Upper Extremity Soft Tissue injuries

Prepared by Farrah Camille Amik, PTRP

I. Introduction
A. Soft Tissue 
 Diverse group of connective tissues (Ligaments, Tendons, Muscle, Cartilage, Fascia, Synovium, Articular Cartilage, Adipose Tissue, Intervertebral Discs)
 Function as support, transmit and distribute mechanical forces, and act as a conduit for neurovascular structures
 Composed of collagen fibers; ground substance
 Proteoglycans 
 Water
 Specialized Cellular Components
 Susceptible to failure under conditions of stress and strain
 Most common mechanisms of injury include acute trauma and repetitive overuse or overload
B. 3 Phases of Soft Tissue Healing
 Cellular Response to Injury
 Repair and Regeneration
o Immature collagen is laid down
 Scar Remodeling
o May continue for years


C. Nature and Classification of Soft Tissue Injury
 Specific to the involved structure - incl. injury response
 Ligament Sprains
o Grade I
 Negligible loss of structural integrity
 Minimal signs of inflammation
 Generally recover quickly and completely
o Grade II
 Partial rupture of ligaments
 Significant Pain and Inflammation
 Functional recovery generally occurs within 4 to 6 weeks - with pain often experienced for months after injury
 Tensile strength of involved structure is reduced to 50%
o Grade III
 Prolonged healing time
 Chronic Instability
 Susceptibility to recurrent sprains
 Impaired proprioception
 Tendon Injuries
o Tensile overload and repetitive overuse
o Vulnerable to failure when:
 tension is applied quickly or obliquely
 tendon is tense before trauma
 attached muscle is maximally innervated
 muscle group is stretched by external stimuli
 tendon is weak in comparison to its muscle

o
 Muscular Injuries
o Classified as:
 Contusions 
 Result as a direct blow
 graded as mild, moderate, severe
 Susceptible to developing Myositis Ossificans
  Strains
 result from overstretching or peak contraction - eccentric
 occur more commonly at the musculotendinous junction
 Avulsions 
 DOMS
 occurs within the first 24 to 48 hours after an intense bout of exercise
 Self-limiting
 Requires activity modification or anti-inflammatory medications
II. Soft Tissue Injuries of the Shoulder
- 2 Factors make the shoulder joint susceptible to soft tissue injuries:
1. Surrounding soft tissue -> main support system for UE
2. Small glenoid fossa -> large range of motion -> excessive mobility
A. Anatomy of the Shoulder
 Joints
o Anatomic/Structural
 Acromioclavicular
 OPP: Arm at side
 CPP: 90 deg abduction
 CP: Extreme motion – H. Adduction & Full Elevation
 Sternoclavicular
 OPP: Arm at side
 CPP: Full Elevation
 CP: Extreme motion - H. Adduction & Full Elevation
 Glenohumeral
 OPP: 55 deg abduction, 30 deg H adduction (scaption)
 CPP: Full abduction & ER
 CP: ER, Ab, IR
 Labrum
o Functional
 Scapulothoracic
 Suprahumeral

 Capsule
o Divided into 3 functional bands:
 SGHL
 MGHL
 IGHL
 Ligaments
o CHL – Coracoid -> G. & L. Tuberosities
o CA
o AC Ligament
o CC
 Conoid
 Trapezoid
B. Kinesiology of the Shoulder
 2:1 ratio of movement – GH = 120 deg; Scapular Rotation = 60 deg
 Deltoid initiates abd, SITS holds humeral head creating torque for rotation
 Scapula rotated upward
C. Disorders of the Shoulder
 Contusions and Myositis
 blunt trauma to the soft tissue
 divided into intermuscular and intramuscular
o Intramuscular lesions
 take longer to resolve – confined
 High incidence of compartment syndrome (rare) and myositis ossificans
 If compartment syndrome is suspected, release and drainage are critical to prevent long-term injury
 Myositis ossificans
- Invasion of calcium and bony islands within the muscle
- Erythema, swelling, and significant amount of pain.
- Radiographs early in the process may not reveal the ossification
 Instability
 Glenohumeral Sublaxation & Dislocation
o 95% occur in the anterior-inferior direction
o Anterior>Inferior
o MOI: Baseball player-pitcher position (late-cocking)
o Anterior-Inferior occurs when an abducted UE is forcefully rotated -> tearing of IGHL / ant. Capsule / glenoid labrum
o Posterior Dislocations are rare and occur with multi-directional laxity of the GH joint
o Assessment:
- MMT
- ROM
- Diagnostic Imaging:
 Plain film imaging
 CT scan
 MRI
- Special Tests:
 Anterior Apprehension Test and Relocation Tests
 Posterior Apprehension Test
 Sulcus Sign
 Crank Test
o Treatment:
 Strengthening of add, IR (Supraspinatus & Subscapularis)
 FES: bipolar tech on supraspinatus and deltoid
o PT Goals:
 Joint mob. To specific restrictions
 Strengthening/ endurance/ coordination exercises to regain dynamic GH stabilization and mm reeducation
o Post-Surgical Repair:
SHOULD AVOID:
  flexion and horizontal adduction to 90 deg. or greater; and ER to 80 deg
 Activities or sports that will induce dilocation
o Complications:
 Axillary Nerve Injury
 Compression Fx of the Humeral head & post. Labrum (Hill Sach’s Lesion)
 Tearing of superior glenoid labrum from posterior to anterior (SLAP Lesion)
 Avulsion of ant-inf capsule and ligaments associated c glenoid rim

