CHAPTER 17 The shoulder
The upper limb attaches to the trunk via the shoulder (pectoral) girdle. The shoulder complex in total consists of the scapula and clavicle, articulating with the ribcage and sternum to form four joints, all of which require attention in the management of shoulder pain. The clavicle forms a strut for the shoulder, holding the arm away from the side of the body and allowing a greater range of unencumbered movement. At one end the clavicle joins the sternum through the sternoclavicular joint, while at the other it joins the scapula via the acromioclavicular joint.
The acromioclavicular (A/C) joint is formed between the acromion process of the scapula and the lateral (outer) end of the clavicle. The sternoclavicular (S/C) joint is formed between the top of the sternum and the medial (inner) end of the clavicle.
The scapula rests on the ribcage through muscle tissue alone, an essential point when dealing with stability of the shoulder complex. The glenohumeral joint is the articulation between the head of the humerus and the shallow glenoid fossa of the scapula.
The glenoid fossa is only one third the size of the humeral head, but the fossa is extended by the glenoid labrum attached to its periphery. This fibrocartilage rim is about 4 mm deep with its inner surface lined by, and continuous with, the joint cartilage. The joint itself is surrounded by a loose capsule with a volume twice as large as the humeral head. The anterior capsule is strengthened by the three glenohumeral ligaments. The lower portion of the capsule is lax in the anatomical position, and hangs down in folds. It has two openings, one for the passage of the long head of biceps and the other between the superior and middle glenohumeral ligaments which communicates with the subscapular bursa (between subscapularis and the joint capsule). The capsule is further strengthened by the rotator cuff muscles which act as ‘active ligaments’ and blend with the lateral capsule. The ‘roof’ of the joint is formed by the bony coracoid and acromion processes and the coracoacromial ligament which runs between them, the three structures together forming an arch. Surface marking of the shoulder is shown in Fig. 17.1.
Figure 17.1 Joints of the shoulder complex. 1. Sternoclavicular joint. 2. Acromioclavicular joint. 3. Glenohumeral joint. 4. Scapulothoracic joint.
Rotator cuff action
Most joints have a high degree of passive stability provided by their capsules and ligaments (see also Table 17.3). The shoulder, however, depends more on the active stability provided by its muscles to maintain joint integrity. In the anatomical position, the weight of the arm is largely supported by the coracohumeral ligament and superior capsule. When the arm moves away from the side of the body, tension in the superior capsule is immediately lost. Now joint stability is provided by the rotator cuff muscles alone.
The fibres of the joint capsule are angled forwards and slightly medially when the arm is hanging by the side of the body. As abduction progresses, tension within these fibres causes the shoulder to passively externally rotate. This movement prevents the humeral head from being pulled closer to the glenoid and facilitates a greater range of movement. Importantly, the external rotation also allows the greater tuberosity to clear the acromion process (see below).
The fibres of the joint capsule, angled downwards and slightly medially, are under slight tension at rest. Recoil of these fibres produces a passive lateral rotation force during abduction.
Active abduction of the humerus is accomplished by the supraspinatus and deltoid, acting as the prime movers. With the arm dependent, contraction of the deltoid (particularly the middle fibres) merely approximates the joint (upward translation), because the medial muscle fibres run almost parallel with the humerus. Unopposed, this pull would force the head of the humerus into the coracoacromial arch, resulting in impingement. Contraction of the infraspinatus, subscapularis, and teres minor (Fig. 17.2) causes compression and downward translation to offset the upward translation of deltoid (Culham and Peat, 1993). In an overhead throwing or serving action (Fig. 17.3) the subscapularis moves superiorly because the humerus has externally rotated and the muscle can no longer effectively control the humeral head. The infraspinatus and to a lesser extent the teres minor stabilize the joint anteriorly in this position (Cain, Mutschler and Fu, 1987). For this reason sEMG addresses this muscle in stabilization programmes targeted at throwing sports. By 90° abduction, the pull of the deltoid no longer tends to cause impingement, as shear forces are exceeded by compression, and the humeral head is stabilized into the glenoid (Perry and Glousman, 1995).
Figure 17.2 (A) Deltoid pull at 30° and 90° abduction. (B) Muscles counteracting pull of deltoid. (i) Supraspinatus, (ii) infraspinatus and teres minor. (C) Subscapularis. Resolution of muscle force: S, shear; C, compression.
Figure 17.3 Muscular restraints to anterior displacement of the humeral head in an overhead throwing action.
Adapted from Reid (1992), with permission.
The supraspinatus is better placed to produce a rotatory action and therefore initiates abduction for the first 20°. The line of action of supraspinatus is such that less translation is caused, and its contribution to abduction is to reduce the reliance on deltoid and, as a consequence, reduce translation. After 30° of abduction the scapula starts to rotate to alter the glenoid position.
Motion of the shoulder girdle as a whole changes the position of the glenoid fossa, placing it in the most favourable location for the maximum range of humeral movement. When the glenoid cavity moves, it does so in an arc, the diameter of which is the length of the clavicle (Palastanga, Field and Soames, 1989). The medial border of the scapula moves in a similar but smaller arc and as a consequence the positions of the shoulder girdle structures change in relation to each other.
As the scapula moves medially and laterally towards and away from the vertebral column, the curvature of the ribcage forces the scapula to change from a frontal to a more sagittal position. This, in turn, alters the direction in which the glenoid cavity faces. With elevation, the scapula is accompanied by some rotation, the glenoid cavity gradually pointing further upwards as the scapula gets higher.
