1. Unit 7
Upper Extremity

2. Shoulder complex

3. Tell me what you know about the shoulder…

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

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

6. Bones of shoulder

7. 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

8. 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

9. Ligaments

10. 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

11. 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

12. Muscles

13. Muscles

14. 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?

15. 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

16. 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

17. 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

18. 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

19. Evaluation- Special tests
What it tests for…
Videos
Load and Shift
Anterior instability
O’briens test
Labrum/SLAP tear
Sulcus
Inferior instability
Hawkins-Kennedy
Impingement
Empty Can
Supraspinatus injury/biceps injury
Piano Key
AC joint
Crank
Glenoid labrum/SLAP injury

20. Shoulder injuries Clavicular fractures SC sprain AC sprain
Dislocations
Impingement

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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