Chapter 18: The Shoulder Complex

Shoulder Joint-Anatomy (1) Sternum Clavicle Scapula- acromion process and coracoid process, glenoid fossa and glenoid labrium, spine of scapula Humerus- Greater tubercle, Lesser tubercle, head of humerus, http://www.readingshoulderunit.com/shoulder_anatomy.htm

Anatomy

Sternoclavicular (SC) Joint ** ___________________________________ Allows for rotation during movements like shrugging the shoulders and reaching above the head. Supported by 4 ligaments- __________________________________ Costoclavicular ligament Interclavicular ligament

Acromioclavicular (AC) Joint** Lies between the acromion process and the clavicle ______________________ Primary ligament: ________________ Secondary ligaments Coracoacromial ligament Coracoclavicular ligaments

Glenohumeral (GH) Joint**(1) ___________________________ Glenoid fossa of the scapula ____________________ Head of the humerus (3-4 x larger than glenoid)-plunger/volleyball example _________________________

GH joint** (2) Joint is deepened by a meniscus like structure called the glenoid labrum functions to add stability to the joint Stabilized by two types of stabilizers Static stabilizers joint capsule several glenohumeral ligaments

GH joint** (3) Dynamic stabilizers rotator cuff muscles (SITS) _______________

Other shoulder anatomy (3) Bursa _______________ (clinically most important) Nerve supply brachial plexus (________) Blood supply _____________________________

Shoulder movements Flexion (180) and Extension (80-90) Abduction (180) and Adduction Horizontal Adduction/Flexion (130) Horizontal Abduction/Extension (60) External rotation (90) Internal rotation (90)

ROM/Muscle Testing Shoulder flexion- __________________ Shoulder extension-Post Delt Shoulder abduction-____________________ Shoulder adduction- ___________________ Shoulder internal rotation-Ant Delt/ Subscapularis Shoulder external rotation- ____________________________________ Horizontal ADD/Flex- ________________ Horizontal ABD/Ext- _________________ Scapula elevation, depression, protraction, and retraction

Apprehension test (Crank test) Apprehension test used for anterior glenohumeral instability This motion should not be forced

Test for Shoulder Impingement Neer’s test and Hawkins-Kennedy test for impingement used to assess impingement of soft tissue structures Positive test is indicated by pain and grimace

Test for Supraspinatus Weakness Empty Can Test 90 degrees of shoulder flexion, internal rotation and 30 degrees of horizontal adduction Downward pressure is applied Weakness and pain are assessed bilaterally

Special Test Continue Yerguson’s Drop Arm

Prevention of Shoulder Injuries Proper physical conditioning is key Develop body and specific regions relative to sport Warm-up should be used before explosive arm movements are attempted _____________________________________________________________________ Protective equipment ________________________________

Preventing shoulder problems General muscle strengthening Try and avoid exercises above 90 degrees in the beginning Stretching for shoulder capsule, but be careful Strengthening rotator cuff muscles including eccentric work http://www.asmi.org/SportsMed/throwing/thrower10.html Throwing Program Strengthen scapular stabilizers push-ups press-ups

Throwing Mechanics Instruction in proper throwing mechanics is critical for injury prevention

Windup Phase Cocking Phase Acceleration First movement until ball leaves gloved hand Lead leg strides forward while both shoulders abduct, externally rotate and horizontally abduct Cocking Phase Hands separate (achieve max. external rotation) while lead foot comes in contact w/ ground Acceleration Max external rotation until ball release (humerus adducts, horizontally adducts and internally rotates) Scapula elevates and abducts and rotates upward

Deceleration Phase Follow-Through Phase Ball release until max shoulder internal rotation Eccentric contraction of ext. rotators to decelerate humerus while rhomboids decelerate scapula Follow-Through Phase End of motion when athlete is in a balanced position

Recognition and Management of Specific Injuries Clavicular Fractures Cause of Injury ____________________________, fall on tip of shoulder or direct impact Occur primarily in middle third (greenstick fracture often occurs in young athletes) Signs of Injury _____________________________________________________________________________ Clavicle may appear lower Palpation reveals pain, swelling, deformity and point tenderness