With both shoulder abduction and flexion, the clavicle axially rotates. As the scapula twists, the coracoclavicular ligament ‘winds up’ and tightens, causing the clavicle itself to rotate. As the arm is abducted to 90° (phase I and II, see below) the clavicle elevates by 15° but does not rotate. Above 90° (phase III) further elevation of the clavicle occurs (up to 15°) but marked posterior rotation now occurs to 30–50° (Magee, 2002). For this reason a diminished range of movement at either SC or AC joints which reduces clavicular rotation will also impair scapular and therefore glenohumeral motion.
The abduction cycle
Movement of the arm into abduction may be divided into three overlapping stages (Table 17.1).
In stage (I), no movement of the scapula should occur. The scapular stabilizers (serratus anterior especially) should hold the scapula firmly on the ribcage, providing a stable base for the humerus to move upon. As the arm abducts, lateral rotation of the humerus may be detected by palpation of the bicipital groove (intertubercular sulcus). If the humerus is maintained in a neutral position, abduction in the frontal plane is limited to about 90°. Laterally rotating the humerus increases this range to 120° (Lucas, 1973). When the arm is elevated in the sagittal plane, abduction is accompanied by medial rotation due to tightness in the coracohumeral ligament (Gagey, Bonfait and Gillot, 1987). No rotation is required for elevation in the scapular plane (30–45° anterior to the frontal plane). In this position, the joint capsule does not undergo torsion, and the deltoid and supraspinatus are optimally aligned.
At the beginning of abduction in the frontal plane, slight approximation of the humerus should occur (maximum 3 mm) to overcome the weight of the arm as the fibres of the joint capsule are taken off stretch and no longer support the arm through elastic recoil. No noticeable elevation of the shoulder should occur, unless the upper fibres of trapezius dominate the movement. The instantaneous axis of rotation in stage (I) is near the root of scapular spine, and moves superiorly and laterally as abduction progresses.
By the beginning of stage (II), from 30° of abduction, the scapula should be upwardly rotating to maintain clearance between the acromion and the approaching greater tuberosity of the humerus. Scapular rotation in the beginning of stage (I) occurs as a result of elevation of the clavicle on the SC joint. Between 80 and 140° the instantaneous axis of rotation (IAR) migrates towards the AC joint along the upper central scapular area. Movement then occurs as elevation of the clavicle on the SC joint, and rotation of the scapula on the clavicle at the AC joint. More movement occurs at the glenohumeral joint than at the scapulothoracic joint. Ratios of 2 : 1 are normally quoted, giving 120° of movement at the glenohumeral joint and 60° at the scapulothoracic joint in a total abduction range of 180°. However, some authors (Lucas, 1973) have argued that the ratio is closer to 5 : 4 or 3 : 2 after phase (I) of abduction.
Scapular rotation occurs as a result of force-couples between the various muscles attached to the scapula (Fig. 17.4). Upward (lateral) rotation accompanying shoulder joint abduction or flexion is brought about by contraction of the upper and lower fibres of trapezius and the lower portion of serratus anterior. Serratus anterior is probably the most important of the group. It has two sets of fibres. The fibres of the upper portion run horizontally and slightly upwards, while those of the lower portion are aligned downwards. Both sets pull powerfully on the scapula, anchoring it to the ribcage and causing scapular upward rotation as trapezius lifts the lateral end of the clavicle and acromion process. If serratus anterior and the lower fibres of trapezius are ineffective, the upper trapezius will dominate the movement. In this case, these fibres show increased tone and can be tight. As the abduction moves further into stage (II), the moment arm of lower trapezius is lengthened and this portion of the muscle becomes increasingly active in the movement.
Figure 17.4 Muscle force couples which create scapular rotation. (A) Lateral rotation. (B) Medial rotation.
From Palastanga, Field and Soames (1989), with permission.
Downward (medial) rotation frequently occurs as a result of eccentric action of the above muscles. However, in activities such as hanging and chinning a beam, active scapular rotation is accomplished by levator scapulae and the rhomboids pulling upwards on the medial side of the scapula together with pectoralis minor pulling the coracoid process down. In cases where these muscles are tight or overactive, upward rotation of the scapula will be limited during abduction.
As scapular rotation progresses, lateral rotation of the humerus should be apparent as the cubital fossa and thumb orientate towards the ceiling. Ineffective scapular upward rotators, especially lengthening of the lower fibres of trapezius, will prevent correct orientation of the glenoid and increase the risk of impingement. Tightness in the medial rotators, especially the pectoralis major and subscapularis, combined with lengthening and weakness of the lateral rotators, may lead to delayed lateral rotation at the glenohumeral joint, resulting in impingement of the greater tuberosity against the inferior acromion.
During stage (II), as the humerus reaches 90° abduction, its head slides beneath the acromion, and a noticeable dip is formed in the skin. Failure of the shoulder musculature to pull the humerus into this position may result in the head slipping beneath the acromion with a sudden thud as the arm raises above 90° and similarly in this position during descent.
