1. Chapter 18: The Shoulder Complex

2. 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,

3. Anatomy

5. 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

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

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

8. 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

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

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

13. 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)

14. 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

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

16. 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

17. 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

18. Special Test Continue
Yerguson’s
Drop Arm

19. 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
________________________________

20. 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
Throwing Program
Strengthen scapular stabilizers
push-ups
press-ups

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

22. 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

23. 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

24. 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

25. 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

27. 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

28. 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

29. 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
_________________________________________________________________________

31. 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.

32. 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
_______________________________________

33. 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)

34. 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

35. 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

36. 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

37. 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