The shoulder Chapter 21
The Shoulder Girdle Complex • 3 joints make up the shoulder girdle • The Sternoclavicular joint • The Acromioclavicular joint • The Glenohumeral joint
The Sternoclavicular Joint • Formed through the articulation of the sternum and the clavicle. • Also called the SC joint • Injuries to this joint can be very debilitating, but are very rarely seen in athletics.
Acromioclavicular Joint • Formed by the articulation of the acromion process of the scapula and the distal end of the clavicle. • Also called the AC joint • Its is located superiorly to the glenohumeral joint and is commonly exposed to injury in contact sports.
Glenohumeral Joint • Formed by the Humerus and the scapula • The head of the humerus is attached to the glenoidfossa of the scapula • Shallowness of the socket allows for a great deal of movement • Supported by • several muscles • ligaments • Soft tissue
Structure and Function • Dynamic Stability refers to mobility with stability • Shoulder accomplishes this through the coordinated movement of the scapula in concert with the humerus • Several muscle groups work together synergistically to create the dynamic stability of the shoulder.
Rotator Cuff • A set of 4 deep muscles of the glenohumeral joint • They originate on the scapula and insert onto the superior aspect of the humerus • Will often be referred to as the SITS muscles • Supraspinatus • Infraspinaus • Teres Minor • Subscapularis
Muscles of the Shoulder Girdle • Muscle Force Coupe • Formed by the actions of the deltoid and rotator cuff muscles • Allows the humeral head to spin while remaining in place on the glenoid • Scapulothoracic Mechanics • Allows the scapula to move in several places using the following muscles • Trapezius • Rhomboids • Serratus • Pectoralis Minor
Muscles that move the Scapula • There are several muscles that move the scapula • Levator scapulae • Rhomboids • Major and Minor • Pectoralis Minor • Serratus Anterior • Trapezius
Muscles that move the Arm (Humerus) • There are several muscles that move the Humerus • Coracobrachialis • Pectoralis Major • Teres Major/Minor • Deltoid • Supraspinatus • Infraspinatus • LatissimusDorsi
Overuse Injuries to the Shoulder • Overuse injuries of the shoulder are usually limited to the soft tissues. • Usually caused by repetitive activity to the point of causing tissue damage and inflammation • Common among athletes that participate in overhead movements • Many athletes are unaware that an injury is occurring until symptoms manifest • Overuse Injuries include • Impingement syndrome • Tendonitis • Bursitis • Muscle strains
Impingement Syndrome • Impingement syndrome describes a situation causing injury when the space between the humeral head and acromion becomes narrowed. • The bones “impinge” or squeeze structures within the space • Structures affected are the joint capsule, tendons of the rotator cuff, and a bursa • Impingement causes mechanical irritation of the cuff tendons, resulting in hemorrhage and swelling • Commonly called tendonits of the rotator cuff • Supraspinatus is the muscle usually involved • If the bursa is involved, bursitis is the result.