During stage (III), as the arm approaches 120° abduction, no further movement is available from the glenohumeral joint. Additional range to reach the arm overhead is achieved by sliding the scapula over the thorax into further upward rotation and abduction. To facilitate this movement, the thoracic spine must reverse its kyphosis and flatten. A kyphotic posture and inflexibility in the thoracic spine will therefore limit the final degrees of abduction. As a simple test for this, the patient is asked to stand with the back flat against a wall and the pelvis posteriorly tilted to avoid any possibility of hyperextension at the lumbar spine. Both arms are then abducted, keeping them in full contact with the wall. If thoracic extension is limited, the patient will be unable to perform pure abduction to full range. Instead, the arm moves through flexion–abduction to bring it in front of the forehead. In conditions where abduction is limited, therefore, greater range may often be gained by mobilizing the thoracic spine as well as working on the glenohumeral joint.
As the arm moves into its final overhead position and the scapula rotates maximally, the inferior angle of the scapula juts out through the outer edge of the thorax. However, no more than 1–2 cm of the inferior angle should be visible at this point. During this final phase the IAR moves to the AC joint. Clavicular elevation is limited by tension in the costoclavicular ligament. As the coracoid process moves away from the clavicle, tension in this ligament causes dorsal rotation of the clavicle about its long axis.
Figure 17.5 (A) Stages of throwing. (i) wind-up—athlete positions him- or herself for the throw; (ii) cocking—lead leg moves forwards, arm moves backwards, stretching body; (iii) acceleration—body drives forwards, leaving arm behind; (iv) deceleration—object released. Elbow continues to extend and shoulder to internally rotate; (v) follow through—trunk and lead leg show eccentric activity to dissipate energy. (B) Similarity to tennis serve.
After Fleisig, Dillman and Andrews (1994), with permission.
The biomechanics of throwing
In sport, throwing is to the upper limb what gait is to the lower limb. It is an activity seen in many sports in some form, and there are similarities between all types of throw and with shots in racquet sports. Throwing can be divided into five stages which form a single continuous motion. In the early stages, up to ball release, the body is accelerating the object. By the later stages, following release, the aim is to decelerate and reduce the effect of stress on the body. The phases are as follows:
Screening examination of the shoulder complex
After a subjective history has been taken, a screening examination is performed to enable the examiner to focus more closely on the injured area. The patient’s posture and actions are noted while undressing, and the area is inspected for swelling, colour and deformity. A combination of active, resisted and passive movements are used to assess the shoulder complex (Cyriax, 1982). The patient is viewed from behind to note any alteration in scapulohumeral rhythm. It is helpful to have the patient facing a full length mirror, so the anterior aspect of the shoulder and the patient’s facial expression may also be assessed. Active abduction and flexion–abduction are performed with overpressure applied at end-range, to assess end-feel. Positional changes of the scapula, either at rest or during movement, warrant closer inspection. Active glenohumeral rotation may be performed by asking the patient to place a hand behind the back (medial rotation) and then behind the head (lateral rotation). Passive lateral rotation is performed with the elbow flexed and upper arm held into the side. This is also the position for resisted lateral and medial rotations. Passive medial rotation is performed with the patient placing a hand into the small of the back. The examiner stabilizes the upper arm, and keeps the patient’s elbow tucked into the side of the body. The examiner then gently pulls the patient’s forearm away from the body, increasing medial rotation. Any limitation of movement is noted, and the percentages of limitation relative to each other reveal if a capsular pattern exists. The capsular pattern for the glenohumeral joint is gross limitation of abduction with some limitation of lateral rotation and little limitation of medial rotation.
The capsular pattern for the glenohumeral (shoulder) joint is gross limitation of abduction with some limitation of lateral rotation and little limitation of medial rotation.
Resisted abduction and adduction are performed in mid-range, the examiner stabilizing the patient’s pelvis to prevent any lateral trunk flexion occurring at the same time as the shoulder moves. Elbow flexion, extension and forearm rotation may be assessed at the same time with the elbow flexed and the upper arm held close to the body. The patient’s forearm rests on the examiner’s when testing the triceps, and resistance is given from above when testing the biceps. Resisted shoulder shrugging tests the trapezius. When a small physiotherapist is examining a large athlete, it is particularly important that resistance is applied from a position which gives maximum mechanical advantage to the therapist.
Referred pain from the neck must always be considered in cases of shoulder pain, and the neck screening examination is performed to establish whether movement is painful or reproduces the patient’s shoulder symptoms. This simple but methodical examination should take no more than 2–3 minutes and tells the examiner whether the shoulder is the cause of pain, if a contractile or non-contractile structure is affected, and reveals if a capsular pattern exists to suggest an intracapsular lesion.
Figure 17.6 Angular displacement of the shoulder during a throwing action.
After Fleisig, Dillman and Andrews (1994), with permission.
Locking test and quadrant test
Should movement apparently be full and painless at the glenohumeral joint, two further procedures are useful to reproduce the patient’s symptoms. These are the locking test and the quadrant position (Maitland, 1991). Both tests refer to the position of the greater tuberosity relevant to acromial arch and glenoid (Corrigan and Maitland, 1994). Each should be assessed for pain and end-feel, and compared with the uninjured side.
The locking position combines internal rotation, extension and abduction of the shoulder with the scapula fixed. In this position the subacromial space is compressed and will give pain should an impingement syndrome be present. Cadaveric studies have shown that in the locking position the posterosuperior tip of the glenoid is in contact with the humeral head (Mullen, Slade and Briggs, 1989).
The locking position compresses the subacromial space and gives pain with an impingement syndrome.
