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The Shoulder
Shoulder Girdle Complex
Glenohumeral jointAcromioclavicular jointScapulothoracic joint
Glenohumeral JointGlenoid fossaHead of humerus
Acromioclavicular JointAcromion process of
scapulaClavicle
Scapulothoracic JointScapulaPosterior ribcage
Bony Landmarks
SternumClavicleHumerus
◦ Head of humerus◦ Greater tubercle◦ Lesser tubercle◦ Bicipital groove◦ Epicondyles
Greater tubercle
Lesser tubercle
Scapula ◦ Acromion◦ Coracoid process◦ Glenoid fossa◦ Spine
Bony Landmarks
Shoulder Girdle
Peer-Share-Review
Bones & Markings
Ready, Set, Go
Muscles of the ShoulderDeltoidTrapeziusPectoralis MajorPectoralis MinorSerratus anterior
Rhomboid majorRhomboid minorLevator scapulaeCoracobrachialisBiceps brachii
Deltoid◦ Abducts shoulder
Trapezius◦ Rotates scapula
Shoulder depressionScapular depression
Punching
Flex shoulderAdduct shoulder IR shoulder
Rhomboid Major/Minor◦ Retract scapula◦ Elevate scapula
Levator Scapulae◦ Elevates scapula
Flexes shoulderAdducts shoulder
Coracobrachialis
Biceps BrachiiWeakly flexes
shoulderTwo proximal
heads◦ Long head—
supraglenoid tubercle of scapula
◦ Short head—coracoid process of scapula
Rotator Cuff Muscles
Collective set of four deep muscles of the GH joint
Supraspinatus◦Abduction of the arm
Infraspinatus◦External Rotation of the shoulder
Teres Minor◦External rotation of the shoulder
Subscapularis◦Internal rotation of the shoulder
Rotator Cuff Muscles
Ligaments of the Shoulder
CoracoclavicularCoracoacromialCoracohumeralGlenohumeralAcromioclavicula
r
Levator Scapula
Rhomboids Minor
Rhomboids Major
Acromioclavicular (AC) joint
Serratus Anterior
Trapezius
Deltoids
Infraspinatus
Teres Minor
Pectoralis Major
Pectoralis Minor
Biceps (short & long head)
OVERUSE INJURIES TO THE SHOULDER
Common Injuries of the Shoulder
Shoulder Impingement SyndromeWidely used term to describe
pain occurring when space between humeral head and acromion become narrowed
Bones “impinge” or compress structures that occupy the subacromial space
Three structures:◦Joint capsule◦Tendons of rotator cuff◦Bursa
Impingement SyndromeOverhead sports
◦Baseball, tennis, swimming, volleyballSigns & Symptoms
◦Pain and tenderness in GH◦Pain and/or weakness with
active abduction in mid-range◦Limited IR◦Confirmation with special tests
Empty can
◦Point tenderness in subacromial area
Impingement Syndrome—TreatmentAddress biomechanicsSubstitute with cross-training
until condition resolvesLimit excessive overhead
movementRehab exercises & stretching
Rotator-Cuff Strain/Tears
Traumatic injury◦i.e. FOOSH
Unusual demands on young athleteRepetitive use leads to chronic
condition◦Ultimately tear in tendons
Partial thickness tear◦Not completely severe tendon◦May respond well to non-op treatment
Full thickness tear◦Require surgery
Rotator-Cuff Strains/Tears- Signs & SymptomsPain with muscle contraction“Catching” sensation when arm
movedInability to sleep
on affected sideVarying degrees
of disabilityDecreased
strengthSwelling
Rotator-Cuff Strains/Tears-TreatmentRICELimit activity - asymptomaticShoulder strengtheningProgressive RTP throwing
program
Biceps TendonitisDiscomfort in
anterior shoulderOften confused
with RC tendonitisCan be caused by
impingement
TRAUMATIC SHOULDER INJURIES
Common Injuries of the Shoulder
Glenohumeral DislocationForced abduction,
external rotation of shoulder
Signs and Symptoms◦ Flattened deltoid◦ Pain and Swelling ◦ Disability
Requires immediate care by physician
Additionally injuries include:◦ Fractures◦ Glenoid labral
tears◦ Axillary nerve
damage
Glenoid LabrumCartilaginous ring that acts to
keep the humeral head positioned on the glenoid by blocking unwanted movement
Glenoid Labrum InjuriesInjury occur with :
◦ Acute trauma (dislocation)
◦ Repeated trauma Degenerated tear
