Injuries/Ailments of the Shoulder,Allyson Howe, M.D. Capt, USAF, MC Primary Care Sports Medicine Fellow,SHOULDER,Incidence Review pertinent anatomy History and physical exam Cases with expected exam findings,Incidence,Second most common musculoskeletal complaint Difficult joint to examine Multidirectional range of motion- UNIQUE! Shoulder injury can affect nearly every sport as well as impede many daily activities,Bony Anatomy Anterior,Bones,Bony Anatomy Posterior,Bony Anatomy Joints and Articulations,STATIC STABILIZERS,LABRUM,Clinical Anatomy,Deltoid Rotator cuff Teres major,Latissimus dorsi Biceps Pectoralis muscles,Clinical Anatomy,Rotator Cuff Supraspinatus Infraspinatus,teres minor Supscapularis,POSTERIOR,ANTERIOR,Clinical Anatomy,Rotator Cuff Supraspinatus Abd Infraspinatus ER,teres minor ER Supscapularis IR,Depress humeral head against glenoid to allow full abduction,Muscular Anatomy Posterior,Clinical Anatomy,Bursae subacromial subdeltoid subscapular,Functional anatomy,Glenohumeral= ball and socket joint Very shallow (“golf ball sitting on a tee”) Inherently unstable Static stabilizers glenohumeral ligaments, glenoid labrum and capsule Dynamic stabilizers Predominantly rotator cuff muscles Also scapular rotators (trapezius, levator scapulae, serratus anterior, rhomboids),Clinical Exam History,Pain Acute Chronic Weakness Deformity,Clinical Exam History,Single event Repetitive overload Instability Does it feel like its going to come out? Catching/Locking Disability,Clinical Exam History,Sport/occupation Frequency Duration Previous injury Previous treatment Systemic illness Other joints involved,Physical Exam,Inspection Note deformity, swelling, color changes Palpation Bony structures, soft tissue anatomy Range of Motion Flexion, Abduction, Internal and External rotation,Physical Exam,Strength testing Internal/External rotation, Abduction Rotator cuff muscles,Special Tests Isolate anatomy,Physical Exam Inspection,Front & back Height of shoulder and scapulae Muscle atrophy, asymmetry,Physical Exam Palpation,At rest & with movement ie. can feel supraspinatus, AC joint Bony structures Joints Soft tissues,Physical Exam Range of Motion,Abduction 0-180o,Physical Exam Range of Motion,Forward flexion: 0o 180o,Physical Exam Range of Motion,Extension 0o 40 to 60o,Physical Exam Range of Motion,Internal rotation T5 segment,External rotation 80-90o,Physical Exam Strength,Resisted external rotation Tests infraspinatus, teres minor strength,Physical Exam Strength,Resisted internal rotation Tests subscapularis strength,Physical Exam Strength,Empty can test 45o angle Steady downward pressure Tests supraspinatus strength,Radiographs,Radiographic Anatomy,Radiographic Anatomy,Case #1,22-year-old male rugby player falls onto right shoulder while being tackled Severe pain on top of right shoulder,Case #1,Notable deformity over superior shoulder Painful range of motion Unable to lift right arm above waist Diagnosis?,Acromioclavicular (A-C) Sprain,Damage to A-C joint ligaments Pain and/or deformity over A-C joint Graded I-VI I-III usually treated non-operatively IV-VI referred to orthopedic surgery,Cross-Arm Adduction Test,AC joint pathology Arm flexed to 90 Hyperadduct arm across body as far as possible Pain in AC = (+) test,A-C Shear Test,Interlock fingers with hand on distal clavicle and spine of scapula Pain in A-C joint when hands squeezed together = (+) test,Case #2,24-year-old male handball player Fell onto shoulder after being pushed Intense pain Hand is tingling and arm feels like its hanging xrays,X RAYS,DIAGNOSIS?,Shoulder Dislocation/Anterior Instability,Humeral head dislocates from glenoid fossa Almost always anterior Usually traumatic mechanism with injury to capsule-labrum complex,SHOULDER INSTABILITY Classification,AMBRI Atraumatic Multidirectional Bilateral Rehab Inferior capsular shift,TUBS Traumatic Unilateral Bankart Surgery,Shoulder Dislocation/Anterior Instability,Treatment Reduction of dislocation Protection & rehab, rehab, rehab Most will have future dislocations and/or instability At least 70%! (young) May require surgical tightening/repair of the capsule/labrum complex,Sulcus Sign,Inferior instability Arm relaxed in neutral position, pull downward at elbow (+) test = sulcus at infra-acromial area compare to unaffected side,Apprehension Test,Anterior and Posterior instability Shoulder at 90 abducted, slight anterior pressure & External rotation (+) test = dislocation apprehension some false (+),Relocation Test,Perform after positive apprehension test Apply post force over humeral head during external rotation (ER) (+) test = increased ER tolerance,Load & Shift Test,Test for multidirectional instability Grasp humeral head, slide anteriorly and posteriorly while securing rest of shoulder (+) if greater than 50% displacement (graded 1-3),Case #3,35-year-old male tennis player Shoulder pain exacerbated by practicing serves Develops dull, aching pain in right shoulder Exam?,SHOU