PT ORTHO GOALS OF TREATMENT FOLLOWING A

FIRST SEMESTER (1ST CYCLE) STERNOCLAVICULAR INJURY INCLUDE:

SHOULDER CONDITIONS  Pain Control
 Reduction and/or immobilization as
STERNOCLAVICULAR JOINT PATHOLOGY indicated
 Dislocation is commonly anterior than posterior.  Identification and management of associated
If posterior dislocation happened, usually life injuries,
threatening.  Education regarding protection and
 MOI : Direct : a hockey player hitting the medial prevention of subsequent injury especially in
side of the clavicle on the goalpost or on another a traumatic type of dislocation
player’s knee.  Complications of anterior sternoclavicular
 Indirect : the athlete may be lying on his side, dislocation include cosmetic deformity, recurrent
and the uppermost shoulder is compressed and instability, and late osteoarthrosis
rolled backward, resulting in an anterior  Complications od posterior dislocation include
sternoclavicular dislocation on that side. If the all of these plus pressure on or rupture of the
shoulder rolls forward and is compressed, a trachea, pneumothorax, rupture of the esophagus,
posterior dislocation is more likely pressure on the subclavian artery or brachial
plexus, voice change, and dysphagia.

ACROMIOCLAVICULAR JOINT
PATHOLOGY
 Injuries to the AC joint result in what is often
called a “separated” shoulder, and they account
for 9% to 10% or acute injuries to the shoulder
girdle in the general population, whereas
separations of the AC joint account for 40% of
shoulder girdle injuries in athletes.
GRADING  MOI :
 Mild sternoclavicular joint injuries are those in  Falls on an outstretched hand or elbow (I.e.,
which the joint is stable and the ligamentous FOOSH injury)
integrity has been maintained.  Direct blows to the shoulder, or
 Moderate injuries have had part of the  Falling onto the point of the shoulder
ligamentous tissue disrupted, and the GRADING
sternoclavicular joint has partially separated or  Grade 1 is defined as pain at the joint; however,
subluxed. the ligaments are intact, and there is no
 Complete ligamentous disruption, resulting in an subluxation
unstable sternoclavicular joint, is considered a  Grade 2 is movement of the joint related to a
severe injury. tear in the AC ligament but not in the CC
 A first-degree sternoclavicular dislocation results ligaments.
in minor tearing (first-or second-degree sprain)  Grade 3 indicates a tear through both AC and
of the sternoclavicular and costoclavicular CC ligaments.
ligaments, with no true displacement of the joint.  Grade 4 & 6 are defined by displacement of the
 A complete tear (third-degree sprain) in the clavicle posteriorly, superiorly, and anteriorly,
sternoclavicular ligaments and a second-degree respectively.
sternoclavicular dislocation and actually result in
subluxation of the joint. A third-degree
sternoclavicular dislocation is a true dislocation
of the joint, caused by third-degree sprains in the
sternoclavicular and costoclavicular ligaments.
TREATMENT
 Typically, grades 1 to3 are treated conservatively,
whereas grades 4 to 6 require reconstruction.
 Treatment of a grade 1 separation would include
ice,sling and swath, or resting of the arm for a
short period of time. Range of motion is
progressed as tolerated, the supporting
musculature is strengthened, and weight loading
of the joint is avoided for about 6 weeks. A
grade 2 injury requires a slightly longer rest
period (up to 2 weeks) before returning to range
and strengthening activities. Grade 3 injuries do
not require surgical reconstruction. Grade 4 to 6
are still thought to do better with surgical TREATMENT
intervention.  Most patients with a frozen shoulder can be
managed successfully with nonoperative
treatment, using a multidisciplinary approach of
patient education, physical therapy, analgesic
medication, and injection therapy.
 Secondary frozen shoulder requires management
of the preceding factor (e.g., shoulder surgery) or
contributory factor (e.g., diabetes) as well.
Although there is a lack of evidence to support
these common treatment interventions they are
