The Shoulder

Shoulder Girdle Complex Glenohumeral joint Acromioclavicular joint Scapulothoracic joint

Glenohumeral Joint Glenoid fossa Head of humerus

Acromioclavicular Joint Acromion process of scapula Clavicle

Scapulothoracic Joint Scapula Posterior ribcage

Bony Landmarks Sternum Clavicle Humerus Head of humerus Greater tubercle Lesser tubercle Bicipital groove Epicondyles Lesser tubercle Greater tubercle

Bony Landmarks Scapula Acromion Coracoid process Glenoid fossa Spine

Shoulder Girdle

Peer-Share-Review Bones & Markings Ready, Set, Go

Muscles of the Shoulder Deltoid Trapezius Pectoralis Major Pectoralis Minor Serratus anterior Rhomboid major Rhomboid minor Levator scapulae Coracobrachialis Biceps brachii

Deltoid Abducts shoulder

Trapezius Rotates scapula

Shoulder depression Scapular depression Punching Flex shoulder Adduct shoulder IR shoulder

Rhomboid Major/Minor Levator Scapulae Retract scapula Elevate scapula Elevates scapula

Coracobrachialis Flexes shoulder Adducts shoulder

Biceps Brachii Weakly flexes shoulder Two proximal heads Long head— supraglenoid tubercle of scapula Short head—coracoid process of scapula

Rotator Cuff Muscles Collective set of four deep muscles of the GH joint Supraspinatus Abduction of the arm Infraspinatus External Rotation of the shoulder Teres Minor External rotation of the shoulder Subscapularis Internal rotation of the shoulder www.round-earth.com/RotatorCuffTests.html

Rotator Cuff Muscles

Ligaments of the Shoulder Coracoclavicular Coracoacromial Coracohumeral Glenohumeral Acromioclavicular

Levator Scapula Trapezius Rhomboids Minor Deltoids Acromioclavicular (AC) joint Infraspinatus Rhomboids Major Serratus Anterior Teres Minor

Pectoralis Major Biceps (short & long head) Pectoralis Minor

Overuse injuries to the shoulder Common Injuries of the Shoulder Overuse injuries to the shoulder

Shoulder Impingement Syndrome Widely used term to describe pain occurring when space between humeral head and acromion become narrowed Bones “impinge” or compress structures that occupy the subacromial space Three structures: Joint capsule Tendons of rotator cuff Bursa

Impingement Syndrome Overhead sports Signs & Symptoms Baseball, tennis, swimming, volleyball Signs & Symptoms Pain and tenderness in GH Pain and/or weakness with active abduction in mid-range Limited IR Confirmation with special tests Empty can Point tenderness in subacromial area

Impingement Syndrome— Treatment Address biomechanics Substitute with cross-training until condition resolves Limit excessive overhead movement Rehab exercises & stretching

Rotator-Cuff Strain/Tears Traumatic injury i.e. FOOSH Unusual demands on young athlete Repetitive use leads to chronic condition Ultimately tear in tendons Partial thickness tear Not completely severe tendon May respond well to non-op treatment Full thickness tear Require surgery

Rotator-Cuff Strains/Tears- Signs & Symptoms Pain with muscle contraction “Catching” sensation when arm moved Inability to sleep on affected side Varying degrees of disability Decreased strength Swelling

Rotator-Cuff Strains/Tears- Treatment RICE Limit activity - asymptomatic Shoulder strengthening Progressive RTP throwing program

Biceps Tendonitis Discomfort in anterior shoulder Often confused with RC tendonitis Can be caused by impingement

Traumatic Shoulder injuries Common Injuries of the Shoulder Traumatic Shoulder injuries

Glenohumeral Dislocation Forced abduction, external rotation of shoulder Signs and Symptoms Flattened deltoid Pain and Swelling Disability Requires immediate care by physician Additionally injuries include: Fractures Glenoid labral tears Axillary nerve damage

