Scapular fractures
MOI: high energy trauma
Physio:
- No further harm to fracture site
- Maintaining integrity of musculoskeletal, circulatory and respiratory systems
- Facilitating safe and independent return to function
- Sling (non-operative) and early PROM’s to prevent stiffness
5 Stage
- Haematoma formation and tissue destruction
- Inflammation and cellular proliferation
- Callus (woven bone) formation
- Consolidation
- Remodelling
Snapping scapula syndrome
Loud pop/snap, grating, grinding, crepitus when the scapula cannot move smoothly over the rib cage during elevation
Two infra-serratus bursa can become enlarged, inflamed and then fibrotic
Causes:
- Scapula dyskinesis
- Muscle strength/length deficits
- Infra-serratus bursitis
- Osteochondroma
- Trauma - rib or scapula fractures
- Neural paralysis (long thoracic)
Treatment:
- Strengthening of serratus anterior and lower traps
- Stretching of external rotators
- Ice for inflamed bursa
Scapular dyskinesis
- Lack of ability to achieve and maintain scapula resting position
- Loss of ability to control/achieve: 60 degrees upward scapula rotation, external rotation on downward movement, retraction of the scapula
Results in alteration of:
- Glenoid position, acromion and muscle length and strength
Causes (can be a combination):
- Weakness of LT and/or SA
- Fatigue or associated inhibition of LT and SA
- Pec minor tightness
- Delayed upper trapezius activation/overactive upper traps
- Proximal nerve injury (e.g. long thoracic nerve injury)
- Bony thoracic spine kyphosis/scoliosis
- GHJ instability come from rotator cuff or labral tears
- ACJ dislocation
Consequences:
- Increased risk of glenohumeral pain (GHJ) pain
- Capsule length changes and associated microtrauma and potential laxity
- Altered muscle tension and loading
- Increased AC joint stress and tension
Treatment TREAT THE CAUSE - Strengthen LT and/or SA - Stretch out pec minor - Proprioceptive exercises for LT and/or SA - Soft tissue massage over upper traps and stretches - Treat posture - Treat rotator cuff weakness - Rehab for ACJ dislocation
SICK scapula
Scapula malposition
Inferior medial border prominence
Coracoid pain and malposition
Kinesis (movement) abnormalities of scapula
Treatment
- Scapula setting exercises
- SA strengthening
- Proprioceptive exercises
- Scapula and GHJ AROMs whilst keeping scapular position correct
- LT strengthening
Subluxations/dislocations of sternoclavicular joint
Can be due to hypermobility disorder
Surgery can be problematic
Rare condition and mainly occur anteriorly
If dislocates posterior can be life-threatening (pressure on blood vessels, trachea, oesophagus etc.)
MOI
- Can be a direct blow to medial clavicle or seat belt injuries
- Can be indirect by athlete lying on their side - uppermost shoulder compressed and rolled backwards
Signs and symptoms
- Deformity, local pain and tenderness (arm is rolled forwards
- SOB, venous congestion in neck (from posterior dislocation)
Consequences
- Instability (can be recurrent)
- Cosmetic deformity
- Chronic subluxation (damage to intra-articular disc)
- Discomfort of repetitive/strong movements of the upper limb
Sternoclavicular joint sprain degrees
1st degree
- Minor tearing of SC and CC ligaments (no true displacement
2nd degree
- Complete tear of SC, 2nd degree tear of CC + subluxation
3rd degree
- True dislocation, Third degree sprain of SC and CC ligaments
Fractured clavicle
MOI
- Fall onto tip of shoulder/direct contact with opponent
- Adult: distal third clavicle most common
- Child: distal and medial (more rare) clavicle physeal injury
Treatment is based on degree of overlap
- Conservative: figure 8 bandage + passive/active assisted ROM to 90 degrees flexion
Distal end clavicle fractures are more prone to non-union as it may involve AC and CC ligaments
AC Joint sprain
Signs and symptoms
- TOP, pain, step deformity, instability, restriction shoulder movement
MOI
- Fall onto tip of shoulder
- Direct blow to tip of shoulder
- FOOSH
Consequences
- Severe joint sprains can cause scapular dyskinesis and/or SICK scapular
