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Functional Anatomy
The glenohumeral joint is an inherently unstable shallow ball and socket joint.
Effective Sh function and stability require both:

Static constraints (GH ligaments, glenoid labrum and capsule)

Dynamic constraints (Rotator cuff and scapular stabilizing mm.)

Static stabilizeis
Main static stabilizers in the fxnl position (Abd) are:

Ant band of Inf GH ligt

- Prevents ant translation
- Sup margin attaches to the Glenoid fossa @ 2oclock
- Previous subluxation when arm is abd and ext 1

Post band of inf GH ligt

- Prevents post translation
Both attach to the labrum which in turn attaches to the fossa.
The Labrum also ! Sh stability by increasing the size and depth of
the Glenoid cavity
Bynamic stabilizeis
The Rotator cuff muscles act in co-contraction to seat the humeral head in the glenoid.
The rotator cuff (primarily supraspin) counteract the action of the delt by preventing the humeral
head from moving superiorly when the arm is raised.
Scapulohumeial ihythm
- Normal Sh fxn requires smooth integration of mvt @ GH, AC, SC and Scapulo-Tx joints.
- Adequate Scapulo-Tx rhythm is required for full Sh elevation.
- Full elevation req upward rot of the scap to clear the coracoacromial arch from the path of the
greater tuberosity (avoiding impingement)
- Control ! stability at Abd >90 by placing the fossa underneath the HOH & stability is ! by deltoid
- A stable scapula allows optimal length-tension relationship
- Should be smooth, coordinated and symmetrical. JERKY MVT = ABNORMAL
- Abn Rhythm may be as a result of injury or could be the predisposing factor
- Abnormalities are most commonly due to:

Weakness and/or poor motor control of stabilizers ( +/- weak rotator cuff)

Shortening of Scapulohumeral muscles

Involuntary adaptation to avoid painful arc

Muscles controlling the scapula: (NB retrain and strengthen after injury)

Trapezius (all 3 portions)

