Basic Functional Anatomy of Shoulder Joints

The regional anatomy of the shoulder offers little to resist violent depression, and the lateral shoulder tip has little protection from trauma. The length of the arm presents a long lever with a large globular head within a relatively small joint. This allows a great range of motion with little stability. The stability of the shoulder is derived entirely from its surrounding soft tissues: capsule, muscles, and ligaments.


The Shoulder Joint

The glenohumeral (shoulder) joint, a ball-and-socket joint, is freely movable and lacks a close connection between its articular surfaces. Mennell points out that although only two bones comprise the glenohumeral joint, it depends on the normally synchronous motion of the (1) acromioclavicular, (2) sternoclavicular, and (3) scapulothoracic articulations. Although the latter are not synovial joints, they act as so in many respects. For example, motion can be restricted by scapulothoracic contractures or adhesions and this restricts shoulder motion.

The highly mobile glenohumeral joint is aided somewhat by a narrow fibrocartilaginous rim around the glenoid fossa. A surrounding joint capsule extends loosely from the lateral scapula and clavicle to attach firmly at the anatomic neck and shaft of the humerus. A series of anterior glenohumeral ligament bands and tendon fibers reinforces the articular capsule, and the transverse humeral ligament forms a canal for the long tendon of the biceps brachii within the bicipital groove. The arm rotates about a point that is at or near the center of the head of the humerus.


The Sternoclavicular and Acromioclavicular Joints

The sternoclavicular joint is supported by a capsule and reinforcing anterior and posterior ligaments. It is the sole point where the shoulder girdle articulates with the thorax. An interclavicular ligament crosses the jugular notch, connects the manubrium with both clavicles, and tends to restrict sternoclavicular motion. A costoclavicular ligament straps the inferomedial clavicle to the 1st rib below.

The articulation between the acromion and the lateral clavicle is supported by a capsule reinforced superiorly by the acromioclavicular ligament. An incomplete articular disc is sometimes at the upper aspect of the joint.


The Coracoclavicular and Coracoacromion Unions

The clavicle is strapped to the coracoid process of the scapula by the coracoacromial and trapezoid ligaments. The coracoacromial ligament extends between the coracoid process and acromion.


Shoulder Motion

Almost all shoulder muscles have the same triangular design - broadly fanned fibers at their origins that narrow and converge at tendinous insertions. Because of overlapping innervation, portions of these muscles can function separately and in harmony with portions of other muscles acting on the shoulder. 

"The troublesome fifth cervical area" is common knowledge within chiropractic. In the context here, note that shoulder girdle flexion, extension, abduction, adduction, internal rotation, external rotation, scapular elevation, scapular depression, and shoulder protraction are all subject to function of the C5 root.


Testing Ranges of Mobility

Complete patient relaxation is necessary to obtain an accurate judgment of the range of motion. Tension produces considerable restriction. As in all range of motion tests, passive motion should not be attempted if there is any possibility of fracture, dislocation, severe tears, advanced bone pathology, etc. If active motion is normal, there is usually no need to test passive motion unless unusual circumstances exist that make active motion difficult. It is important during all tests that the examiner form a mental picture of the underlying anatomy and normal motion.

Spasm, contractures, fracture, and dislocation are the common causes of motion restriction and muscle weakness. In uncomplicated muscle weakness, a joint may move through its normal range passively but not actively. Active and passive restriction is likely from a bone or soft-tissue block, and any atrophy will likely be from disuse. With passive movement, bone blocks are perceived as abrupt inflexible stops in motion, while extra-articular soft-tissue blocks will be less abrupt and slightly flexible upon additional pressure.

Elevation, depression, abduction, adduction, extension, flexion, internal rotation, and external rotation are the basic movements of the shoulder girdle. Other movements normally tested are scapular retraction (military position of attention) and shoulder protraction (reaching). The patient may be in either the standing or sitting position during testing. See Table 6.


Table 6.   Shoulder Girdle and Shoulder Motion

SHOULDER GIRDLE
Joint Motion	Prime Movers	Accessories
Elevation	Trapezius, upper Levator scapulae Rhomboids, major and minor
Depression	Trapezius, lower Latissimus dorsi Pectoralis major, sternal head Pectoralis minor
Abduction	Serratus anterior Pectoralis major and minor
Adduction	Trapezius, upper and lower Rhomboids, major and minor
Upward rotation	Serratus anterior Trapezius, upper and lower
Downward rotation	Levator scapulae Rhomboids, major and minor Pectoralis minor	Latissimus dorsi
SHOULDER
Joint Motion	Prime Movers	Accessories
Flexion	Deltoid, anterior Coracobrachialis Pectoralis major, clavicular head
Extension	Deltoid, posterior Teres major Latissimus dorsi Pectoralis major, sternal head	Infraspinatus, lower fibers Teres minor Triceps, long head
Abduction	Deltoid, middle Supraspinatus	Infraspinatus, lower fibers Deltoid, anterior and posterior
Horizontal abduction	Deltoid, posterior	Infraspinatus Teres minor
Adduction	Pectoralis major Teres major Latissimus dorsi	Triceps, long head Coracobrachialis Biceps brachii, short head
Adduction	Pectoralis major Teres major Latissimus dorsi	Triceps, long head Coracobrachialis Biceps brachii, short head
Horizontal adduction	Pectoralis major Deltoid, anterior	Biceps brachii, short head Coracobrachialis
External rotation	Infraspinatus Teres minor	Deltoid, posterior
Internal rotation	Subscapularis Pectoralis major Latissimus dorsi Teres major	Deltoid, anterior

Elevation and Depression.   Elevation and depression are checked by having the patient hunch the shoulders and return to the normal position. Active external rotation and abduction are easily tested by having the patient reach up and over the shoulder and attempt to touch the spinal border of the opposite scapula. External rotation and abduction can be tested bilaterally at the same time by having the patient place both hands behind the neck with interlocking fingers, then the elbows, which are initially pointing forward, are moved laterally and posteriorly in an arc.

Passive Abduction.   In checking solely glenohumeral joint passive abduction, the stabilizing hand should firmly anchor the scapula while the examiner's active hand passively abducts the patient's arm with the forearm horizontal. The shoulder blade will normally not be felt to move until about 20 degrees of abduction has occurred. Abduction should normally continue in this position to about 120 degrees where the surgical neck of the humerus meets the tip of the acromion. The examiner should next externally rotate the patient's forearm to move the surgical neck away from the acromion, then continue abduction to its maximum. For every 3 degrees of humeral abduction, 1 degree occurs at the scapulothoracic articulation for every 2 degrees at the glenohumeral joint.

Full active bilateral abduction is tested by having the patient abduct the arms horizontally to 90 degrees while keeping the elbows straight and the palms turned upward then continuing abduction in an arc until the hands meet in the middle over the head.

Internal Rotation and Adduction.   Internal rotation and adduction are checked by having the patient reach across his chest, keeping the elbow as close to the chest as possible, and touch the opposite shoulder tip. A more extreme method is to have the patient reach behind the back and attempt to touch the bottom angle of the opposite shoulder blade. In each of these tests, both upper limbs may be tested simultaneously to compare bilateral action.

Kinesiology

Flexion.   Strength of flexion can be tested from the back of the patient by placing the stabilizing hand on the patient's shoulder so that the anterior deltoid may be palpated during testing. The examiner's active hand grips the patient's anterior lower arm. With the patient's elbow flexed to 90 degrees , resistance is increased as the patient is asked to flex the shoulder. Muscle strength is recorded by grade or in a percentage and compared bilaterally.

Extension.   Extension strength is judged from the back of the patient with the stabilizing hand in nearly the same position to palpate the posterior deltoid while the palm of the active hand grips the patient's lower arm at the posterior. The patient's elbow is again flexed, and he or she is asked to slowly extend the shoulder against increasing resistance.

Abduction.   Strength of abduction can be tested at the side of the patient by placing the stabilizing hand on the lateral shoulder tip so that the middle of the deltoid may be palpated. The examiner applies increasing resistance laterally above the flexed elbow of the patient as abduction is attempted.

Adduction.   Strength of adduction is measured from behind the patient with the stabilizing hand still on the shoulder tip. The patient's arm is abducted and the elbow is flexed. The examiner then applies increasing resistance medially above the flexed elbow of the patient as the patient attempts adduction.

Internal Rotation.   Strength of the internal rotators is tested with the examiner's stabilizing hand and active hand in the same position. An increasing pulling resistance is applied to the patient's wrist as the patient attempts internal rotation of the arm by moving the hand toward the abdomen.

External Rotation.   External rotation strength is judged at the side of the patient by placing the stabilizing hand on the patient's flexed elbow with the examiner's thumb in the angle of the patient's elbow. The active hand, gripping the patient's wrist, applies an increasing pushing resistance to the patient's attempt to externally rotate the arm by moving the hand away from his body.

Scapular Elevation.   Strength of scapular elevation is judged by the examiner standing behind the patient and applying increasing resistance with both palms on the patient's shoulders as the patient attempts to shrug his shoulders.

Scapular Depression.   To evaluate the strength of scapular depression, the examiner stands in front of the patient with his hands grasping the patient's shoulder over the upper deltoids. The doctor's thumbs are braced under the patient's clavicles, and the fingers are behind the deltoids. The patient is instructed to slowly "throw his shoulders back and down" while the examiner applies increasing resistance; ie, forward toward the thumbs.

Shoulder Protraction.   In determining strength of protraction, with the examiner behind the patient, the patient is asked to flex the arm so that it is parallel to the floor with the elbow at a right angle to the arm. The examiner's stabilizing hand is placed in the midscapular area to stabilize the patient's spine from rotating, and the active hand is cupped around the patient's flexed elbow. Increasing resistance is applied as the patient attempts to slowly thrust the arm forward as if to touch a forward wall. During this movement, the examiner observes the scapula for possible winging.

1. Stage of Acute Inflammation and Active Congestion

The major goals are to control pain and reduce swelling by vasoconstriction, compression, and elevation; to prevent further irritation, inflammation, and secondary infection by disinfection, protection, and rest; and to enhance healing mechanisms. Common electives include:

Disinfection of open skin (eg, scratches, abrasions, etc)
Cryotherapy
Cold packs
Ice massage
Vapocoolant spray
Pressure bandage
Protection (padding)
Elevation
Indirect therapy (reflex therapy)
Iontophoresis/phonophoresis
Auriculotherapy
Meridian therapy
Pulsed alternating current
Spondylotherapy
Mild pulsed ultrasound
Rest
Bedrest
Sling
Immobilization
Rigid appliance
Strap
Plaster cast
Indicated diet modification and nutritional supplementation.

2. Stage of Passive Congestion

The major goals are to control residual pain and swelling, provide rest and protection, prevent stasis, disperse coagulates and gels, enhance circulation and drainage, maintain muscle tone, and discourage adhesion formation. Common electives include:

Indirect articular therapy (reflex therapy)
Alternating superficial heat and cold
Pressure bandage
Protect lesion (padding)
Light nonpercussion vibrotherapy
Passive exercise of adjacent joints
Mild surging alternating current
Mild pulsed ultrasound
Phonophoresis
Cryokinetics (passive exercise)
Meridian therapy
Spondylotherapy
Rest
Bedrest
Sling
Immobilization
Semirigid appliance
Strap
Plaster cast
Indicated diet modification and nutritional supplementation.

