Sternoclavicular Joint

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Sternoclavicular Joint

• capsule properties
• capsule reinforcers
• movement of joint

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Capsule properties

• A synovial joint with a fibrocartilaginous disk
  separating cavity in two
• Strong joint capsule surrounds medial end of
  clavicle, fibrocartilaginous disk, and articular
  surface of manubrium of sternum

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Capsule reinforcers

• Three ligaments
• posterior and anterior sternoclavicular ligaments
  anterior and posterior surface of the capsule
• interclavicular ligament extends from one
  clavicle to the other
• costoclavicular ligament strong accesory
  ligament which joins the clavicle to the first rib

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Capsule reinforcers

• subclavius muscle
• Originates at costal cartilage of first rib
• Inserts on inferior aspect of clavicle

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Movement of joint

• Superiorly/inferiorly with 30 to 40 of motion
• Anteriorly/posteriorly with 30 of motion
• Rotates anteriorly/posteriorly along axis with
  40 to 50 of motion

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Injuries to the Sternoclavicular Joint

• Dislocation of the clavicle at the sternum
• May impinge on the great vessels of the superior
  mediastinum and compress or disrupt them
• Fracture of the clavicle
• Most commonly broken bone in thoracic cavity
• Occurs mainly in middle third of clavicle
• May cause damage to the axillary artery

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Acromioclavicular Joint

• It is where the oval facet on the medial surface
  of the acromion and similar facet on the lateral
  end of the clavicle meet.
• It is a small gliding synovial joint that serves
  as a bony restriction to moving the arm above the
  head.

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Ligaments

• This joint in reinforced by three different
  ligaments.
• Superior acromioclavicular ligament- a
  quadrilateral band that extends from the superior
  acromial end of the clavicle to the superior
  portion of the acromion process.
• Inferior acromioclavicular ligament- This
  ligament is somewhat thinner than the superior,
  and it covers the inferior part of the
  articulation.
• Coracoclavicular ligament- This is not actually a
  part of the AC joint but serves as a supporting
  mechanism for retaining contact between the
  clavicle and acromion process. It is composed of
  a trapezoid ligament, which attaches to the
  trapezoid line on the clavicle, and a conoid
  ligament, which attaches to the related conoid
  tubercle.

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Ligaments
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Movement

• Protration/Retraction with a range between 30
  and 50 degrees.
• Lateral and Medial movement with a range of
  roughly 60 degrees.
• Scapular elevation and depression with a range of
  roughly 30 degrees.
• The movements of the AC joint are opposite of the
  movements of the sternoclavicular joint for
  elevation, depression, protraction and
  retraction.

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Injuries

• The acromial end of the clavicle tends to
  dislocate at the AC joint with trauma (a direct
  blow to the shoulder football or hockey
  injuries).
• A minor injury will often tear the fibrous joint
  capsule and acromioclavicular ligament.
• A more severe injury will disrupt the
  coracoclavicular ligament and result in elevation
  and upward subluxation of the clavicle.

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Injuries

• There are different severities of joint
  separation at the AC joint. The are 6 types of
  separation.
• Type I A sprain (without a complete tear) of
  either of the ligaments holding the joint
  together. The clavicle is not displaced.
• Type II A complete tear of the acromioclavicular
  ligament and a partial tear of the
  coracoclavicular ligaments. The clavicle is
  slightly displaced.
• Type III A complete tear of both the
  acromioclavicular ligament and the
  coracoclavicular ligaments. When this occurs the
  clavicle is severely displaced (dislocated).
• Types IV, V, VI A complete tear of the
  acromioclavicular ligament and the
  coracoclavicular ligaments. The clavicle is
  severely dislocated and usually requires surgical
  intervention.

shoulderpaininfo.com/shoulderACSeparation.html
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Injuries
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The Glenohumeral Joint
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Ball and Socket

• Synovial ball and socket joint
• Greatest ROM and movement potential of any joint
  in the body

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Structural Makeup
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Structural Makeup

• Contains a small, shallow socket called glonoine
  fossa
• Deepened by a rim of fibroid cartilage called the
  glenoid labrum that is strengthened by
  surrounding ligaments and tendons
• Allows for excessive range

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Anterior Support

• CCL - coracoclavicular ligamentsCAL -
  coracoacromial ligaments
• SGHL - Superior GlenoHumeral LigamentMGHL -
  Muperior GlenoHumeral LigamentIGHL - Inferior
  GlenoHumeral Ligament

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Anterior Support

• Also supported by
• Glonoine labrum
• 3 reinforcements in the capsule
• Fibers of the subscapularis and the pectoralis
  major

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Posterior Support

• Reinforced by
• Joint capsule
• Glenoid labrum
• Fibers of the teres minor and infraspinatus

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Superior Aspect

• Ganoid labrum
• The coracohumeral ligament
• Supraspinatus
• Long head of the biceps brachii

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Inferior Aspect

• Minimally reinforced by the capsule and the long
  head of the triceps

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Bursa

• Subacromial bursae lie over the supraspinatus
  muscle
• The bursa and supraspinatus muscle are compressed
  as the arm rises above the head