To perform the test, the patient is in a supine position, and the practitioner stands by the patient’s side towards the shoulders. The therapist places the palmar aspect of his or her forearm beneath the patient’s shoulder, and grips the trapezius muscle to stop the shoulder shrugging. The therapist holds the patient’s elbow, slightly medially rotates the arm, and lifts it into abduction.
The quadrant position stresses the anterior and inferior capsule, and combines external rotation, slight flexion and full abduction of the shoulder. The therapist’s forearm grips the patient’s shoulder to prevent shrugging. The action is to hold the elbow and move the patient’s arm into abduction, allowing the humerus to move from medial rotation (palm to chest) to lateral rotation (palm to ceiling). The point at which the humerus begins to change from medial to lateral rotation marks the beginning of the quadrant (Petty and Moore, 2001). From this point horizontal extension is examined by pressing the elbow to the floor, releasing it and then moving into further abduction before pressing again. Both the quality and the range of motion are assessed, as well as the occurrence of muscle spasm. The affected shoulder is compared to the unaffected side.
The sternoclavicular (SC) joint provides, via the clavicle, the only structural attachment of the scapula to the rest of the body (Norkin and Levangie, 1992). The joint performs functionally as a ball and socket. The medial end of the clavicle articulates with the clavicular notch of the sternum, and the adjacent edge of the first costal cartilage. The congruity of the joint is enhanced by the presence of an interarticular fibrocartilage disc, which separates the joint cavity into two. In addition to improving the congruity of the joint, the disc also provides cushioning between the two bone ends. Furthermore, it holds the medial end of the clavicle against the sternum, preventing it moving upwards and medially when pushing actions are performed.
The joint is strengthened by a capsule attached to the articular margins and four ligaments (anterior SC, posterior SC, interclavicular and costoclavicular). Three degrees of movement are possible at the joint, elevation–depression, protraction–retraction and axial rotation. The axis of rotation for the first two movements (not rotation) is lateral to the joint itself, passing through the costoclavicular ligament. Consequently, when the lateral end of the clavicle moves in one direction, its medial end moves in the opposite direction, an important consideration with clavicular joint dislocation.
A total of about 60° of elevation and depression is available, elevation being limited by tension in the costoclavicular ligament, and depression by the interclavicular ligament and articular disc. When the lateral end of the clavicle is protracted, the medial end moves backwards, the opposite movement occurring with retraction. The total range of motion here is about 35°. This fact may be used in the emergency situation where posterior SC dislocation is causing asphysia (blocked oxygen intake). A folded towel is placed on the ground between the athlete’s shoulders to act as a fulcrum and the arm on the injured side is pushed firmly backwards to draw the medial aspect of the clavicle forwards and away from the trachea.
When the lateral (outer) end of the clavicle moves forwards in a protraction movement, the medial (inner) end moves back. In retraction the movement is reversed.
Axial rotation is purely a passive action accompanying scapular movements. The range of rotation is small (20–40°), but increases slightly as the lateral end of the clavicle is pulled back.
Injury to the SC joint is unusual, forming about 3% of all shoulder girdle trauma. Anterior dislocations occur more commonly than posterior dislocations in a ratio of 20 : 1 (Zachazewski, Magee and Quillen, 1996). Normally, the clavicle will fracture or the acromioclavicular joint will give way before the SC joint is seriously injured. However, when damage does occur, it is frequently the result of direct lateral compression of the shoulder, such as occurs when falling onto the side of the body. The injury is more common in horse-riding and cycling where sufficient force is produced, but is seen in rugby and wrestling.
The SC joint will dislocate in the opposite direction to the applied force, thus an anterior force (falling onto the back) will dislocate the joint backwards. Several important structures lie in close proximity to the joint including the oesophagus, trachea, lungs, pleurae, brachial plexus and major arteries and veins. Posterior dislocation therefore, if it is severe, may be potentially life-threatening. In contrast, anterior dislocation can occur in the absence of trauma, and frequently results only in slight discomfort.
The SC joint can dislocate in a fall onto the side of the body. The joint will move in the opposite direction to the applied force, an anteriorly directed force causing the joint to move backwards. If severe, this may be potentially life-threatening as the trachea may be damaged.
Initial examination (of posterior dislocation) on the field must obviously be aimed at ruling out life-threatening injury. The presence of stridor, dyspnoea, cyanosis, difficulty with speech, pulsating vessels and neurological signs may all necessitate immediate hospitalization.
If these are not present, joint examination may continue. Pain is generally well localized, and may become progressively more limiting over time. Anterior dislocation leaves a visible step deformity, and with posterior dislocation the usual prominence over the medial clavicle is lost. Local swelling is sometimes present, with crepitus and pain to motion, especially horizontal flexion. The shoulder is frequently held protracted.
Radiographic investigation will rule out clavicular fracture, and may enable differentiation between fracture and epiphyseal injury in the young (below 25 years) athlete. Closed reduction is often possible immediately after injury if pain is not too severe and before muscle spasm sets in. Both anterior and posterior dislocations may be reduced by placing a knee between the scapulae of the seated athlete and gently pulling the shoulders back. The joint often reduces with an audible thud. After reduction the joint is immobilized with a figure-of-eight bandage and ice is used to reduce local swelling.