3. Stage of Consolidation and/or Formation of Fibrinous Coagulant

The major goals are the same as in Stage 2 plus enhancing muscle tone and involved tissue integrity and stimulating healing processes. Common electives include:

Mild articular adjustment technics
Moist superficial heat
Thermowraps
Spray-and-stretch
Cryokinetics (active exercise)
Moderate active range-of-motion exercises
Meridian therapy
Mild alternating traction for passive stretch
Sinusoidal current
Ultrasound, continuous
Phonophoresis
Microwave
Vibromassage
High-volt therapy
Interferential current
Spondylotherapy
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Rest
Bedrest
Sling
Semirigid support
Indicated diet modification and nutritional supplementation.

4. Stage of Fibroblastic Activity and Potential Fibrosis

At this stage, causes for pain should be corrected but some local tenderness likely exists. The major goals are to defeat any tendency for the formation of adhesions, taut scar tissue, and area fibrosis and to prevent atrophy. Common electives are:

Deep heat
Articular adjustment technics
Spondylotherapy
Local vigorous vibromassage
Transverse friction massage
Spray-and-stretch
Active range-of-motion exercises without weight bearing
Mild alternating traction for passive stretch
Negative galvanism
Ultrasound, continuous
Sinusoidal and pulsed muscle stimulation
Microwave
High-volt therapy
Interferential current
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Rest by sling
Indicated diet modification and nutritional supplementation.

5. Stage of Reconditioning

Direct articular therapy for chronic fixations
Progressive remedial exercise
Passive stretching
Isometric static resistance
Isotonics with static resistance
Isotonics with varied resistance
Plyometrics
Aerobics
Indicated diet modification and nutritional supplementation.

Brachial Plexus Injury

The branches of the brachial plexus of the shoulder lie just anterior to the glenohumeral joint. The axillary nerve is just below the joint. In brachial plexus overstretch, the entire plexus or any of its fibers may be damaged. These injuries may be divided into three general types: total-arm palsies, upper-arm palsies (most common), and lower-arm palsies. Motor involvement is the main feature. Sensory loss is obscured by the overlapping innervation.

Clinical Features.   The roots of the plexus are relatively fixed at their origin in the spinal cord. Any sudden or severe traction of the upper extremity may avulse roots from the cord or stretch the plexus to the point of tearing. During avulsion, the spinal cord itself is damaged and contralateral cord symptoms develop. If the lesion is due to stretching, contusion, or partial tearing, the prognosis is good and complete recovery may be anticipated but guarded.

Management.   Treatment measures include support in the functional position, initial cold followed by light massage, electric stimulation, progressive exercises, and acupuncture. Suture is required in complete tears, and some improvement can be hoped for. The prognosis is usually hopeless in avulsion from the cord. Fortunately, most injuries are a neurapraxia, and full recovery can be anticipated in time.

Shoulder Girdle Neuralgia

Neuralgia arising in the shoulder girdle is usually caused by a cervical subluxation complex, 1st rib subluxation, or an underlying thoracic outlet neurovascular impairment. Other etiologies include extraspinal nerve entrapment, spinal cord or column disease, subacute neuritis (eg, toxicosis), carcinomatous invasion, or a lung tumor. The pain is usually perceived lateral to the upper thoracics or in the deltoid area. A degree of fibrositis and multiple trigger points is often associated, especially in the suprascapular and rhomboid areas.


Symptomatology and Physical Diagnosis

A stabbing, paroxysymal, remittent pain with slow relief on rest is characteristic. The pain may radiate down the upper extremity or to the neck, or both. Severe spasm may occur during the height of an episode. Aside from conducting standard physical, laboratory, orthopedic, and neurologic examining procedures against resistance and graded, autonomic imbalance should be tested if suspicions of vagotonia or sympathicotonia arise.

Clinical Features.   Contributing spinal majors will likely be found in the C5-T1 area. Fixations found in the shoulder girdle or involved upper extremity should be released. After relaxing the tissues and adjusting the subluxated/fixated segments, deep high-velocity percussion spondylotherapy is applied over segments C7-T4 for 3-4 minutes.

Other helpful forms of treatment include cryotherapy and massage with peppermint oil during an attack. Common rehabilitation therapies often include moist heat or shortwave diathermy, ultrasound for heat and massage at the cellular level, hot needle-spray showers, Epsom salts baths, interferential therapy, iontophoresis with magnesium, local vibration- percussion, alternating current, high-voltage therapy, or tendon friction massage of involved muscles. Temporary TENS is often helpful in situations of intractable pain. The attending physician should demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.

Contusion of the Axillary Nerve

Contusions of the axillary (circumflex) nerve commonly result from blows suffered along the nerve's course between the coracoid and head of the humerus. It is not an infrequent complication of the common anterior dislocation of the shoulder (10%).

Management.   The major sign in severe cases is loss of abduction from inadequate deltoid function. An area of anesthesia about the size of a silver dollar is found on the lateral aspect of the arm at the distal insertion of the deltoid. This is an important sign. In minor contusions, numbness and tingling may occur over the sensory area of the nerve in the upper deltoid area only during strenuous activity. Weakness may be difficult to determine, but swelling and tenderness can usually be found high and deep within the posterior axilla.

Clinical Features.   Treat as any nerve contusion. Ice massage is helpful initially. Rest the deltoid by using an arm sling. Measures to reduce spasm and intrinsic muscle swelling will relieve tenderness and paresthesias. Initiate progressive exercises when local symptoms subside. Electrical stimulation is beneficial in strengthening related muscle. In severe contusions, fibrous tissue and neuroma usually form that require surgical care unless preventive posttraumatic therapy is applied.

Shoulder-Hand Syndrome

This complex is often described under such labels as upper- extremity causalgia, Sudeck's atrophy, algodystrophy, and reflex neurovascular dystrophy. Some authors differentiate among them but these are minor points that have little clinical significance.

An infarction may have occurred but be unknown to the patient until the history is deeply probed (eg, an attack of chest pressure, faintness, cold sweating, etc). A neurologic or neurovascular cause should be sought. An upper rib, or sternocostal subluxation may mimic infarction, especially if the autonomics are involved. Similar symptoms also may be referred from the stomach, diaphragm (eg, hernia), or liver. Infrequent causes include mild stroke, drug toxicosis, and various spinal cord lesions involving the autonomics.


Symptomatology

The syndrome typically features upper-extremity pain, shoulder stiffness, and ipsilateral hand pain, tenderness, redness, coldness, and swelling. These symptoms often follow myocardial infarction but they are not restricted to a cardiac disorder. In the late stage, the skin of the involved hand(s) is glossy, the finger and wrist joints are extremely stiff, and muscle atrophy is advanced. Hyperhidrosis is common because of autonomic involvement.


Physical Examination

Besides standard examination procedures, the shoulder girdle and upper extremities should be motion palpated bilaterally as well as the spine. Findings are correlated with the patient's complaints and confirmed with appropriate orthopedic and neurologic tests. Autonomic imbalance should be thoroughly investigated. To be thorough, alarm points, visceral Valleix areas of the foot, Chapman's points, and potential contributing trigger points should be checked.

Clinical Features.   Contributing spinal majors will likely be found in the C6-T2 area. Fixations found in the shoulder girdle, anterior thorax, or involved upper extremity should be mobilized. After relaxing the tissues and adjusting the subluxated/fixated segments, deep low- velocity percussion spondylotherapy may be applied over segments C7-T4 for 1-2 minutes. Other helpful forms of treatment include moist heat or shortwave diathermy, hot needle-spray showers, interferential therapy, local vibration-percussion, or high- voltage therapy. The attending physician should demonstrate and prescribe progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.

The word subluxation refers to an incomplete or partial dislocation in which the articular surfaces have not lost contact. Partial malpositions may be extremely slight (beyond palpatory perception) yet be the focus for initiating a chain reaction in a kinematic chain that may express itself acutely in another joint or for establishing numerous adverse proprioceptive reflexes that may find expression in either the soma or viscera, or both.

In states of articular malposition, a certain degree of fixation must exist else the malalignment would readily reduce itself during joint function because the direction of least resistance would be toward normalization (congruent surfaces). Thus, it is just as important to determine what is holding the joint in malalignment (eg, spasm, shortened ligaments, adhesions, mineral deposits, entrapped cartilage, neogenic bone, neoplasm, degenerated joint surfaces, fracture, etc) as it is to determine that a joint is subluxated-fixated to some extent.

While it's likely that some degree of fixation always accompanies a subluxation, it is also likely that a dynamic subluxation also accompanies a fixation even when the fixation is found in the joint's position of rest. For, example: (1) joints fixated unilaterally tend to encourage compensatory contralateral joint laxity, and (2) joints fixated bilaterally tend to encourage compensatory joint laxity in the adjacent movable joints of the kinematic chain.

It is for these reasons the site of fixation is typically asymptomatic, with symptoms expressing at the site of compensatory hypermobility where activity is likely to produce irritation and inflammation. A fixation in the shoulder, for example, may exhibit as symptoms in the hand, wrist, elbow, or cervical and/or thoracic spine, or vice versa. Thus, the entire kinematic chain must be evaluated in any extremity neuromusculoskeletal disorder. Localized evaluation at the site of pain offers extremely limited information in itself and can readily lead to false conclusions.

The term fixation, as used in chiropractic, rarely means ankylosis (complete immobility). Rather, it implies a state of reduced mobility, essentially due to soft-tissue changes, and commonly found within the range of 20 to 90%. This degree of reduced mobility may be a gradual increasing resistance, as commonly encountered in passive motion against taut muscles, or normal motion to a point that meets a firm "rubbery" motion block, as commonly found when ligament straps have shortened or a piece of dislodged cartilage serves as a barrier to motion.

Once the possibility of fracture and underlying pathology has been eliminated, antalgic spasm is probably the only type of fixation involved in an acute subluxation syndrome. However, with chronic subluxations, concern must be given to the mobilization of degenerated para-articular and intra-articular tissues that have lost much of their elasticity and plasticity.

Although subluxations and fixations commonly accompany each other, each requires a different therapeutic rationale. Subluxations, being bony malpositions, are usually corrected with an adjustment applying a high-velocity thrust within a short range of motion. This can usually be accomplished instantly and only is repeated on a subsequent office visit if the adjustment does not "hold." Such a force, however, would usually be contraindicated with most types of soft-tissue fixations if bleeding is to be avoided, as even minute hematoma encourages further soft-tissue fibrosis and calcification.

Thus, most fixations are treated by using a slow repetitive stretching maneuver applied (up to patient tolerance) against the resistance, which may extend through a relatively long range of motion. It may take many months (eg, frozen shoulder) to achieve the optimal results possible when the joint has been in a prolonged state of hypomobility. Both high-velocity and low- velocity techniques require firm stabilization of adjacent joints that could possibly be adversely stressed during adjustment or mobilization maneuvers.