Serratus ant (upper and lower

Rhomboids

Levator scapula

Pectoralis minor
They work in force couples to control 3D mvt of the scapula

Upward rotation = Upper traps + Lower traps/ Serratus ant

Ant/ post tilt and 1 = Upper traps/Pecs minor with Seratus ant/Lower traps
Clinical Perspective
Diagnoses of Sh pain Requires: Thorough history, Thorough examination and Appropriate investigation
organization
Piactical Appioach to Sh pain
Numerous structures can cause Sh painfirst narrow the prob down to one of the following
catagories:
1. Rotator cuff
2. Instability
3. Labral injury
4. Stiffness
5. AC joint pathology
6. Referred pain
1 .Rotatoi cuff muscles anu tenuons
Injuries to the muscles/tendons may be acute, chronic or acute on chronic.
- Acute = muscle strain, partial or complete tendon tear
- Overuse= Tendinopathy
- Acute on chronic = eg. complete tear on previously degenerative tendon
Rotator cuff tendon injuries present with sh pain and difficulty with overhead activities
2. Sh instability
Pain arises from ant/post or superior Sh capsule and labrum or pericapsular mm.
May be obvious in pt with recurrent dislocation/subluxation
Instability may result from :
- Hyper mobility (Changes to passive structures like ligt, capsule, labrum)
- Dynamic instability ( Poor motor control)
S.Labial injuiy
From acute or overuse injury.
May lead to instability.
4.Sh stiffness
Hypomobility may be due to :
- Trauma (surgery, injury to cervical nerve roots, brachial plexus injury)
- Spontaneous in middle age ( idiopathic capsulitis / frozen Sh)
S.AC }oint Pathology
Localized pain
6.Refeiieu pain
From:
- Cervical spine
- Upper thoracic spine
- Associated soft tissue
Shoulder dysfunction can lead to traps fatigue or radiate to:
- Neck
- Behind scapula
- Upper arm
- Fore arm
- Wrist + hand
Bistoiy
Most Sh pain is diffuse (AC and bicipital pain is well localized)
1. Onset may be:
- Accute (Dislocation, subluxation, rotator cuff tear)
Identify Sh position at time of injury - wrenching = ant subluxation or dislocation
Fall onto Sh = AC joint injury
- Insidious (Tendinopathy)
In Chronic pain the painful position/activity of the Sh should be noted
2. Note the severity of pain, easing/aggravating factors and the effect of P on ADL/sport
3. Sensory symptoms ( pins and needs, dead arm in a pitcher suggests labral injury-)
4. Assess UL strength
5. May report catching/locking or inability to develop N speed.
6. Problems elsewhere in the kinetic chain eg. Knee or ankle or lower back pain
7. Exact physio for previous local or distant problems
8. Predisposing factors (over training ect)
Examination
Resisteu mvt
1. External Rotation (Pic)
2. Gerbers test (Sub scap lift-off)
3. Deltoid (Resisted abd @ 90)
4. Empty can (Supraspinatus)
- (90 abd, 30 horizontal flex, full internal 1)
- ! strength with Scap retraction = rotator cuff is NOT injured but is weak due to scapular dyskinesis
5. Long head of biceps tendon (upper cut)
Special Tests
1. AC Joint
a) Modified OBreins test (+ if pain in this position - 90 flex,10 hor flex, max int 1)
b) Active Horizontal flexion (Closing of AC joint)
2. Supraspinatus Impingement
a) Neer Test (+ if elicit known pain while moving greater tuberosity under acromion)
b) Hawkins and Kennedy (forcefully int 1 Sh from 90 flexion - remember to stabilise Scap)
c) Empty can (90 abduction, 30 hor flex, full int1)
d) Scapular assistance test (# pain = +)
e) Scapular Retraction test ( + If Impingement signs are #)
3. Long Head Of Biceps Tendinopathy
a) Speeds Test b) Uppercut c) Yergesons test (Resisted supination)
4. Instability
a) Load shift test drawer test
b) Apprehension Relocation test (Anterior) (+ if pain is relieved with relocation)
c) Sulcus test (Inferior)
d) Posterior instability test (supine, 90 flex, give compression through Sh joint AP)
5. SLAP Lesion
a) Dynamic Labral shear (NB maintain tension with external rotation)
b) OBriens Test ( Pain Supinated<Pronated)
c) Crank test (160 abd)
d) Anterior slide
6. Scapular mvt
a) Lateral slide test (Measured with arm by side,hand on hip and 90 abd. Compare L = R)
Sh Investigations
X-iay
Can identify:
- Joint space
- Dislocation
- Calcific Tendinopathy
- Arthritis
- Sclerosis
- Humeral head migration
- Fractures
Aithiogiaphy
Stain is used in combo with CT or MRI and
allows detail examination

Small avulsion # of:

- Glenoid rim (Bankart lesion)
- Humeral head (Hill-Sachs lesion)
0ltiasounu
High resolution
Used to evaluate soft tissue (Muscle, Bursa,
and Tendon)
Tendon tear >50% less likely to respond to
non-operative Rx
NRI
Ct scan better to view bone
Examination c Sh mvt is not possible
NB Labral tears or instability
Aithioscopy
Red synovium and thickened capsule are
indicative of adhesive capsulitis
Impingement
Clinical sign NOT a diagnosis
- Syndrome begins as an overuse injury ! Tendinopathy of supraspinatus (on the under surface near
biceps)
- Pain -> Rotator cuff dysfxn -> humeral head migration -> Subacromial bursitis.
- The additional Pain from the bursitis -> ! dysfxn and impingement -> Ossification of coracoacromial
ligt (bone spur), which is known X-rays as evidence of impingement -> bursal damage
- Young sportspeople present with : under surface tendinopathies and tears
- Chronic over use presents with: Bursal side changes, intrasubstance tears and severe tendinopathies.
Associated diagnoses with + signs and symptoms of Impingement:

Scapular Dyskinesis

Cervical Radiculopathy

Biceps Tendinopathy

GH instability

Superior Labral injury

Rotator cuff dissease

AC joint arthrosis and/or bone spurs

Subacromial bone spurs and\or bursal hypertrophy

GH internal 1 deficit
Sh impingement may be External (primary or secondary) or Internal
Piimaiy exteinal Impingement (Bony cause)
Abnormalities in superior struct lead to encroachment into the Subacromial space.
Undersurface may be beaked, curved or hooked.
Cause can be a congenital abnormality or osteophyte formation.
Abnormalities that tend to occur in the older pt include osteophyte formation on the inf surface of
the ac joint and thickening of the coracoacromial arch
In any sports person presenting with
impingement, NB to consider superior labral
injury or instability. These may lead to
impingement and if untreated the symptoms
will persist.
Seconuaiy exteinal impingement - biomechanic of nature
Encroachment in the younger athlete may be resultant from Excessive angulation (Excessive internal
1 and ant tilt) of the acromion due to inadequate scapular stabilization
Muscles may be deficient due to:
1. Altered activation in force couples
2. Altered strength balance
This results in failure to adequately control the Scapulohumeral rhythm, thus abnormal scapular mvt.
The tilt and rotation = narrowing of the Subacromial space = symptoms.
This is the exacerbated by pec minor tightness that pulls the scapula into protraction.
If an imbalance between the HOH elevators (Deltoid) & the HOH stabilizers (Rotator cuff) exists:
HOH will move superiorly with deltoid contraction forcing it against the rotator cuff tendons and
narrowing the
sub AC space.
Inteinal impingement - Look for laxity and labral injuries too
Occurs mainly in overhead sports during the late cocking stage. (ext, abd, ext rot) when the undersurface
of the rotator cuff occurs against the posterior surface of the glenoid.
This normally a physiological occurrence, may become pathologic with repetitive trauma, overuse and
injury to the labrum.
Rotator cuff injuries
Rotatoi cuff Tenuinopathy
The tendon becomes: swollen, hyper cellular, with collagen matrix being disorganized
- leaving tendon weaker with an increase in vasculature and nerve density.
Volume of work is a major determinant in the onset of a Tendinopathy.
Sometimes calcifications can appear
- most often seen in the Supraspinatus tendon, but may occur in any
tendon.
- may be asymptomatic, however if symptomatic = severe pain at
rest, with mvt and at night
Clinical featuies
- Pt complains of pain with overhead activities
- Activities in < 90 abduction are usually pain free
- May have a history of instability
- Night pain is common
- Tenderness at or just proximal to the insertion of
Supraspinatus on the greater trochanter
- Painful Abduction arc (70-120 Abduction)
Int 1 is commonly # and Rotator cuff strength should be
assessed with the scapula stabilised
Sxs with impingement tests and with end range flexion
MRI = investigation of choice
Diagnostic US can:
- Rule out a full thickness tear & define a partial thickness tear
- Indentify a thickened Subacromial bursa and rule in/out impingement of the bursa under the lateral
acromion with abduction
Tieatment of iotatoi cuff Tenuinopathy
Treatment consists of 2 parts:
1. Treat the Tendinopathy itself (PRICEM)
- No level 2 evidence to support NSAIDS, US, IFST, Laser, Magnetic field therapy or Massage.
- Level 2 evidence for Nitric Oxide donor therapy (patches applied locally @ 1.25mg/day)
Successful outcomes within 3-6 months
- Subacromial corticosteroid injection to allow adequate rehabilitation
2. Correction of associated abnormalities (eg. Instability, muscle weakness, training errors etc)
- Decrease rotator cuff strength is also predisposition to the development of a Tendinopathy.
- Rx involves strengthening of the ext rotators (if there is an imbalance of int vs ext rotators)
- Posterior capsule tightness is associated with increased int rotation and rotator cuff weakness.
- Thus stretching of the posterior capsule is NB.
- Symptomatic pts fire trapezius, and asymptomatic fire lateral deltoid.
- No level 2 support for a specific rehabilitation strategy
3. Abnormalities along the kinetic chain must be identified and corrected
Calcific Tendinopathy can be difficult
Mature calcific lesions may be disrupted by Shock Wave Therapy
Can use Nirschl Phase Rating Scale for tendinopathies:
1. Mild stiffness or soreness after activity with resolution of symptoms within 24hours
2. Mild stiffness or soreness prior to activity that is relieved by warm-up; Sxs are not present
during activity but return afterwards and resolve within 48hours
3. Pain that is present during activity without causing activity modification
4. Pain that is present during all activities and occurs with activities of daily living
5. Intermittent rest pain that does not disturb sleep
6. Constant rest pain that disrupts sleep
Rotatoi cuff teais
Commonly older sports people who present with Sh pain during activity.
Inability to sleep on affected Sh
+ Impingement signs and sometimes weak Supraspinatus m
Confirmed with MRI or Diagnostic Ultrasound
Partial/small tear = Conservative Rx
Full thickness = Surgical repair
In older people, symptoms and level of fx should guide Rx
Glenoid Labrum Injuries
Clinically ielevant anatomy
The Labrum is a ring of fibrous tissue attached to the rim of the glenoid
Wedge shape in cross-section
It expands the size and depth of the glenoid
Also plays a role in proprioception and spreads weight evenly over the interface.
Labral attachment blends directly into articular surface
Occasionally the attachment is meniscoid
- free edge extends into the articular surface and can be mistaken for a tear
Primary attachment site for the capsule and the GH ligts
Tendon of long head of biceps attaches at the superior aspect of the labrum.
Slap lesion: Superior labrum, Ant to post of the biceps tendon tear (Type 1-4)
Stable or unstable according to whether the majority of the superior labrum and biceps tendon are
attached to the glenoid margin
Labral injuries are divided into Type 1-4:

Naking the uiagnosis
The diagnosis depends on an appropriate mechanism of injury, investigation and clinical assessment
Common mechanisms of injury:

Excessive traction on the labrum through the long head of biceps (Superior labrum)

Throwing injuries due to a combo of:

o peel-back traction of biceps on the labrum in cocking
o Posterior humeral translation in cocking due to deficit in internal rot
o Excessive scapular protraction
Localised pain posterior or posterior-superior of joint line - esp in abduction
Pain exacerbated by over-head and hand behind back mvt.
On Examination: Pain with resisted biceps contraction and tender over ant aspect of SH.
The DLS is reliable, highly sensitive, and specific and has a high predictive value.
Plain radiography unremarkable.
Interpretation of MR arthrography is complicated due to wide range of normal variants.
Combinations of clinical tests are more sensitive than MRI.
Tieatment
- Conservative Rx only successful in minor SLAP lesions in young sports people.
- Unstable SLAP (type 2 and 4) repaired arthroscopically by reattaching the labrum to glenoid.
- Stable SLAP (type 1 and 3) and stable non-SLAP = arthroscopic debridement to eliminate
irritation.
- Unstable non SLAP (Bankart) = arthroscopic fixation.
- In pt >50 surgical repair does not yield additional over conservative RX.
- Those who do not participate in over-head sport do well with conservative care
- Difficult to determine which SLAP will respond best to non-surgical (Only able to classify
Arthroscopically)
- RX: NSAIDS + PHYSIO that includes Scapular stab exercises and Stretching of the posterior
capsule.
Specific exercises based on Mechanism of injury, clinical findings and type. :

Compression injury = non weight bearing exercises

Traction injury = No heavy weights

NB to know if the biceps tendon is involved
uoals:
1. Restore ROM, Neuromuscular control, dynamic stability and proprioception
2. Full strength, power and endurance
If conservative Rx is successful = return to sport in 3-6 months
Symptoms can frequently be lessened or
relieved by the scapular assistance test
(SAT).This test identifies pts who will respond
favourably to scapular stabilisation exercises
If the pt does NOT have a good history consistent with
a labral tear AND has a + DLS test, the MRI signal
changes in the labrum are likely NOT clinically relevant.
Dislocation of the glenohumeral joint
Anteiioi Bislocation
Most common traumatic sports injury (Almost always an anterior dislocation)
Caused by arm being forced into abduction and ER
Often associated :

Bankart lesion (Damage to the anterior labrum attachment to the anterior Glenoid margin)

Bony Bankart (# of ant glenoid rim)

Disruption of the glenohumeral ligt

Hill-Sachs lesion (Compression # of humeral head posteriorly)

Tearing of the posterior superior labrum

Damage to the axillary n. (# sensation on Lateral aspect of Sh and Deltoid weakness)

History: Acute trauma (Direct or Indirect), Feeling of popping out, sudden pain.
On Examination:

Prominent humeral head

Hollow below the acromion

Loss of smooth contour when compared to opposite side

Nanagement of fiist time uislocation
If @ hospital, do X-ray before reduction
If not, do post reduction X-ray to eliminate possible #
The sooner the dislocated Sh is reduced, the easier it is to reduce
Placing Sh in 30 ER significantly improves position of the labro-ligamentous lesion on the labrum
Adults < 30y there was a 75% reduction in relative risk for subsequent instability in the surgical group
Aithioscopic Stabilization
For Bankart lesion:
1. Commence pendular mvt after 24h
2. Sling for 3-4 weeks
3. Active ER mvt to just short of limit as soon as pain subsides
4. Active IR gradually introduced as pain subsides
5. Strengthening commences @ 6 weeks
6. Return to sport by 3 months
Recuiient Bislocations
If the dislocation is reoccurring and leading to a chronic instability, the above should be considered.
Posteiioi uislocation
- Far less common
- Due to direct trauma or fall on the arm that is to some degree of IR.
- Anterior sulcus
- The arm is held in IR and Adduction
- The cardinal sign is the limited ER
- Suspicion of this Dx should be based on:
(1) The mechanism of injury
(2) Loss of Function ! presence of Pain
- Can easily be overlooked with AP X-ray
Shoulder instability
Anteiioi instability
The instability may be:

Traumatic (Acute traumatic episode)

o Pt usually reports specific incident and Sh never returning to normal
o Commonly forceful Abduction and ER

Atraumatic type (Common in pt with Capsular laxity, esp those involved in overhead sports)
Or a Combination (traumatic on an already lax Sh)
Clinical Featuies
Symptoms: Recurrent dislocation/subluxation, Sh pain, dead arm
Pain :
1. From impingement of the rotator cuff tendon, with recurrent translation of the humeral head
This is aggravated by the eventual weakening of the Rot cuff, which in turn fail to depress the
humeral head and results in a Tendinopathy. (Secondary external impingement)
2. May be due to catching of the labral detachment (May be reproduced by Ant drawer test)
Episodes of dislocation and subluxation usually increase in frequency
On examination:
1. Note ligament laxity (Sulcus sign Generalised ligt laxity)
2. Amount of ER
3. Assess m. strength to rule out neurological deficit
4. Tenderness Ant $ Damage to ant structures
Post$ Supraspinatus tear is common with the older pt
5. Which position causes sympt/dislocation (usually Abd and ER)
6. Degree of laxity can be measured with: (If instability, these will cause pain or apprehension)
a. Load and shift drawer test
b. Apprehension-augmentation-relocation test (Greater reliability)
- Apprehension is a better indication than pain
- Sensitise and desensitise b.m.o ant/post pressure
- If the instability is minor and this position does not give apprehension the humeral
head is first anteriorly translated the the arm is taken into Abduction and ER
Investigations
CT and X-ray may be useful in demonstrating associated injuries (Hill-Sachs and Bankart)
MRI Bony lesions, Soft tissue (Labrum), Capsule and Tendons
Tieatment
First time as above. A traditional sling should not be used to manage instability
! Traumatic instability
Arthroscopic Bankart repair is the Rx of choice.
Other structures can the also be repaired (Rot cuff tear, labrum etc.)
Tendon transfer, Magnusson-Stack and Putti-Platt results in loss of ER and is thus not
recommended for sports people
! Atraumatic instability
Intense rehab that involves strengthening of dynamic stabilisers (rotator cuff) and scapular
stabilisers and emphasizing the muscles opposing the instability
If conservative fails $ Surgery for capsular shift
Labral injuries are often associated with Sh instability and must be addressed
Posteiioi Instability
Commonly Atraumatic and part of a Multidirectional instability. Usually there is a + Posterior drawer.
Rx = Strengthening the posterior stabilizing mm, surgery should be considered if these measures fail.
Always keep post labrum in mind with recurrent instabilities (needs surgery if injured too much)
Nultiuiiectional instability
- Combo Anterior; posterior and inferior instability
- Commonly Atraumatic associated with generalized ligamentous laxity throughout the body which
should be assessed at the thumbs, wrist, elbow and knees.
- May also be due to repetitive trauma
On examination:
1. Ant instability : Drawer test and apprehension relocation
2. Posterior instability : Drawer test
3. Inferior Instability : Longitudinal caudate traction = sulcus sign
Pain in mid ranges (Due to translation) is a major characteristic. This indicates a prominent role of
altered muscle activation:
1. # Lower traps and Seratus ant
2. ! Pecs minor and Latisimus dorsi
This leads to scapular protraction and tilting of the glenoid
Relief of symptoms and # translation when placing the scapula in stabilized retraction will point to
the need for an exercise program for scapular and Sh stabilizers (SAT = NB)
No stretching of the muscles around the Sh joint
If this is unsuccessful = Surgical intervention (Not as successful with generalized ligt lax)
Adhesive Capsulitis
GH stiffness is not uncommon after trauma, following injury to the neural structures or occur spontaneously
Adhesive capsulitis (Spontaneous Sh stiffness) occur between 40-60 years of age and affects the L > R with
diabetes being a predisposing factor.
Diagnose by evaluating passive ER ! elbow at side & Scapula stabilized
Normal surgical stiffness resolves within 12 months
Fracture of the clavicle
Fall onto the point of the Sh or direct trauma
Niuule thiiu claviculai fiactuie
Usually # at middle third = Displacement : Outer fragment#, inner fragment!
On exam: Deformity, swelling, local tenderness (extremely painful)
The scapula will assume a protracted position with clavicular angulation or shortening
If conservative Rx the overlapping and shortening should be monitored for 2-4 weeks
Rx:
Mainly to provide pain relief, # heals within 4-6 weeks
Best managed conservatively
Often the clavicle is foreshortened which leads to significant functional deficits
A figure of 8 bandage is designed to prevent foreshortening and has significant theoretical
advantage over a sling or collar
Pt should preform self-assisted Sh flexion to a max of 90 to prevent stiffness
Surgical :
! Open #
! Non-union
! Foreshortening of >1-2cm
Rx:
Self-limiting and resolves in 1.5y
No evidence that physio,
injections or drugs # the outcome
Bistal clavicle fiactuie
May involve disruption of the AC joint and or coracoclavicular ligt
More prone to non- and mal-union
# Med to ligt has greater displacement of fragments = !risk of delayed/non-union if Rx conservatively