Posterior dislocations, even if successfully reduced, will still require hospital referral and observation. Posterior dislocations usually stay reduced, but anterior dislocations are apt to recur. Surgical fixation of anterior dislocation is possible, but the number of complications makes the procedure undesirable. Migration of a Steinmann pin or Kirchner wire into the heart or major vessels has been reported (Garrick and Webb, 1990). Rockwood and Odor (1989) reported excellent results following conservative management of atraumatic anterior displacement 8 years after initial treatment. Patients treated surgically (not by these authors) in the same study had complications including scarring, instability, pain and limitation of activity.
Even though the joint is frequently hypermobile, joint mobilizations may be used to relieve pain (Maitland, 1991). Anteroposterior gliding may be performed with the therapist placing his or her thumbs over the sternal end of the clavicle.
This joint is formed between the oval facet on the lateral end of the clavicle and the similarly shaped area on the acromion process. The lateral end of the clavicle overrides the acromion, slightly. The joint capsule is fairly loose and strengthened above by fibres from trapezius, and by capsular thickenings which make up the superior and inferior acromioclavicular (AC) ligaments. As with the SC joint there is an intra-articular disc, but this time it does not divide the cavity into two. The joint is further stabilized by the coracoclavicular ligament, divided into its conoid and trapezoid parts. The conoid ligament is fan-shaped and resists forward movement of the scapula, while the stronger trapezoid ligament is flat and restricts backward movements. As with the SC joints, the AC joint moves only in association with the scapula. Three types of movement are again present, protraction–retraction, elevation-depression and axial rotation.
The AC joint is examined using the ‘cross body’ or ‘scarf’ test. Here, the patient’s hand is taken across their chest (horizontal adduction) and placed on top of their other shoulder. Where the joint is especially painful this is carried out as a passive movement with the therapist supporting the weight of the patient’s arm. In cases of high irritability, minimal horizontal adduction is all that is required to provoke symptoms.
Where the AC joint is suspected to be the source of pain, horizontal adduction with overpressure (‘cross body’ or ‘scarf’ test) can be used as a confirmatory test.
The cross body test has been shown to gap the AC joint by an average of 6.4 mm measured using ultrasonography compared to a gap of 7.7 mm with passive end range external rotation. However, greater direct stress is placed on the AC joint using the cross body manoeuvre than with humeral rotation (Park, Park and Bae, 2009). The cross body test has been shown to have a sensitivity of 77% compared to 41% for the active compression test (Chronopoulos et al., 2004). This latter test was designed to assist the diagnosis of labral tears and to differentiate them from AC joint involvement depending on the patient’s description of their pain location as ‘on top’ or ‘inside’ the shoulder (Brian et al.: O’, 1998).
The most common conditions affecting the AC joint are sprains and degeneration. AC joint sprains vary in intensity between minor grade I injuries to grade III ruptures representing complete disruption of the coracoclavicular ligament and AC joint dislocation (sprung shoulder) (Fig. 17.11). The injury may be further classified using weight-lifting radiographs. Here, the anterior deltoid is contracted by having the patient hold a weight with the elbow flexed and arm next to the body. If the clavicular attachment of the deltoid is intact, the joint may reduce as weight is taken (IIIa), or there may be no change in the joint appearance (IIIb). However, if the lateral end of the clavicle becomes more prominent, the clavicular attachment of the deltoid may have been stripped off (Dias and Gregg, 1991). Radiographs are also used to differentiate the condition from fractures of the distal clavicle where this is suspected.
Figure 17.11 Acromioclavicular joint injuries. Type I (sprain), type II (subluxation), type II (dislocation), type IIIa (reduces as weight taken), type IIIb (no change as weight taken), type IIIc (lateral end of clavicle more prominent as weight taken).
Injury is usually the result of a superiorly directed force as occurs with a fall onto the point of the shoulder or being struck from above. The force drives the scapula downwards, an action resisted by the coracoclavicular ligament.
AC joint dislocation normally occurs with a downwardly directed force such as a fall, or blow, onto the point of the shoulder.
Examination reveals local tenderness over the AC joint, sometimes with a noticeable step deformity. The deformity may occur later, if initial muscle spasm reduces acromioclavicular separation.
Initial treatment aims to reduce the symptoms. Ice and a sling support to take the weight of the arm are recommended. The joint is immobilized in the sling for 2–3 weeks, and then gradually mobilized within pain-free limits. With grade I injuries, some relief may be provided by taping.
Stress may be taken off the AC joint by a simple taping designed to press the clavicle down and take some of the weight of the arm away from the distal shoulder structures (Austin, Gwynn-Brett and Marshall, 1994; Macdonald, 1994). The athlete is positioned in sitting at the side of the couch with the elbow flexed to 90° and the shoulder abducted to 30°. The shoulder is slightly elevated and the arm rests on the couch. The shoulder and chest on the injured side of the body should be shaved of long hair. Spray adhesive is applied, making sure that the athlete turns the head away from the spray and covers the eyes with the unaffected hand. Also, the nipple area must be protected with a non-adhesive pad.
