SHOULDER PROBLEMS

• Anatomy = key to injury and rehab

• Common injuries
• Examination
• Diagnosis
• Treatment
• Rehabilitation
• Prevention
 BASIC JOINTS
• Ball and Socket • Hinge
(ball and small saucer)

• HIP • KNEE

• SHOULDER • ELBOW
Shoulder Bones
• Clavicle = collar bone
– attaches to acromion spur
of Scapula and in midline to
Sternum (chest bone)

• Scapula = (Shoulder blade)

• Humerus = upper arm

The 4 joints in the shoulder complex
3 stable and 1unstable

Sternoclavicular Stable joints

Scapulo thoracic

Acromio clavicular (AC)

Glenohumeral Joint
the ball and socket
Joint that is very unstable
LIGAMENTS
• Ligaments join bone to
bone
• Ligaments give stability
to a joint

• Most commonly injured

Ligaments around
shoulder are the ones
attaching collar bone to
scapula
SHOULDER main TENDONS
• Tendons have to be
loaded correctly or will
become unhappy……
• Tendons don’t like being
compressed
 NERVES
• The wiring system of
the body that sends
messages from Brain to
Tissues
• Entrapment in the neck
can refer pain to the
shoulder and arm
 Subacromial Bursa
• Many bursa in body
• Exist where two structures need
to slide freely past each other
but no joint exists
• Subacromial most important in
shoulder-sits between rotator
cuff and overlying structures
• Inflammation-many terms used-
bursitis, impingement
The rotator cuff stabilising muscles
hold the ball in the socket

Supraspinatus

Infraspinatus
Teres major & minor
Subscapularis
BICEPS MUSCLE crosses 2 joints
Other MAIN Shoulder MUSCLES
• PECTORALS
• LATISSIMUS DORSI
• Upper TRAPEZIUS+ LEVATOR
SCAPULA
• Rhomboids and Lower
TRAPEZIUS stablise Scapula

• Main movements assessed

– Flexion/ Extension
– Abduction/ adduction
– Internal and external rotation
 Don’t get too hung up with big words
on shoulder movement
• Basics =
• Stabilising muscles Hold
ball and socket in safe
functional position
• Dynamic Muscle move
the arm for the sport
 Shoulder problems
Common Acute injuries Common Chronic problems
• Fractures • Referred pain from neck
• Dislocations • Frozen shoulder
• Muscle rotator cuff injury • Chronic impingement of bursa
• Labral injury +/- biceps or supraspinatus
tendinopathy

Key REHAB is range of

movement and stabilising Key REHAB is range of
scapula and strengthen movement and stabilising
rotator cuff scapula and strengthen rotator
cuff
 Common shoulder fractures -Clavicle
Acromio-clavicular injury • Clavicle Fracture
(Sometimes called AC
dislocation or Springing)
graded 1-3
Grade 3 may need surgery
• Common in fall onto
shoulder
• If badly displaced needs
surgery
Common shoulder fractures -Humerus
• Very painful , usually
obvious
• Can get small “ chips”
around head of
humerus where rotator
cuff pulls bone off

• Treatment orthopaedic
surgeons…
 Dislocation- commonly ANTERIOR
Posterior or inferior less common
• Chance of second Treatment = Hospital to
dislocation in relocate and consider
operative stabilisation of
young athlete 90% ligament and capsule

• .
 Muscle tendon injury
• Rotator Cuff injury • Key rehab is PHYSIO
• Tendon tears • Working on balance and
• Muscle tears control of humeral head
• Impingement = the sign in the joint
of pinching of the rotator • Mainly by working on
cuff (commonest posture control - scapulo
Supraspinatus and Biceps thoracic control= set
and involve bursa) shoulder blade on back
of ribs then strengthen
rotator cuff at various
positions for sport
Ultrasound-rotator cuff interval
 Glenoid Labrum
• Ball and socket joint
• The socket is not very
deep (fossa)
• Labrum acts to deepen
the glenoid fossa
• Fibrocartilaginous
• Labral tears often seen
in acute trauma and
dislocations-usually
superior or inferior
LABRAL Injury (SLAP)
• A sporting injury
• Where the long head
of the biceps tendon
is torn at it’s
attachment inside the
shoulder joint
• Often diagnosed late
• Treatment: physio
and surgery if not
settling
• SLAP = Superior labral anterior to
posterior injury
 Frozen Shoulder= Adhesive capsulitis
• Only seen in shoulder
joint
• Inflammation and
thickening and tightening
of the capsule around the
shoulder
• Cause not known
Comes on slowly over months • Related to older people,
pain first then reduced previous small injury,
movement . Gets better on its Diabetes, heart disease
own BUT takes about 2years and chest surgery!
untreated. Best RX is injection
therapy early.
What are the main shoulder injuries in
your sports ?
• Impingement
• Rotator cuff injury
• Dislocation
• Labral Injury
• Fractures
Different Sports shoulder problems
• Swimming • Impingement with rotator
• Racquet sports cuff tendon involvement
• Throwing sports
• Cricket

• Rugby, football • Trauma dislocations

fractures (rugby football)
• Labral injuries
 History
• History of mechanism will often suggest the
injury:-
• Impingement- pain with any overhead
movements , often shows trick movements to get
arm above head
• Dislocation- first one generally traumatic and
VERY PAINFUL, But recurrent =instability, hx of
dislocation-how many and why?
• Labral Injury – clunk, generalised pain, catching
pain
 Principal of all Musculoskeletal
Examination
1. Look… swelling 2. Movements
bruising, deformity • Active
• Passive
2. Movement • Resisted