noninvasive, inexpensive, and have minimal
FROZEN SHOULDER risk.
 AKA Adhesive Capsulitis
2 TYPES SCAPULAR FRACTURES
 Primary which is Idiopathic  Fractures of the scapula account for only 1% of
 Secondary due to trauma or immobilization all fractures, 3% of all shoulder injuries, and 5%
 Follows capsular pattern of fractures involving the entire shoulder.
 Scapular fractures are classified according to the
location of the fracture, specifically the body,
neck, glenoid fossa, acromion, spine, or coracoid.
The distribution of the different fracture sites has
been reported as 35% to 43% at the scapular
body, 26% at the neck, 10% at the glenoid fossa,
8% to 12% at the acromion, 6% to 11% at the
spine, and 5% to 7% at the coracoid.
 Nonoperative treatment is recommended for
most scapular fractures, with the exception of
those that occur at specific sites and/or according
to certain classifictaions. These include (1)
acromion or scapular spine fractures with
downward tilting of the lateral fragment and
resultant subacromial narrowing, (2) coracoid
fractures that extend into the glenoid fossa, and
(3) glenoid rim and intra-articular glenoid
fractures associated with persistent or recurrent
glenohumeral instability.
 Treatment consists of approximately 7 to 10 days
of sling immobilization, followed by a
 rogressing regimen of pendular and gentle CLAVICULAR FRACTURE
passive ROM exercises as comfort and control  Most commonly reported fracture of the
allow. Once follow-up radiographic findings shoulder girdle
indicate sufficient healing, the patient is  Incidence is highest among children and
encouraged to discontinue immobilization and adolescents
proceed with active-assisted and active ROM  MOI : either a direct blow from a fall onto the
exercises.Consideration must always be given to affected shoulder or an impact such as a tackle in
restrenghtening the muscles that attach to the football
scapula nd those that arise from the scapula (I.e.,  Most common site is reported to be between the
the rotator cuff and biceps brachii), which may medial two thirds and lateral one third of the
have been affected by disuse and painful bone (80%) followed by fractures in the distal
inhibitions. one third (17%) and those that occur in the
proximal one third (2%)
FLOATING SHOULDER
 The term floating shoulder was introduced by
Herscovic in 1992 to describe an ipsilateral
fracture of the clavicular shaft and the scapular
neck. The combination of these two types of
fractures has a significant effect on the
stabilizing role of the clavicle. Goss107 defined
floating shoulder as “a double disruption of the
superior suspensory shoulder complex (SSSC).”
He described three struts of this complex: (1) the
AC joint-acromial strut, (2) the clavicular
coracoclavicular ligament-coracoid linkage, and
(3) the three process-scapular body junction.  Fractures a re classified according to their
 MOI : Combined clavicular and ipsilateral anatomical location: group I are in the midhaft
scapular neck fractures are usually caused by a (middle third) of the clavicle, group II are in the
high-energy mechanism of injury, most distal (lateral) third of the clavicle, and group III
commonly motor vehicle accidents (80% to are in the medial (proximal) third of the clavicle.
100%). Other causes have been cited, such as a
direct blow, fall onto the tip of the shoulder, or a  The goal of treatment, relative to clavicular
FOOSH injury. fractures, is to minimize the risk of nonunion and
 Treatment options mentioned range from malunion. Nonunion is defined a s the absence
conservative management with or without early of clinical radiographic healing after 4 to 6
mobilization to operative treatment through open months, whereas malunion is associated with
reduction and internal fixation of the clavicle angulation, shortening, and poor cosmetic
only or of the clavicle and the scapular neck appearance. Generally it was believed that
fracture sites together. malunion did not affect functional capacity;
however, studies have discovered that malunion
may lead to weakness and fatigability.

