2. Chapter 21
The Shoulder

3. 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

4. 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

5. Shoulder Muscles

6. Rotator Cuff Muscles supraspinatus Teres minor subscapularis
Infraspinatus

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

8. The Shoulder Girdle

9. 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

10. Movements of the Scapula

11. Movements of the Scapula

12. Movements of the Scapula

13. Movements of the Scapula

14. Movements of the Shoulder

16. 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

18. 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

20. 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

21. 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

23. 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)

26. 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

28. 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

29. 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

32. 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

34. 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

38. Animation – Shoulder Injuries
Click Here to Play Shoulder Injuries Animation

39. Shoulder Stretches

41. 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

42. 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