(baseball pitchers)
◦ Repetitive subluxation Labral rim degenerate
over time
Signs & Symptoms◦ Pain◦ Catching or
popping sensation◦ Limited ROM◦ Varying degrees
of weakness◦ Special Tests◦ MRI
SLAP TearSuperior Labrum
from Anterior to Posterior
Occurs at point where biceps tendon inserts on labrum
Area of relatively poor blood supply
FOOSHRepetitive
overhead actionsLifting a heavy
object
Acromioclavicular Separation
Direct blow to tip of shoulder◦ FB player falling on
tip of shoulder or FOOSH
Signs & Symptoms◦ Pain in vicinity of
AC joint◦ Possible deformity
of joint depending on degree of sprain
AC Separation—Treatment RICERehab
◦ ROM & strengthening as tolerated
◦ Overhead exs not recommended
2nd degree◦ 3-4 weeks immob◦ Most painful
3rd degree◦ 6-8 weeks immob◦ May leave
permanent deformity
Acromioclavicular Separation
Clavicle Fracture• Fall on tip of shouldero FOOSH
• Direct impact• Signs and Symptomso Pain, deformity, and swelling
• Refer to physician
Brachial Plexus Injury
StingerBurnerOccurs when
head and neck forcibly moved/hit to one side
Nerves and brachial plexus compressed on that side
Painful and disabling
Brachial PlexusGroup of
peripheral nervesLeave spinal cord
& extend from vertebrae into shoulder
Give arm ability to function
Brachial Plexus Injury—Signs & SymptomsIntense pain from neck down to armArm will feel like it’s on fire or have
pins-and-needles sensationArm/hand may be weak and numbIntense pain in area of brachial
plexusSymptoms last several minutes to
several hours or moreWeakness may last for several days
◦ depends on severity of injury
Brachial Plexus Injury—TreatmentResting neck/arm until pain &
symptoms go awayIce pack 20 minutes every 3-4
hoursAnti-inflammatoriesStrengthening exercisesRTP determined by sports
medicine staffSubsequent stingers cause for
further testing
Brachial Plexus Injury—TreatmentChronic stingers may
eliminate athlete from contact sports
Scar tissue develops around nerve◦ ® Causes nerves to
become entrapped If athlete receives
another blow, brachial plexus may not be able to flex◦ shatters instead,
tearing major nerves of arm
◦ Causes permanent neurological damage
Avoid by:◦ Keeping neck and
shoulders as strong as possible
◦ Properly fitted equipment
◦ Proper tackling & blocking techniques
SPECIAL TESTS
Special Tests for ShoulderHawkin’s-Kennedy
ImpingementAnterior ApprehensionPiano SignApley’s ScratchEmpty CanDrop-arm Sign
Hawkin’s-Kennedy• Seated
• Shoulder in 90 degrees of flexion, slight horizontal adduction, & maximal internal rotation
• (+) reproduction of pain• Subacromial
Impingement
Drop Arm Sign
Apprehension-relocation
• Supine with are @ 90 degrees of abduction & external rotation
• 1 had placed as a fulcrum just posterior to humeral head then passively move shoulder into maximal external rotation against fulcrum of other hand
• (+) reproduction of shoulder pain, or apprehension with movement• Glenohumeral
subluxlation
Piano Key/Sign – AC Separation
• Seated or standing
• Clinician presses downward on elevated end of clavicle
• (+) pain or excessive movement of clavicle• AC separation
Empty Can Test—Supraspinatus
• Seated
• Elevate UE to 30-45 degrees in plane of scapula with internal rotation (thumb down); resist elevation
• (+) pain & weakness
Apley’s Scratch – shoulder mobility
• Sitting
• 3 part test1. Reach across
chest & place hand on opposite sholder
2. Reach overhead to place hand between scapula
3. Reach behind back as high as possible
*compare bilaterally
• (+) asymetrical motion1. Restriction in horizontal adduction, IR, scapular protraction2. Restriction I abduction, ER, scapular upward rotation and
elevation3. Restriction in adduction, IR, scapular downward rotation and
retraction
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