ATC 222 Chapter 21 The Shoulder Complex Anatomy n n Bones – –clavicle – –humerus – –scapula.

ATC 222ATC 222Chapter 21Chapter 21

The Shoulder The Shoulder ComplexComplex

AnatomyAnatomy Bones

– clavicle– humerus– scapula

Ligaments Sternoclavicular Sternoclavicular Acromioclavicular Acromioclavicular GlenohumeralGlenohumeral

MusclesMuscles Rotator CuffRotator Cuff

– S.I.T.S.S.I.T.S.– surrounding musculaturesurrounding musculature

Nerve SupplyNerve Supply

Brachial Plexus C5-T1Brachial Plexus C5-T1

Blood SupplyBlood Supply

Subclavian ArterySubclavian Artery Axillary ArteryAxillary Artery Brachial ArteryBrachial Artery

Shoulder Shoulder AssessmentAssessment

H.O.P.S.H.O.P.S.– HistoryHistory– ObservationObservation– PalpationPalpation– Special TestsSpecial Tests

Recognition & Recognition & Management of Management of Specific InjuriesSpecific Injuries

FracturesFractures ClavicularClavicular HumerusHumerus

– ShaftShaft– ProximalProximal– EpiphysealEpiphyseal

Clavicular Clavicular FracturesFractures

EtiologyEtiology– fall on outstretched arm or tip of fall on outstretched arm or tip of

shouldershoulder– direct impactdirect impact

Signs and SymptomsSigns and Symptoms– supports the arm on the injured supports the arm on the injured

side tilting the head toward that side tilting the head toward that side and the chin oppositeside and the chin opposite

ManagementManagement– apply sling and swatheapply sling and swathe– refer for x-rayrefer for x-ray– immobilize 6-8weeksimmobilize 6-8weeks

Clavicular Clavicular FracturesFractures

Humeral Humeral Fractures-ShaftFractures-Shaft EtiologyEtiology

– direct blow or fall on the armdirect blow or fall on the arm Signs and SymptomsSigns and Symptoms

– probable deformityprobable deformity– wrist drop and inability to wrist drop and inability to

supinate the wristsupinate the wrist

Humeral Humeral Fractures-ShaftFractures-Shaft ManagementManagement

– splint and referral to a physiciansplint and referral to a physician– 3-4 months3-4 months

Humeral Humeral Fractures-Fractures-ProximalProximal

EtiologyEtiology– direct blow, fall on outstretched direct blow, fall on outstretched

arm, or dislocationarm, or dislocation Signs and SymptomsSigns and Symptoms

– often mistaken for a shoulder often mistaken for a shoulder dislocationdislocation

– possible severe hemorrhagingpossible severe hemorrhaging

Humeral Humeral Fractures-ProximalFractures-Proximal

ManagementManagement– sling and swathe and referralsling and swathe and referral– 2-6 months2-6 months

Humeral Humeral Fractures-Fractures-EpiphysealEpiphyseal

EtiologyEtiology– direct blow or indirect force along the direct blow or indirect force along the

axis of the humerusaxis of the humerus Signs and SymptomsSigns and Symptoms

– shortening of the armshortening of the arm– appearance of a false jointappearance of a false joint

ManagementManagement– splint and referralsplint and referral to a physician to a physician

– immobilization for 3 weeksimmobilization for 3 weeks

SprainsSprains SternoclavicularSternoclavicular AcromioclavicularAcromioclavicular Glenohumeral;Glenohumeral;

Sternoclavicular Sternoclavicular SprainSprain

EtiologyEtiology– indirect force transmitted through the indirect force transmitted through the

humerushumerus– twisting of an posteriorly extended armtwisting of an posteriorly extended arm

Signs and SymptomsSigns and Symptoms– Grade 1Grade 1– Grade 2: visible deformity and inability Grade 2: visible deformity and inability

to abduct armto abduct arm


– Grade 3: complete dislocation, if Grade 3: complete dislocation, if posterior, it’s a MEDICAL posterior, it’s a MEDICAL EMERGENCYEMERGENCY


ManagementManagement– RICERICE– reduction, immobilization 3-reduction, immobilization 3-