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Movement of the GHJ
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RotationLimited by abduction
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Internal Rotation90
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IRLimits abduction
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More IR
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Guess what? more IR
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External Rotation90
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More ERLimits flexionWith max ER max flexion
is 30
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Flexion 180Limited by external rotation
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Extension180
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Another way to look at flexion and extension
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Hyperextension 60
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Abduction180Is limited by max internal
rotation-60
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Adduction Hyperadduction 75
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Another way to look at AD and AB duction
horizontally
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Abduction and flexion

• Uses deltoid and teres minor
• Humerus head is depress in these actions
• First 50 is deltoid
• Deltoid tires easily
• Teres kicks in to help

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Scapula

• Uses serratus anterior and trapezes to rotate and
  laterally and superiorly move the scapula

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Rotator Cuff

• Comprised of teres minor, subscapularis,
  infraspinatus, and the supraspinatus
• When the arm is elevated in abduction and flexion
  (including rotation) stabilize the humeral head
  so injuries dont occur

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Ouch

• Extreme range of motion is need for activities
  such as throwing, tennis, swimming, gymnastics,
  hanging wall paper, or activities that require
  your arm to work above your head
• If deltoid and rotator cuff muscle fatigue or are
  weak while participating in activities that need
  extreme range of motion then injuries can occur.

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Rotator Cuff Injuries

• Dislocation
• Tear
• Impingement
• Frozen shoulder
• Tendinopathy

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Dislocation

• Anterior (most frequent)- traumatic incident
• - occurs due to glenoid cavity supported by
  fibrocartilaginous glenoid labrum and its
  ligamentous support
• -inferior glenoid cavity tears
• -becomes susceptible to further dislocations
• -axillary nerve damaged by compression from
  humoral head through quadrangular space
• -lengthening effect may stretch radial nerve
  and produce paralysis

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(Dislocation)

• Posterior (extremely rare)
• -most common cause extremely vigorous muscle
  contractions
• -may be associated with epileptic seizures

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Tears

• Most occur in supraspinatus
• Most common in ages 40
• Patients in acute trauma, overhead work
  activities, and some sports players most at risk
• Ex) painting, stocking shelves, construction,
  swimmers, pitchers, tennis players

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(Tears)

• Symptoms
• -Acute follows trauma
• -Chronic repetitive overhead activity that
  causes degeneration of tendon
• Pain at front down through side of arm
• First response- mild and only present with
  activity (aspirin or ibuprofen)
• Later response- at rest or even NO activity
  (cannot lie on side at night, stiffness, loss of
  motion)

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(Tears)

• Diagnosis
• -measure range of motion in multiple areas
• -test strength of arm
• -check for instability
• -MRI or x-ray

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(Tears)

• Treatment
• -non surgical
• Rest and limit overhead activity
• Wear sling
• Anti-inflammatory medication
• Steroid injection
• Strengthening exercises (PT)
• -surgical
• debridement trimming/ smoothing
• suturing 2 sides of tendon (complete)

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Impingement

• Excessive rubbing of tendons against acromial
  bone
• Tendon begins to break down near its attachment
• Can cause complete tear of tendon from bone

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(Impingement)

• Symptoms
• - aching from top/front (outer side of upper
  arm)
• -worse at night (interrupts sleep)
• -unusual weakness in arm

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(Impingement)

• Development
• - difference in joint anatomy in people
• -form/ dimensions of acromial bone
• -origination of spurs at the front edge
  (effects forward elevation)
• -overuse (sports/ occupational activity)
• -instability of shoulder (slight movement
  forward during certain activities)

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Frozen Shoulder (Adhesive Capsulitis)

• Gradual onset of pain and limitation of shoulder
  motion
• Thickening and tightening of soft tissue capsule
  that surrounds joint
• -upon inflammation scaring occurs and adhesions
  form (intrudes on space needed for movement
  within joint)

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(Frozen Shoulder)

• Types
• - Primary changes in immune system,
  biochemical, or hormonal inbalances
• diabetes, cardiovascular, or neurological
  disorders may contribute
• may affect both shoulders
• may be resistant to most forms of treatment
• -Secondary (acquired) develops from known
  cause (stiffness after injury, surgery, or
  prolonged period of immobilization)

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(Frozen Shoulder)

• Prognosis
• - without treatment it lasts approximately 1-3
  years but is very painful
• - even after years of being cured some patients
  complain of stiffness but no serious pain or
  functional limitations

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Tendinopathy

• Mainly involves supraspinatus (passing through
  acromion and acromioclavicular ligament)
• Swelling of muscle, excessive fluid within
  subacromial/subdeltoid bursae, or subacromial
  spurs may produce significant impingement during
  abduction

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(Tendinopathy)

• Blood supply to tendon is poor
• Repetitive trauma may make susceptible to
  degenerative change resulting in Ca deposits
  (extreme pain)
• -further susceptible to trauma and partial or
  full thickness tears may easily develop
• -most common in older patients resulting in
  considerable difficulty in carrying out ADLs

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