Other important clinical paradoxes are those of posttherapy immobilization and heat versus cold. Following the correction of an acute subluxation, short-term immobilization tends to offer the affected tissues a period of rest to promote healing and prevent further inflammation from activity. Cold would usually be indicated within the first 72 hours to reduce pain and swelling. On the other hand, extended immobilization tends to weaken para- articular muscles (disuse atrophy), encourage circulatory stasis and the accumulation of metabolic debris, and promote shortened ligaments and stiff capsules, which would encourage the formation of soft-tissue fixation. Heat and exercise would usually be indicated to soften taut tissues and enhance circulation.

Following any manual therapy, the common procedure is to recheck joint mobility, apply any adjunctive therapy or rehabilitative procedure that would be appropriate, counsel the patient as to adverse activities, and prescribe and demonstrate necessary home exercises.


Articular Therapy

Most shoulder subluxation-fixations are nonacute and exhibit little or no swelling, but they present with chronic (often episodic) pain, stiffness or "blocks" and other signs of local tissue fibrosis and joint gluing. From mild to moderate local muscle weakness and possible atrophy are characteristic. Postural distortions of the lower cervical and upper dorsal spine and musculoskeletal abnormalities of some aspect of the shoulder girdle are invariably related.

During articular correction of a shoulder subluxation, dynamic thrusts should be reserved for nonacute situations. When subluxation accompanies an acute sprain, attempts at articular correction should be more in line with gentle traction forces after related muscles have been relaxed. Obviously, the suspicion of an underlying bone tumor, fracture fragments, osteoporosis, abscess, etc, must be eliminated before any form of manipulation is done. As a peripheral vascular disorder may be involved, it is usually good policy to palpate the tone of the brachial and radial pulses, measure upper-limb blood pressure, and compare findings bilaterally.

Because the shoulder readily "freezes" after injury, treatment must strive to maintain motion as soon as possible without encouraging recurring problems. The key to avoiding prolonged disability is early recognition; articular correction; early mobilization; normalization of neural, arterial, venous, and lymphatic circulation; and the elimination of contributing extrinsic contributions.


Relocating Structural Displacement

The glenoid cavity covers only a small part of the head of the humerus. In extreme degrees of abduction, extension, and flexion, any force transmitted through the humeral shaft is applied obliquely in the body surface and directly on the capsule of the joint, through which the head of the bone is then forced. In fracture dislocations, the humerus is invariably displaced outside the joint.

Urban practitioners generally refer dislocations to orthopedists for setting. This decision may be based on a lack of personal knowledge, license restraints, working in a litigation- conscious society, or wide availability of specialists and hospitals with highly sophisticated resources. On the other hand, the rural practitioner may be looked to as the most logical source for professional help when reduction of a simple luxation is within the authorized scope of practice. Fracture-dislocations or those exhibiting complications beyond the skill of the attending physician should always be referred to specialized care.

Clinical Features.   In primary dislocation, symptoms may be severe even if the soft-tissues and capsule are not greatly damaged. Most shoulder dislocations involving the shoulder girdle complex are anterior dislocations of the glenohumeral joint (85%), followed by acromioclavicular separations/dislocations (10%), sternoclavicular dislocations (3%), and posterior glenohumeral dislocations (2%). True dislocations must be differentiated from pseudosubluxations where the humerus is displaced inferiorly by hemarthrosis. Poor muscle tone is usually related in the poorly conditioned individual. In primary glenohumeral dislocation, symptoms may be severe even if the para-articular soft tissues and capsule are not greatly damaged. Heroic reductions should be avoided.

Orthopedic Tests

Dugas' Test.   The patient places his hand on his opposite shoulder and attempts to touch his chest wall with his elbow and then raise his elbow to chin level. If it is impossible to touch the chest with the elbow or to raise the elbow to chin level, it is a positive sign of a dislocated shoulder. This classic test is universally used to check the possibility of shoulder dislocation.

Apprehension Test.   If chronic shoulder dislocation is suspected, the examiner begins to slowly and gently abduct and externally rotate the patient's arm with the elbow flexed toward a point where the shoulder might easily dislocate. If shoulder dislocation exists, the patient will become quite apprehensive, symptoms will be reproduced, and the maneuver is resisted as the examiner attempts further motion.

Bryant's Sign.   A posttraumatic ipsilateral lowering of the axillary folds (anterior and posterior pillars of the armpit), with level shoulders, is indicative of dislocation of the glenohumeral articulation.

Calloway's Sign.   The circumference of the proximal arm of a seated patient is measured at the shoulder tip when the patient's arm is laterally abducted. This measurement is compared to that of the uninvolved side. An increase in the circumference on the affected side suggests a dislocated shoulder. Consideration must be given to the individual who occupationally uses the involved arm almost exclusively (eg, a tennis player).

Hamilton's Sign.   Normally, a straight edge (eg, a yardstick) held against the lateral aspect of the arm cannot be placed simultaneously on the tip of the acromion process and the lateral epicondyle of the elbow. If these two points do touch the straight edge, it almost always signifies a dislocated shoulder.

Roentgenography

Careful evaluation of the glenohumeral articulation is necessary to judge alignment congruity. An axillary (bird's-eye) view to clearly expose the articular relationship is often quite helpful. A tangential view of the scapula may be an aid in exhibiting a fracture of the coracoid process or glenoid margin or to find evidence of defects in the humeral articular margin following chronic dislocation.

In approximately 20% of cases of shoulder dislocation, fractures of the glenoid are related. Lesser tuberosity fractures are often associated to a posterior dislocation of the shoulder. Vigorous contractions of the triceps muscle, as seen in throwing, may produce avulsion injuries to the inferior aspect of the glenoid. Thus, roentgenography is necessary to analyze possible complications before any considered reduction.


General Management Protocols

Techniques for reducing long-duration dislocation or those with complications requiring anesthesia or surgery are orthopedic procedures that require referral to an appropriate specialist. However, the reduction of dislocations is within the chiropractic scope of practice in some states; thus, commonly applied techniques for these conditions will be briefly described, especially techniques to reduce simple, uncomplicated displacements. These will usually be recurring dislocations where only mild or moderate force is necessary for correction.

Some authorities report that, when possible, reduction should be made within 10 minutes after injury when local numbness is present and severe spasm has not occurred. A firm gentle manipulation will usually result in reduction. If not, avoid persistent attempts and refer to an orthopedist. Such rapid reduction is rarely possible unless the doctor is an on-field sports physician or just happens to be near the scene. Other authorities believe that prior x-rays should always be taken before attempting reduction to avoid possible problems associated with a fracture.

There is always a danger of forcing a bone chip into the joint that would require surgery. Thus, a decision must be made to either offer immediate relief with some risk by making one good attempt or leaving the patient in severe pain until films can be taken, processed, and analyzed. The longer reduction is delayed, the greater the muscle spasm, which makes reduction difficult.

Following reduction, strapping and a sling should be used to rest the joint and a harness employed to restrict shoulder abduction and exterior rotation. Such a sling should have a controlling swath around the thorax to stabilize the joint as incorporated within a modified Velpeau bandage. Local soreness subsides in a few days as the soft tissues heal. Cold can be applied initially to reduce pain and swelling, followed by the usual treatment for severe sprain. The typical athlete is too eager to have the sling removed; thus, strong warnings must be given.

Professional opinion differs as to the length of immobilization. The average is 4 weeks. Some feel prolonged immobilization (over 3 weeks) produces more harm (atrophy) than good, while many others feel that at least 6 weeks are necessary to avoid recurring problems. Regardless, the shoulder should be allowed to heal thoroughly before progressive exercises are initiated. The fingers and wrist, however, should be actively exercised early during immobilization.

The older patient is more prone to later stiffness problems than recurrence problems. Mild circumduction exercises may be initiated after about 4 days and progressive range-of-motion regimens after 3 weeks. Full external rotation and abduction should be avoided for 6 weeks in older patients; 9 weeks in younger patients. Isometric exercises of involved muscle groups are always recommended while the shoulder is immobilized.


Uncomplicated Anterior Humeral Head Displacement

There is difficulty in raising the arm overhead. A fullness will be noted on the upper anterior arm that will be tender during palpation. The deltoid will feel taut and stringy. A sensitive coracoid process will be found that is higher than the head of the humerus. Signs of acute or chronic sprain will likely be found, depending on the history.

Subcoracoid (most common), intracoracoid, and subclavicular types of anterior dislocation of the head of the humerus may be found. The typical mechanism of injury involves a combination of abduction, extension, and external rotation of the shoulder.

The three most common means of injury are: (1) a fall on the outstretched arm where the force drives the humeral head forward against the anterior capsule; (2) a fall or blow to the lateral shoulder from the rear; and (3) forced abduction with the humerus in internal rotation or forward flexion with the humerus in external rotation, limited by the acromial arch. In this latter type, if forceful elevation is applied when the point of impingement is reached, the arch is used as a fulcrum to dislocate the head of the humerus anterior and inferior. In many instances (eg, an unexpected jolt), only a relatively trivial force is necessary to produce an anterior dislocation.

Adjustment of an Externally Rotated Anterior Humerus.   If the patient's humeral head is fixated in an anteriorly and externally rotated position, stand behind the patient (seated on a low stool). The patient's hand on the involved side should be placed on the patient's opposite shoulder near the neck to internally rotate the involved humerus. The patient's elbow is then fully flexed so that the arm will be almost horizontal to the floor and the elbow is positioned approximately over the sternum. The patient's other hand can rest loosely in the lap. Reach around the patient with both arms and clasp your fingers over the patient's flexed elbow. Brace your chest against the patient's dorsal spine for counterpressure. Ask the patient to relax, and when this is done, lift the patient's elbow slightly and apply firm pressure. This maneuver is followed by a short quick thrust (pull) that is directed posteriorly and slightly superiorly. As with many adjustive procedures conducted with acute conditions, this adjustment should be followed with sprain therapy and rehabilitation measures to assure against future joint looseness or restrictions.

Adjustment of an Internally Rotated Anterior Humerus.   The procedure to correct a humerus that is fixated in an internally rotated anterior position is essentially the same as that described above except that, before the adjustment, the patient is instructed to grasp the back of his neck on the ipsilateral side with the palm of the hand on the affected side to externally rotate the humerus.

Suspicion of Complications.   When the humerus dislocates anteriorly, its posterolateral margin is often forced against the rim of the glenoid to produce a compression fracture (Hill-Sach's deformity). The malpositioned humerus frequently tears the cartilaginous labrum and capsule from the glenoid rim (Bankhart lesion) with an avulsed fragment of bone.

If there is fracture of the anatomical neck, the humeral head (if it can be felt) will not participate in passive movement of the shaft. Crepitus can usually be felt. Fracture of the greater tuberosity and tears of the rotator cuff are common complications. Anterior fracture-dislocations are usually related with displacement of the greater tuberosity, but the capsule is not displaced. Any anterior luxation can do great harm to the brachial artery, vein, or nerves. Circulation should always be checked and contraindications eliminated before in-office reduction is attempted.

