Unit 7 Upper Extremity

Shoulder complex

Tell me what you know about the shoulder…

Shoulder Great degree of mobility Mobility  instability Ball and socket joint Mobility  instability Instability  injury Overuse

Anatomy Bony Clavicle (collar bone) S-shaped bone Sternum (breast bone) 3 parts: manubrium, body, and xiphoid process Scapula (shoulder blade) Humerus (upper arm)

Bones of shoulder

Articulations Sternoclavicular joint (SC) Acromioclavicular (AC) joint Joint between sternum and clavicle Acromioclavicular (AC) joint Joint between acromion and clavicle Glenohumeral (GH) joint Joint between glenoid (of scapula) and humerus

Ligaments SC joint AC joint GH joint SC joint ligaments Anterior and posterior SC ligaments Prevent upward displacement of clavicle Interclavicular Prevents lateral displacement of clavicle Costoclavicular Prevents lateral and upward displacement of clavicle AC joint Acromioclavicular Coracoclavicular GH joint Superior, middle, and inferior GH ligaments

Ligaments

Muscles of the shoulder GH joint muscles Allow for: flexion, extension, abduction, adduction, horizontal adduction/abduction, internal rotation/external rotation, circumduction Muscles: Pectoralis major Latissimus dorsi Deltoid Rotator cuff muscles: supraspinatus, infraspinatus, subscapularis, teres minor Teres major Coracobrachialis

Muscles of the shoulder Muscles acting on scapula Help provide dynamic stability of the shoulder Muscles: Levator scapulae Trapezius – upper, middle, lower Rhomboids- major and minor Serratus anterior and posterior

Muscles

Muscles

Evaluation- History What caused the injury? Overuse vs. acute Has it continually gotten worse over time? Have you been doing a lot of repetitive overhead motions? Did you fall on an outstretched arm? Take a direct hit? What sport do they play? Overhead sport? Do they have a history of shoulder issues? What kind of discomfort are you having? Sharp pain? Pinching pain? Ache? Weakness? Have you lost any function? Range of motion?

Evaluation- Observation Position of the head Head forward? Position of the arm and ability to move the arm Rounded, slumped shoulders Level of the shoulders Is one higher than the other? Symmetry of musculature Is one side more defined? Clavicle Acromion process Scapula

Evaluation-Palpation Bony Clavicle Acromion process Coracoid process Humeral head Humerus Scapula- spine, superior angle, inferior angle, axillary border, vertebral border Joints- GH, SC, AC Muscles- rotator cuffs, rhomboids, traps, biceps, triceps, delotid

Range of motion Movement/Motion Normal ROM Flexion 0-180 degs Extension 0-60 degs ABDuction Internal rotation 0-70 degs External rotation 0-90 degs

Evaluation- Special tests Muscle testing- Flexion Biceps brachii- flexion Anterior deltoid- flexion ADDuction ABDuction Middle deltoid- ABDuction Extension Posterior deltoid- extension Elevation Upper trapezius- elevation (shrug) Retraction Rhomboids- retraction Internal rotation Subscapularis External rotation Supraspinatus, Infraspinatus, Teres minor Horizontal ADDuction and ABDuction

Evaluation- Special tests What it tests for… Videos Load and Shift Anterior instability https://www.youtube.com/watch?v=AcNWkR7uq3U O’briens test Labrum/SLAP tear https://www.youtube.com/watch?v=v_EL9XqTJQQ Sulcus Inferior instability https://www.youtube.com/watch?v=re7Nm3h8k5E Hawkins-Kennedy Impingement https://www.youtube.com/watch?v=3LU1xsUrKV4 Empty Can Supraspinatus injury/biceps injury https://www.youtube.com/watch?v=qjHOqydDhxo Piano Key AC joint https://www.youtube.com/watch?v=gFwXwPD1Lxw Crank Glenoid labrum/SLAP injury https://www.youtube.com/watch?v=LPbc7HfHlAQ

Shoulder injuries Clavicular fractures SC sprain AC sprain Dislocations Impingement

Shoulder injuries Clavicular (collar bone) fracture MOI: fall on outstretched arm, fall on tip of shoulder, or direct impact Most occur at middle 1/3 of bone Signs and symptoms: Swelling Point tenderness Mild deformity Posture: supporting injured arm and tilts head toward that side Treatment: Sling X-ray Refer to physician

Shoulder injuries SC sprain MOI: indirect force transmitted through the humerus of shoulder joint by direct violence Blow to shoulder Twisting or torsion of posteriorly extended arm 3 grades: Grade 1: little pain and disability Point tenderness, but no deformity Grade 2: Visible deformity, pain, swelling, point tenderness Inability to ABDuct shoulder in full ROM or bring arm across chest Grade 3: complete dislocation with gross displacement of clavicle at sternal junction Swelling and disability Complete rupture of SC and costoclavicular ligaments

Shoulder injuries AC sprain MOI: direct impact to tip of shoulder; upward force exerted against the long axis of the humerus by a fall on an outstretched arm 6 grades: Grade 1: point tenderness and discomfort during movement; no disruption in AC joint Grade 2: tearing or rupture of AC ligaments w/ stretching of coracoclavicular ligament; partial displacement Point tenderness during palpation of injury Unable to full ABDuct arm or bring arm completely across the chest Grade 3: complete rupture of AC and coracoclavicular ligaments

Shoulder injuries AC joint cont’d Grade 4: posterior separation of clavicle with complete disruption of AC ligament Grade 5: complete rupture of AC and coracoclavicular ligaments; tearing of trapezius and deltoid Gross deformity Severe pain Loss of movement Instability Grade 6: Clavicle displaced inferior to coracoid behind the coracobrachialis tendon Treatment: Ice and pressure, stabilization with sling, referral to doctor

Shoulder injuries Dislocations Anterior Direct impact to the posterior or posterolateral aspect of the shoulder Forced ABDuction, external rotation, and extension May cause a tear in the glenoid labrum May have rotator cuff muscle injury Moderate pain and disability Posterior Forced ADDuction and internal rotation of the shoulder or fall on an extended and internally rotated arm May have glenoid labrum injury May have fracture of lesser tuberosity Has severe pain and disability Position: arm ADDucted and interally rotated

Shoulder injuries Impingement Compression of the supraspinatus tendon, subacromial bursa, and long head of biceps tendon Seen with repetitive overhead activities Repetitive motions causing compression and decrease space in the subacromial arch Poor posture Signs and symptoms: Pain around acromion Pinching sensation Overhead activities increase pain ROM may be decrease Shoulder weakness Treatment: rehab to fix biomechanics; RICE and modalities

Rehab In small groups come up with a 3 day ankle/lower leg rehab program Show progression through the program Pick one of these injuries: Impingement Labral injury Biceps tendinitis AC sprain

Rehab Exercises for shoulder rehab… Resisted band exercises Internal rotation/External rotation Rows Lat pull downs Sidelying External Rotation Scaption/Full can exercise Serratus Punches Y’s, T’s, I’s, and W’s Arm circles