 AC Joint Sprain
 MOI: FOOSH with UE adducted or direct blow to shoulder
 Pain and increased joint mobility - on crossed adduction and in end range abduction
 Diagnosis: x-ray with a weighted view
 Grade for AC Jt Strain and Sepparation
o Grade 1 - pain at the jt, intact ligaments, no subluxation
o Grade 2 - movement of the joint related to a tear in the AC ligament but not in the CC ligaments
o Grade 3 - Tear through both AC and CC
o Grade 4 - posterior displacement of clavicle
o Grade 5 - Superior displacement of clavicle
o Grade 6 - Anterior displacement of clavicle, c entrapment of distal clavicle
 Assessment:
o ST: Shear Test
 Treatment:
o grades 1 to 3 are treated conservatively, whereas grades 4 to 6 require reconstruction
o grade 1 separation include ice, sling and swath in neutral position, or resting of the arm for a short period of time
o Progressed ROME
o Strengthening of supporting mms
o Loading of joint is avoided
 Bicipital Tendinitis
 Inflammation of the longhead of biceps
 Mechanical impingement of the proximal tendon between the anterior acromion and bicipital groove
 Common; usually associated with overhead activities
 The tendon is swollen, stenotic at the transverse ligament, and frequently hemorrhagic
 Possible adhesion development
 If the transverse ligament is lax or ruptured, the biceps tendon can subluxate – snapping sensation when palpated
 Special Tests: Yergasson vs Speed’s
 Bursitis
 The subdeltoid & subacromial bursae (which may be continuous) have a close relationship with rotator cuff tendons -> susceptible to
overuse
 Impinge beneath the subacromial arch
 Painful and significantly limits abduction
 Tx: Lidocaine and Crystalline Steroid
 Impingement
 Soft tissue inflammation of the shoulder (Tuberosities of the humerus) against the acromion with repetitive overhead AROM (Abd & ER
position to IR & flexed position)
 common in throwing sports and swimmers
 usually associated with a painful arc (60 – 120 deg)
 ST:
o Hawkin’s Maneuver
o Neer’s Sign
o Drop Arm Test
 3 Stages of Impingement by NEER
o 1st Stage – Noted Edema and hemorrhage along the supraspinatus tendon
o 2nd Stage - fibrosis, thickening of the coracoacromial ligament, and bony changes of the acromion
o 3rd Stage – Seen in people older than 40; s associated with partial or complete cuff tears
 PT Goals:
o Joint mobilization to the specific restrictions to correct biomechanical faults
o Strengthening, coordination, flexibility & endurance exercises to correct muscle imbalances
 Internal (posterior) Impingement
 An irritation between the Rotator Cuff and greater tuberosity or posterior glenoid and labrum
 Seen in athletes performing overhead activities
 PAIN – commonly noted in posterior shoulder
 Rotator Cuff Tendinitis
 Tendons of the rotator cuff are susceptible to tendinitis due to poor blood supply near the insertion of the muscles
 Due to the mechanical impingement of the rotator cuff on the anterior acromion and/or coracoacromial ligament with repetitive overhead
injuries
 Diagnostics:
o MRI
 ST:
o Empty Can Test
o Neer Impingement Test