 The minimally displaced clavicular fractures do

not require urgical intervention and can be
 treated conservatively with immobilization using after approximately 4 weeks when clinical union
either a sling or a figure-of eight brace for has occurred.
approximately 4 to 6 weeks.
 Clavicular fractures that require surgical LONG HEAD OF THE BICEPS TENDON
consideration include open fractures, STRAIN
concomitant displaced scapular neck fractures  Occurs in patients more than 40 years of age
that disrupt the superior shoulder suspensory with a prolonged history of outlet impingement
complex, the presence of neurovascular or skin and rotator cuff disease.
compromise, and a patient with multiple trauma  Patients frequently experiences a “pop’ at the
who needs assistance with early mobilization. time of the injury, which often occurs during
lifting or pulling activities. Some patients,
PROXIMAL HUMERAL FRACTURE however, just present with a painless retraction
 The proximal humerus is a common site of of the biceps distally resulting in an exaggeration
injury in the young and the elderly. In a of the biceps muscle contour.
skeletally immature athlete, the fracture  Results in a loss of approximately 8% of elbow
frequently presents as a fracture at the proximal flexion strength and 21% of supination strength,
humeral growth plate or physis (Little Leaguer’s function is not significantly affected in most
Shoulder); this type of injury most often is individuals.
associated with young patients involved in  Also known as Popeye’s Muscle
throwing sports.  This injury is best evaluated radiographically
 MOI : Powerful medial rotation and adduction with MRI or ultrasound, which demonstrate the
traction force on the proximal humeral epiphysis biceps tendon’ absence in the bicipital groove.
that occurs during the deceleration and  Treatment in patient more than 40 yaers of age
follow-through phases of throwing or pitching. who are relatively sedentary includes sling
immobilization
 Strengthening exercises of the rotator cuff,
shoulder girdle, and arm musculature
 In younger or physically active patients, early
surgical intervention might be warranted.
Mariani et al. reported that 93% of the surgically
treated patients and 63% of the nonsurgically
treated patients were able to return to full work
TREATMENT capacity.
 In children, rest is the primary treatment, along
with patient education regarding why absolute BURSITIS
cessation from activity, at least initially, is  Includes subdeltoid, subacromial, and
essential. The bone may require up to 8 to 12 subcoracoid bursae separate the rotator cuff and
months reossify and remodel. Rehabilitation the acromial arch
should include activities to improve strength,  Subacromial bursa can become inflamed in the
coordination, proprioception endurance, and younger athlete by direct trauma or in the older
ROM. individual with overuse and cuff problems
 In adult, commonly seen in patient with  Syndrome is typically painful and significantly
osteoporosis. limits abduction of the arm. Movements in other
 If the fracture is classified as nondisplaced and is planes are typically unaffected.
impacted or stable, initial period of  An injection of lidocaine and crystalline steroid
immobilization is indicated, using either a into the subacromial bursa can be helpful as a
conventional sling or a collar and cuff sling that diagnostic tool and therapeutic treatment for the
allows the weight of the arm to apply slight bursitis.
traction of the fracture. Early ROM exercises
follow, at nondisplaced but is considered
unstable, the immobilization period is more
strictly adhered to the ROM exercises beginning
SUPERIOR LABRAL ANTERIOR TO of anterosuperior or posterior shoulder pain with
POSTERIOR LESIONS no history of trauma
 SLAP lesion, which stands for superior labral  Impingement signs include Hawkin’s maneuver,
anterior to posterior injury, has been used to with the arm flexed, slightly abducted, and
name injuries to the superior labrum and biceps internally rotated, or Neer’s sign, with the arm in
tendon complex. full flexion at 90º, internally rotated while
 The glenoid labrum, which serves to deepen the resisting flexion
glenoid socket, increases the contact area of the  Primary impingement include a hooked
humeral head by approximately 70%. In addition acromion or a thick coracoacromial ligament
to increasing the static stability of the  Secondary impingement has many causes,
glenohumeral joint, the superior aspect of the including glenohumeral joint instability, weak
glenoid labrum serves a s an attachment point for scapular stabilizers, or scapulothoracic
the long head of the biceps tendon duskinesis and instability.
 Type 1 lesions involve a fraying injury to the TYPES OF IMPINGEMENT
superior labrum without detachment of the  Coracoid Impingement Syndrome occurs
biceps tendon when the lesser tuberosity of the humerus
 Type 2 lesions, the biceps tendon is detached enroaches on the coracoid process and has been
from the supraglenoid tubercle associated with subscapularis tears. The
 Type 3 lesions are characterized by bucket condition has been reported in swimmers tennis
handle tearing of the superior labrum without players, weight lifters, and brick layers.
detachment of the biceps tendon  Primary Anterior (External) Impingement
 Type 4 lesions involve a tear of the superior other type of impingement occurs in individuals
labrum that extends into the biceps tendon over age 40, arising from alterations in the soft
tissues (e.g., rotator cuff, labrum) and possibly
bony changes
 Secondary Anterior (External) Impingement
which seen in younger patients (ages 15 to 35),
muscle dynamic is the primary problem (I.e.,
weakness of the scapular and humeral
stabilizers). Primarily is due to scapular
dyskinesia and posterior rotator cuff fatigue
 Posterior Internal Impingement which
involves contact of the undersurface of the
 MOI : falling on an utstretched arm, traction rotator cuff with the porsterior superior glenoid
injuries, torsional peeling back of the labrun labrum. Burkhart et al. reported that posterior
during the late cocking phase of overhead internal impingement is a normal phenomenon
throwing, and traction forces from the long head that sometimes can result in pathology of the
of the biceps tendon during the deceleration rotator cuff and labrum
phase of overhead throwing
 Complaints of pain with overhead throwing, and
mechanical symptoms such as clicking, catching,
or grinding
 (+) O Brien Test
 Standard diagnostic tool : Arthroscopy
 Tx : Surgery

