1. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 6: The Shoulder

2. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy, Function, and Dysfunction of the Shoulder Complex General Overview –Bones: scapula, clavicle, sternum, humerus, ribs –Joints Typical: glenohumeral, sternoclavicular, acromioclavicular, scapulothoracic Functional: coracoacromial arch –Shoulder facts Most mobile joint in body & most frequently injured Function depends on many joints Most shoulder disorders affect several structures in region

3. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy, Function, and Dysfunction of the Shoulder Complex (cont’d) Anterior view of the bones and joints of the shoulder complex

4. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy, Function, and Dysfunction of the Shoulder Complex (cont’d) Bones and Joints of Shoulder Girdle –Bones Scapula Clavicle Sternum –Joints Sternoclavicular Acromioclavicular Scapulothoracic

5. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy, Function, and Dysfunction of the Shoulder Complex (cont’d) Glenohumeral Joint –Structure Ball-and-socket synovial joint Joins glenoid fossa of scapula & head of humerus –Function Greatest ROM of any joint in body Six basic motions: flexion, extension, abduction, adduction, medial & lateral rotation

6. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy, Function, and Dysfunction of the Shoulder Complex (cont’d) Glenohumeral Joint

7. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy, Function, and Dysfunction of the Shoulder Complex (cont’d) Glenohumeral Joint –Dysfunction & injury Susceptible to dislocation & subluxation (partial dislocation) Instability due to traumatic dislocation, rotator cuff injury or weakness, or acquired or congenital joint laxity –Treatment implications For instability: contract-relax (CR) muscle energy technique (MET) in rotator cuff & muscles stabilizing scapula For muscle dysfunction and injury: soft tissue mobilization, joint mobilization, MET

8. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy, Function, and Dysfunction of the Shoulder Complex (cont’d) Bones and Soft Tissue of Glenohumeral Joint –Humerus –Joint capsule –Labrum –Ligaments –Coracoacromial arch –Bursae –Nerves

9. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy, Function, and Dysfunction of the Shoulder Complex (cont’d) Bones and Soft Tissue of Glenohumeral Joint –Muscles of the shoulder region Muscles that stabilize the scapula: rhomboids, trapezius, levator scapula, serratus anterior Muscles of the rotator cuff: supraspinatus, infraspinatus, teres minor, subscapularis –Function of rotator cuff muscles: dynamic stabilization –Two common conditions that decrease stability of joint: Thoracic kyphosis Weakness in scapular stabilizing muscles

10. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy, Function, and Dysfunction of the Shoulder Complex (cont’d) Muscles of the posterior shoulder region

11. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy, Function, and Dysfunction of the Shoulder Complex (cont’d) Muscles of the anterior shoulder region

12. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Dysfunction and Injury Factors Predisposing to Shoulder Pain –Instability of glenohumeral joint –Weakness in scapular stabilizing muscles –Previous injury (dislocation of glenohumeral joint, separation of AC joint) –Hypomobility of cervical or thoracic spine –Postural dysfunction –Muscle imbalances

13. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Dysfunction and Injury (cont’d) Differentiation of Shoulder Pain –Active inflammation: pain that occurs or increases at night –Irritation of a sensory nerve root: sharp pain, numbing, & tingling in a dermatome –Rotator cuff injury: pain at lateral portion of upper arm, painful limitation when elevating arm overhead –Bicipital tendinitis: well-localized pain at anterior portion of head of humerus & aggravation with Speed’s test –Adhesive capsulitis: stiffness in shoulder, dramatic loss of arm motion (especially external rotation)

14. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Dysfunction and Injury (cont’d) Differentiation of Shoulder Pain –Impingement: pain over anterior humerus, loss of internal rotation, & painful Neer’s test –Instability: clunking in shoulder with active circumduction & excessive joint play in passive motion test for glenohumeral joint –Pain originating in glenohumeral joint: rarely felt at joint, but over lateral brachial region

15. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Dysfunction and Injury (cont’d) Characteristics of Shoulder Pain (vs. neck pain) –Elicited or increased from active shoulder motion & relieved by rest –Isometric challenge will be painful with localized lesion –Painless weakness in arm & shoulder muscles from motor nerve root problem in cervical spine

16. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Dysfunction and Injury (cont’d) Common Dysfunctions and Injuries of the Shoulder –Rotator cuff tendinitis (supraspinatus tendinitis) –Infraspinatus tendinitis –Subscapularis tendinitis –Adhesive capsulitis (frozen shoulder) –Impingement syndrome –Instability syndrome of the glenohumeral joint

17. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Dysfunction and Injury (cont’d) Common Dysfunctions and Injuries of the Shoulder –Bicipital tendinitis –Subacromial (subdeltoid) bursitis –Acromioclavicular ligament sprain –Suprascapular nerve entrapment –Costoclavicular syndrome (part of thoracic outlet syndrome) –Pectoralis minor syndrome (part of thoracic outlet syndrome)

18. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Assessment History Questions Specific to Shoulder Pain –Where is the pain? What is the quality of the pain? –Is there a loss of motion in the arm? Observation Questions –Anterior view Are the clavicles level? Is shoulder height even? Is there a smooth contour to the area of the lateral shoulder? Is there a sulcus sign from the flattening of the deltoid? –Posterior view: Is there scapular winging? –Side view: Are there rounded shoulders and FHP?

19. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Assessment (cont’d) Motion Assessment –Scapular stabilization test –Abduction –Medial rotation –Flexion with internal rotation (Neer’s impingement test) –Lateral rotation –Horizontal flexion (adduction)

20. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Assessment (cont’d) Scapular stabilization test

21. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Assessment (cont’d) Passive Movements –Abduction –Lateral rotation –Circumduction Isometric Tests –Middle deltoid –Empty-can test –Resisted lateral rotation –Long head of biceps (Speed’s test)

22. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques Guidelines to Applying Techniques –Two underlying assumptions 1. An injury or dysfunction in one structure causes compensations in entire region of injury & elsewhere in body 2. An injury or dysfunction localized in one tissue affects many other tissues in area –Three techniques Muscle energy technique (MET) Soft tissue mobilization (STM) Joint mobilization

23. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques (cont’d) Guidelines to Applying Techniques –Intentions of treatment for acute conditions To stimulate movement of fluids to reduce edema, increase oxygenation & nutrition, & eliminate waste products To maintain pain-free joint motion, prevent adhesions, & maintain health of cartilage To provide mechanical stimulation to help align healing fibers & stimulate cellular synthesis To provide neurological input to minimize muscular inhibition & help maintain proprioceptive function

24. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques (cont’d) Guidelines to Applying Techniques –Intentions of treatment for chronic conditions To dissolve adhesions and restore flexibility, length, & alignment to myofascia To dissolve fibrosis in ligaments and capsular tissues surrounding the joints To rehydrate the cartilage & restore mobility & ROM to joints To eliminate hypertonicity in short, tight muscles; strengthen weakened muscles; and reestablish normal firing patterns To restore neurological function by increasing sensory awareness and proprioception

25. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques (cont’d) Muscle Energy Technique (MET) –Assessment of muscle length & glenohumeral joint passive ROM Lateral rotation Medial rotation –Contract-relax & postisometric relaxation techniques Medial & lateral rotators of shoulder, pectoralis major & minor, supraspinatus To increase medial rotation, external rotation, & inferior glide of glenohumeral joint –Treatment for loss of shoulder motion: external rotation & elevation

26. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques (cont’d) Soft Tissue Mobilization (STM) –Wave mobilization: a combination of joint mobilization & STM –Performed in rhythmic oscillations, 50 to 70 cycles/min –Level I: for every client; designed to enhance health & bring body to optimum performance –Level II: for treating acute conditions; typically applied after level I strokes