1. The shoulder z Shallow G-H jt- glenoid labrum deepens capsule;also requires strong muscle force to stabilize the joint- z RTC (rotator cuff muscles) SITS ms.

2. zLigaments of shoulder joint: zA-C ligament-sup and inf reinforce the joint capsule and prevent post dislocation of the clavicle zG-H ligaments-originate from labrum and attach to lesser tubercle and anat neck (reinforce capsule) sup, mid and inf bands zCoracoclavicular lig.- lat(trapezoid) and med(conoid) Both prevent backward mvmt of the scapula and ind they limit scap rotation

3. Acromioclavicular Joint A-C joint capsule Coracoclavicular ligaments

4. Clavicular Ligaments Conoid ligament A-C Joint

5. Common Glenohumeral Problems zRotator cuff tendinitis zRotator cuff tears zBicipital tendinitis, rupture zGlenohumeral dislocation/subluxation zLabral Tears zFrozen shoulder syndrome zArthritis

6. Rotator Cuff Problems

7. Rotator Cuff Impingement

8. Rotator Cuff Tear (RCT)

10. Phase 1 (0 to 6 weeks)Passive range of motion exercises only for almost all tears. Active-assisted range of motion for very small tears or repairs with exceptionally good tissue Phase 2 (6 to 12 weeks) Full passive motion Begin active-assisted motion Strengthen intact cuff muscles Begin to strengthen the muscles that stabilize the shoulder blade

11. Phase 3 (12 to 16 weeks) Passive stretching beyond the patient's own range of motion Strengthening the repaired cuff muscles More strengthening of the stabilizers of the shoulder blade Phase 4 IV (> 16 weeks)Functional strengthening Rehabilitation for sports

13. Normal Cuff, Torn Supraspinatus on MRI

14. Bicipital Tendinitis z Long biceps tendon in intimate with joint capsule. z May be impinged beneath acromion, or sheared within bicipital groove. Impingement Shear in bicipital groove

15. Bony Structures

16. Avascular Necrosis of Humeral Head zMay be seen with chronic corticosteroid use. z(GENTLY handle patients with history of steroid use.) zCan lead to total shoulder replacement.

17. Glenohumeral Arthritis

19. Frozen Shoulder Syndrome z“Freezing” shoulder z“Frozen” shoulder z“Thawing” shoulder

20. Freezing Shoulder z“Freezing” shoulder yUsually starts with inflammatory process, such as impingement syndrome. ySubscapularis trigger points limit external rotation, abduction yShoulder becomes painful, then stiff yBest opportunity for intervention is here!

21. Frozen Shoulder zCapsule undergoes fibrotic changes z(“Adhesive capsulitis”) zPT intervention alone is of questionable help. zMay benefit from manipulation under anesthesia, followed by PT care.

22. Thawing Shoulder zShoulder spontaneously becomes less painful, less stiff. zIf in rehab, take credit for result, but probably little effect from treatment. zNearly all frozen shoulders spontaneously resolve in 6 to 18 months zMay recur on opposite side zRare in African-Americans

23. Glenohumeral/Scapulothor acic Rhythm zOccur in 2:1 ratio GH/ST, but not in constant ratio. zGH joint moves first, with stabilized scapula zThen, move in 1:1 ratio. zThen finish with mostly GH motion zFINAL ratio is 2:1

24. Glenohumeral Dislocation zUsually caused by violent abduction/external rotation of humerus. zHumerus dislocates in anterior, inferior direction. zCauses disruption of anterior labrum (Bankart lesion) zIf repeated, posterior aspect of humerus strikes labrum, producing indentation in humerus (Hill Sachs lesion.)

25. Superior Labral Tear Anterior and Posterior to Biceps Attachment (SLAP) Biceps tendon Anterior tear Posterior tear

26. Bicipital Tear (Longhead)

27. Scapulothoracic Problems zWinging scapula from poor posture, habit. yCommon in tall, early developing females, swimmers yCorrelated with G-H problems zMay be from long thoracic nerve palsy, taking out serratus anterior. yResults in inability to raise arm above 120 degrees (ever.)