Type 1: Rx with sling for comfort, early ROM and isometric strengthening. If displacement is
present, rehab should progress slow and ROM when pain #

Type 2: More controversial as there may be more displacement, surgery often recommended

Type 3: If stable should be treated conservatively

Acromioclavicular conditions
Acute AC joint conuitions
Common site of injury with a fall on the point of the Sh
AC joint stability is provided by the following (descending)
1. Coracoclavicular ligaments
2. Acromioclavicular ligaments
3. The joint capsule
Classification by Rockwood:
1. Type 1: Sprain of the joint capsule, characterised by local pain with mvt (esp horizontal flexion)
2. Type 2: Complete tear of the Acromioclavicular ligt with a sprain of the coracoclavicular ligts (step
deformity on palpation)
3. Type 3: Complete tear of the coracoclavicular ligts (Conoid & Trapezoid)
a. Marked step deformity
b. 25%-100% greater coracoclavicular space than the uninjured side
4. Type 4: Characterized by posterior displacement of the clavicle
a. Complete rupture of all ligt complexes
5. Type 5: Complete tear of the coracoclavicular ligts
a. Complete rupture of all ligt complexes
b. Marked step deformity
c. Between 3 and 5 times greater coracoclavicular space than normal
d. Typically involves soft tissue damage incl muscle, fascia and occasionally skin
6. Type 6: Inferiorly displaced clavicle into the Subacromial or subcoracoid position
a. Complete rupture of all ligt complexes
Types 4, 5 and 6 are less common than 1, 2 and 3
Nanagement
Based on general principles of ligt injuries

ICE

Immobilised in a sling for pain and comfort

o 2-3 days for Type 1
o Up to 6 weeks for Type 2 or 3

Isometric strengthening once pain allows

Return to sport when full ROM (Pain free) and no local tenderness
Major Fx problems in high grade type3/4 injury is due to the loss of strut function to stabilize the
Scapula, GH joint and arm. 73% of type 3 AC separations lead to an alteration in scapular mechanics
Surgery for type 4,5 and 6 and type 3 that does not respond to conservative management.
aLhology
1ype 1 lracLure dlsLal Lo coracoclavlcular llgL wlLh llule dlsplacemenL
1ype 2a lracLure medlal Lo coracoclavlcular llgL
1ype 2b lracLure beLween coracoclavlcular llgL
1ype 3 lnLra-arucular # wlLhouL dlsrupuon

Chronic AC joint pain
AC joint pain is usually localized over the joint
Symptoms reproduced by: Modified OBreins test
Persistent pain may require distal clavicle excision
Chronic pain may be due to:
1. Repeated minor injuries (maybe following type2/3) which can damage the fibrocartilagenous
meniscus in the AC
2. Osteolysis of the distal end of the clavicle (moth eaten appearance on Xray)
a. Painfull horizontal flexion
b. Impingement due to abnormal scapular position due to loss of strut Fxn
c. Electro, mobilization and strengthening
3. Osteoartheritis (due to recurrent injuries)
a. Osteophite formation or sclerosis on X-ray
Referred Pain