Impingement Syndrome - Symptoms • Symptoms • Pain and tenderness in GH area • Pain and/or weakness with ABD in midrange • Limited IR • + results from special tests • Hawkin’s impingement • Tenderness to palpation in subacromial area
Impingement Syndrome - Treatment • Treatment options • Correction of improper sport technique • Preseason conditioning • Specialized taping • Rehabilitation and Prevention • Most rehab techniques involve strengthening the weakened muscles of the shoulder girdle
Rotator Cuff Tears • Could be partial tear or full thickness of the tendon • Can happen to people of any age • In younger people often caused by more traumatic injuries • Falling on outstretched arm • Unusual demands on the joint • Older people • Usually caused by degeneration of the muscle and tendon tissues • Treatment • Usually determined by severeity of injury and how it responds to rehab • Small and partial tears respond well to non-operative rehab program • Moderate to large tears, and small tears that are non-responsive to rehab, require surgery
Rotator Cuff tears (cont’d) • Symptoms • Pain • Full ROM with partial tears • Loss of ROM with full tears • Athlete will not be able to lift the arm overhead, and often when they try, the can be observed to hike or shrug
Muscle Strains • Can be caused by excessive overuse or traumatic injury • Symptoms • Pain • Tenderness in muscle belly caused by • Palpation • RROM • Stretch • There could be a delay of a day or two before symptoms actually show • Treatment • PRICE • Gentle stretching • Strengthening program
Biceps (long head) Tendonitis • Can cause discomfort in the front of the shoulder and will often be confused with rotator-cuff tendonitis. • Both can be caused by impingement and will have the same treatment
Biceps Tendon Rupture • Not common in athletics, but results from vigorous activity • Described as a sudden onset of pain in the front of the shoulder and an associated “pop” • Symptoms • Drooping of the biceps muscle near the distal upper arm • Ecchymosis
Biceps Tendon Rupture (cont’d) • This injury is considered a Grade III injury and usually affects the biceps tendon long head. • People who have a prior history of tendonitis may be more prone to this injury • Treatment • Surgery is usually not needed • PRICE • Gradual return to strengthening and activity • Athletes can usually return to full activity after a period of conservative care • There may be a small loss of shoulder flexion in the long term, but not enough to result in loss of high-level functioning
Traumatic Shoulder Injuries • Usually are caused by a sudden onset • Blow to arm or shoulder • Shoulder joint being forced beyond physiologic limits • Common Injuries • Glenohumeral dislocation • Acromioclavicularseparation • Fractures • Tendon Ruptures
Anterior Shoulder Dislocation • Results in the head of the humerus being completely out of the glenoidfossa • Usually caused by shoulder being forced into abduction, extension and external rotation. • Most common means of dislocation is anterioinferiorly • Immediate transport to a physician is required • Physician should also check for other injuries • Fractures • Glenoid labial tears • Axillary nerve damage • Hill-Sachs lesions can occur if the head of the humerus hits the front of the glenoid hard enough to cause an indentation
Anterior Shoulder Dislocation (cont’d) • If the injury is not properly managed and fully rehabilitated, there is a high risk for recurrent dislocations. • Immobilization may be as long as 8 weeks
Glenoid Labrum Injuries • These injuries involve the deepest soft tissue in the shoulder • Can often occur along with dislocations • Happens commonly with baseball pitchers when degenerative changes in the labrum cause it to become loose • Permits humeral head to slip forward • Symptoms • Pain • Popping sensation • Limited use of the arm • Varying degrees of weakness • Special tests and MRI will confirm diagnosis • Treatment includes specialized rehab program • Suspected tears must be referred to a physician
Multidirectional Instability • Refers to the ability of the athlete to voluntarily dislocate their shoulders • usually due to athlete being hyperelastic or overly flexible • This causes problems with athlete playing overhead sports. • Weight bearing exercises can be helpful in dealing with this problem • Push-ups • Plyometrics • Weight training
Acromioclavicular Separation • This injury is a traumatic sprain of the AC joint • Usually caused by a blow to the tip of the shoulder • Symptoms • Pain near the AC joint • Obvious deformity • Treatment • Physician referral • 1st degree sprains • PRICE • 2nd / 3rd degree sprains • Require 6-8 weeks of immobilization
Brachial Plexus Injury • Is often called a stinger or burner • Usually caused by a stretching of the brachial plexus on the opposite side • Symptoms • Intense pain from the neck down to the arm • On-fire or pins-and-needles sensation • Weakness • Numbness • Treatment • Referral to specialist • Rest • Ice • Anti-inflammtory meds • Strengthening exercises for neck and shoulders • Prevention • Keeping neck and shoulders strong • Wearing properly fitted equipment that distributes forces during collision • Using proper technique
Fractures • Fractures of the shoulder girdle most commonly involve the clacivle and humerus • Scapular fractures may not be seen on standard x-rays • Present on bone scans • Any suspected fracture should be referred to an emergency room physician
Is it a Shoulder Injury • Often times pain in the shoulder can be referred pain from another injury. • Pain in the shoulder does not always indicate a shoulder problem • Cardiac problems or Heart attack • Referred pain to the left shoulder, neck and arms • Spleen Injury • Refer pain to the left shoulder and down the upper portion of the left arm • Kehr’s sign