SHOULDER IMPINGEMENT SYNDROME

 Occurs as a result of microtrauma, macrotrauma,
or functional instability.
 Impingement is raised by the presence of a
painful arc during attempted active abduction or
forward flexion or in patients with a complaint
ROTATOR CUFF TENDONITIS  Anterior - Clavicle, coracoid process of
 Injuries to the rotator cuff are common. scapula, pecs minor
Although mocrotrauma can cause rotator cuff  Syndromes of TOS
injuries, repetitive microtrauma and outlet  Scalene Anticus Syndrome
impingement between the acromion and greater  Brachial Plexus
tuberosity of the humerus are more common  Subclavian Artery
 Neer categorized this type of rotator cuff injury  Common in pt suffering from COPD;
intro three stages due to overuse of accessory muscles of
 Stage 1 injuries involved inflammation and respiration
edema in the rotator cuff  Impingement:
 Stage 2 rotator cuff injuries had  Behind the Ant Scalene
progressed to fibrosis and tendonitis  Trunk of Brachial Plexus
 Stage 3 when a partial complete rotator  Behind the First Rib
cuff tear occurred  Divisions of Brachial Plexus
 In the overhead athlete, underlying instability  Axillary Area
patterns of the glenohumeral joint with  Cord of Brachial Plexus
associated excessive translation of the humeral  Pectoralis Minor Syndrome
head frequently led to outlet impingement and  May develop in persons assuming
rotator cuff disease kyphotic posture
 There is a relationship between the acromial  May lead to impingement
shape and the presence of rotator cuff tears  Brachial Plexus
CLASSIFICATION F ACROMION  Subclavian Artery and Vein
1. Type 1 acromions were relatively flat,  Avoid bench pressing
whereas Type 2 acromions demonstrated a curve,  Costoclavicular syndrome
and Type 3 acromions were hooked. The incidence  Between first rib and clavicle
of rotator cuff tears increased as the acromion  Narrowing can cause impingement
progressed form a type 1 to a type 3 shape. This was  BP
presumably related to the greater outlet impingement  Subclavian art & vein
of the rotator cuff caused by an increasing acromial  Common in pt that wear heavy
curve. backpacks
 Common in pt wearing heavy coat
SPRENGEL’S DEFORMITY  Pancoast tumor is a tumor of the pulmonary
 The scapula is abnormally small and medially apex. It is a type of lung cancer defined
rotated primarily by its location situated at the top end of
 The scapular muscles are under-developed either the right or left lung. It typically spreads to
 The affected scapula is 1-4in higher than the nearby tissues such as the ribs and vertebrae that
other eventually lead to TOS
 Usually (B) affectation
SHOULDER DISLOCATION
THORACIC OUTLET SYNDROME (TOS)  MOST dislocations (95%) occur in
 Excessive repetitive demands place on the anterior-inferior directions
shoulder such as pitching may lead to TOS,  More fragile anteriorly
axillary artery occlusions  Foramen of Weitbrecht - between superior
 Structures affected: and middle GH ligaments
 Brachial Plexus  Foramen of Rouviere - between middle and
 Subclavian Artery & Vein inferior GH ligaments
 Borders  Lack of support inferiorly
 Medial - scalene anterior, medius, &  Features/Clinical Signs:
posterior; first rib  Palpable humeral head below glenoid
 Lateral - axilla  Increase in length of the UE on affected side