The cervical and upper thoracic spine structures can refer pain to the Sh region

Active trigger points in the muscles or fascia

o Ant Sh pain: Infraspinatus, Supraspinatus, Deltoid, Scalene, Pec Major, Pec Minor, Biceps
Brachii, Coracobrachialis, Latissimus dorsi
o Post Sh pain: Deltiod, Levator Skapulae, Scalene, Supraspinatus, Teres Major, Teres Minor,
Subscapularis, Latissimus dorsi, Triceps, Trapezius, Illiocostalis

Neural structures (Rx with neural glides)

Less common causes
Biceps Tenuinopathy
Overuse injury
Occurs with a large volume of weight training
Often incorrectly diagnosed instead of referred pain or rotator cuff Tendinopathy
Local tenderness at bicipital groove or bicep tendon
Uppercut test or passive stretch of biceps
Ruptuie of the long heau of biceps
Occurs in the older sports person and is accompanied by a sharp pain and tearing sensation
Obvious deformity in distal upper arm that is accentuated by bicep contraction
In those who perform power sports surgery is indicated
Pectoialis majoi teais
Complete: Gr 3
- Occurs at the site of insertion.
- Sudden onset of pain on the medial humerus with local tenderness and swelling
- Resisted contraction is weak and painful
- Surgical repair
Partial: Gr 1and 2 - Treated conservatively with Ice and Strengthening 4-6 weeks
Subscapulaiis muscle teai
Occurs with sudden forceful ER or Extension applied to the abducted arm
No associated instability
Complain of pain (ROM may be obtained)
On examination:

Increased external rotation with the Sh adducted

Weak internal rotation

+ lift off sign

Neive entiapments
Supiascapulai neive - (CS,C6)
Most common of the three
Nerve runs from the brachial plexus, underneath the Traps, then underneath the transverse scapular
ligt through the Suprascapular notch and supplies the Supraspinatus.
The nerve also branches here and runs through the Spinoglenoid notch to supply Infraspinatus.
Pain is deep and poorly localized posteriorly and laterally of the Sh.

Weakness and wasting of Supraspinatus & Infraspinatus = trapped at the Suprascapular notch

Weakness and wasting isolated to Infraspinatus = entrapment is at the Spinoglenoid notch

Confirm diagnosis with electromyogram
Long thoiacic neive - (CS,C6,C7)
Supplies the Serratus anterior m
The nerve may be injured by
1. Long thoracic nerve palsy
2. Traction on the neck and Sh
3. Blunt trauma
4. Viral illness
Abnormality to the nerve causes paralysis to Serratus anterior = Scapular winging
Clinical features:

Pain and limited Sh elevation

Scapular winging when pt pushes against the wall

Secondary impingement due to poor scapular control

Confirm with electromyography
Prognosis: Most patients will recover fully, but in rare cases surgical tendon transfer may be required
Axillaiy neive compiession
Thoiacic outlet synuiome
The neurovascular structures run from the thorax to the UL through the Thoracic outlet
There is 4 specific areas, namely:
1. Superior Thoracic outlet
2. Scalene triangle
3. Costo-clavicular area
4. Pathway of the coracoid
5. Pectoralis
Symptoms will depend on specific structures influenced - (Brachial plexus or Subclavical arteries)
- Sx may be neural, vascular or both
- Loss of stereognosis, Fine coordination
- Clumsiness of the hands
- Patient complains of Swollen hands, or hands feel heavy & numb
- Fingers feel numb or get cramps
- Vascular WORSENS with Sh elevation & when carrying something heavy
- Symptoms may be aggravated by Abduction of the arm
- Onset usually spontaneous
- Neurological signs with 3 min stress test
- Vascular signs with Abduction, Extension and Lateral rotation during Radial pulse palpation
% Add rotation of the head, Deep breathing
% Positive if: Pain, #Pulses and Pallor of the hands
- Remember ULTT
Treatment:
Conservative, except if severe neurological (surgery)
Handling of fear and ignorance
Posture correction
Strengthening: Pectoral girdle
Mobilisations: 1st rib, Cervical, Upper and Mid thoracic
Stretches: Scalenii and Pectoralis
TPs of Scalenii and Trapezius
Relaxation exercises
Avoid: carrying heavy objects; Wearing heavy jackets; Letting arm hand down while sleeping
Always keep Sh slightly elevated
Last resort: Resection of 1st rib/Clavicle
Axillaiy vein thiombosis
Fiactuies
neurologlcal SympLoms:
%nerve rooL paln
%Abnormal sensauon
%Weakness
vascular SympLomes:
%lschaemlc paln
%Weakness
%Claudlcauon
Principles of Sh rehabilitation
Nake a complete anu accuiate uiagnosis
Piinciple
Rehab program is only as good as the diagnosis
Often the diagnosis is incomplete due a combination of factors influencing the Sh function
Piactise
Diagnosis must include local (Bankart lesion, Impingement etc.) deficit as well as biomechanical
deficits that exist in the spine and Sh girdle
Distant deficits should also be included (#hip rot, #Hamstring length, inflexibilities of back)
Alterations in mechanics : Hyperlordosis, #trunk/hip rot, alteration of plant leg
A complete diagnosis include :
1. Clinical symptoms and tissues injured
2. Tissues that are overloaded
3. Functional and biomechanical deficits that exist
4. Subclinical adaptations of sports person (Compensation)
Eaily pain iuuction
Piinciple
Pain is a major cause of altered Sh function
Avoidance of pain causes the pt to assume abnormal positions of the back and arm
Pain causes muscle inhibition and thus alters firing patterns
Piactise
Pain should be controlled early in rehab by means of :