3. Special tests.. Vary Joint above and below

with every joint
Think referred neural
4. Palpation/feel
 Shoulder Examination
• Look Movements Shoulder
– Symmetry look at quality & range
– Swelling e.g. AC joint • Active
– Muscle bulk – Flexion and extension
• Movement – abduction and adduction
– internal and external rotation
• Special tests • Passive
– There are >120 for shoulder • Resisted
but few lack specificity and
reliability
Joint above and below= neck and
• Palpation/feel elbow
– AC joint, Muscle tone, tender
areas , swelling Think referred nerve pain (neural)
What do the muscle tests tell us ?
• Active moves test • Passive moves test the
muscle and tendon possible range of
complex. movement in the joint
• It is possible to have an • Pain free isometric
almost full pain free (static) muscle
range of move passively contraction is possible
with a tendon rupture, when there is reduced
but pain actively. joint range of
• Resisted moves movement e.g. Frozen
assesses strength shoulder
 Shoulder pure Movements
• Flexion –straight up in • Abduction (movement
front to above head away from the body
• Extension- from hanging midline)
by side move arm back • Adduction (movement
• Internal Rotation- with towards the body
elbow at 90o hand midline)
towards belly button
• External Rotation- elbow
at 90o and out to side of
body
Resisted Tests
 Specific shoulder tests
• There are about 120 special tests for the
shoulder.. Often named after their
inventors…none very specific and reliable.
• Many pre date reliable cheap imaging e.g.
Hawkins-Kennedy, false positives in SLAP(46%)
and Bankhart’s(25%)
• Now .. Imaging preferred
 Imaging Modalities-Ultrasound
• Excellent for all shoulder injuries except labral
• Gives a good overall picture of the rotator cuff, ACJ
and any tendinopathy or bursitis
• Cheap, quick, portable
• Useful for guided injections if indicated
MRI Imaging in Labral Injuries
• MRI will potentially
show an injury however
• Magneto Resonance
Arthrogram MRA is the
gold standard for this
 Shoulder injury
What questions will you ask ?
• A player is tackled and • History of injury
falls to the ground – Mechanism of injury
screaming with – Exactly what happened
shoulder pain • Easing
• DR ABC = Normal – Supporting with other
“With this sport are you hand
allowed on the field of • Aggravating
play?” e.g. Judo – Any movement

Can they continue play?

History mechanism of acute injury
• History of injury
– Mechanism of injury
– (what happened?)
e.g -Falls on outstretched arm
e.g-Thrown in the air and lands on
shoulder tip
• Easing
– Supporting with other hand
Hanging down
• Aggravating
– Any movement?
e.g. Shaking arm or holding it still
 Shoulder Examination
• Look Movements Shoulder
– Symmetry look at quality & range
– Swelling • Active
– Muscle bulk – Flexion and extension
• Movement – abduction and adduction
– internal and external rotation
• Special tests • Passive
– There are >120 for shoulder • Resisted
but few lack specificity and
reliability
Joint above and below= neck and
• Palpation/feel elbow
– AC joint, Muscle tone, tender
areas , swelling Think referred nerve pain (neural)
 SHOULDER REHABILITATION
• https://www.shoulderdoc.co.uk/documents/S
houlder-Rehab-Book-v4-book.pdf
• 178 pages of exercises ..free

• 1. Full range of movement

• 2. scapular stabilisation and proprioception
• 3 strengthen rotator cuff
• 4. sport specific
 Patient Case 2
• 38 year old male high sided off motorbike
landing heavily on his left shoulder
• Normally fit and well
 Examination
• On arrival at scene C-spine, A, B, C cleared,
2ndry survey-significant pain left shoulder
humeral area and clavicle distal end,
neurovascular intact-badge patch normal
• Into ambulance-arm in sling-became unwell,
dropped blood pressure, HR went up, pale,
sweaty
• To hospital diagnosed with fracture humerus
and clavicle
 Trauma Sport-consider
• Mechanism of injury (high side v low)
• Speed
• Protective equipment worn
• Temperament of individual
• Given the above have different differentials
than a non contact sport-pelvic injury,
fractures etc.
 Patient Case 3
• 45 year old male
• Injury to his shoulder in wrestling 6 weeks ago
• Landed heavily in a throw directly onto the
shoulder
• X-ray in A + E and discharged with a soft tissue
injury no follow up arranged
• Physiotherapy since but presented with
generalised pain worsened by abduction and
flexion
 Examination
• Muscle wasting around his shoulder
• ACJ right prominent
• Flexion to 90 degrees
• Abduction to 90 degrees
• Pain all resisted tests
• Impingement tests-difficult to assess
• Instability tests-normal
• Labral tests-difficult to assess
• Empty Can test positive
 Differential diagnoses
• Rotator cuff tear
• Labral injury
 Review
• Shoulders are complex
• Put the picture together-history and
examination
• Many clinical Tests for the shoulder are
generally non specific and not sensitive
• Physiotherapy working on muscle imbalance
and scapula stability is generally key to
prevent and rehab shoulders
• Ref www.shoulderdoc.co.uk