The Shoulder

1. The Shoulder Chapter 21

2. Shoulder Girdle Complex • Glenohumeral joint • Acromioclavicular joint • Scapulothoracic joint

3. Glenohumeral Joint • Glenoid fossa • Head of humerus

4. Acromioclavicular Joint • Acromion process of scapula • Clavicle

5. Scapulothoracic Joint • Scapula • Posterior ribcage

6. Bony Landmarks • Sternum • Clavicle • Humerus • Head of humerus • Greater tubercle • Lesser tubercle • Bicipital groove Lesser tubercle Greater tubercle

7. Bony Landmarks • Scapula • Acromion • Coracoid process • Glenoid fossa • Spinous process

9. Shoulder Girdle

10. Muscles of the Shoulder • Deltoid • Trapezius • Pectoralis Major • Pectoralis Minor • Serratus anterior • Rhomboid major • Rhomboid minor • Levator scapulae • Coracobrachialis • Latissimus dorsi

11. Deltoid • Abducts shoulder

12. Trapezius • Rotates scapula

13. Shoulder depression • Scapular depression • Punching • Flex shoulder • Adduct shoulder • IR shoulder

14. Levator Scapulae • Elevates scapula • Rhomboid Major/Minor • Retract scapula • Elevate scapula

15. Flexes shoulder • Adducts shoulder

16. Biceps Brachii • Weakly flexes shoulder • Two proximal heads • Long head—supraglenoid tubercle of scapula • Short head—coracoid process of scapula

17. Rotator Cuff Muscles Collective set of four deep muscles of the GH joint • Supraspinatus • Inserts into humerus anteriosuperiorly • Infraspinatus • Inserts onto the humerus posterosuperiorly • Teres Minor • Inserts onto the humerus posteriorly • Subscapularis • Inserts onto humerus anteriorly

18. Rotator Cuff Muscles

19. Rotator Cuff Muscles

20. Ligaments of the Shoulder • Coracoclavicular • Coracoacromial • Coracohumeral • Glenohumeral • Acromioclavicular

21. Common Injuries of the Shoulder Overuse injuries to the shoulder

22. Impingement Syndrome • Widely used term to describe pain occurring when space between humeral head and acromion become narrowed • Bones “impinge” or squeeze structures that occupy the subacromial space • Three structures: • Joint capsule • Tendons of rotator cuff • Bursa

23. Impingement Syndrome • Overhead sports • Baseball, tennis, swimming, volleyball • Signs & Symptoms • Pain and tenderness in GH • Pain and/or weakness with active abduction in mid-range • Limited IR • Confirmation with special tests • Point tenderness in subacromial area

24. Impingement Syndrome—Treatment • Address biomechanics • Substitute with cross-training until condition resolves • Limit excessive overhead movement • Rehab exercises & stretching

25. Rotator-Cuff Tears • Traumatic injury • i.e. FOOSH • Unusual demands on young athlete • Repetitive use leads to chronic condition • Ultimately tear in tendons • Partial thickness tear • Not completely sever tendon • May respond well to non-op treatment • Full thickness tear • Require surgery

26. Rotator-Cuff Tears—Signs & Symptoms • Vague pain in shoulder area • “Catching” sensation when arm moved • Inability to sleep on affected side • Varying degrees of disability

27. Muscle Strains • Caused by overuse or traumatic injuries • Signs & Symptoms • Pain, tenderness in muscle belly • Symptoms provoked by: • Direct palpation • Stretch • Contraction against resistance • Mild strains can resolve within few days • Severe strains can take several months to heal

28. Muscle Strains—Treatment • PRICE • Gentle stretching • Strengthening program • Cross-train • Functional progression

29. Biceps Tendonitis • Discomfort in anterior shoulder • Often confused with RC tendonitis • Can be caused by impingement

31. Proximal Biceps Tendon Rupture • Not common in athletics • Sudden onset of pin in front of shoulder • Associated with a “pop” during vigorous activity • Drooping biceps muscle at distal arm • “Popeye” muscle

32. Proximal Biceps Tendon Rupture

33. Common Injuries of the Shoulder Traumatic Shoulder injuries

34. Shoulder Dislocation • Direction depends on nature of injury • Antero-inferiorly (most common direction) • Inferiorly • Posteriorly • Requires immediate care by physician • Additionally injuries include: • Fractures • Glenoid labral tears • Axillary nerve damage

36. Glenoid Labrum • Cartilaginous ring that acts to keep the humeral head positioned on the glenoid by blocking unwanted movement

37. Glenoid Labrum Injuries • Injury 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

38. SLAP Tear • Superior Labrum from Anterior to Posterior • Occurs at point where biceps tendon inserts on labrum • Area of relatively poor blood supply • FOOSH • Repetitive overhead actions • Lifting a heavy object

39. Multidirectional Instabilities • Hyper-elastic or overly flexible individuals, often can sublux shoulder voluntarily • May have problems with overhead sports • Positive Sulcus sign • Weight-bearing exercises & weight training helpful • Condition normally not improved with surgery

40. 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

41. AC Separation—Treatment • PRICE • Rehab • 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

42. Acromioclavicular Separation

43. Brachial Plexus Injury • Stinger • Burner • Occurs when head and neck forcibly moved/hit to one side • Nerves n brachial plexus compressed on that side • Painful and disabling

44. Brachial Plexus • Group of peripheral nerves • Leave spinal cord & extend from vertebrae into shoulder • Give arm ability to function

45. Brachial Plexus Injury—Signs & Symptoms • Intense pain from neck down to arm • Arm will feel like it’s on fire or have pins-and-needles sensation • Arm/hand may be weak and numb • Intense pain in area of brachial plexus • Symptoms last several minutes to several hours or more • Weakness may last for several days • depends on severity of injury

46. Brachial Plexus Injury—Treatment • Resting neck/arm until pain & symptoms go away • Ice pack 20 minutes every 3-4 hours • Anti-inflammatories • Strengthening exercises • RTP determined by sports medicine staff • Subsequent stingers cause for further testing

47. Brachial Plexus Injury—Treatment • Chronic 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

48. Fractures of Shoulder • Usually caused by impact or blow to shoulder • Common areas: clavicle & humerus • Scapular fx not show on x-ray; use bone scan • Clavicleobvious deformity • Ecchymoses may be present • Consider injury to joints, muscles, ligaments, vessels, and nerves

49. Special Tests

50. Special Tests for Shoulder • Neer’s Impingement • Hawkin’s-Kennedy Impingement • Cross-over Impingement • Speed’s test • Empty Can • Drop-arm Sign • Shoulder Hike • Cross-arm adduction • Anterior apprehension • Posterior glide • Feagin’s Test • Sulcus sign • Clunk test • AC Shear Test • Roos Test • Piano Sign