Uncomplicated Posterior Humeral Head Displacement

This type of dislocation is often a diagnostic challenge in the young well-muscled patient because all joint motions may be unrestricted yet the disability is acute. Two types are seen that differ only in the extent of displacement; ie, subacromial and subspinous types. The cause is direct pressure applied laterally and posteriorly or a force exerted in the same direction along a flexed, adducted, and internally rotated humerus. It is sometimes produced during a convulsion.

Physical Features.   Physical signs of this rare malposition are often negative. Stress films taken bilaterally for comparison are required for confirmation. In some cases, the posterior area may feel fuller than the unaffected side. An unusually prominent coracoid process may be felt, and a slight hollow may be palpated above the humerus. Signs of taut tissues on the posterior aspect of the humeral head and lax tissues on the anterior aspect are classic. The patient's arm is abducted and rotated internally, and the elbow is directed slightly forward. The shoulder is flat in front and full behind, where the head of the humerus may be felt. The coracoid process is prominent. The head of the humerus lies on the outer edge of the glenoid fossa or further posterior to lie under the scapular spine or on the infraspinatus. These features are not as obvious as those of anterior dislocation. Passive abduction and external rotation motions are restricted. In severe cases, the lateral side of the capsule is usually torn, and there may be associated rotator cuff tear or an avulsion fracture of the greater tuberosity resulting in persistent pain. The internal and external scapular muscles are often torn and may contain fragments of the avulsed tuberosities.

Management.   In many instances, simple axial traction of the humerus in the classic position will reduce a posterior humeral head subluxation (or uncomplicated dislocation). If not, the following procedure is suggested: The patient is placed prone with the involved extremity resting loosely at the side. Stand on the side of involvement, obliquely facing the patient's shoulder. Take a pisiform contact on the patient's posterior proximal humerus, as far cephalad as possible, with your medial hand. Your lateral hand then stabilizes your contact hand. Direct pressure toward the floor, and then make a short thrust to complete the correction.

Correction of a humeral head that has become fixated in a posterior position can also be made in the same doctor-patient position as for the alternative adjustment procedure of an inferior humerus subluxation. Traction is applied to the humerus first laterally toward yourself and then anteriorly toward the ceiling. A slow steady lateral pull should be concluded with an anterior tug to stretch the contracted tissues and "reseat" the humeral head in its normal position. Follow with standard therapy for acute or chronic sprain, depending upon the history.

In uncomplicated cases of posterior luxation, reduction can usually be accomplished by inferior and lateral traction with direct anterior pressure. Unreduced dislocations exhibit an unusual amount of disability. When viewed from the lateral, the posterior area appears fuller than the unaffected side. An unusually prominent coracoid process may be palpated, and a hollow may be felt above the humerus. Tearing of the subscapularis makes recurrence probable unless appropriate muscle rehabilitation regimens are not instituted.

In contrast with the management of anterior dislocations, a posterior dislocation should be immobilized after reduction with the arm in external rotation and abduction. This usually requires the use of an abduction splint.

Uncomplicated Inferior Humeral Head Displacement

Subglenoid and luxatio erecta types are infrequently seen in which the head of the humerus lies below the glenoid fossa. The typical cause is forcible abduction followed by rotation or impulsion. The mechanism of injury is usually a leverage force on an abducted arm such as in a football arm tackle.

Clinical Features.   A slight hollowness may be found at the joint space, indicating that the head of the humerus has dropped from its normal position. The deltoid will often feel firm and stringy, suggesting a chronic disorder. Physical signs are often vague; thus suspicions should be confirmed by bilateral roentgenography and other appropriate diagnostic procedures. There are severe pain and disability. The arm is fixed at about 45ø abduction. A hollowness will be found at the joint space, with the head of the humerus inferior to its normal position and often palpable within the axilla. The deltoid is flattened and extremely spastic.

In subglenoid luxation, the major physical feature is marked subcoracoid flattening. The upper part of the greater tuberosity is often torn. In rare instances of luxatio erecta, forcible elevation of the arm causes the head of the humerus to be displaced so far downward that the extremity remains in an erect position.

Management.   First, determine if correction is necessary for any associated internal or external rotation in addition to the superior displacement. The patient is then placed supine if there is internal rotation, prone if there is external rotation. Stand obliquely (facing the patient's affected side), and take contact on the patient's medial proximal humerus with the web of your medial (active) hand. Grasp your stabilizing (lateral) hand around the patient's distal humerus from above. Pressure is applied cephalad with your active hand, and then a short thrust is made while your lateral hand firmly stabilizes the patient's humerus.

In subglenoid dislocation, treatment is by moderate abduction with direct pressure. This is a most difficult type of dislocation to reduce without anesthesia, and usually requires an orthopedist. To reduce mild displacements, the patient is placed supine. Sit perpendicular to the affected side, and, if possible, place the patient's flexed elbow in your axilla for stabilization. The head of humerus must be first pulled laterally toward you and then cephally in one smooth movement. Counterpressure is applied by your knee against a pillow placed in the patient's axilla. Reduce any degree of luxatio erecta by upward traction until the head of the humerus slips in place.

In another technic, correction is induced by abduction, moderate traction, and then superior pressure. The patient is placed supine. Sit perpendicular to the affected side, and flex the patient's elbow. The forearm of the affected extremity can be placed in your axilla for control. Grasp the patient's humerus high with both hands and pull the head of humerus first laterally toward yourself and then cephalad in one smooth quick movement. Counterpressure is applied by your knee firmed against padding placed in the patient's axilla. This "reseating" procedure should be followed by short-term immobilization to encourage the lax tissues to tighten, and then rehabilitation procedures to strengthen weakened muscles and lax ligaments and capsule.

Uncomplicated Superior Humeral Head Displacement

Because of its bony arch, the humerus cannot dislocate much superiorly unless there is severe traction involved. However, some authorities believe that superior subluxation can often be demonstrated on bilateral roentgenography. Schultz feels this is the most common shoulder subluxation seen. This author, however, believes the term to be a misnomer as the suprahumeral joint is not an articulation in the true sense of the word but is solely a structure that serves as a protective and supportive mechanism.

Most likely what is called a superior humeral subluxation is the result of contractures within the superior humeral area that prevent the greater tuberosity from gliding smoothly under the coracoacromial ligament during abduction. The result is chronic compression, irritation, and ischemia of the enclosed tissues. Remember that the acromioclavicular meniscus progressively thins with age. It is quite thick in the young but may be completely gone by the 5th or 6th decade.

A supraglenoid luxation is extremely rare except in sports and severe accidents. A routine A-P view may show narrowing of the space between the head of the humerus and the acromion, indicating a tear. In many cases, arthrography should be recommended. Special care should be taken not to confuse the growth plate of the proximal humerus with a fracture line.

Management.   First determine if correction is necessary for any associated internal or external rotation in addition to the superior displacement. The patient is then placed supine if there is internal rotation; prone if there is external rotation. Position yourself above the affected limb, oblique to the patient's affected side. The patient's elbow is flexed, and the patient's shoulder is abducted to near 90 degrees. With the web of your active medial hand, take contact on the lateral aspect of the patient's proximal humerus. With your lateral stabilizing hand, grasp the medial aspect of the distal humerus. Apply pressure against the proximal humerus in a caudad direction (transverse to the humeral shaft), and then make a thrust while your lateral hand stabilizes and slightly abducts the patient's distal humerus.

As above, but an alternative Technic, is to determine if correction is necessary for any associated internal or external rotation in addition to the superior displacement. This technic is a variation of the Hippocratic method of reducing subcoracoid dislocations, which will be described in the next section. Sit near the affected side, and face the head of the supine patient. Place a shoeless foot in the patient's axilla for counterpressure and stabilization of the shoulder girdle. Apply straight axial traction with both hands grasped around the patient's arm. Direct the traction toward the inferior and slightly lateral. After a few seconds and with steady traction, rotate the patient's arm internally (usually) or externally, as need be, and then make a short tug toward your body to correct any rotational deficit that exists.

Orthopedic Subluxation of the Humeral Head

This acute condition is probably a dislocation that has partially reduced itself spontaneously. It usually occurs when the greater tuberosity has been displaced upward as a whole so that it lies between the humeral head and the glenoid. The capital part rotates to a degree but does not completely escape from its capsular envelope. Films will show that the outer border of the shaft is impacted firmly into the cancellous tissue of the head of the humerus.

The chief obstacle in obtaining reduction is in the difficulty of removing the tuberosity from within the joint and overcoming the extremely firm impaction of the two main fragments. It is rarely possible to overcome these obstacles by conventional manipulation, especially without anesthesia, thus referral for orthopedic attention should be seriously considered.


Subcoracoid Dislocation

In subcoracoid luxation, the head of the humerus lies under the coracoid process, either in contact with it or at a finger's breadth distance at most below it. The dome of the humerus may be displaced inward until three-fourths of its diameter lies to the medial side of the process or be simply balanced on the anterior edge of the glenoid fossa. The humeral axis passes to the medial side of the fossa. Note that the elbow hangs away from the side, the lateral deltoid bulge is flat, and the acromion is prominent. The glenoid cavity is relatively empty. Palpation reveals the absence of the usual bony resistance below the lateral aspect of the acromion and the presence of abnormal resistance below the coracoid process or in the axilla. Voluntary movement is lost, and assisted abduction is strongly resisted by the patient. Dugas' test is positive. That is, the arm can be passively adducted but not to the degree that the elbow can touch the chest with the fingers resting on the opposite shoulder. Linear limb measurement in abduction, compared to the uninvolved side, shows shortening.

Before any reduction technique is used, the integrity of the circumflex nerve should be established by checking the dermatome (C5) with a pin or pinwheel, and signs of possible fracture should be sought. As a rule, early reduction of a mild shoulder dislocation may not require an anesthetic except in the highly apprehensive patient or if complications are suspected. Reassurance, warmth, and a quiet area help to enhance relaxation. Occurrence, the absence of complications, and reduction should always be confirmed by x-ray and other diagnostic procedures.

The Classic (Hippocratic) Method.   This crude but effective method is accomplished by the seated doctor placing a shoeless foot in the supine patient's axilla for counterpressure and applying straight axial traction with both hands on the patient's arm. The slow gentle pull is toward the inferior and slightly lateral, never upward and outward as there is danger of lacerating vessels. After a long steady pull (never a jerk), the muscles yield and allow the head of the humerus to slip back into the socket as the arm is slowly internally rotated. If successful, relief is immediate. During the traction, some doctors attempt to push the humeral head into the socket with the ball of the stockinged foot.

Note:   The author has performed this maneuver many times. It has only been recently that I realize how silly this procedure may appear to a patient; ie, the doctor removing a shoe and placing a foot in the patient's armpit. But I have never received a complaint because the patient entering the office in severe pain leaves with only a mild residual soreness.

The doctor-patient position described above will frequently be referred to in subsequent portions of this monograph as simply the classic position. A less effective but more "sophisticated" approach can be used by applying a padded counterpressure strap beneath the axilla rather than using a foot.

