The Shoulder

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The Shoulder
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Shoulder Girdle Complex

• There are three primary articulations
• Glenohumeral joint
• Aromioclavicular joint
• Sternoclavicular joint

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Shoulder Girdle

• Dynamic Stability- mobility with stability.
• as in it can move around and be stable.
• Glenoid Fossa- concave part of the scapula that
  the humeral head articulates with.
• Glenohumeral joint- multi directional ball and
  socket joint that is held together by the
  ligments and muscles of the shoulder. Less
  stable than the hip ball and socket.

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The Joints of the Shoulder

• Acromion Process-
• The superior part of
• the scapula that you can palpate.
• Acromioclavicular joint (AC)- where the
  acromion and clavicle come together.

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The Joints of the Shoulder

• Sternoclavicular joint (SC)- where the clavicle
  and the sternum come together.

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The joints of the Shoulder

• Scapulothoracic Joint- the scapula slides over
  the back of the thorax (ribcage).
• Synergistically- muscle groups working together
  to move one joint and maintain dynamic stability.

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Rotator Cuff Muscles

• Infraspinatus- posterior inferior shoulder
• External rotation

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Rotator Cuff Muscles

• Subscapularis-anterior shoulder
• Internal rotation

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Rotator Cuff Muscles

• Supraspinatus-anterior superior shoulder
• abduction

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Rotator Cuff Muscles

• Teres Minor- posterior shoulder
• Adduction

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Muscle Force Couple

• Force Couple-two equal forces acting in opposite
  direction to rotate a part around an axis.
• deltoid
• Rotator Cuff

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Scapulothoracic Mechanics

• Scapular Movers-upper, lower, middle trapezius,
  rhomboids, serratus anterior and pectoralis
  minor.
• They work with rotator cuff muscles to
• Flex and extend shoulder
• Internal and externally rotate shoulder
• Abduct and adduct shoulder
• Hoizontally abduct and adduct shoulder

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Shoulder Injuries

• They can be one of two varieties
• Overuse-chronic typically limited to the soft
  tissue of the shoulder.
• Traumatic-acute

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Impingement Syndrome

• A condition that occurs when the space between
  the humeral head and the acromion above becomes
  narrowed.
• The three things that can get pinched are the
• joint capsule, tendons of rotator cuff, and
  bursa.

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Impingement Syndrome

• Impingement can create either bursitis, or
  tendonitis depending on what structure is being
  squeezed.
• Overhead athletes are more likely to have
  problems with this injury.
• 1/3 of shoulder problems are due to impingement.

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Impingement Syndrome

• Signs and Sx
• Pain and tender GH joint
• Pain and weak active abd in mid range
• Limited internal rotation
• Hawkins Test
• Tender subacromial area possibly into the deltoid

• Treatment
• Correct technique
• Strengthen inferior muscles
• Strengthen weak rotator cuff muscles

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Impingement Syndrome

• Special Tests
• Hawkins Test
• Neers Impingement
• Cross over Test

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Impingement Syndrome

• Stretches-
• 3 way door stretch
• Posterior shoulder
• Internal Rotation with
• Exercises
• Internal Rotation
• External Rotation
• Adduction

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Rotator Cuff Tears

• In the young person it is
• more of a traumatic injury,
• fall on outstretched arm,
• arm yanked back.
• Young person can have
• chronic injury that ultimately tears a
  tendon.
• In the older person it is a result of lose of
  elasticity in the muscle and tendon and can tear
  with everyday activities or a bone spur.

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Rotator Cuff Tears

• Signs and Sx
• With a parcial tear the athlete will feel pain
  but still be able to move with normal ROM.
• With a complete tear the athlete will not have
  normal ROM.
• Overhead motions are hardest.
• A shrug motion will result.
• Pain sleeping on injured side.