5weeks5weeks

AcromioclaviculaAcromioclavicular Sprainr Sprain

EtiologyEtiology– direct impact to tip of shoulderdirect impact to tip of shoulder– upward force against long axis of upward force against long axis of

humerus, falling on outstretched humerus, falling on outstretched armarm


Signs and SymptomsSigns and Symptoms– Grade 1:Grade 1:– Grade 2: prominent lateral end of Grade 2: prominent lateral end of

clavicle, unable to completely abduct clavicle, unable to completely abduct or horizontally adductor horizontally adduct

– Grade 3: rupture the AC and Grade 3: rupture the AC and Coracoclavicular ligaments resulting Coracoclavicular ligaments resulting in a dislocation of clavicle, very in a dislocation of clavicle, very prominent distal clavicleprominent distal clavicle


ManagementManagement– apply ice and sling and swatheapply ice and sling and swathe– referralreferral– Grade 1: 3-4 daysGrade 1: 3-4 days– Grade 2: 10-14 daysGrade 2: 10-14 days– Grade 3: 2 weeks, Operative vs. Grade 3: 2 weeks, Operative vs.

Non-operativeNon-operative

Glenohumeral Glenohumeral Joint SprainJoint Sprain

EtiologyEtiology– forceful abduction and ERforceful abduction and ER– forceful movement posteriorly forceful movement posteriorly

with flexion of armwith flexion of arm Signs and SymptomsSigns and Symptoms

– decreased ROMdecreased ROM– pain with reproduction of pain with reproduction of

mechanismmechanism

Glenohumeral Joint Glenohumeral Joint SprainSprain

ManagementManagement– ice and sling for comfortice and sling for comfort– initiate active and passive ROM initiate active and passive ROM

after 1-3 daysafter 1-3 days

Acute Acute Subluxations & Subluxations &

DislocationsDislocations accounts for up to 50% of all accounts for up to 50% of all

dislocationsdislocations only 1-4% are posterioronly 1-4% are posterior 85-90% recur85-90% recur

Glenohumeral Glenohumeral Dislocations-Dislocations-

AnteriorAnterior EtiologyEtiology

– direct impact on posterolateral direct impact on posterolateral or posterior aspect of shoulderor posterior aspect of shoulder

– forced abduction and ERforced abduction and ER

Glenohumeral Glenohumeral Disloccations-Disloccations-

AnteriorAnterior

Signs and SymptomsSigns and Symptoms– flattened deltoid contourflattened deltoid contour– humeral head in the axillahumeral head in the axilla– arm carried in slight abduction and ERarm carried in slight abduction and ER

Glenohumeral Glenohumeral Dislocations-Dislocations-

AnteriorAnterior ManagementManagement

– immobilize in sling and immobilize in sling and application of iceapplication of ice

– referral to a physician for referral to a physician for reduction and x-rayreduction and x-ray

– DO NOT attempt to reduceDO NOT attempt to reduce

Glenohumeral Glenohumeral Dislocation-Dislocation-

PosteriorPosterior EtiologyEtiology

– forced adduction and IRforced adduction and IR– fall on extended and internally fall on extended and internally

rotated armrotated arm Signs and SymptomsSigns and Symptoms

– arm held in adduction and arm held in adduction and internal rotationinternal rotation

– head of humerus may be seen head of humerus may be seen posteriorlyposteriorly

Chronic Shoulder Chronic Shoulder InstabilitiesInstabilities

EtiologyEtiology– traumatic (micro vs. macro), traumatic (micro vs. macro),

atraumatic, congenital, and atraumatic, congenital, and neuromuscularneuromuscular

Signs and SymptomsSigns and Symptoms– AnteriorAnterior– PosteriorPosterior– GlobalGlobal

Chronic Shoulder Chronic Shoulder InstabilitiesInstabilities

ManagementManagement– Conservative vs. SurgicalConservative vs. Surgical– shoulder harnessshoulder harness

Shoulder Shoulder Impingement Impingement

SyndromeSyndrome EtiologyEtiology

– repetitive overhead activities repetitive overhead activities – capsular laxity leading to capsular laxity leading to

inflammationinflammation– forward head and rounded forward head and rounded

shoulders shoulders – hooked shaped acromion processhooked shaped acromion process