A felt pad is placed over the acromion to protect it from abrasion. Two anchors of 7.5 cm elastic adhesive tape are applied. The first runs horizontally from the sternum to the paravertebral area on the side of injury. The second is placed around the mid-humerus with light tension, ensuring that the limb is not excessively compressed (Fig. 17.12A). Two stirrups of 7.5 cm elastic adhesive tape are placed (pre-stretched) from the front to the back of the chest anchor, passing over the acromion (Fig. 17.12B). These are then reinforced by two strips of 5 cm zinc oxide taping. Two further strips of elastic adhesive tape are placed (pre-stretched) laterally from the arm anchor across the anterior aspect of the shoulder to join the chest stirrups over the acromion, and laterally from the anchor, passing posteriorly over the shoulder to the acromion (Fig. 17.12C). Again, these stirrups are reinforced by 5 cm zinc oxide taping. If the shoulder stirrups have been applied correctly, their tension will tend to lift the arm into abduction slightly. The chest and arm stirrups are closed by reapplying the chest and arm anchors (7.5 cm elastic adhesive tape) to act as fixing strips. Sensation and pulse should be re-tested after tape application.
Figure 17.12 Acromioclavicular joint taping. (A) Anchors. (B) Stirrup applied under tension. (C) Arm stirrups.
In the acute phase of injury, the forearm weight may also be taken by a collar and cuff sling. With time, when pain-free arm motion to 90° is available, the humeral portion of the tape may be dispensed with.
Specific exercise therapy
As inflammation subsides, exercise therapy is commenced to restore function. This is used initially to maintain muscle tone in the absence of joint movement. Isometric contractions of the scapular and glenohumeral muscles are used, and the athlete maintains general fitness and lower body strength by exercising with the AC joint taped. When pain subsides and movement commences, gentle scapular actions are used, such as shoulder shrugging and bracing within the limits of pain. These may progress to a scapular stabilization programme. Range of motion exercises for the glenohumeral joint are begun, ensuring that correct scapulohumeral rhythm is maintained.
When full pain-free motion is obtained, the athlete may be seen to have a permanent step deformity, and some joint degeneration may occur in later years. The major problem resulting from this injury is lack of confidence when falling in contact sports. The effects of direct trauma may be limited by placing a felt doughnut pad over the joint. Confidence is built using progressive closed chain exercises and rehearsal of falling actions. These may begin with forward rolls onto the outstretched arm on a mat, initially from a kneeling position, progressing to standing and finally a diving forward roll over a bench. Pressure over the point of the shoulder begins with log rolling on the floor, and builds up to shoulder blows on to a rolled mat or punch bag.
There is some controversy concerning the treatment of this condition. Both conservative and surgical approaches restore function to a similar degree (Larsen, Bjerg-Nielsen and Christensen, 1986; Dias et al., 1987; Bannister et al., 1989), and some surgical methods have been shown to give long-term functional detriment. Certainly, removal of the distal end of the clavicle (Gurd, 1941) will disrupt the acromioclavicular ligament, a main stabilizer of the joint (Fukuda et al., 1986). In the literature, the main argument for surgery has been the development of degenerative changes in the joint as a result of non-operative management. However, degeneration does not occur in all patients, and when it does occur, it is not necessarily a limitation (Dias et al., 1987). In addition, surgery is often as effective if done in the acute or chronic condition, so there is normally no advantage to operating immediately. Importantly, surgery carries with it a high risk of complications (Ejeskar, 1974; Lancaster, Horowitz and Alonso, 1987; Taft, Wilson and Oglesby, 1987).
In a literature review of 11 papers detailing the long-term results of both surgical and conservative management of this injury, Dias and Gregg (1991) found poor results to have occurred in 13 out of 247 patients treated conservatively (5.3%), and 22 out of 233 managed surgically (9.4%). These authors argued that as comparable results were obtained regardless of the method used, conservative management was the treatment of choice for most AC injuries. Looking at strength testing following grade III AC injuries treated conservatively (average 4.5 year follow-up), Tibone, Sellers and Tonino (1992) found no subjective complaints in patients, all of whom were able to participate in sport. Full motion occurred in all subjects, and no significant differences were found in muscle strength of injured and non-injured sides in rotation, abduction/adduction or flexion/extension.
AC joint degeneration
Joint degeneration is common in later years following injury, regardless of the grade of damage which occurred, and particularly after repeated trauma. In addition, some sports, such as weight-lifting, have a higher incidence of degenerative changes in the AC joint, even where no incidents of trauma may have occurred. Cahill (1982) reported 46 cases of osteolysis of the distal clavicle, all but one occurring in weight-lifters. He argued that degeneration occurred as a result of subchondral stress fractures resulting from repeated microtrauma. The condition presents as pain, usually dull and aching in nature, brought on by activities such as lifting and throwing. On examination there is point tenderness over the joint, with pain and crepitus to passive horizontal adduction (cross body test).
Where the diagnosis is uncertain, radiographs will frequently reveal degeneration, and injection of local anaesthetic into the joint is helpful to establish if the degeneration is the cause of the patient’s symptoms.
Movements which stress the joint (for example, press-ups, weight training or throwing) should be avoided. Initially, immobilization in a sling may be required in the very acute lesion. Later, joint mobilization provides good results. Anteroposterior gliding may be performed with the patient in a sitting position. The therapist grasps the distal end of the clavicle with his or her thumb and forefingers of one hand, and the acromion process in a similar fashion with the other hand. The hands are worked against each other to glide the joint. Injection of corticosteroid may give many months of relief, a technique made easier if the shoulder is laterally rotated to distract the AC joint.
Fractures of the clavicle
The most common mechanism of injury is a fall onto the outstretched arm, and occasionally direct trauma to the shoulder. Although common, these injuries should not be taken too lightly, as it must be remembered that the subclavian vessels and the medial cord of the brachial plexus lie in close proximity, as does the upper lobe of the lung (Fig. 17.13). Neurovascular and pulmonary examination may therefore be required.
