Knowledge of the anatomy and normal range of motion of shoulder is crucial in making the proper diagnosis and treatment (see Table 26.3). In this section, the anatomy of shoulder would be explained briefly.

Glenohumeral joint (ball and socket) and acromioclavicular joint form the shoulder joint. In addition to these joints, sternoclavicular joint should be examined in the shoulder injury. The two most important shoulder muscle groups are as follows:

Rotator cuff impingement should be diagnosed clinically. It occurs when the tendons, especially supraspinatus, are impinged as they cross the subacromial space and beneath the acromion. This impingement leads to inflammation, which in turn increases the likelihood of tendon tear. This injury is very common in all athletes, particularly swimmer, lifters, adaptive athletes, and throwers. Neer divided rotator cuff injury and impingement into three stages (see Table 26.4) [7, 8].

Detection of rotator cuff impingement requires a good history and physical exam. In a classic presentation, the athlete complains of shoulder pain particularly with overhead movement. It is frequently associated with limited shoulder motion and occasionally weakness. The degree of weakness depends on the severity of pain and the extent of the inflammation or the possible tear. Additional symptoms associated with rotator cuff pathology include a clicking sound (with calcific tendinitis) and pain with lying on the affected shoulder. The physical exam may reveal limited range of motion accompanied with pain especially with shoulder abduction, extension, and external or internal rotation. Positive tests can include the Hawkins test, Neer’s test, and resisted external rotation test (Empty Can) [8–10]. True rotator cuff weakness relies on the severity of damage to the muscle or tendon. Since these findings are often complex, imaging studies can be helpful. Outlet view X-rays are used to detect bone spurring on the front edge of the acromion. MRI and ultrasound reveal better soft information including rotator cuff inflammation, bursa, and partial or complete rotator cuff tears [10–12].

Initial treatment is usually nonsurgical. The athlete is recommended to modify exercises particularly overhead activities. Nonsteroidal anti-inflammatory medicines might be helpful for reducing pain and inflammation but are less effective if the injury is chronic in nature. Physical therapy should start as soon as possible. It must initially focus on enhancing range of motion and scapular stabilization techniques, then progress to rotator cuff strengthening. If these treatments fail, corticosteroid injections could be considered. Prolotherapy and platelet-rich plasma injections can be considered as potential options as well [7–9, 13].

When the patient does not respond to conservative management or in the case of a significant tear, surgical treatment may be recommended. However, additional consideration should be taken by the surgeon on how surgery would impact a wheelchair bound individual who use their upper extremities for mobility. Postoperatively, a shoulder sling would be placed to keep the arm in about 20–30° of abduction, which decreases tension of the repair. Initially it may start a passive range of motion and then progress to active motion with terminal stretching 6 weeks after surgery. Subsequently 10 weeks after the procedure, resistive exercises may be added. Recovery time might be as long as 4–6 months and in some cases it even takes 1 year [7–9, 12, 14].

Glenohumeral arthritis can be divided into primary and secondary arthritis. Primary osteoarthritis affects the shoulder joint and usually in persons older than 60 years in the general population. The secondary osteoarthritis is subdivided into non-traumatic (inflammatory arthritis) and traumatic. Traumatic glenohumeral arthritis is commonly seen following fracture and chronic instability (dislocation arthropathy). It can also be found after significant rotator cuff tears are left untreated in athletes. In regard to adaptive sports, glenohumeral osteoarthritis is common in wheelchair athletes who are using their shoulders for primary locomotion [15, 16].

A thorough history should be taken and should include inquiries regarding episodes of trauma, recreational/sport/social activities, and prior medical and surgical treatments such as physical therapy, medications, and shoulder injections. The patient typically has complaints of pain/discomfort, clicking noises, decreased range of motions, feelings of catching, and instability [15, 17].

The physical examination should rule out pathology that could confound the examination and treatment outcomes in the shoulder including cervical spine or acromioclavicular joint injury. Restricted painful shoulder range of motion is commonly found. Typically, end range of motion pain is due to impingement, osteophytes, and capsular contracture. Impingement signs should be evaluated as well as evaluation of the biceps tendon. Radiographic studies such as anteroposterior X-ray in neutral rotation, scapular outlet, and an axillary view illustrate degree of glenohumeral arthritis [18, 19].

A Bernageau view can be performed to assess shoulder (see Fig. 26.1a, b).