If replacement is not complete, remove your foot from the patient's axilla, and flex the patient's elbow. Stabilize the elbow with one hand while applying gently pressure downward on the forearm to cause slight internal rotation of the humeral head to complete the reduction. Place the flexed arm over the patient's chest and instruct him to hold it there until the joint can be secured with tape.

Muscle spasm may be difficult to overcome in the highly muscled athlete. Regardless, never use severe leverage against the chest as it will undoubtedly break a rib if the thorax is used as a fulcrum. However, some doctors are skilled at applying forceful adduction over a padded closed fist placed in the patient's axilla.

Kocher's Method.   This procedure is performed by (1) applying gentle downward traction to the flexed elbow and pressing it closely to the patient's side; (2) most carefully, easing the arm into full possible external rotation by moving the patient's arm away from the trunk (a sudden motion may fracture the humerus); (3) while maintaining the external rotation, carrying the elbow well anterior and superior to gently adduct the elbow across the patient's chest; then (4) reduction can be felt (and often heard) when adduction is complete. The patient's arm is then rotated internally so that the hand rests on the patient's opposite shoulder. The elbow is simultaneously lowered. If this method fails, the classic method may be attempted. Keep in mind, however, that failure in reduction may indicate a complicating fracture that would make further attempts contraindicated.

Stimson's Method.   A gentle alternative to the technics described above is to place the patient prone on a cot or table with the affected limb hanging toward the floor. Fix about a 10- lb weight to the padded wrist with tape. Frequently, this gentle continuous traction will reduce the dislocation within 20 minutes. It works best with the patient not presenting with highly developed muscles.

If one of these methods is not successful, referral for reduction during general anesthesia should be considered. Open reduction is rarely required.

Intracoracoid and Subclavicular Dislocations

In intracoracoid and subclavicular luxations, the head of the humerus is displaced and fixed further medially. The symptoms and signs are similar to those of the subcoracoid type of dislocation except that the head of the humerus is felt further displaced and the lateral aspect of the shoulder appears to be more flattened. The arm may be fixed in horizontal abduction. Severe capsule laceration is usually involved, which allows for the greater displacement.

Management.   Outward traction usually has no difficulty in reducing these types of dislocations unless the subscapularis or a torn capsule intervenes. If this is the case, surgery is the only recourse. Angelvin's method of reduction is applied by placing the hand of the dislocated extremity about your neck. Then, in intracoracoid luxation, direct the head of the humerus with your hands by applying extension, counterextension, and lateral traction pressure as need be. In subclavicular luxation, the same forces applied more energetically will force the head of the humerus into the socket.

With this knowledge of how to reduce shoulder luxations, let us turn attention to a much more frequent problem seen in practice; ie, mobilizing articular restrictions within the normal range of mobility. Such fixations are a common source of shoulder complaints.

Lateral Shoulder Girdle Hypomobility

Function of any joint governs its integrity. The head of the humerus is frequently flexed and abducted in most life-styles and occupations, but it is less often used in wide adduction and rarely used in backward extension. Likewise, internal rotation of the humerus is made much more frequently than is external rotation. Lack of exercise in any range of normal motion readily leads to uncomfortable or painful motion restrictions when unaccustomed movements are made with or without external loading. Mobilizing such points of restriction relieves functional shoulder complaints as well as symptoms referred from the site of restriction.

Data on the normal range of shoulder motion vary several degrees among the authorities. Below are averages that are generally adequate for clinical practice:

      Flexion      180°
      Extension     50°
      Abduction    180°
      Adduction     50°
      Internal
        rotation    90°
      External 
        rotation    90°

Mobilization of Articular Fixations

Fixations in the shoulder girdle may be primary conditions after intrinsic overstress or extrinsic trauma. Sometimes they occur weeks or months after reduction of a dislocation when follow-up care was inadequate. Thus, in cases of chronic shoulder pain, the history should be probed for possible shoulder dislocation and spontaneous reduction.

The most common causes of motion restriction are muscle weakness, spasm, contractures, fracture, or dislocation. In muscle weakness, a joint will move through its normal range passively but not actively. Consistent active and passive restriction is likely to be the result of a bony or soft-tissue block, and the atrophy will most likely be from disuse. With passive movement, bone blocks will feel as abrupt inflexible stops in motion, while extra-articular soft-tissue blocks will be less abrupt and slightly flexible when additional pressure is applied.


Lateral Clavicle Mobility Restrictions

For the glenohumeral joint to move freely, the clavicle must be free to pivot and rotate up to 40 degrees in accommodation for the wide range of motion of the shoulder joint. Limitation of mobility at either the acromioclavicular joint or the sternoclavicular joint severely limits glenohumeral motion. Sternoclavicular fixation (eg, shortened interclavicular ligament) is an often overlooked cause of restricted shoulder motion.

Clinical Findings.   The patient complains of an ache within the joint, tenderness at the lateral end of the clavicle, and loss of some arm function. A partial ligament tear, which will complicate the situation, will be demonstrated by looseness of the joint. Subluxation can be detected by bilateral palpation of the lateral end of the clavicle for the characteristic down step. Bilateral comparison is necessary because some people normally have enlarged clavicle ends laterally that can be mistaken for subluxated clavicles. When subluxated, the clavicle tends to displace to the superior and anterior. In chronic cases, a degree of soft-tissue shortening will inevitably exist that is determined by placing two finger pads on the acromioclavicular joint and circumducting the patient's abducted arm.

Dynamic Palpation of the Acromioclavicular Joint.   Neither the acromioclavicular joint nor the sternoclavicular joint (which contains an articular disc) can be moved by voluntary action, yet they play a vital involuntary role in all motions of the shoulder girdle. Dynamic palpation to evaluate the normally small but necessary joint play at both the lateral and medial aspects of the clavicle can sometimes be achieved if the patient is able to achieve full relaxation. The joint play elicited at the acromioclavicular articulation is felt as a slight inferior and superior glide. Although the clavicle rotates on its axis several degrees during humeral flexion and extension, this movement is difficult to perceive unless the patient has abnormally flexible joints (eg, a contortionist) or the joint is unstable.

Anterosuperior Lateral Clavicular Subluxation

Acromioclavicular subluxations commonly result from falls, blows, and contact injuries and are usually accompanied by new or old joint ligament separations. An anterosuperior subluxation is by far the most common subluxation of the lateral clavicle.

Management.   For this technic, the patient is asked to sit on a low stool. The palm of the patient's hand on the involved side is placed on the back of the neck or occiput. Stand behind the patient and place the web of your medial contact hand on the superior aspect of the patient's lateral clavicle. Stabilize the patient's elbow with your lateral hand by cupping your palm underneath the patient's lower humerus (medial aspect) and apply as much traction as possible short of patient discomfort. Apply pressure inferiorly with your contact hand. Then, with your active medial hand, make a short thrust directed inferiorly and posteriorly, while simultaneously elevating the patient's elbow superiorly and medially with your stabilizing hand. Conclude the adjustment by maintaining contact pressure and gently circumducting the abducted humerus.

If the arm is just abducted, the greater tuberosity of the humerus will be forced against the acromion and increase patient discomfort. It is suggested that mild external rotation be added to a pure abduction position as this will produce much less discomfort to the patient during the maneuver.

In an alternative technic, the doctor-patient position and the doctor's contact are the same as described above. With this technic, however, the patient's arm is abducted, the elbow is flexed, and the patient's hand points inferiorly and medially toward the floor. Rather than stabilizing the patient's elbow, place your stabilizing forearm under the patient's abducted arm and grasp the dorsal surface of the patient's forearm. Apply pressure directed inferiorly with your contact hand, and then make a short thrust directed to the inferior and posterior while simultaneously elevating the patient's elbow to the superior and medial with your stabilizing forearm.

Jammed Shoulder Joint

With a spastic and painful jammed shoulder joint, a proximal humerus can be jammed into the glenoid by a fall on the outstretched hand or simply by severe para-articular muscle spasm. Almost any type of axial traction will help to relieve this condition. One common technique is to place the patient supine (to stabilize the scapula) with the involved limb resting comfortably at the side, elbow extended, and wrist pronated. Stand at the side and face the patient. Cup your stabilizing hand (medial) on the patient's shoulder so that your fingers extend around the shoulder, your thumb enters the axilla, and the web of your hand contacts the inferior neck of the glenoid below the lateral aspect of the clavicle. Firmly grasp the patient's arm just above the elbow and apply axial traction directly caudad. The patient's extended forearm can be tucked between your stabilizing arm and medial hip. While applying traction, it sometimes helps to rotate your hips and shoulders clockwise for added leverage. Slowly stretch to patient tolerance, hold, and then slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of abduction as can be tolerated by the patient.

Restricted Upward Glide During Abduction.   To free restricted inferior glide during abduction, place the patient supine, and stand almost perpendicular to the patient but turn your body slightly away from the patient's face so that your medial hip is firm against the table. Partially flex the patient's elbow, and slowly move the limb into abduction up to patient tolerance. The fingers of your stabilizing hand grasp the patient's arm distally, just above the elbow, and the patient's elbow rests in your palm. The patient's hand can be tucked between the elbow and trunk of your lateral (stabilizing hand) side. The heel of your supinated active hand (medial) is placed against the lateral aspect of the patient's upper arm. While holding a firm contact with your stabilizing hand, apply a pushing force (directed caudally) to patient tolerance, hold, and slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of horizontal abduction by moving the patient's elbow progressively toward the head of the table. This technique is especially effective when impingement is found under the greater tuberosity of the acromial arch during horizontal abduction (a common finding).

Restricted Downward Glide During Flexion.   To free restricted inferior glide during flexion, place the patient supine, fully flex the elbow, and lift the patient's arm so that the elbow points toward the ceiling. The patient's fingertips should come near to the shoulder tip. Stand at the side and face the patient. Grasp your hands around the patient's proximal humerus, fingers intertwined. If your treatment table is low enough, you can stabilize the patient's elbow with your chest. While maintaining firm contact with your stabilizing hand, slowly apply a pulling force (to patient tolerance) toward your body with your active hand, hold, and slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of internal and external rotation by moving the patient's elbow laterally and medially.

Restricted Horizontal Glide During Flexion.   To free restricted lateral glide during flexion, the technique is similar to that described for restricted inferior glide during flexion except that the pulling force is directed laterally rather than caudally.

Externally Rotated Humerus with Restricted Internal Rotation

An external subluxation of the humerus is usually related to restricted internal rotation of the humerus. Supraspinous tendinitis, bicipital tendinitis, tendon displacement from the bicipital groove, and inferior humerus subluxation are common complications. The corrective technic is almost identical to the previously described mobilization of an externally rotated anterior humerus.

An alternative technic is to place the patient prone on the adjusting table, and stand facing the patient's shoulder on the side of involvement. The patient's elbow is flexed and the supinated hand is placed under the patient so that the palm comfortably rests against the patient's chest and the back of the hand is in contact with the table. This "sling position" will allow some internal rotation tension that will assist the forthcoming adjustment. In this position, your stabilizing hand should cup the patient's shoulder so that the heel of your hand holds the patient's clavicle while your fingers stabilize the patient's scapula. Your contact hand should firmly grasp the patient's humerus just below the acromion process. A deep, but not severe, rotary thrust is then made that is directed to produce internal rotation of the humerus.