There is usually a cracking sensation at the time of injury, with immediate pain over the fracture sight and rapid swelling. Signs of injury to vital structures are rare, but include dyspnoea and paraesthesia and obviously warrant immediate hospitalization. Laceration of the subclavian artery presents as a readily expanding pulsating haematoma. Deformity following clavicular fracture is common, as is crepitus.
Following suspected clavicular fracture signs of altered sensation (paraesthesia) or breathlessness (dyspnoea) warrant immediate hospital referral.
Fractures of the proximal and middle thirds of the clavicle make up the largest proportion (80%) of such injuries. If not displaced these should be immobilized with the shoulders retracted in a figure-of-eight bandage for 6 weeks. With young athletes the risk of non-union may make it necessary to curtail activity for up to 3 months after injury. Figure-of-eight bandages must not be applied so tightly as to constrict the blood or nerve supply to the arm. When little displacement is present, support in a sling may be all that is required. Some step deformity usually occurs as complete immobilization of athletes (other than in a cast) is difficult. This type of deformity is usually cosmetic rather than functional.
Distal fractures tend to be displaced by retraction immobilization, and are better wired. Internal fixation of the proximal clavicle carries with it similar complications to that of the sternoclavicular (SC) joint. Fractures to the extreme proximal end of the clavicle may be misdiagnosed as SC dislocations, and in the younger individual epiphyseal injury should be considered in this region. It should be noted that the sternoclavicular epiphysis may remain open until the age of 25 (Zachazewski, Magee and Quillen, 1996), so radiological examination must be accurate.
During normal scapulohumeral rhythm, the scapula slides over the ribcage, and is held in place by the serratus anterior. If weakness or paralysis of the serratus anterior occurs, the scapula will stand prominent from the ribcage when the arm is protracted against resistance. In addition to muscular weakness, there are a number of other causes including damage to the long thoracic nerve, brachial plexus injury, conditions affecting the fifth, sixth and seventh cervical nerve roots, and certain types of muscular dystrophy (Apley and Solomon, 1989).
Where weakness is due to nerve palsy, spontaneous recovery is to be expected. Re-education of scapulohumeral movement is required as habitual alteration of scapulohumeral rhythm is often seen. Strengthening the shoulder musculature in general, and especially serratus anterior, is also useful.
Occasionally, a congenitally undescended scapula (Sprengel’s shoulder) is seen, sometimes associated with marked thoracic kyphosis. Normally, the scapulae descend completely by the third month of fetal life. However, if undescended, the scapula appears slightly smaller, higher, and more prominent. Scapulohumeral rhythm is affected and abduction is limited as a consequence. Minor cases respond to rehabilitation although marked deformity may require surgery.
Apparent winging may occur when the scapulae abduct through lengthening of the scapular retractors and tightening of the protractors. As the scapulae move away from the mid-line, they roll around the ribcage, lifting their medial border. This is not true winging, however, because the condition is present at rest and during muscle contraction. Treatment note 17.1 shows exercise therapy and manual therapy techniques used in the restoration of scapulothoracic stability.
Treatment note 17.1 Restoraton of scapulothoracic stability
Scapular stability is enhanced by restoring the functional capacity of the lower trapezius and serratus anterior, which, as stability muscles, often show reduced activity and lengthening. Surface electromyography (sEMG) may be used with the active electrode placed over the lower trapezius or serratus anterior. The patient is placed in prone lying and the scapula is passively positioned into its neutral position by the therapist. This often requires retraction and depression to neutralize the protraction/elevation often found (Fig. 17.14). The patient is encouraged to hold this position through his or her own muscle activity, gaining feedback from the sEMG readout. Enough muscle activity should be used to keep the anterior aspect of the shoulder off the treatment couch, but not to retract the scapulae. Once this position can be maintained actively, the holding time is built up until the patient can perform 10 repetitions, holding each for 10 seconds.
Figure 17.14 Enhancing scapulothoracic stability. (A) Scapular repositioning. (B) Rhythmic stabilization. (C) Trunk rocking. (D) Arm movement progressions.
The main scapular stabilizers are serratus anterior and the lower trapezius. These muscles are worked using low load scapular depression and retraction. The inner range scapular position is held to build postural endurance.
Taping may be used to give feedback about the position of the scapula and lengthened muscle. A positional box tape may be used to facilitate position of the scapula (Fig. 17.15). The tape has two horizontal strips to draw the medial borders of the scapulae together and two vertical strips to facilitate thoracic extension. Non-elastic taping is used to take up skin tension and act as a feedback system for the patient. Facilitatory taping may be used over the serratus anterior (Fig. 17.16A), lower trapezius (Fig. 17.16B) or to increase patient awareness of body segment position and facilitate underlying muscle action.
The scapular force couples may be maximally challenged using a side lying, braced position (Wilk and Arrigo, 1993). The patient begins in side lying with the arm flexed/ abducted to 90° and internally rotated. The hand is now flat on the couch with the fingers pointing towards the patient. Scapular fixation is maintained against the rhythmic stabilization provided by the therapist in all planes.
