Chapter 21 The Shoulder

Objectives Upon completion of this chapter, you should be able to: Name the three articulations that constitute the shoulder girdle complex Describe how stability of the shoulder is maintained Recite the names of the four muscles that come together to form the rotator cuff

Objectives (cont’d.) Upon completion of this chapter, you should be able to (cont’d.): Explain the anatomy of the shoulder complex Identify major injuries and conditions of the shoulder

Shoulder Muscles

Rotator Cuff Muscles supraspinatus Teres minor subscapularis Infraspinatus

Scapula Anatomy Vertebral Border Body Spinous Process Acromion Process Coracoid Process Coracoid Process Glenoid Fossa Body Spinous Process Axillary Border Vertebral Border Axillary Border

The Shoulder Girdle

The Shoulder Girdle Complex (cont’d.) The base of support of the shoulder complex comes from the scapula All of the muscles work synergistically to move the shoulder Force Couple- two forces acting in opposite directions to rotate a part around an axis Deltoid- raises ; Rotator Cuff MM. compress and depress Have them perform all shoulder movements : IR, ER, Abduction, Adduction, Horizontal abduction/adduction, Flexion, Extension (Scapula: elevate, depress, protraction, retraction) Show them scapula movement when they are doing these motions

Movements of the Scapula

Movements of the Scapula

Movements of the Scapula

Movements of the Scapula

Movements of the Shoulder

Overuse Injuries to the Shoulder Impingement syndrome Mechanical irritation of cuff tendons Symptoms: pain, tenderness in glenohumeral area, weakness with active abduction, limited IR, and test confirmation Treatment: prevention, preseason conditioning, cross-training, exercise, taping, and rehabilitation Avoid above head lifts or too many upper body lifts Tests – Neer (passive flexion), Hawkin’s, and crossover

Overuse Injuries to the Shoulder (cont’d.) Rotator cuff tears Treatment: Rehab may work, Surgery Partial thickness Symptoms: pain, able to move full ROM Full thickness Symptoms: pain, unable to move full range of motion, unable to lift the arm overhead, “catching” sensation, and varying degrees of disability Full- when trying to actively lift arm over head, can observe them shrug or hike their shoulder

Overuse Injuries to the Shoulder (cont’d.) Muscle strains Caused by overuse or traumatic injuries Symptoms: pain and tenderness Treatment: PRICE, gentle stretching, strengthening program, and cross-training

Overuse Injuries to the Shoulder (cont’d.) Biceps Tendonitis Can be confused w/ rotator-cuff tendonitis due to location Both can be caused by impingement and treated similarly Biceps tendon ruptures Not common in athletics Symptoms: sudden pain in the front of the shoulder associated with a “pop” Treatment: PRICE, can return to full activity without surgery Grade 3: complete rupture of biceps tendon long head; short head still attached

Traumatic Shoulder Injuries Anterior shoulder dislocation Head of the humerus is dislocated completely off of the glenoid fossa Arm is abducted to the side, with the elbow bent, and force applied to the arm causes external rotation Immobilization, aggressive rehab, may need surgery if rehab doesn’t help Most common Need comprehensive medical exam to evaluate for other injuries (fx, labral tear, nerve damage)

Traumatic Shoulder Injuries (cont’d.) Glenoid labrum injuries Deepest of the soft tissues in shoulder Sits on periphery of glenoid fossa Occurs with trauma (ie dislocation) Symptoms: pain, catching or popping sensation, weakness and limited use of arm Treatment: strengthening program, physician diagnosis, and sometimes surgery -Cartilagenous ring that acts to keep the humeral head positioned on the glenoid by blocking unwanted movement (ie wedge on bottom of door to hold in place) -Degenerated tear= repeated traumas (baseball pitchers susceptible) -Strenthening program with special attention to rotator cuff -Surgery to trim flaps or to repair

Traumatic Shoulder Injuries (cont.) Multidirectional Instabilities Humerus can slip out of joint without injury or provocation Usually bilateral Overly flexible Treatment Weight-bearing exercises: push-ups, plyometrics, and weight training Surgery does not usually improve condition -Can be a problem in sports requiring overhead movements

Traumatic Shoulder Injuries (cont’d.) Acromioclavicular separations Traumatic sprains of acromioclavicular joint Usually caused by direct blow to tip of the shoulder Symptoms: pain and deformity Treatment: physician referral 1st Degree: PRICE, and exercise to restore ROM and strength 2nd Degree: 3-4 weeks immobilization 3rd Degree: 6-8 weeks immobilization -”E” in this case means Exercise NOT Elevation -Overhead exercises not recommended -2nd degree most painful; 2nd and 3rd degree may leave permanent cosmetic deformity, but should not impede function in long run

Traumatic Shoulder Injuries (cont’d.) Brachial plexus Injury Head and neck are forcibly pushed to one side, stretching the brachial plexus on the opposite side; Can compress the brachial plexus on the same side Brachial plexus- group of nerves leaving the spinal cord and extend from vertebrae into shoulder giving arm its ability to function Symptoms: pain, burning, and weakness Treatment: rest, ice, anti-inflammatory medication, and exercises to strengthen the neck and shoulder -Weakness/numbness in arm or hand; symptoms can last several minutes to several hours or more -chronic stingers may keep them from contact sports; each injury creates scar tissue developing around the nerves causing them to be entrapped. If too much scar tissue develops, if they receive another hit to the area, nerves may not be able to flex and will shatter instead which can cause permanent neurological damage. -Avoid with proper strengthening, proper fitting equipment, and proper blocking/tackling techniques

Traumatic Shoulder Injuries (cont’d.) Fractures of the shoulder Usually caused by an impact or blow Common areas: clavicle and humerus Can also fx glenoid and scapula Symptoms: deformity, ecchymoses, and bruising Treatment: support and transport to emergency room

Animation – Shoulder Injuries Click Here to Play Shoulder Injuries Animation

Shoulder Stretches

Is It a Shoulder Injury? Pain in the shoulder region does not always indicate a shoulder problem Referred pain can originate in other areas Cardiac problems Pinched or stretched nerves Pulmonary Pathology Visceral Pathology Spleen injury Cardiac-left shoulder ; -Pinched nerve, pulmonary, visceral- upper back and shoulder ; -Spleen- “Kehr’s sign”- left arm

Conclusion The upper extremity is one of the most challenging areas of the body to treat Understanding the mechanisms of injury will ensure appropriate rehabilitation The ATC must understand causes of common upper extremity conditions, so they can assess and manage the many different injuries