Relative rest

Cryotherapy

Avoiding painful arch

#Throwing activities

Meds

Electrotherapy

If true signs of inflammation (NSAIDS, Judicious injection into Subacromial space)

Integiation of the kinetic chain into iehabilitation
Piinciple
Important to re-establish the kinetic chain early in rehab
In ground based sports the Sh works within a kinetic chain from the ground through the trunk.
Leg and trunk exercises should be prescribed to ensure that the base of the kinetic chain is ready for
linkage when the Sh is ready for rehab
After the Sh is ready for rehab, activation of the chain patterns from the legs through the back and to
the Sh restores the force dependent motor activation patterns
This is NB to generate force and velocity
Piacice
Correct :

Inflexibilities (Hamstrings, Hip and trunk)

Weakness or Imbalance (Trunk and Hip rotators, Flexors and extensors)

Sub clinical adaptations of gait and stance

Rehab of the legs and hips should be concerned with generating sport specific force and velocity
and should be done in closed chain fashion.
Eccentric forces should also be emphasized (Plant leg in throwing)
Combined patterns (L hip$R Sh and visa versa)
An excellent exercise is to jump onto a trampoline and simultaneously extending the hips and
scapula on landig (Hip and trunk rot with scapular retraction which mimics the cocking phase)
Endurance for LL is equally important
See fig 21.30/31
Scapulai stabilization
Piinciple
Early in the injury process, pain inhibits lower traps and serratus anterior which jeopardizes scapular
stability and acromial elevation
The scapula has 4 major functions:
1. Protraction and retraction during throwing
2. Elevation of the acromion with abduction
3. Acts as platform for the humerus
4. Base of origin of intrinsic (rotator cuff) and extrinsic muscles (Delt, Biceps, Triceps)
Piactise
Evaluate motion and position of the scapula in various phases
Assess Muscle strength and scapular stability
Integrate scapular retraction with rotator cuff co-contraction for normal patterns
Exercises for scapular stabilization:
1. Isometric scapular pinch
2. The scapular clock
3. The lawnmower
4. Inferior glide
5. Low row See fig 21.32
Eaily achievement of 9u abuuction anu l glenohumeial iotation
Piinciple
Throwing activities require 90 abduction and a large arch of glenohumeral rotation
Length- and force-dependent motor patterns are based on 90 abduction
Alteration by 15 in joint position changes the activation patterns
Inferior glenohumeral ligamentous constraints become taught and contribute maximally to control
Thus a throwers Sh should be rehabilitated at 90 to recreate patterns
Piactise
To achieve 90 abduction as soon as possible:
1. # Pain from impingement or other source
2. Maintain stabilizer strength for acromial clearance
3. #Tendinopathy
Specific exercises include:
1. Active-assisted wand maneuvers
2. Gentle joint mobilizations
3. PNF
4. Passive stretching (Including sleeper stretching)
Insert fig 21.33
Closeu chain iehabilitation
Piinciple