Treatment varies depending on grade - Grade 1-2 = usually conservative, grades 4-6 = sometimes surgical. For grade 3 conservative is recommended first and then can progress to surgery if need be
Conservative treatment:
- Sling and POLICE initially
- Phase 1: scapular setting, keeping arm in a sling or taped when at rest, IR and ER, elevation in scaption, ROM exercises
- Phase 2: Progressing exercises with weight and in gravity unassisted positions, continuing with ROM and maintaining scapular strength (LT and SA) and position, proprioception
- Phase 3: Upper traps and deltoid dynamic drills, return to sport activities, progress to bent over rows, reverse flies with weight, strict press, cable pulls (involve kinetic chain)
AC joint grades
Type 1
- Sprain capsule
- 1 degree sprain AC lig
- Local tenderness, no deformity
Type 2
- Complete AC lig tear, partial CC lig tear
- Local tenderness, palpable step deformity
- Reduced ROM with abduction/adduction
Type 3 and 5
- Complete CC lig tear
Type 4
- Posterior displacement clavicle
Type 6
- Inferior displacement clavicle
Osteolysis distal clavicle (stress fracture)
MOI
- Overuse - weightlifters who use excessive amounts in weight in bench press (lowering weights below the midline into extension)
Signs and symptoms
- Pain
- Stiffness
- Swelling distal clavicle
- Pain with horizontal flexion
- X-ray shoes bone with moth-eaten like appearance
Treatment
- Rest from aggravating activities
- NSAIDS
- Physiotherapy (electro, muscle re-education, trigger point release)
OA of AC joint
Intimately related to OA of the GHJ
Signs and Symptoms
- Pain
- Stiffness,
- Reduced strength and ROM
- Swelling
Treatment
- NSAIDS
- Modification of ADLS
- Physio (Scapular stabilisation and strength, RC strength, ROM exercises, AC joint glides)
Long thoracic nerve palsy
C5, 6, 7 - paralysis of serratus anterior (winging medial border of scapula
Causes:
- Traction of neck
- Blunt causes
- Viral infection
Treatment
- Treat
Suprascapular nerve entrapment
Entrapment in suprascapular notch
Common in: weightlifters, overhead workers/athletes and extreme range throwers
Can cause suprascapular and/or infrascapular weakness
Burner-stinger syndrome
Traction injury of suprascapular nerve
Common in rugby - traction/compression/direct blow
Patient feels a ‘sting’ and weakness and nerve sensations around shoulder/clavicle
Axillary nerve damage
Commonly injured/associated with anterior GHJ dislocation
Quadrilateral space syndrome = compression in posterior scapular space - teres minor superiorly; teres major inferiorly; long head of triceps medially and surgical neck of Humerus
Seen in throwers and post trauma
Signs and symptoms
- Vague shoulder pain
- Numbness and tingling in the arm
- Tenderness to pressure over the area of the quadrilateral space
- Dull ache may worsen overtime with repeated overhead activities
- Weakness and instability can be noted
Thoracic Outlet Syndrome
MOI
- Stretch or compression of neurovascular bundle that transverses from cervical spine to axilla
Symptoms: Neck and shoulder pain Numbness, tingling Weakness/fatigue of arm \+ve Roos hyperabduction/external rotation test
Possible causes
- Elevated first rib; cervical spine; (extended transverse process of C7)
- Overhead sports
- Poor postures - drooping shoulders, protraction scapula
- Shortening Scalenes
Treatment:
- Correction of posture (scapula and head of humerus positioning)
- Pectoral and scalene stretching
- Soft tissue massage
- Pams of AC and SC joint
- Brachial plexus neuromobility exercises
Fractured clavicle treatment
Middle third clavicle - often much overlap dysfunction
- Conservative: figure 8 bandage
- PROM/AROM to 90 degree flexion
Distal end clavicle (effects AC and CC ligs) - more prone to non union
- Conservative: sling
- AAROM and isometric exercises
Treatment of SC joint dislocation
Early treatment: Address pain
- POLICE, rest, NSAIDS
- Gentle joint mobs (grades 1 and 2)
- Support and positioning (clavicle strap)
- Don’t typically tape
Later stage treatment
- Joint mobilisations (APs, MWM with AP/PA/rotation with active shoulder elevation) - depends on direction of deformity
- Gentle muscle massage and stretches (pectoralis, scalenes etc.)