Rotator Cuff TearsRotator Cuff Tears

partial thickness vs. complete partial thickness vs. complete thickness tearsthickness tears

acute trauma or impingementacute trauma or impingement nearly always involves the nearly always involves the

supraspinatus musclesupraspinatus muscle


SyndromeSyndrome Signs and SymptomsSigns and Symptoms

– diffuse pain around the acromiondiffuse pain around the acromion– pain with overhead activitiespain with overhead activities– weak external rotatorsweak external rotators


SyndromeSyndrome Stage IStage I

– aching after activityaching after activity– pain with abduction that becomes worst pain with abduction that becomes worst

at 90 degreesat 90 degrees– pain with flexion and resisted pain with flexion and resisted

supination and external rotationsupination and external rotation Stage IIStage II

– aching during activity that becomes aching during activity that becomes worst at night, restricted movementworst at night, restricted movement


SyndromeSyndrome Stage III (25-40)Stage III (25-40)

– pain during activity with increase pain during activity with increase pain at nightpain at night

– possible muscle tear and possible muscle tear and permanent thickening of rotator permanent thickening of rotator cuff & bursacuff & bursa

– scar tissuescar tissue


SyndromeSyndrome Stage IV (40+)Stage IV (40+)

– infraspinatus and supraspinatus infraspinatus and supraspinatus wastingwasting

– a lot of pain with abduction to 90a lot of pain with abduction to 90– limited AROM and PROMlimited AROM and PROM– weakness during abduction and ERweakness during abduction and ER


SyndromeSyndrome ManagementManagement

– RICERICE– Modification of activityModification of activity– Strengthening of ER and Strengthening of ER and

Scapular StabilizersScapular Stabilizers– Surgery vs. InjectionSurgery vs. Injection

Shoulder BursitisShoulder Bursitis EtiologyEtiology

– fall on tip of shoulderfall on tip of shoulder– direct impact or shoulder direct impact or shoulder

impingementimpingement Signs and SymptomsSigns and Symptoms

– pain with abduction, flexion and IRpain with abduction, flexion and IR ManagementManagement

– cold, antiinflammatory medicationscold, antiinflammatory medications

Bicipital Bicipital TenosynovitisTenosynovitis

Biceps Brachii Biceps Brachii RuptureRupture

Peripheral Nerve Peripheral Nerve InjuriesInjuries

EtiologyEtiology– blunt trauma or stretchblunt trauma or stretch

Signs and SymptomsSigns and Symptoms– constant “burning” pain, muscle constant “burning” pain, muscle

weakness and atrophyweakness and atrophy– paralysisparalysis

Peripheral Nerve Peripheral Nerve InjuriesInjuries

ManagementManagement– iceice– resume play when symptoms resume play when symptoms

subsidesubside– referral to a physician is referral to a physician is

ESSENTIAL if symptoms persistESSENTIAL if symptoms persist

Thoracic Outlet Thoracic Outlet Compression Compression

SyndromeSyndrome EtiologyEtiology

– compression of brachial plexus, compression of brachial plexus, subclavian artery and vein subclavian artery and vein (neurovascular bundle)(neurovascular bundle)

– compression by the scalene and compression by the scalene and pectoralis muclespectoralis mucles


SyndromeSyndrome

Signs and SymptomsSigns and Symptoms– paresthesia and painparesthesia and pain– impaired circulation in the fingersimpaired circulation in the fingers– muscle weakness and atrophymuscle weakness and atrophy


SyndromeSyndrome ManagementManagement

– stretching of pectorals and stretching of pectorals and scalenesscalenes

– strengthening of the traps, strengthening of the traps, rhomboids, serratus anteriorrhomboids, serratus anterior

ATC 222 Chapter 21 The Shoulder Complex Anatomy n n Bones – –clavicle – –humerus – –scapula.

Documents

humerus n signs

dislocation n signs

days slide

shoulder assessment

wrist slide

musculature slide

flexion of arm n signs

extended arm n signs