Restricted Posterior Glide During External Rotation.   To free restricted posterior glide during external rotation, place the patient in the supine position, stand at the side of the table, and face the head of the table on the involved side. With your lateral hand, grasp the patient's wrist. Flex the patient's elbow and abduct the humerus as close as possible to 90. With your medial hand, take a broad contact with the heel of the hand against the anteromedial surface of the proximal humerus and your fingers wrapped around the deltoid. Very slowly produce external rotation by moving the patient's wrist slightly toward the tabletop with your lateral hand and rotating the proximal humerus externally with your medial hand. Extreme caution and patience must be used with this maneuver to avoid dislocating the joint.

Restricted Anterior Glide During External Rotation.   To free restricted anterior glide during external rotation, place the patient in the supine position. Stand at the side of the table obliquely facing the patient on the involved side. Partially flex the elbow of the involved limb, and grasp the patient's lower humerus with your stabilizing (lateral) hand. From the medial aspect, reach under the superior aspect of the patient's upper arm with your active (medial) hand so that the posterior aspect of the upper arm rests in your palm. Bend forward, maintain firm contact with your stabilizing hand, and slowly lift the head of the humerus toward the anterior (toward the ceiling). After the slack in the shoulder girdle is removed, continue the pulling force to patient tolerance, hold, and slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of internal and external rotation by moving the patient's hand (elbow partially flexed) progressively medially and laterally.

Restricted Anterior Glide During Internal Rotation.   To free restricted anterior glide during internal rotation, place the patient in the lateral recumbent position with the uninvolved side against the table. Stand at the side of the table (anterior to the patient) so that you are facing obliquely to the head of the table. Extend the patient's involved limb, pronate the wrist so that the back of the patient's hand rests near the buttock, and then slowly flex the patient's elbow to tolerance. Firmly cup the patient's elbow with your stabilizing (caudad) hand. Lean over the patient, and with your active (cephalad) hand, apply a pisiform contact over the posterior aspect of the head of the humerus. Maintain firm contact with your stabilizing hand, apply a pushing force (to patient tolerance) with your active hand that is directed toward your body, hold, and slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of internal rotation by moving the patient's hand progressively cephalad.

Restricted Posterior Glide During Abduction.   To free restricted posterior glide during abduction, place the patient supine, stand at the side and face the patient, and abduct the patient's involved arm of the partially flexed limb to tolerance. The patient's hand can be tucked between the elbow and trunk of your lateral (stabilizing hand) side. The palm of your stabilizing hand cups the patient's elbow while the fingers grasp the lower arm. The heel of your pronated active hand (medial) is set against the anterior surface of the patient's upper arm, as cephalad as possible without losing contact with the humerus. The greatest pressure should be felt on your pisiform. Bend over the patient so that your active hand is perpendicular to the patient's arm, and extend your elbow. Maintain firm contact, apply a pushing force (to patient tolerance) toward the floor hold, and slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of internal and external rotation by moving the patient's elbow laterally and medially.

Recurring Displacements of the Humeral Head (Lax Joint)

Repeated subluxations without clinical dislocation often produce a loose joint. The history reveals frequent episodes of mild trauma, each incorporating a period of pain and limited motion, followed by an audible "click" as the head of the humerus slips painfully back into the fossa. After reduction, examination reveals little except residual tenderness and a lax capsule. If episodes are frequent, an external bridle can be provided. It is doubtful that strength-building exercises will be effective. The patient should be advised of the risks involved in repeated subluxation. Incidence is highest in males 20 40 years of age.

Several factors influence recurrent dislocation. The younger the patient is with a glenoid-rim fracture, the size of the capsular deformity (Hill-Sach's deformity), and the range of normal lateral motion increase the chances for recurrent dislocation. If the head of the humerus is driven directly forward during injury, the cartilaginous labrum glenoidale is torn from its anterior attachment. This leaves a potential cavity into which the head can repeatedly slip. Another cause is too early mobilization following a primary dislocation.

A recurring dislocation is a different problem from that of a primary dislocation. Recurring luxations are almost always of the subcoracoid type. Recurring posterior dislocations are usually not as painful and may be of the snapping variety. Whatever the type, the dislocating force is usually mild and reduction is easy in comparison to reducing primary dislocations. As with primary dislocations, the pain may be severe and unrelieved until reduction is made. After reduction, symptoms disappear in 1 or 2 days whereupon progressive strengthening exercises can be initiated. Prolonged immobilization is ill-advised. In some cases of a permanently loose joint, surgical fixation may be the only solution, and this is an orthopedic decision.

Young patients suffering glenoid-rim fracture or a labrum glenoidale tear often retain a residual capsule weakness (Hill- Sach's deformity) and abnormally wide range of motion encouraging recurrent glenohumeral dislocation. The recurrent luxation is almost always subcoracoid, but snapping posterior displacements are sometimes found.

Clinical Features.   The clinical picture exhibits classic but mild symptoms and signs of dislocation. These features disappear in 1-3 days after reduction. Alone with standard examining procedures, an empiric analysis might include checking alarm points, visceral Valleix areas of the foot, Chapman's points, and potential contributing trigger points.

Lax Capsule Test.   To determine a lax capsule, have the patient clasp his fingers behind his head and laterally abduct his elbows. Palpate high in the axilla over the glenohumeral capsule while applying posterior force on the patient's flexed elbow. While laxity of the anterior capsule can always be demonstrated by this maneuver, special care must be taken not to dislocate the humerus within its loose capsule.

Management.   Replacement of a recurrent dislocation is usually simple to perform and frequently painless. Many patients learn to achieve this themselves. Thus, the major problem is not the corrective adjustment as much as it is strengthening the holding elements to inhibit recurrence. Contributing spinal majors will likely be found at the C5-T1 area. Fixations found in the shoulder girdle or involved upper extremity should be mobilized. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep low-velocity percussion spondylotherapy over segments C7-T4 for 1-2 minutes to enhance circulation and nerve tone.

Supplemental nutrients C, B6, manganese, potassium, and zinc are recommended. The patient should be counseled to avoid appropriate antivitamin and antimineral factors. Other helpful forms of treatment include alternating current for passive exercise, ultrasound for heat and massage at the cellular level, hot needle-spray showers, interferential therapy, iontophoresis with zinc, or local vibration-percussion. Taping or casting is necessary in the early stage to rest the joint and enhance healing. After the acute stage, the attending physician should demonstrate and prescribe progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.

Injuries of the Lateral Clavicle

Distal Trapezius Contusion.   The tip of the shoulder, near the lateral aspect of the clavicle, is a common site of extremely painful and tender contusions to the trapezius.

Clinical Features.   Localized swelling is easily seen and palpable. The patient will depress the entire shoulder girdle in an attempt for relief. Caution must be taken to not confuse this contusion with acromioclavicular separation.

Management.   Treatment consists of cold packs and an arm sling for 24 hours, followed by moist heat, passive manipulation, and progressive active exercises. Attending cervical, upper dorsal, or shoulder girdle subluxations and muscle spasms should be corrected. Normal activity can usually be achieved in a few days.

Anterosuperior Lateral Clavicular Subluxation

Clinical Features.   With anterosuperior lateral clavicle fixated displacement within the normal range of motion, the patient will complain of an ache within the joint, tenderness at the lateral end of the clavicle, and loss of some arm function. A partial ligament tear will be demonstrated by looseness of the joint during Schultz's test. The subluxation can be detected by bilateral palpation of the lateral end of the clavicle for the characteristic "step down."

Bilateral comparison is necessary because some people normally have enlarged clavicle ends laterally which can be mistaken for subluxated clavicles. When subluxated, the clavicle tends to move superior and anterior. The integrity of the clavicular division of the pectoralis major, anterior and middle deltoid, subclavius, and upper trapezius should be checked. In older cases, a degree of fixation will inevitably be present that can be determined by placing two finger pads on the acromioclavicular joint and circumducting the patient's abducted arm.

Adjustment.   The patient is placed on a low stool with the palm of his hand on the involved side on the back of his neck. Stand behind the patient and place the web of your medial contact hand on the patient's lateral clavicle. Stabilize the patient's elbow with your lateral hand, and apply as much traction as possible. Apply pressure inferiorly with your contact hand. Then, make a short thrust inferior and posterior while simultaneously elevating the patient's elbow superior and medial with your stabilizing hand. Conclude by maintaining contact pressure and gently circumducting the abducted humerus.

Alternative Technic.   The doctor-patient position is the same as above, and the doctor's contact is the same. The patient's arm is abducted, his elbow is flexed, and his hand points somewhat inferior and medial toward the floor. Rather than stabilizing the patient's elbow, place your stabilizing forearm under the patient's abducted elbow and grasp the dorsal surface of his wrist. Apply pressure inferiorly on your contact hand. Then, make a short thrust inferiorly and posteriorly while simultaneously elevating the patient's elbow superiorly and medially with your stabilizing forearm.

Postadjustment Management.   The treatment formula is similar to that for sternoclavicular subluxation. Following adjustment, tape should be applied to force the humerus up tightly in the socket to relieve gravitational pull on the tendons and ligaments. The strapping procedure is identical to that for separation. If taping offers good support, a simple arm sling is necessary for only 3-4 days. The strapping should remain for 10-14 days. Frequent mild mobilization between tapings is necessary to avoid adhesion development during healing.

Acromioclavicular Sprain

The acromioclavicular joint is one of the weakest joints of the body, but it is assisted by the strong coracoclavicular ligament. The ends of the joint are bound loosely so the scapula can raise the glenoid fossa. Those who expose the joint to excessive and repeated trauma risk contusion, sprain, and separation. Posttraumatic arthritis is a typical consequence.

Any force tending to spring the clavicle from its attachments to the scapula will cause severe sprain to the acromioclavicular, coronoid, and trapezoid ligaments unless the clavicle fractures beforehand. Keep in mind that the acromioclavicular ligament can be considered a part of the acromioclavicular joint's capsule, thus sprain must involve a degree of capsule tear.

Injury Mechanisms.   During shoulder injury, the scapula often rotates around the coracoid, which acts as a fulcrum. The intrinsically weak superior and inferior acromioclavicular ligaments give way and the joint dislocates. In other instances, a downward force of great intensity lowers the clavicle onto the 1st rib, which acts as a fulcrum, tearing the acromioclavicular and coracoacromial ligaments. The result is complete acromioclavicular separation. Continued force can fracture the clavicle. Incomplete luxation can tear the intra-articular meniscus and lead to degenerative arthritis of the joint.