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Rotator Cuff Tears

• Special Tests
• Active Abdcution-look for hiking shoulder
• Drop Arm sign- athlete abduct above head then
  lowers slow, look for loss of muscle control.
• Supraspinatus muscle test- looking for weakness
• MRI is final diagnostic tool

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Biceps Tendonitis

• Discomfort in the front of the shoulder.
• Can be caused by impingement.
• Special Tests-
• Speeds Test
• Yergesons Test

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Traumatic Shoulder Injuries

• Shoulder Dislocation
• Glenoid Labrum Injuries
• Multidirectional Instabilites
• Acromioclavicular Separation
• Brachial Plexus Injury
• Fractures

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Anterior Shoulder Dislocation

• A humerus can dislocate
• Anteroinferiorly-front and down (most common)
• Inferiorly down
• Posteriorly -back

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Anterior Shoulder Dislocation

• Anterior dislocation happens when the arm is
  abducted to the side and a forceful external
  rotation happens.
• A doctor visit is necessary, immediately if the
  humerus does not relocate on its own.
• Even if it goes back a Hill-Sachs Lesion can
  occur.

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Anterior Shoulder Dislocation

• Rehabilitation is very important to this injury.
• Reinjury will likely happen if a first time
  injury happens before the age of 20.
• Surgery may be necessary if repeated dislocation
  occurs.

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Special Test-Dislocation

• Apprehension test

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Glenoid Labrum Injury

• Glenoid Labrum-a ring of cartilage attached to
  the margin of the glenoid cavity of the scapula.
• The labrum acts to keep the humeral head
  positioned on the glenoid by blocking unwanted
  movement.

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Glenoid Labrum Injury

• A labral tear can occur with a shoulder
  dislocation, more likely to occur with numerus
  dislocations.
• A degenerative tear can occur when a shoulder
  becomes loose, letting the humeral head slip over
  the labrum numerus
  times and eventually the
  labrum will fail/tear.

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Glenoid Labrum Injury

• Signs and Sx
• Pain with catching and popping
• Possible weakness
• Possible limited ROM
• Special Tests
• Clunk Test
• Cross Over Test

• Treatment
• Rotator Cuff strengthening
• Surgery

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Multidirectional Instabilities

• Typically an anatomical problem.
• Multiple dislocations will make it worse.
• Exercise may help with the problem, surgery
  sometimes, but not always
• Weight bearing exercise are helpful. Like what?

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Acromicavicular Separation

• Also known as an AC sprain.
• Occurs due to fall on outstretched arm or tip of
  shoulder. May be due to blow to tip of shoulder

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AC separation

• Signs and Sx
• deformity
• Pain in vicinity of AC
• Special Test
• Shear Test
• Sulcus Sign

• Treatment
• Three grades the grade determines treatment
• Grade one is exercise and ice
• Grade two immobilize 3 weeks and then exercise
• Grade three immobilize 5 weeks and then exerccise

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Brachial Plexus Injury

• Brachial Plexus-group of nerves that leave the
  spinal cord and extend into the shoulder giving
  arm function.
• AKA-stinger or burner
• A result of stretching or compression of the
  nerves.

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Dermatones

• When looking at nerves you need to know level off
  spine injury relative to sensation and movement.
  
• Dermatomes is sensation areas corresponding to
  nerve.

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Myotomes

• Each of the spinal nerves controls certain
  muscles.  The muscles (or muscles) controlled by
  a particular nerve root are called its myotome.
• C4-Trapezius-shrug
• C5-deltoid-abduction
• C6-biceps- elbow flex
• C7-triceps- elbow ext
• C8-thumb ext
• T1- finger abduct/adduct.

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Brachial Plexus Injury

• Signs and Sx
• Pain in neck and arm
• Weakness in neck and arm
• Numb or pins and needles down arm

• Treatment
• Rest till Sx go away
• Ice after activity
• Anti-inflammatory
• Possible dr visit

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Fractures

• Typically caused by a direct blow.
• Clavicle and humerus, very rarely the scapula.
• Typically you will see deformity
• Xray necessary, immobilization 4-6 weeks minimum.

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We have strong shoulders

• cause we stay athletic as we age