 Posterior - Upper trapz, scapula  (-) of roundness of shoulders = atrophy of
deltoids (affected axillary nerve)
  MOI : baseball player-ptcher  Complications of Dislocation:
 Abducted upper extremity is forcefully  Bankart Lesion - injury of the anterior
externally rotated (inferior) glenoid labrum of the shoulder due
 Tearing : Inferior glenohumeral to anterior shoulder dislocation
ligament, Anterior capsule and Glenoid  Scraping of antero-inferior portion of
labrum glenoid labrum
 Phases of Throwing  Hill-Sachs Lesion - a posterolateral humeral
 Winding up head compression fracture, typically
 Concentric contraction of ERs secondary to recurrent anterior dislocations,
 Cocking Phase as the humeral head comes to rest against
 Abducted approx. 90º and ER the antero-inferior part of the glenoid
 Critical position for dislocation  Stretch anteriorly, but compresses
 Eccentric contraction of IRs - to posterior aspect
prevent anterior displacement of  Because of the compression, the labrum
humeral head  Bennett’s Lesion - posterior dislocation; (+)
 Acceleration bony spur at the posterior glenoid
 Concentric contraction of IRs  Rare
 Deceleration & Follow through  PT Management/Intervention
 Adducted and IR at end  Immobilize and prevent stiffness by ROM of
 Prone to be dislocated posteriorly other joint
 Scapular stabilizers should be strengthened
to provide a stable base where the shoulder
rotates
 After surgery; avoid flexion, horizontal
abduction (90º or more), ER
 Avoid abd and ER (critical position)
 Finger ladder and pulley - used to regain
motion
 Finger Ladder - if <90º arm elevation
 Pulley - >90º but not full rage
 Management  If the pt has any subluxation; they
 Strengthening of IRs are contraindicated to pulley
 SPLAT - exercise
 Subscapularis
 Petoralis major BICIPITAL TENDINITIS
 Latissimus dorsi  Distal biceps brachii tandonitis is uncommon
 Anterior deltoids  MOI : result of eccentric overload of the biceps
 Teres major during the deceleration and follow-through
 Posterior Dislocations - rare; horizontal phases of throwing
abduction, flexion ,IR  Patients report actecubital fossa pain during
 Inferior dislocation is common in pt with repetitive elbow bending activities and the
stroke, and weakness with deltoids follow-through phases of throwing. Physical
 Sulcus Sign examination typically shows tenderness to
 Subacromial/suprahumeral space increased palpation over the distal biceps tendon and pain
due to inferior translation of humeral head with resisted elbow flexion and/or forearm
 Grading supination
 +1 = <1cm  Radiologic evaluation is usually normal
 +2 = 1-2cm
 +3 = >2cm
 Pt standing
 Best position: 20-30º adb, neutral rotation
 PT pull distal aspect of humerus downward
BICIPITAL TENDON RUPTURE

 Rupture of the distal biceps brachii tendon is

also an uncommon injury
 30 and 50 years of age, with a significant
predilection for men and the dominant limb. The
injury usually
 MOI : occurs during a heavy lifting activity
while the elbow is at 90º of flexion
 The rupture usually involves the distal biceps
brachii tendon at the radial tuberosity insertion
site, with variable involvement of the lacertus
fibrosus
 Shows degenerative changes in the distal biceps
brachii tendon

Godbless
-Rae :) -