Clavicular Fractures (continued) Care Closed reduction - sling and swathe, immobilize w/ figure 8 brace for 6-8 weeks Removal of brace should be followed w/ joint mobes, isometrics and use of a sling for 3-4 weeks Occasionally requires operative management

Sternoclavicular Sprain Cause of Injury Indirect force, blunt trauma (may cause displacement) Signs of Injury Grade 1 - pain and slight disability Grade 2 - pain, subluxation w/ deformity, swelling and point tenderness and decreased ROM Grade 3 - gross deformity (dislocation), pain, swelling, decreased ROM Possibly life-threatening if dislocates posteriorly Care PRICE, immobilization Immobilize for 3-5 weeks followed by graded reconditioning

Acromioclavicular Sprain Cause of Injury Result of direct blow (from any direction), upward force from humerus, FOOSH Signs of Injury Grade 1 - point tenderness and pain w/ movement; no disruption of AC joint Grade 2 - tear or rupture of AC ligament, partial displacement of lateral end of clavicle; pain, point tenderness and decreased ROM (abduction/adduction) Grade 3 - Rupture of AC and CC ligaments with dislocation of clavicle; gross deformity (Step deformity);+ Piano Key Test, pain, loss of function and instability

Care Ice, stabilization, referral to physician Grades 1-3 (non-operative) will require 3-4 days (grade 1) and 2 weeks of immobilization ( grade 3) Aggressive rehab is required w/ all grades ______________________________________________________________________________ Progress as athlete is able to tolerate w/out pain and swelling _________________________________________________________________________

Glenohumeral Dislocations Cause of Injury Head of humerus is forced out of the joint Anterior dislocation is the result of an anterior force on the shoulder, forced abduction, extension and external rotation Occasionally the dislocation will occur inferiorly (Hill-Sachs Lesion vs Bankart Lesion vs SLAP Tears) Signs of Injury Flattened deltoid, prominent humeral head in axilla; arm carried in slight abduction and external rotation; moderate/severe pain and disability Care RICE, immobilization and reduction by a physician Begin muscle re-conditioning ASAP Use of sling should continue for at least 1 week Progress to resistance exercises as pain allows Hill-Sachs Lesion (Damage to the Humeral Head- seen via x-Ray vs Bankart Lesion (Inferior labral tear) – Both can be associated with shoulder dislocation.

Shoulder Impingement Syndrome Cause of Injury Mechanical compression of supraspinatus tendon, Glenoid labrum, subacromial bursa and long head of biceps tendon due to decreased space under coracoacromial ligament _________________________________________________________________________ Signs of Injury Diffuse pain, pain on palpation of subacromial space; Decreased strength of external rotators compared to internal rotators; tightness in posterior and inferior capsule _______________________________________

Care Restore normal biomechanics in order to maintain space Strengthening of rotator cuff and scapula stabilizing muscles Stretching of posterior and inferior joint capsule Modify activity (control frequency and intensity)

Rotator cuff tear Signs of Injury Involves supraspinatus or rupture of other rotator cuff tendons Primary mechanism - acute trauma (high velocity rotation- degrees per sec??????) Occurs near insertion on greater tuberosity Full thickness tears usually occur in those athletes w/ a long history of impingement or instability Signs of Injury Present with pain with muscle contraction Tenderness on palpation and loss of strength due to pain Loss of function, swelling With complete tear impingement and empty can test are positive

Care RICE for modulation of pain Progressive strengthening of rotator cuff Reduce frequency and level of activity initially with a gradual and progressive increase in intensity

Shoulder Bursitis Etiology Signs of Injury Management ___________________________________________________________________________ May develop from direct impact or fall on tip of shoulder Signs of Injury Management Cold packs and NSAID’s to reduce inflammation Remove mechanisms precipitating condition Maintain full ROM to reduce chances of contractures and adhesions from forming

Bicipital Tendonitis Cause of Injury Signs of Injury Care Repetitive overhead athlete - ballistic activity that involves repeated stretching of biceps tendon causing irritation to the tendon and sheath Signs of Injury ______________________________________________________________________ ___________________________________ ____________________________ Care Rest and ice to treat inflammation NSAID’s Gradual program of strengthening and stretching