28. Serratus Anterior Loss Winging 120 degrees abduction

29. Suprascapular Nerve Palsy z Suprascaular nerve innervates supra- and infraspinatus. z Injury results in selected weakness. z What’s the sensory pattern??

30. zCoracoacromial lig- provides roof over the humeral head - acts as a protective arch zScapular movements must be accompanied by shoulder joint movements therefore if you have impairment at G-H joint, must look at scapula zKinematics of shoulder joint- zscapulohumeral rythym zexternal rotation with abduction zscapular plane

31. zMuscles-RTC(rotator cuff muscles) SITS zsupraspinatus-imp to keep head of humerus in glenoid fossa along with other ms. zInfra, teres minor, subscap-act to depress head during flexion and abduction-counteract strong deltoid zlong head of biceps becomes very active in shld flex and abd past 90 zMs. named from areas they originate and insert-grouping as follows:

32. zScapulohumeral:deltoid, supraspinatus, infraspinatus, teres minor, subscapularis, teres major, coracobrachialis zAxioscapular:pect minor, trapezius, rhomboids, lev scap, serr ant zAxiohumeral: pect major, lat dorsi zDeltoid-ant, mid and post portion zOrigin: ant portion-lateral 1/3rd of clavicle zmid-acromion, post-spine of scapula zInsertion-deltoid tuberosity of humerus zaction-all portions abduct, ant fibers flex

33. zand med rotate, post fibers extend and laterally rotate zinnervation-axillary (C5,6) zsupraspinatus: zorigin-supraspinatus fossa of scapula zinsertion-greater tubercle of humerus zaction- stabilizes head of humerus in capsule, assists in abduction-acts as force couple with deltoid to assist with abd zinnervation-suprascapular (C4,5,6)

34. zInfraspinatus-origin-infra fossa zinsertion-greater tubercle and shld capsule zinnervaton-suprascap nerve zaction-ext rotation of shoulder and depression of humeral head and stabilizes head during movement zTeres minor-origin-upper lateral border of scapula zinsertion-greater tub and shoulder capsule zaction-lat rotation and add of humerus along with infra zinnervation-axillary nerve

35. zSubscapularis-origin-subscapular fossa zinsertion-lesser tubercle of humerus and capsule zaction-int rotation of humerus and works with other ms. zInnervation-subscapular (C5-7) zTeres major-origin-acillary border of inf angle of scap zinsertion-med tip of inter groove zaction-med rotation, adduction and shouler ext zInnervation-lower subscapular(C5-7)

36. zAxioscapular-pect minor: zorigin-ribs 3,4,5 and fascia of intercostal ms zinsert-coracoid process zaction-elevation and downward rot of scap zinnervation-medial pect (C8-T1) ztrapezius-origin-upper from occ protuberance, nuchal line and spinous porcess of C7, middle from spinous process T1-5 and lower from T6-12 zinsertion- upper from lat clav and acromion zmiddle from acromion and spine of scap zlower from apex of spine of scap

37. zRhomboid major-origin-spinous process T2-5 zinsertion-vertebral border zaction-down rotation, elevation and adduction of scap zinnervation-dorsal scapular (C4-5) zrhomboid minor-origin-spinous processes C7-T1 zinsert-root of spine of scap zaction-same as major zinn-same as major

38. zLevator scapula-origin-transverse processes C1-4 zinsertion-sup med border of scap zaction- elevation, down rotation and add of scap zinnervation-dorsal scapular zSerratus anterior-origin-upper 8-9 ribs ant surface zinsertion -medial, inf surf of scap zaction-up rot, elevation and abduction zinn-long thoracic (C5-7)

