Clinical Presentation Patients with an AC joint sprain will present with anterosuperior shoulder pain and will describe a traumatic event as mentioned above. Pain is usually worse with shoulder movement or when sleeping on the affected side (Kiel et al., 2022). Swelling, bruising, and/or deformity of the AC joint may be visible with inspection. Tenderness at the AC joint as well as restricted active and passive motion secondary to pain are possible (Kiel et al., 2022). A piano key sign occurs when the clavicle rests in an elevated position and it rebounds after inferior compression (Kiel et al., 2022). Sternoclavicular joint dislocations Injuries to the sternoclavicular joint are caused by high- energy injuries, including motor vehicle crashes and contact sports like football and wrestling (Pinto et al., 2018). Radiographs can miss sternoclavicular joint dislocations because of overlap of bones and soft tissue in this area (Pinto et al., 2018). Also, this injury frequently occurs with other associated injuries, which may distract the examiner from focusing on the sternoclavicular joint (Kalantar et al., 2021). Dislocations commonly occur posteriorly or anteriorly, with posterior dislocations having the potential to compress adjacent mediastinal structures such as the aorta (Kalantar et al., 2021). Anterior sternoclavicular dislocations are nine Traumatic shoulder instability Traumatic shoulder instability is typically caused by a traumatic event that causes pain, discomfort, subluxation, or dislocation (Brownson et al., 2015). Approximately 96% of shoulder dislocations have been attributed to a traumatic event, and 97% of shoulder dislocations have been anterior. Anterior dislocation usually occurs when a fall occurs on an outstretched hand. This injury is most common in competitive athletes as well as the elderly population, who experience a decline in functional mobility and balance. Special tests for shoulder instability Three special tests can be done in quick succession to assess for anterior shoulder instability. 1. Apprehension test : With the patient supine, the examiner positions the involved arm in 90 degrees of abduction, elbow in 90 degrees of flexion, and shoulder in maximal external rotation. The examiner then applies an anterior and external rotatory force. The test is positive if the patient feels a sense of impending dislocation (Cotter et al., 2018). 2. Jobe relocation test (as previously described) : If the patient’s apprehension and/or pain dissipate, this test is considered positive (Cotter et al., 2018). 3. Release test : With the patient supine, the posteriorly directed force from the Jobe relocation test is abruptly released. If the patient experiences a feeling of impending dislocation, this test is considered positive (Cotter et al., 2018). Proximal humeral epiphysitis (Little league shoulder) The proximal humerus ossifies from four ossification centers: Humeral head, greater tuberosity, lesser tuberosity, and humeral shaft. The humeral head and the tuberosity unite to form a large proximal humeral epiphysis. Throwers experience epiphysis injury via two mechanisms: Distraction and torsion (Frush & Lindenfeld, 2009). During ball release, a distracting force is created across the physis as the rotator cuff muscles contract to center the humeral head in the glenoid (Frush & Lindenfeld, 2009). Throwing also creates torsional or rotational stress at the proximal humerus during
times more common than posterior dislocations (Garcia et al., 2020). Signs and symptoms of anterior sternoclavicular joint dislocation include pain, tenderness, swelling over the sternoclavicular joint, anterior chest pain, and pain with shoulder abduction (Kalantar et al., 2021). Signs and symptoms of posterior sternoclavicular joint dislocation include depression at the sternoclavicular joint with possible hematoma, sternoclavicular joint tenderness, decreased shoulder strength and range of motion, shoulder pain radiating into the neck, and pain on swallowing/throat irritation (Kalantar et al., 2021). The risk of recurrent dislocation is inversely proportional to the age of the patient at the time of injury, with younger patients having the highest likelihood of dislocation recurrence. In addition, 40% of patients over the age of 40 years who experience a traumatic anterior glenohumeral dislocation will have a rotator cuff tear. Tears are associated with degenerative rotator cuff tendons or acute on chronic rotator cuff tears (Brownson et al., 2015). The load and shift test can be used to assess for both anterior and posterior shoulder instability. With the patient upright or supine, the shoulder is placed in either 0, 20, or 90 degrees abduction in the scapular plane with neutral rotation. The examiner grasps the humeral head, applying an axial load and anteriorly directed force (for anterior instability) or posteriorly directed force (for posterior instability) while stabilizing the scapula with the other hand. If pain is reproduced or a palpable clunk is noted with subluxation, this test is considered positive (Cotter et al., 2018). The sulcus test can be used to assess for multidirectional instability. With the patient seated with the arm relaxed in neutral rotation, the examiner grasps the arm and gently applies a downward force. The head should be assessed for inferior translation in the glenoid. Inferior translation of 2 cm or greater has been shown to be highly specific for multidirectional instability. the late cocking phase (Frush & Lindenfeld, 2009). This repetitive microtrauma to the physis can lead to a local inflammatory reaction or a fatigue fracture. This injury is typically seen around age 13. Patients describe pain in the proximal humerus while throwing and with resisted shoulder strength testing. Differential diagnosis in adolescent throwing athletes includes glenohumeral instability, rotator cuff tendinopathy, impingement, and proximal humerus physeal fractures (Frush and Lindenfeld, 2009).
EliteLearning.com/Physical-Therapy
Page 25
Powered by FlippingBook