1. 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/sh oulder_anatomy.htm http://www.readingshoulderunit.com/sh oulder_anatomy.htm

2. Shoulder Anatomy (2) The shoulder encompasses 5 separate articulations Sternoclavicular (SC) joint Acromioclavicular (AC) joint Coracoclavicular joint Glenohumeral (GH) joint Scapulothoracic (ST) joint

3. Sternoclavicular (SC) Joint ** Joint between the sternum and clavicle Allows for rotation during movements like shrugging the shoulders and reaching above the head. Supported by 4 ligaments- Fig 8-1 anterior and posterior SC ligament Costoclavicular ligament Interclavicular ligament

4. Acromioclavicular (AC) Joint** Lies between the acromion process and the clavicle Has limited motion Primary ligament: AC ligament Secondary ligaments Coracoacromial ligament Coracoclavicular ligaments

5. Glenohumeral (GH) Joint**(1) Fig 8-2 “true” shoulder joint Glenoid fossa of the scapula VERY shallow Head of the humerus (3-4 x larger than glenoid)-plunger/volleyball example lacking in bony stability

6. 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

7. GH joint** (3) Dynamic stabilizers rotator cuff muscles (SITS) Supraspinatus Infraspinatus Teres minor Subscapularis

8. Scapulathoracic Joint** Gliding joint Scapula rotates to allow full abduction and adduction Called Scapulothoracic rhythm Several important muscles are stabilzers including the: levator scapula, rhomboids, trapezius, and serratus anterior

9. Other shoulder anatomy (3) Bursa Subacromial (clinically most important) Nerve supply brachial plexus (C5-T1) Blood supply subclavian, axillary artery

10. 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)

11. Throwing Motion Activity Cocking, Acceleration, Deceleration Flexion, Extension, Hyperextension Abduction, Adduction Horizontal Adduction/Flexion Horizontal Abduction/Extension External rotation, Internal rotation Elbow Extended, Elbow Flexed

12. Anatomy of throwing Three phases of over arm throwing- Fig 8-10 and Box 8-1 Preparatory or cocking phase Acceleration or delivery phase Deceleration or follow-through phase Shoulder goes thru over ???°/sec-knee ???°/sec when walking Common injuries during the throwing motions Box 8-2

13. Cocking phase Arm in horizontal abduction, hyperextension and external rotation eccentrically loaded: horizontal adductors internal rotators scapular muscles rhomboids pull scapula back serratus anterior stabilizes the scapula

14. Acceleration or delivery phase Ball brought forward and released humeral horizontal add, elbow extension, rapid internal rotation romboids relax Large stresses placed on ligaments,

15. Arm deceleration/ follow through After ball release, until maximum shoulder internal rotation, horizontal adduction are reached Eccentric loads placed on: infraspinatus, supraspinatus, teres major and minor, lats, posterior deltoid

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

17. SC joint Sprain MOI: direct blow to clavicle or transition forces from a blow to the shoulder driving the clavicle out of place HOPS point tenderness over SC joint bruising, swelling and pain over SC joint deformity increases with degree; posterior is serious Motion decreases with degree TX-See Field Strategy 8.4

18. AC joint sprain “Separated Shoulder” MOI: fall on tip of shoulder, direct blow to the tip of the shoulder, falling on outstretched hand (FOOSH) HOPS point tenderness over AC joint bruising, swelling and pain over AC joint deformity increases with degree; or step deformity Piano key test positive in 3 degree TX: place in sling, x-ray; Field Strategy 8.5

19. GH joint sprains Two forms: Acute Dislocations Recurrent subluxations/ dislocations Acute Dislocations MOI: external rotation, abduction, extension Most are anterior dislocations may cause a avulsion of the anterior portion of the glenoid = Bankart lesion

20. Acute Dislocations (con’t) HOPS Intense pain Tingling and numbness down arm into the hand arm held at slight abduction, external rotation, and stabilized against the body Flattened appearance to the shoulder; acromion process becomes prominent (Fig 8-14) inability to move shoulder Tx-check neurovascular status, sling and ice if able; referral; DO NOT REDUCE

21. Chronic dislocations/ subluxation MOI: same as acute, force required is less HOPS: less symptoms than acute “dead arm syndrome” TX: conservative: therapy surgery if needed

22. Rotator Cuff impingement (1) Involves several structures: supraspinatus tendon micro-tears subacromial bursa coracoacromial ligament Glenoid labrum long head of bicep May lead to rotator cuff rupture if unchecked

23. Rotator Cuff impingement MOI: repetitive microtrauma (overuse) HOPS: pain with activity pain with overhand motions painful arch (between 70 and 120 degrees of AB) Inability to sleep on involved side + supraspinatus tests, impingement test TX: TX: cryotherapy, NSAID’s, rest, gradual strengthening, retraining of muscles

24. Bicipital Tendonitis MOI- overuse during rapid overhead movements with excessive elbow flexion and supination; Bicep tendon gets irritated in the bicipital groove and may partially sublux HOPS-pain in anterior aspect of shoulder over the bicipital groove; athlete may say something is “popping”; pain with resistive elbow flex and supination and passive stretch of bicep Tx- rest from motions that aggravate, ice, NSAID’s, strengthening and stretching

25. ROM/Muscle Testing Shoulder flexion-Ant Delt/Pec Major Shoulder extension-Post Delt Shoulder abduction-Middle Delt Shoulder adduction-Pec Major/Lats Shoulder internal rotation-Ant Delt/ Subscapularis Shoulder external rotation-Infraspinatus/ Teres Major Horizontal ADD/Flex-Ant Delt Horizontal ABD/Ext- Post Delt Scapula elevation, depression, protraction, and retraction

26. Special Tests Apprehension test (shoulder dislocation) Empty Can and Drop Arm Tests (supraspinatus) Impingement (impingement) Yergerson’s (biceps tendinitis)

27. HOPS History Observation Palpation