39. zAxiohumeral- zPectoralis major-origin:clavicle, sternum and cartilage of first 6-7 ribs zinsert-lat inter. Groove zaction: med rotation, flexion and horizontal adduction zLatissimus dorsi-origin-sp processes of T6-12, last 3 ribs, thoracolumbar fascia and iliac crest zinsert-inter groove zaction-med rotation, adduction and ext of shld, ext of L spine, flex of T spine

40. zDisorders of PNS- zneuropraxia-local blockage interfering with conduction, it’s OK above and below-commonly caused by compression-Saturday night palsy-radial nerve or Bell’s palsy, no disruption of axon zAxonotmesis-nerve injury characterized by disruption of the axon and myelin sheath but with preservation of supporting CT resulting in axonal degeneration distal to the injury site-the deficit depends on the # of axons affected

41. zneurotmesis- partial or complete severance of a nerve with disruption of axons, myelin sheaths and supporting connective tissue resulting in degeneration of axons distal to the injury site (worst of the 3)

42. Disorders of PNS

43. zErb’s palsy-compression or stretching of upper BP nerve roots (C5,6)-results in “waiter’s tip” sign zKlumpke’s paralysis-compression or stretching of lower BP (C8,T1)-results in functionless hand zBursae-fluid filled sac which can be inflammed-bursitis-most common in shoulder-subdeltoid and subacromial- least likely subscapular bursitis zSigns-warm, edematous with tenderness over area

44. zPain quality-intense, dull, throbbing all movements painful zTendonitis-inflammation of the tendon zRTC tendonitis-supraspinatus most involved-results from overuse, tennis, baseball, carpenters, plumbers-can also be poor blood supply causing scarring or Ca deposits-can bring about tears, bursitis or impingements; local steroids can relieve symptoms but may cause structural wknss of tendon zPain quality-sharp twinges ie. Donning jacket, reaching OH, abd or IR arm

45. zOnset-gradual. May sometimes refer to C5-6 dermatome zRTC tears-acute, chronic, full, partial thickness tears; 5cm. Massive-usually traumatic but may be degenerative zpain-not always severe but pt con’t raise arm and has severs atrophy lat and ant deltoid region-may require surgery zAdhesive capsulitis-frozen shld.-trauma, disuse, immobilization, RTC lesions zpain-dull-severe with activity, pain at night

46. zOnset-gradual, will see increase activity of upper traps zImpingement syndrome-supra, long head biceps, subacro bursa most affected-pt. will exhibit painful arc of motion b/w 70-120 degrees z3 stages: zI-edema-athlete or poor posture, young person with no recollection of injury zII-fiborsis and tendinitis (20-40 yo)recurrent pain with activity zIII-bone spurs and tendon ruptures- long history (50-60yo)

47. zG-H instability-hum head dislocates through ant capsule, RTC ms. Can be weak zBrachial plexus lesions-numbness and burning entire arm, hand, fingers, sensory loss over 2 or more dermatomes, paralysis of arm, may be transcient - tenderness over BP with increased symptoms with movement of head to opposite side

48. zThoracic outlet syndrome-often called neurovascular compression-symptoms resulting from injury at upper border of thorax where BP and subclavian a are located-can be caused from a C-rib ztreatment-postural correction ex to bring back shoulders zBrach plex lesions-numbness and burning entire arm, hand, fingers-sensory los over 2 or more derm-paralysis of arm-may be transcient-tenderness over BP with increase symptoms when turning head opp. side

49. zDiagnostic tests- zX-ray-for bony defects, alignment, exostosis (bone spurs), osteophytes and diseases zC-T scans-specific for bone zMRI-magnetic resonance imaging-soft tissue-no radiation as in X-ray zangiography-contrast mat injected into vascular system zmyelograpy-inject dye into SA space zEEG-records brain electrical activity

50. zEMG and NVC-see if diseases are neuromuscular in origin zarthrogram-injects dye and air-views jt space, cartilage, ligs