 Rotator Cuff Tears

 Traumatic
o older people are more susceptible because of underlying degeneration
 Degenerative
o Area in the cuff with less vascularization
o Cuff thins and becomes frayed
 Diagnostics:
o ultrasound, arthrography, and MRI
 Clinical Manifestations:
o pain at the site along the tuberosity
o night pain
o exacerbation of the symptoms with lying on that shoulder at night
o pain along the lateral aspect of the arm toward the insertion of the deltoid
o pain with overhead activities
o Painful arc
 o Significant weakness – full thickness
o Mild or no weakness – Partial Tears
 ST:
o Drop Arm Test
 Labral Tears
 a history of trauma or falling on an outstretched arm
 Pain in the anterior shoulder, clicking sometimesnoted with abduction & ER
 ST:
o Clunk Test
o Obrien’s Test
 Diagnostics:
o MRI- superior labrum anterior posterior lesion (SLAP)
 Adhesive Capsulitis 
 Restriction in Shoulder motion d/t inflammation and fibrosis of the Sh capsule secondary to disuse following injury or repetitive microtrauma
 can be either idiopathic or associated with internal derangement
 Commonly seen in association with DM
 Capsular Pattern: ER>Ab>IR
 Stages of Adhesive Capsulitis
o Stage 1 – “Pre-Freezing”
 Gradual onset of pain
 Increases c movement
 Present during the day and at night
 Loss of external rotation motion
 intact rotator cuff strength
 Less than 3 months duration
o Stage 2 – “Freezing”
 persistent and more intense pain even at rest
 Motion is limited in all directions
 3-9 months
o Stage 3 – “Frozen Stage”
 pain only with movement
 significant adhesions
 limited GH motions with substitute motions in the scapula
 Atrophy of the deltoid, rotator cuff, biceps, and triceps
 9-15 months
o Stage 4 – “Thawing Stage”
 Minimal pain and no synovitis
 Significant capsular restrictions
 Motion may gradually improve in this stage
 15-24 months
 spontaneous recovery occurs, on average, 2 years from onset
 PT Goals:
o Strengthening/coordination/flexibility & endurance exercises to correct mm imbalances
o Joint mob. to the specific restrictions to correct biomechanical imbalances
 ST:
o Appley’s Scratch Test
o Lift Off Sign
 PT Mx:
o Codman’s or pendulum exercises (Sperry’s c weights; Chandler’s in prone position) (0-60 deg)
o Finger Ladder (60 – 90 deg)
o Shoulder wheel (90 – 180 deg)
 Sprengel’s Deformity
 Congenitally high or undescended scapula
 MC congenital deformity of the shoulder complex
 Scapular mms are poorly developed or are replaced by a fibrous band
 Can be unilateral or bilateral
 Shoulder abd ROM decreases
 Scapula is smaller than normal and is medially rotated

 NEUROVASCULAR COMPROMISE
 Plexus Injury
o Result of traction-type injuries
o Sports-related – neuropraxic c good prognosis (Burner’s / Stinger’s) usually affecting the upper part of the plexus
o Avulsion-type injuries are usually traumatic and require significant force -> poor prognosis
 Erb-duchenne Palsy
o Upper lesions of the brachial plexus(C5-C6)
o Injuries from displacement of the head to the opposite side and depression of the shoulder on the same side
o Paralyzed mms: supraspinatus, infraspinatus, subclavius, biceps brachii, greater part of the brachialis, coracobrachialis, deltoids, teres
minor
o Position of the upper limb: Porter’s / Waiter’s tip
o Loss of sensation down the lateral side of the arm
 Klumpke Palsy
o Lower lesions of the brachial plexus (C8-T1)
o Usually traction injuries caused by excessive abduction of the arm
o Clawed hand appearance
 Spinal Accessory Nerve
o Trapezius mm weakness
o Scapular depression
o lateral scapular winging with inferior angle rotated laterally – 90 deg of abd
 Axillary Nerve
o C5-C6
o greatest risk with dislocations of the shoulder and fracture of the surgical neck of the humerus
o PT Assessment:
 Sensation: Lat aspect of Sh
 Suprascapular Nerve
o sensitive to entrapment at the notch and along the spine of the scapula
 o Commonly seen in throwing athletes, or other overhead sports
o Symptoms include diffuse shoulder pain, impingement, weakness, atrophy, or scapular dysfunction
 Long Thoracic Nerve
o Serratus anterior muscle weakness
o Causes scapula to elevate and move medially, with the inferior angle rotating medially
o Open-book deformity
o Can be injured by blows of pressure on the posterior trunk or during the surgical procedure of radical mastectomy
o PT Assessment:
 Punch out test

 Thoracic Outlet Syndrome

 Common areas of compression:
o Cervical Rib Syndrome
o Scalenus anterior syndrome
o Costoclavicular syndrome – between clavicle and 1st rib
o Hyperabduction Syndrome – between pectoralis minor and thoracic wall
 Clinical Manifestations:
o vague arm pain
o numbness and tingling - medial aspect of the arm
o pain along the neck and shoulder region
o weakness that is diffuse and does not follow a nerve root distribution
o muscle spasms
 ST:
o Adson’s test
o Halstead
o Costoclavicular Test
o Wright test
o Allen’s test
o Roo’s Test
 PT Mg:
o MFR
o Stretching of scalene and pectoralis
o Mobilization of 1st rib
o Postural exercises
III. General Principles of Shoulder Rehabilitation
 Establishing good scapular position is essential for proceeding with a progressive exercise program
 Glenohumeral range can be advanced
 Progressive strengthening program should be prescribed – open/closed-chain exercises
 Started with the arm in a pain-free position -> loading the arm in an upright position on a wall with the arm either flexed or abducted
 Scapular stabilization prior to rotator cuff strengthening
 Eventually, plyometrics should be added - eccentric loading just before concentric forceful contractions