Glenoid Labrum Cartilaginous ring that acts to keep the humeral head positioned on the glenoid by blocking unwanted movement

Glenoid Labrum Injuries Injury occur with : Acute trauma (dislocation) Repeated trauma Degenerated tear (baseball pitchers) Repetitive subluxation Labral rim degenerate over time Signs & Symptoms Pain Catching or popping sensation Limited ROM Varying degrees of weakness Special Tests MRI

SLAP Tear Superior Labrum from Anterior to Posterior Occurs at point where biceps tendon inserts on labrum Area of relatively poor blood supply FOOSH Repetitive overhead actions Lifting a heavy object

Acromioclavicular Separation Direct blow to tip of shoulder FB player falling on tip of shoulder or FOOSH Signs & Symptoms Pain in vicinity of AC joint Possible deformity of joint depending on degree of sprain

AC Separation—Treatment RICE Rehab ROM & strengthening as tolerated Overhead exs not recommended 2nd degree 3-4 weeks immob Most painful 3rd degree 6-8 weeks immob May leave permanent deformity

Acromioclavicular Separation

Clavicle Fracture Fall on tip of shoulder Direct impact FOOSH Direct impact Signs and Symptoms Pain, deformity, and swelling Refer to physician

Brachial Plexus Injury Stinger Burner Occurs when head and neck forcibly moved/hit to one side Nerves and brachial plexus compressed on that side Painful and disabling

Brachial Plexus Group of peripheral nerves Leave spinal cord & extend from vertebrae into shoulder Give arm ability to function

Brachial Plexus Injury— Signs & Symptoms Intense pain from neck down to arm Arm will feel like it’s on fire or have pins- and-needles sensation Arm/hand may be weak and numb Intense pain in area of brachial plexus Symptoms last several minutes to several hours or more Weakness may last for several days depends on severity of injury

Brachial Plexus Injury— Treatment Resting neck/arm until pain & symptoms go away Ice pack 20 minutes every 3-4 hours Anti-inflammatories Strengthening exercises RTP determined by sports medicine staff Subsequent stingers cause for further testing

Brachial Plexus Injury— Treatment Chronic stingers may eliminate athlete from contact sports Scar tissue develops around nerve ® Causes nerves to become entrapped If athlete receives another blow, brachial plexus may not be able to flex shatters instead, tearing major nerves of arm Causes permanent neurological damage Avoid by: Keeping neck and shoulders as strong as possible Properly fitted equipment Proper tackling & blocking techniques

Special Tests

Special Tests for Shoulder Hawkin’s-Kennedy Impingement Anterior Apprehension Piano Sign Apley’s Scratch Empty Can Drop-arm Sign http://www.operationsnow.com/hper/physed/athletictraining/ch22.mhtml

Hawkin’s-Kennedy Seated Shoulder in 90 degrees of flexion, slight horizontal adduction, & maximal internal rotation (+) reproduction of pain Subacromial Impingement

Drop Arm Sign

Apprehension-relocation Supine with are @ 90 degrees of abduction & external rotation 1 had placed as a fulcrum just posterior to humeral head then passively move shoulder into maximal external rotation against fulcrum of other hand (+) reproduction of shoulder pain, or apprehension with movement Glenohumeral subluxlation

Piano Key/Sign – AC Separation Seated or standing Clinician presses downward on elevated end of clavicle (+) pain or excessive movement of clavicle AC separation

Empty Can Test—Supraspinatus Seated Elevate UE to 30-45 degrees in plane of scapula with internal rotation (thumb down); resist elevation (+) pain & weakness

Apley’s Scratch – shoulder mobility Sitting 3 part test Reach across chest & place hand on opposite sholder Reach overhead to place hand between scapula Reach behind back as high as possible *compare bilaterally (+) asymetrical motion Restriction in horizontal adduction, IR, scapular protraction Restriction I abduction, ER, scapular upward rotation and elevation Restriction in adduction, IR, scapular downward rotation and retraction

Find a partner and let’s practice Questions? Find a partner and let’s practice