Clinical Features.   Signs in minor sprain are minimal local swelling and tenderness, moderate pain on motion, and no signs of diminished joint mobility. This is a simple reactive synovitis that responds well to cold packs, shoulder-cap strapping, and arm sling for 24 hours, followed by passive manipulation and progressive exercises (1-2 weeks). In any acute separation, the most significant sign is that of demonstrable and significant false motion of the acromioclavicular joint because of joint laxity. If examination (with patient sitting) can be made before swelling develops, evaluation can be made by pivoting the joint after the scapula has been stabilized by the nonpalpating hand. The swollen joint may give a false impression of a tender but stable joint.

Major sprain consists of a degree of severe stretching and tearing of the tough coracoclavicular ligaments. Carefully palpate for evidence of conoid or trapezoid tears. Acute tenderness and probable swelling will be found in the area of the coracoclavicular ligament below the clavicle. There is distinct abnormal mobility of the clavicle relative to the acromion process. After a week or more, a subcutaneous discoloration appears. An aftermath of an old injury may be exhibited by laxity of the acromioclavicular joint without localized tenderness.

Schultz's Test.   Standing behind the sitting patient with acromioclavicular separation, face the affected side. Place one hand under the flexed elbow and push up while the other hand, which is placed over the acromioclavicular joint, applies firm pressure. The more "give" that is felt in the joint, the greater the separation.

Sprain can be graded as follows:

Grade I Injury:   This sprain is with some tearing but no subluxation or step-off. The joint is intact, but quite tender. The patient will complain of discomfort upon raising the arm and rotating the shoulder. There is point tenderness over the acromioclavicular area but not over the coracoclavicular area. Swelling is mild. Physical findings are often more reliable than x-ray films in Grade I separations to demonstrate laxity, even if weights are held. The joint should be immobilized and activity restricted until symptoms subside and abduction can be made without pain.

Grade II Injury:   The coracoclavicular ligaments are at least partially intact. There are signs of subluxation and a slight step-off. Symptoms and disability are more severe than Grade I. The shoulder may droop. The elevated lateral clavicle will exhibit a visible and palpable knob. The weight of the dangling arm may intensify pain. Immobilization is required for 3 weeks and strenuous activity restricted for another 3 weeks. Subluxation and joint widening may be confirmed by stress roentgenography.

Grade III Injury:   Complete dislocation and coracoclavicular ligament rupture. The joint capsule is disrupted. The above mentioned symptoms and signs are greatly exaggerated. The skin appears tent-like at the lateral clavicle. Step-off is significant. Open or closed surgical care is inevitably required.

Management.   As injury varies from slight laxity to complete disruption of all ligaments where the distal clavicle projects upward at a wide angle, treatment must be varied accordingly. A recent displacement can be reduced simply by applying downward pressure to the clavicle while the elbow is carefully lifted. Before strapping, a 3" x 4" piece of foam rubber should be placed over the articulation, secured by cross strips. Overlapping 1-1/2" tape is applied horizontally with front to back tension, starting below the neck and working to well below the shoulder cap. A simple sling should be used for added support for several days. A more secure method is a modified Velpeau bandage. Immobilization is required for 10-20 days, depending on the severity of injury. Treat as any severe sprain.

Major sprain requires careful strapping (eg, a modified Velpeau bandage) with a downward pull on the clavicle and an upward pull on the elbow to assure immobilization for 3-6 weeks, followed by a period of intensive rehabilitation. Supplementation with 140 mg of manganese glycerophosphate six times daily is helpful in most any ligamentous injury. Exercises of the shoulder should give particular attention to the pectoralis major and deltoid. Surgical fixation may be required in gross displacements.

Chronic Cases.   Signs of posttraumatic arthritis may appear such as pain over the shoulder region with little or no radiation to the arm, tenderness over the acromioclavicular joint, and pain-free movement until the scapula begins to move. Shrugging the shoulders usually elicits pain.

Acromioclavicular Dislocation

Clavicle dislocations are not as common as fractures. They are most often seen in football, soccer, horse racing, bicycling, gymnastics, wrestling, and unusual accidents at work or in the home. Analysis of complications should be made by roentgenography before planning reduction.

Signs and Symptoms.   In injuries to the lateral clavicle, the bone is elevated to increase the distance between the clavicle and the coracoid process. Thus, a distinct palpable and visible "step" will be noted in the supraspinatus region. If the prominent lateral clavicle is depressed, it will spring back to its elevated position once pressure is released. The scapula falls away from the clavicle, and the acromion lies below and anterior to the clavicle. Fracture of the coracoid process is often associated.

Roentgenography.   Dalinka states that an increase of the coracoclavicular distance by 5 mm or greater than 50% of the contralateral side indicates a true acromioclavicular dislocation. Complete dislocation cannot occur unless the conoid and trapezoid ligaments are severely torn. The soft tissues in the area frequently ossify after injury. After chronic injury, signs of erosion or tapering may be observed along with indications of soft-tissue calcification subsequent to old hematoma.

Management.   Early treatment is necessary to avoid a fixated step deformity. This is true even with severe subluxations. Reduction is usually not difficult, but maintenance is. Recurrent displacement is common. Ice packs should be applied for 24 hours minimum. Proper strapping assures that the shoulder is elevated while the acromion is depressed. The typical procedure is to use a webbing harness or a modified Velpeau bandage for 6-7 weeks. Another method is to pass nonstretch strapping over the clavicle, down the anterior upper arm and under the elbow, and then upward behind to cross the clavicle again. A simple wrist sling is also necessary. Felt pads should be used under the strapping to protect bony prominences. To avoid a large joint knob, a plaster cast is preferred. In most cases of pure dislocation with ruptured ligaments (extremely painful), orthopedic reduction and surgical coracoclavicular fixation may be necessary.

Fractures of the Clavicle

When the tip of the clavicle fractures, broken ends sometimes can be felt under the skin. The involved shoulder may be lower than the other. The patient is unable to raise the involved arm above shoulder level and usually supports the elbow of the involved side with the opposite hand.

Background.   The most common site of clavicle fracture is near the midpoint, but both ends also deserve careful evaluation. In midshaft fracture, there is sometimes inferior, anterior, and medial displacement of the lateral section. Fractures of the inner third are uncommon and often represent an epiphyseal injury as the medial clavicular epiphysis doesn't close until about the age of 25 years. Most fractures (66%) of the outer third of the clavicle present intact ligaments with no significant displacement. About a third of outer-third fractures present detached ligaments medially and attached ligaments distally, with displacement inferior and medial on the trapezius muscle. Early active shoulder movements should be encouraged.

If this injury is due to a fall on an outstretched hand, the impact is transferred from the palm to the carpals, to the radius and ulnar, to the elbow and humerus, to the scapula and clavicle, and to the spine and thoracic cage. Thus, all structures involved in the line of impact deserve careful evaluation -not just the immediate area of obvious fracture.

Roentgenography.   Contralateral x-ray views are almost mandatory, and it frequently helps to have the subject hold a weight (10-15 lb) in each hand. Quite frequently an angled view is necessary to show evidence of displacement because overlapping fragments may be hidden in the A-P view.

Note:   The patient's complaint should not direct a cursory examination. The author has seen a half dozen cases of complete breaks without displacement in young boys (10-14 years) whose only complaint was "It hurts when I raise my arm." Pain was absent at rest when the limb was supported.

Management.   Support should be provided by padded rings that support the shoulder posteriorly or Figure-8 strapping can be used. Immobilization is usually necessary for 20-30 days before abduction can be made without pain on normal stress. In uncomplicated "green stick" fractures, a simple arm sling with thorax stabilization may be all that is necessary. Mild shoulder motions are advised from the onset. To avoid a large callus formation for cosmetic purposes, a plaster cuirass is applied after reduction, and 2 weeks of supine bed confinement against a high pillow between the shoulders is commonly recommended. Most clavicular fractures heal quickly, and complications infrequently include supraclavicular nerve or subclavian vessel injuries that are rarely a problem. Nonunion is rare. Healing should be confirmed by roentgenography.

Most shoulder injuries are not single-entity injuries. They consist of a variety of contusions, strains, sprains, and subluxations. Dislocations, spontaneously reduced dislocations, and fractures also complicate the picture. Thus, any painful shoulder syndrome requires careful differentiation. The shoulder is at the forefront among high-incidence athletic injuries. Tears of the rotator cuff are usually without humeral displacement and are common in a large number of sports. Most are the result of throwing injuries, falls on the shoulder point, and vertical forces directed along the humerus. Careful evaluation of related soft tissues is necessary.

Subclavian and axillary vessel injury may be the result of direct trauma or a violent shoulder movement. Rarely, just muscular hypertrophy may produce venous insufficiency or thrombosis. Brachial plexus and coracoid injuries are sometimes seen in recoil injuries such as in rifle sports. Epiphyseal injuries of the proximal humerus are rare, heal well, and are usually treated closed.

Abduction is quite painful against resistance in tendinitis. Tendon inflammation is not as common in the shoulder as it is in the elbow and wrist. However, because tendons are relatively avascular, they are subject to chronic trauma, microtears, slow repair, and aging degeneration in the shoulder. Overuse is the common cause, both within and outside sports. The initial inflammatory reparative process is often associated with the deposition of calcium salts invading an overlying bursa.


Roentgenography

The margins of the glenohumeral joint are normally parallel arcs. The cartilage space should be clear and uniform. But every image in a film must be evaluated. Not to do so may miss a lung or diaphragm lesion referring pain to the shoulder and invite malpractice. Evaluation must include rib, thoracic outlet, and pulmonary abnormalities in addition to osseous and soft-tissue structures related to a specific injury.


Throwing Injuries

Throwing includes an initial smooth sequence of shoulder elevation, abduction, and external rotation of the upper arm that quickly leads to a sudden forceful forward flexion, anterior abduction, and internal rotation of the shoulder associated with elbow, wrist, and finger extension.


Swimming Injuries

Shoulder pain is a common complaint in swimmers, especially after freestyle and butterfly strokes and during underwater pushoffs. The clinical picture is one of pain and discomfort after activity, tenderness over the supraspinatus or biceps tendon, and a painful arc (often restricted) of shoulder motion. In athletics, shoulder subluxation is most common in backstrokers.


Diffuse Shoulder Overstress

The features of general sprain of the shoulder are diffuse pain, tenderness on pressure, and, infrequently, swelling. Passive motion is somewhat painful; active motion induces sharp pain. Differentiation must be made from rupture of the supraspinatus tendon, subdeltoid bursitis, fracture, and inflammation of other bursae about the shoulder.

Management.   During the acute hyperemic stage, cold, compression, strapping, positive galvanism, ultrasound, and rest are commonly recommended. Prolonged immobilization may be required if effusion and swelling persist. Some authorities report that an application of hyaluronidase is helpful to reduce tissue swelling and edema, especially if it is "driven in" with iontophoresis or phonophoresis. After 48 - 72 hours, passive congestion may be relieved by contrast baths, interferential therapy, gentle passive manipulation, sinusoidal stimulation, galvanism, ultrasound, or light massage. A shoulder and/or cervical subluxation/fixation may be associated. A mild range of motion exercise can be initiated to reduce fibrosis.

