© 2007 McGraw-Hill Higher Education. All rights reserved. Chapter 18: The Shoulder Complex.

© 2007 McGraw-Hill Higher Education. All rights reserved.

Chapter 18: The Shoulder Complex


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/shoulder_anatomy.htm


Anatomy



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


Acromioclavicular (AC) Joint**

Lies between the acromion process and the clavicle

______________________ Primary ligament: ________________ Secondary ligaments

Coracoacromial ligament Coracoclavicular ligaments


Glenohumeral (GH) Joint**(1)

___________________________ Glenoid fossa of the scapula

____________________ Head of the humerus (3-4 x larger than

glenoid)-plunger/volleyball example _________________________


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


GH joint** (3)

Dynamic stabilizers rotator cuff muscles (SITS)

_______________ _______________ _______________ _______________




Other shoulder anatomy (3)

Bursa _______________ (clinically most important)

Nerve supply brachial plexus (________)

Blood supply _____________________________


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)


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


•Apprehension test (Crank test)

Apprehension test used for anterior glenohumeral instability This motion should

not be forced


• 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


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


Special Test Continue

Yerguson’s

Drop Arm


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 ________________________________


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 http://www.asmi.org/SportsMed/throwing/thrower10.html Throwing Program

Strengthen scapular stabilizers push-ups press-ups


Throwing Mechanics

•Instruction in proper throwing mechanics is critical for injury prevention


Windup Phase 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


Deceleration 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


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


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



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


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


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 __________________________________________

_______________________________



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


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 _______________________________________


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)


Rotator cuff tear Involves supraspinatus or rupture of other rotator cuff

tendons Primary mechanism - acute trauma (high velocity rotation-

degrees per sec??????)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


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


Shoulder Bursitis Etiology

___________________________________________________________________________

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


Bicipital Tendonitis Cause of Injury

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

© 2007 McGraw-Hill Higher Education. All rights reserved. Chapter 18: The Shoulder Complex.

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