1. The SHOULDER

2. THE SHOULDER Anatomy Separations Fractured Clavicle Dislocations
Supraspinatus Tendonitis

3. THE SHOULDER Scapulothoracic Acromioclavicular Sternoclavicular
Glenohumeral

4. Shoulder (Anterior View)

5. Acromioclavicular Separation
Mechanisms of Injury:
Fall on the tip of the unprotected shoulder.
Fall on the outstretched hand.
Downward force on the acromion from above.

6. Grade of Injury of A/C Grade 1:
Small tear of the capsule of the AC joint. No instability of joint.
P.O.P.

7. Grade 2: Tear of the A/C joint capsule and a small tear of the coraco-clavicular ligaments.

8. Degree of Injury of A/C
Grade 3: Tear of the acromio-clavicular ligament and the coraco-clavicular ligament.

9. Distal End of Clavicle
GRADE 3 A-C
SEPARATION

10. INSTABILITY OF A-C Jt.
Grade 1: No instability of acromio-clavicular joint.
Grade 2: Slight instability of A-C joint. ‘Springy’ clavicle.
Grade 3: Total separation of A-C joint. The clavicle goes superiorly.

11. ACTIVE MOVEMENTS TO ASSESS A-C Jt.
Abduction
Cross Flexion

12. CROSS FLEXION

13. Active Abduction of the Shoulder Joint
Grade 1: Full R.O.M. with pain at end of range.
Grade 2: Has over 45º of motion but not 90º.
Grade 3: less than 45º.

14. Return Time Estimates
Grade 1: One week to ten days.
Grade 2: Two to three weeks.
Grade 3: Four to six weeks.

15. CRITERIA FOR RETURN
Medical clearance.
Full Range of Motion.
Strength with 90%
Able to do “high five”
Protect the joint.

16. CLAVICLE ‘S’ shape bone.
Protects neuro-vascular bundle and for muscle attachment.
Securely anchored at either end.

17. CLAVICLE FRACTURE
Any force that brings the shoulder to the midline of the body.
Direct impact to clavicle from superior or anterior direction.

18. Clavicle Fracture: Signs & Symptoms
Pain and loss of function of shoulder.
Spasm of trapezius and SCM (sternocliedomastoid) m.
Arm held to body, shoulder elevated.

19. Clavicle Fracture: Signs & Symptoms
May be palpable deformity when palpating the clavicle.
In a pre-pubescent person, they may get a ‘greenstick’ fracture.
MEDICAL REFERRAL!

20. Sternoclavicular Joint
Costoclavicular Ligament
Sternocavicular Ligament
Clavicle
1st Rib
Sternum

21. STERNOCLAVICULAR JOINT SEPARATION
Very stable joint. Major ligaments are the sternoclavicular and costo-clavicular ligaments.
Mechanism of Injury is the same as for the A.C. joint.
Pain. Loss of motion. The unaffected side looks higher.

23. PENDULAR EXERCISES

24. Flexion
CW Rotation
CCW Rotation
Adduction
Abduction
Extension

26. ANATOMICAL PREDISPOSITION TO DISLOCATION
Glenoid Defects
Labral Defects
Neuromuscular Disorders

28. TERMINOLOGY
LUX = DISLOCATE
SUBLUX = PARTIAL DISLOCATION

29. TRAUMATIC
Single force applies excessive overload to the soft tissues of the joint and often damages the Glenoid Labrum (Bankart Lesion) and the joint capsule.

30. ATRAUMATIC
Athlete who has multiple joint laxities, who had frequent episodes of sub-luxations before and a relatively minor one results in dislocation (Congenital hypermobility and/or muscle weakness)

31. ACQUIRED
Sports such as swimming, gymnastics and baseball where repetitive micro-trauma, poor stretching and motion lead to capsular stretching. Eventual feeling of instability.

32. Bones of Shoulder Joint
Clavicle
Acromion Process
Glenoid
Posterior
Anterior

33. LABRUM
Cartilage ring around the glenoid. Deepens the socket of the G-H Joint.

34. Coracoclavicular
Acromioclavicular
Coraco-acromial Lig.
Superior, Middle and Inferior Glenohumeral Ligament

35. Pectoralis Major
Deltoid
Long Head of Biceps

36. 1 2 3 4
Subscapularis
Supraspinatus
Infraspinatus
Teres Minor

37. Posterior Musculature
Supraspinatus
Infraspinatus
Teres Minor

38. PRIMARY MOVERS Deltoid Pectoralis Major
(Latissimus Dorsi is posterior)

39. TYPES OF DISLOCATIONS Anterior (85%) Inferior (5%)
Posterior (10%)
Subcoracoid Dislocation

40. ANTERIOR DISLOCATION
Arm in abduction and external rotation. Force is taken on the hand or arm which increases the external rotation of the arm causing the head of the humerus to dislocate.

41. INFERIOR DISLOCATION
Arm is in excessive abduction and a force is taken on the hand pushing the head of the humerus inferiorly out of the glenoid.

42. Subcoracoid Dislocation

43. Subcoracoid Dislocation

44. Anterior Dislocation

45. Subcoracoid Dislocation
The elbow is held away from the side and the hand can not turn onto the stomach.

46. POSTERIOR DISLOCATION
The arm is in flexion and adduction. Force is taken on the hand, causing the head of the humerus to be push out the glenoid posteriorly.

47. POSTERIOR DISLOCATION
The coracoid process may be prominent. The elbow will be at the side and the hand on the stomach. Attempting to turn the arm out causes shoulder pain.

48. For any dislocated shoulder, do not try to reduce the joint
For any dislocated shoulder, do not try to reduce the joint. Do not pull on the arm.
Try to immobilize as best you can (difficult).
Medical referral!

49. Recurrent dislocations have nothing to do with the treatment after the first dislocation.
Recurrent dislocations are dependent upon the damage that happens during the first dislocation.

50. APPREHENSIVE SHOULDER TEST

51. When an athlete subluxes the glenohumeral joint, they experience a Dead Arm.
We do an Apprehension Test for the shoulder to determine if they subluxed the shoulder.

52. Apprehension Test Tell you to stop Roll their body towards the arm.
Fight what you are doing
Pull the arm to the body

53. SUPRASPINATUS IMPINGEMENT OF THE SHOULDER
OVERUSE INJURIES OF THE SHOULDER
SUPRASPINATUS IMPINGEMENT OF THE SHOULDER

55. IMPINGEMENT To impinge is to pinch.
The supraspinatus gets pinched between the humerus and the acromion and/or the coracoacromial ligament.

56. SUPRASPINATUS MUSCLE

58. FLEXION IMPINGEMENT

59. SIGNS AND SYMPTOMS
Painful Arc (Abduction)
Hand Behind Back decreased.
Weakness of external rotators of the shoulder.

60. INITIAL TREATMENT
Stretch into internal rotation.
Strengthen external rotators.
Modify activity.

61. Hand Behind Back One arm at a time. Thumb to middle of back.
Move up back.

62. STRETCH INTERNAL ROTATION
Arm with limited internal rotation.

63. EXTERNAL ROTATION STRENGTHENING

64. MEDICAL REFERRAL
PHYSIOTHERAPY