc. In some cases, particularly those with a traumatic mechanism,
surgical intervention may be warranted to restore joint stability.

 Types of surgical procedures for traumatic glenohumeral dislocations

 Open capsular shift

 Arthroscopic thermal capsulorraphy
 Labral repair
PHYSICAL THERAPY
MANAGEMENT
 Education to prevent recurrence
 Postural re-education
 Motor control training of specific muscles during
functional activities (rotator cuff muscles, scapular
stabilizers)
 Strengthening in particular the deltoid, rotator cuff
muscles and scapular stabilizers
 Stretching in particular posterior shoulder structures,
pectoralis major and minor and any other muscles
with flexibility impairments
 Manual therapy targeting impairments of mobility in
the glenohumeral, acromioclavicular, sternoclavicular
joints and cervico-thoracic spine
FRACTURE OF THE CLAVICLE
 Group I: Fractures of the middle third or midshaft
fractures (the most common site),

 Group II: Fractures of the distal or lateral third. A

common site for non-union.

 Group III: Fractures of the proximal or medial third.

 HISTORY AND PHYSICAL EXAMINATION
 A patient may cradle the injured extremity with the uninjured arm.
 A patient may report a snapping or cracking sound when the injury
occurs.
 The shoulder may appear shortened relative to the opposite side and
may droop.
 Swelling, ecchymosis, and tenderness may be noted over the clavicle.
 Abrasion over the clavicle may be noted, suggesting that the fracture was
from a direct mechanism.
 Crepitus from the fracture ends rubbing against each other may be noted
with gentle manipulation.
 Difficulty breathing or diminished breath sounds on the affected side may
indicate a pulmonary injury, such as a pneumothorax.
 Palpation of the scapula and ribs may reveal a concomitant
injury.
 Tenting and blanching of the skin at the fracture site may
indicate an impending open fracture, which most often
requires surgical stabilization.
 Nonuse of the arm on the affected side is a neonatal
presentation.
 Associated distal nerve dysfunction indicates a brachial
plexus injury.
 Decreased pulses may indicate a subclavian artery injury.
 Venous stasis, discoloration, and swelling indicate a
subclavian venous injury.
 DIAGNOSTIC PROCEDURES

 Diagnose can often be made by a client's history and

physical examination.
 Radiography of the clavicle and shoulder
 Computed tomography (CT) scanning with 3-
dimensional (3-D) reconstruction
 Arteriography
 Ultrasonography
 MANAGEMENT

 Clavicle fracture is managed either surgically or

conservatively based upon various factors including the
location (mid-shaft, distal, proximal), nature (displaced,
undisplaced, comminuted) of the fracture, open VS closed
injury, age, and neurovascular compromises.
 Traditionally, the management of clavicle fractures has been
through conservative management with sling immobilization
and subsequent rehabilitation.
 This continues to provide satisfactory results for undisplaced
fractures but conservative management of displaced mid-shaft
clavicle fractures results in increased rates of re-injury,
increased return times to sport and suboptimal shoulder
function, secondary to clavicular mal-union and shortening, with
resultant thoracoscapular dyskinesia.
 Similarly, conservative management of displaced lateral
fractures in the athletic patient has been shown to result in high
rates of non-union and subsequent impairment of shoulder
function.

 So for the athletic individual, operative intervention is routinely

performed for displaced lateral fractures and is recommended
for mid-shaft fractures that are completely displaced, shortened
>2 cm or comminuted