Vitamin C and 140 mg of manganese glycerophosphate six times daily are reported helpful throughout care. During the consolidation stage, local moderate heat, moderate active exercise, moderate range of motion manipulation, and ultrasound have shown to be beneficial. In the stage of fibroblastic activity, deep heat, deep massage, vigorous active exercise, negative galvanism, ultrasound, and passive joint manipulation seem to speed recovery and inhibit postinjury effects.

Regional Sprains

Overtreating an upper humeral sprain or fracture is a common pitfall according to some orthopedic authorities.

Clinical Features.   The symptoms of shoulder sprain are pain, tenderness on pressure, and, rarely, swelling. Passive motion is comparatively painless, but active motion induces severe pain. Differentiation must always be made from rupture of the supraspinatus tendon, subdeltoid bursitis, fracture, and inflammation of other bursae about the shoulder.

Management.   During the acute hyperemic stage, structural alignment, cold, compression, strapping, positive galvanism, ultrasound, and rest are indicated. An application of hyaluronidase is helpful to reduce tissue swelling and edema, especially if used in iontophoresis or phonophoresis. After 48 hours, passive congestion may be managed by contrast baths, light massage, gentle passive manipulation, sinusoidal stimulation, ultrasound, and a mild range of motion exercise initiated. Immobilization may be required if effusion and swelling persist.

Vitamin C and a manganese formula may prove helpful throughout care. During the stage of consolidation, local moderate heat, moderate active exercise, moderate range of motion manipulation, and ultrasound are beneficial. In the stage of fibroblastic activity, deep heat, deep massage, vigorous active exercise, negative galvanism, ultrasound, and passive joint manipulation speed recovery and inhibit postinjury effects.

Posttraumatic Trigger Points

The source of many pains in the upper arm or at the front of the shoulder will be found at the insertion of the infraspinatus muscle at the scapula. In other cases, a localized trigger point may be found in the anterior deltoid with pain referred to the subdeltoid bursa. Other common trigger-point sites in this area are found near the lesser tuberosity at the insertion of the subscapularis, the greater tuberosity at the insertion of the supraspinatus tendon, at the glenohumeral joint space, within the bicipital groove, at the acromioclavicular joint, or at the sternoclavicular joint. The levator scapulae, scaleni, pectoralis major and minor, sternalis, and serratus anterior are less common sites.


Shoulder Pointer

Shoulder "pointer" is sports jargon for a contusion from a blow from above striking the prominent upper-deltoid area at the tip of the shoulder. It is easily mistaken early for an acromioclavicular separation.

Clinical Features.   The trapezius medially and the deltoid laterally are simultaneously bruised between the impact force and bone. Acute disability, swelling, and extreme tenderness are exhibited in the trapezius and/or deltoid. The acromioclavicular joint is not lax, nor is tenderness found in the area of the trapezoid, coracoclavicular, or conoid ligaments.

Management.   Initial treatment is by cold packs, shoulder-cap strapping, and a sling for support for 48 hours. For the next 3-4 days, moist heat, passive manipulation, and progressively active exercises should be offered. When the patient returns to work, or an athlete to competition, a protection pad should be applied for 1-3 weeks to the area to reduce potential impact forces.

Subacromial Bursitis

A painfully faltering abduction arc is characteristic of subacromial bursitis but also seen in other shoulder disorders. To differentiate, palpate the coracoid process under the pectoralis major. It is easily found by circumducting the humerus and is normally tender. Once the process is isolated, slide your finger slightly lateral and superior until it reaches a portion of the subacromial bursa. If the same palpation pressure here causes greater tenderness than at the process, it is a positive sign of subacromial bursitis. Still holding pressure, abduct the patient's arm above the horizontal. An inflamed bursa is exposed to palpation when the arm is relaxed but not when the arm is abducted beyond a right angle (Dawbarn's test).


Subdeltoid Bursitis

Of the 140 bursae of the body, none receive the attention in sports as much as the subdeltoid bursa. Anterior, middle, or posterior deltoid strain can easily be associated with acute subdeltoid bursitis, but the clinical picture is quite different. Degenerative changes in the rotator cuff (floor of the subdeltoid bursa) lead to calcific deposits resulting in acute inflammation of the bursa. When a calcium deposit breaks into a bursa, it absorbs water, which enlarges the bursal space, resulting in increased pressure. This causes severe pain and some warmth and redness of the overlying skin.

Clinical Features.   The patient presents with acute, severe, deep-seated local pain and weakness with shoulder movement in any plane but especially on abduction. The entire bursa and peritendinous tissues will be swollen and readily palpable. This swelling prevents the greater tuberosity from sliding under the acromion during abduction. Dysfunction of the rotator, bicipital, and subscapularis tendons (which pass through the bursa) exists. The initial attacks are localized in the vicinity of the greater tubercle. The chronic stage is characterized by subdeltoid tenderness, restricted motion in abduction and external rotation, and associated capsular contraction and adhesions. Keep in mind that bursitis is rarely a primary condition.

Management.   A common pitfall is overtreatment of bursitis. When acute, treat with cold, pressure, and rest in an arm sling for 2-3 days. In severe cases where strapping is necessary, apply the direction of pull in the direction that affords the greatest relief to the bursa involved. When symptoms subside, a very gradual program of active exercise, traction, positive galvanism, and diathermy can usually begin in 4-7 days with careful monitoring. Most cases will respond well to ultrasound, swimming, vitamins C and E, manganese glycerophosphate, and acid calcium to diffuse the calcareous deposit.

For an unknown reason, it is common to find an ipsilateral sacroiliac subluxation. Also associated, as can be expected, is a subluxation complex in the C2-C5 area. A good stretching and mobilization exercise is to have the patient flex the trunk and swing the arm anterior and posterior holding an iron or weight for three or four bouts daily. Reduce activity on the first signs of recurring local symptoms. Referral for aspiration and steroids may be necessary in stubborn cases, but the results of immediate injections in acute injuries are not as good as that of more conservative care.

Supraspinatus Calcification

An example of calcification in tendons is commonly found in the supraspinatus tendon near its insertion to the greater tuberosity of the humerus. In the well-developed patient, symptoms from calcification may not appear for many months after injury. Deposits may appear in shoulder tendons, ligaments, or aponeuroses, and especially within the rotator cuff. They may be chronic, silent, or extremely acute. Spontaneous absorption may occur relatively fast.

Clinical Features.   Symptoms appear suddenly. Pain is usually severe and aggravated by shoulder movement, but the pain is less severe and movements are more tolerated than in supraspinatus tendinitis. Tenderness is localized over the bursa. A painful arc syndrome may be noted, similar to that seen in supraspinatus tendinitis. Calcification is viewed on film as a large dense opacity above the outer head of the humerus and most frequently related to middle age with no definite history of trauma. It's occasionally seen in the young athlete. Associated bursitis may arise and be responsible for acute symptoms.

Management.   Therapy usually includes iontophoresis. Ionization is also frequently helpful with a cloth soaked with magnesium sulfate (4 oz/qt of water) over the deposit. The negative pad is on the cloth over the deposit; the positive pad is placed on the arm. Once pain subsides, ultrasound should follow for a few visits.

Traumatic Arthritis

True osteoarthritis of the shoulder is infrequently seen. When arthritic symptoms are presented, the case is more often a periarthritis in which soft-tissue degenerative changes have occurred. The typical clinical picture is one of pain, tenderness on pressure, and rarely some swelling. As in diffuse shoulder overstress, passive motion is almost painless but active motion induces severe pain. Differentiation must be made from diffuse strain/sprain, subdeltoid bursitis, supraspinatus rupture, and subacromial bursitis.

Management.   When effusion and swelling are overt, cold and immobilization are advised. The lower cervical area and shoulder girdle should be checked for chronic subluxation- fixations and trigger points. In mild-moderate cases, heat, interferential therapy, ultrasound, or transverse friction massage may be efficient adjuncts.

Capsulitis and Adhesions

Shoulder capsulitis is frequently the effect of a sprain attended by a strain (eg prolonged exercise) or a spontaneously reduced dislocation or severe subluxation. Tenderness and other symptoms are generalized in the whole joint area rather than being localized. The pain is aggravated by movement. The recognition of capsular and noncapsular patterns is a great aid in differentiating various shoulder disorders. When capsule adhesions exist, the primary physical signs are (1) full-range medial rotation that is not painful, (2) full-range elevation that is painful, and (3) limited lateral rotation that is painful.

Adhesive Capsulitis and Periarthritis of the Shoulder.   Shoulder motion limitation may be considerable in adhesive capsulitis where the head of the humerus is "glued" to the glenoid cavity. The pain arises immediately as the capsule begins to stretch during range of motion evaluation. There is a firm, if not hard, end feel. In contrast, such a hard end feel is not associated with chronic bursitis, tendinitis, or acromioclavicular joint lesions.

Periarthritis of the shoulder (frozen shoulder, Duplay's syndrome) is often a therapeutic challenge because it is usually near the terminal stage when the patient is first seen. A combination of several chronic, diffuse, degenerative shoulder disorders is usually involved. The most significant feature is the loss of scapulohumeral rhythm, which is readily noted when viewed at the back of the standing patient.

Progression from Acute Adhesive Capsulitis to Chronic Periarthritis.   Humeral motion restriction exhibits in all planes in periarthritis, but adduction and internal rotation are especially involved. Scapulothoracic motion, however, will be normal in the first stage (that of adhesive capsulitis). Area atrophy is readily noted and proportionate to the chronicity of the condition. Tenderness is diffuse throughout the upper arm with the possible exception of posterior and medial aspects. The capsule becomes thick and contracted. This contributes to motion limitation. The rotator cuff also becomes thick and inelastic, and the bicipital tendon becomes cemented within the groove. In time, the adhesions and soft tissues thicken and become tightly fixed, binding capsule to bone.

As the joint cavity "dries," the head of the humerus is pulled tightly against the glenoid fossa. Arm use aggravates the condition, and the symptoms are then more acute at night after a day's activity. Rest offers relief, thus improvement is seen in the morning. The accessory muscles overwork in an attempt to compensate for primary shoulder muscle deficiency, causing aching posterior shoulder and neck muscles. A superiorly subluxated 1st rib or a lower cervical subluxation is often a common and important contributing factor. Roentgenography of the shoulder is usually negative except for an obliterated joint space.

Management.   Unless the instigating factor is removed (eg, subluxation/fixation), a meaningless course of treatments results with progressing deterioration. Rugged "shotgun" manipulation under anesthesia as practiced by some overly enthusiastic surgeons is strongly contraindicated. Specific conservative adjustments, fixation mobilization, progressive passive manipulation with and without traction and countertraction, graduated pendulum stretching exercises, circumduction manipulations against patient resistance, wall finger-walking exercises, and hand clasping behind the head during the late stage of management are advisable.

Sine-wave stimulation to the shoulder muscles, interferential therapy, trigger-point therapy, ultrasound, and heat provide a high percentage of relief even in severe cases. Adhesions must be released at the humerus, clavicle, and scapula in several planes if movement is restricted. As in any case of capsulitis, early care and recurrence prevention is the ideal situation. Vitamin C and calcium lactate with HCL are helpful.