The next stage is to introduce a limited range of movements of the humerus onto the now stable base of the scapular thoracic joint. Initially, the patient assumes elbow support prone lying to work the shoulder in closed kinetic chain format. He or she moves the body over the arm forward and backwards and side to side to create closed chain flexion/ extension and abduction/adduction. At all times the scapula must remain in contact with the thorax. The patient is now moved to the edge of the couch so the affected arm hangs over the couch side. Maintaining scapula thoracic stability, inner-range movements in all three planes are used in an attempt to automatize stability.
The starting position is now changed to sitting or standing and inner-range movements are used with sEMG monitoring of the lower trapezius. Home exercises may be used by asking the patient to place the thumb of the opposite hand beneath the inferior scapular angle. The patient then gently keeps the inferior ankle pressed against the thumb (retraction and depression) while performing inner-range movements.
These initial actions, where stabilization ability is being re-educated, must keep the arm below 30° abduction to prevent scapular movement. Later, greater glenohumeral range may be used as the patient can control scapulothoracic movement.
The scapulothoracic muscles may be selectively strengthened using the individual exercises shown in Figure 17.17.
The subacromial space (Fig. 17.18) lies beneath the coracoacromial arch formed by the coracoacromial ligament together with the coracoid and acromion the so-called ‘roof of the joint’. The coracoacromial arch is covered by the deltoid, and inferiorly its fascia is continuous with that of the supraspinatus. The arch prevents upward dislocation of the glenohumeral joint. The supraspinatus passes beneath the arch, being separated from it by the subacromial bursa. The subacromial distance (space between the inferior acromion and the head of the humerus) is normally about 1cm (Petersson and Redlund-Johnell, 1984). If the supraspinatus tendon has ruptured, or the muscle is no longer active, this space will reduce by as much as 50% due to the unopposed pull of the deltoid.
The subacromial space may reduce by as much as 50% if the supraspinatus muscle is dysfunctional.
During elevation and internal rotation, the greater tuberosity, with the supraspinatus riding on top, may press against the anterior edge of the underside of the acromion (or a spur from a degenerating AC joint) causing impingement pain. During flexion, impingement may also involve the long head of biceps (Peat and Culham, 1994). At the point where the greater tuberosity comes close to the acromion (70–120° abduction), a number of structures may be pinched between the involved bones or the tuberosity and the coracoclavicular ligament. Normally, the structures affected are the suprasinatus tendon, the long head of biceps and the subacromial bursa.
The action of abduction involves a complex series of movements. Impingement is associated with a change in the muscle action involved in the abduction sequence. Most commonly there is a reduction in the stabilizing action of the serratus anterior muscle with other muscles (especially the upper trapezius) compensating. The result is an altered scapular position relative to the humerus during abduction. This movement dysfunction has been termed scapula dyskinesia (Paterson, 2008). EMG studies of patients with impingement pain have shown a reduction in serratus anterior muscle action and a change in scapula position (Ludewig and Cook, 2000). The scapula is more anteriorly tipped drawing it closer to the approaching humeral head, and upward rotation during the early stages of abduction is delayed. Decreased force output in the both the serratus anterior and lower trapezius has also been shown with overhead athletes demonstrating shoulder impingement (Cools et al., 2004).
The screening examination is used initially, followed by observation of both static and dynamic position of the scapula and humerus. Two further tests are useful which are specific to impingement. In test one (Fig. 17.19A) the arm is fully abducted and overpressure is put onto the internally rotated (thumb forwards) shoulder. For test two (Fig. 17.19B), the glenohumeral joint is flexed and internally rotated (Hawkins test). Overpressure is then added to internal rotation and abduction or horizontal flexion. Resisting flexion by placing pressure over the elbow may also bring on the athlete’s pain (Hawkins and Hobeika, 1983; Reid, 1992).
Figure 17.19 Impingement tests. (A) Full abduction with overpressure to the internally rotated shoulder. (B) Hawkin’s sign. Flexion and internal rotation. Overpressure to internal rotation and abduction or horizontal flexion.
In addition to a purely mechanical impingement, changes in the microvascular supply to the area have been noted. Pressure exerted by the humeral head on the supraspinatus tendon, has the effect of ‘wringing out’ the tendon vessels and creating an avascular zone (Rathbun and Macnab, 1970). This area, known as the critical zone (Fig. 17.20), is an anastomosis between the osseous vessels and the tendinous vessels (Moseley and Goldie, 1963). Furthermore, repeated microtrauma results in local oedema within the tendon and an increase in tissue volume. This in turn makes the structures more susceptible to impingement by reducing the subacromial space and so perpetuates the problem.
A reduction in the subacromial space may be the result of individual variation in the anatomical architecture of this region, with some individuals more prone to impingement than others (Ticker and Bigliani, 1994). Cadaveric studies of 140 specimens have identified three types of acromion associated with full thickness tears of the rotator cuff (Bigliani, Morrison and April, 1986).
The flat (type I) acromion occurred in 17% of subjects, the curved (type II) acromion was seen in 43%, and the hooked (type III) type in 39% (Fig. 17.21). The hooked acromion was present in 70% of rotator cuff tears whereas the flat type was only seen in 3%. By assessing the supraspinatus outlet view x-ray, Morrison and Bigliani (1987) showed 80% of those with positive arthrograms to have a hooked acromion. The same authors showed that 66% of patients who underwent open subacromial decompression had a hooked acromion.
Figure 17.21 Acromion types. (A) Type I, flat. (B) Type II, curved. (C) Type III, hooked.
After Ticker and Bigliani (1994).