1. The Shoulder Complex

2. © 2007 McGraw-Hill Higher Education. All rights reserved. The shoulder is an extremely complicated region of the body Greater mobility = Greater Instability Involved in a variety of overhead activities  susceptible to a number of repetitive and overused injuries Movement and stabilization of the shoulder requires the cooperation of: Rotator cuff muscles Joint capsule Scapula stabilizing muscles General Knowledge

3. © 2007 McGraw-Hill Higher Education. All rights reserved. General Knowledge 3 Main Joints  Glenohumeral Joint = humerus and scapula  Sternoclavicular Joint (SC) = Sternum and clavicle  Acromioclavicular Joint (AC)= Acromion and distal clavicle Labrum  cartilage that lines the glenoid fossa providing support and protection to the humeral heal (similar to the meniscus) http://www.virtualmedicalcentre.com/videopage.as p?vidid=849 http://www.virtualmedicalcentre.com/videopage.as p?vidid=849

4. © 2007 McGraw-Hill Higher Education. All rights reserved. Basic Anatomy

5. © 2007 McGraw-Hill Higher Education. All rights reserved. Anatomy

6. © 2007 McGraw-Hill Higher Education. All rights reserved. Anatomy

7. © 2007 McGraw-Hill Higher Education. All rights reserved. Muscular Anatomy

8. © 2007 McGraw-Hill Higher Education. All rights reserved. Muscular Anatomy

9. © 2007 McGraw-Hill Higher Education. All rights reserved. Muscular Anatomy

10. © 2007 McGraw-Hill Higher Education. All rights reserved. Movements http://www.youtube.com/watch?v=FHq3K6J3Wq8 http://www.youtube.com/watch?v=RPRJPNCVRdE

11. © 2007 McGraw-Hill Higher Education. All rights reserved. Prevention of Shoulder Injuries Proper physical conditioning is key Develop body relative to sport – Sport Specific Strengthen through a full ROM  Focus on rotator cuff muscles in all planes of motion  Be sure to incorporate scapula stabilizing muscles  Foundation for the function of the glenohumeral joint

12. © 2007 McGraw-Hill Higher Education. All rights reserved. Warm-up should be used before explosive arm movements – before practices and games Contact and collision athletes should receive proper instruction on how to fall Protective equipment  Football, hockey, catchers, rugby Mechanics versus overuse injuries  Muscular weakness or imbalance VS throwing 200 pitches everyday Prevention of Shoulder Injuries

13. © 2007 McGraw-Hill Higher Education. All rights reserved. Throwing Mechanics Instruction in proper throwing mechanics is critical for injury prevention

14. © 2007 McGraw-Hill Higher Education. All rights reserved. Throwing Mechanics JennyiFinch – Sport Science http://www.youtube.com/watch?v=_de3HJvO-N8 Drew Brees – Sport Science– http://www.youtube.com/watch?v=tVoqA-LKGb4 Pitching Biomechanics http://www.youtube.com/watch?v=h53qlkHveQA Pitching Tips http://www.youtube.com/watch?v=qvNMvOeHUL8

15. © 2007 McGraw-Hill Higher Education. All rights reserved. Windup Phase  First movement until ball leaves gloved hand  Lead leg strides forward while both shoulders abduct, externally rotate and horizontally abduct Cocking Phase  Hands separate (achieve max. external rotation) while lead foot comes in contact w/ ground Acceleration  Max external rotation until ball release (humerus adducts, horizontally adducts and internally rotates)  Scapula elevates and abducts and rotates upward Throwing Mechanics

16. © 2007 McGraw-Hill Higher Education. All rights reserved. Deceleration Phase  Ball release until max shoulder internal rotation  Eccentric contraction of ext. rotators to decelerate humerus while rhomboids decelerate scapula Follow-Through Phase  End of motion when athlete is in a balanced position Throwing Mechanics

17. © 2007 McGraw-Hill Higher Education. All rights reserved. Pitch Count Pitch counts should be monitored and regulated in youth baseball. Pitch count limits pertain to pitches thrown in games only. These limits do not include:  throws from other positions  instructional pitching during practice sessions  throwing drills, which are important for the development of technique and strength. Backyard pitching practice after a pitched game is strongly discouraged.

18. © 2007 McGraw-Hill Higher Education. All rights reserved. Pitch Count  Recommended limits for 9-10 year old pitchers:  50 pitches per game  75 pitches per week  1000 pitches per season  2000 pitches per year  Recommended limits for 11-12 year old pitchers:  75 pitches per game  100 pitches per week  1000 pitches per season  3000 pitches per year  Recommended limits for 13-14 year old pitchers:  75 pitches per game  125 pitches per week  1000 pitches per season  3000 pitches per year

19. © 2007 McGraw-Hill Higher Education. All rights reserved. Assessment of the Shoulder Complex History  What is the cause of pain?  Mechanism of injury?  Previous history?  Location, duration and intensity of pain?  Creptitus, numbness, distortion in temperature  Weakness or fatigue?  What provides relief?

20. © 2007 McGraw-Hill Higher Education. All rights reserved. Observation  Elevation or depression of shoulder tips  Position and shape of clavicle  Acromion process  Biceps and deltoid symmetry  Postural assessment (kyphosis, lordosis, shoulders)  Position of head and arms  Scapular elevation and symmetry  Scapular protraction or winging  Muscle symmetry  Scapulohumeral rhythm Assessment of the Shoulder Complex

21. © 2007 McGraw-Hill Higher Education. All rights reserved. Palpation  Bony structure palpation should occur on both shoulders at the same time  Why?  Palpate soft tissue structures for point tenderness, swelling, spasms, lumps, guarding or trigger points  Be sure to palpate anteriorly and posteriorly Assessment of the Shoulder Complex

22. © 2007 McGraw-Hill Higher Education. All rights reserved. Special Tests  Active and Passive Range of Motion  Flexion, extension  Abduction and adduction  Horizontal Abduction/Adduction  Internal and external rotation  Muscle Testing  Specific muscles of the shoulder and scapula Assessment of the Shoulder Complex

23. © 2007 McGraw-Hill Higher Education. All rights reserved. Apprehension test (Crank test) Apprehension test used for anterior glenohumeral instability  This motion should not be forced Easier to have the athlete lay down

24. © 2007 McGraw-Hill Higher Education. All rights reserved. Test for Shoulder Impingement  Neer’s test and Hawkins-Kennedy test for impingement used to assess impingement of soft tissue structures  Positive test is indicated by pain and grimace Neer’s Hawkins- Kennedy

25. © 2007 McGraw-Hill Higher Education. All rights reserved. Test for Supraspinatus Weakness Empty Can Test  90 degrees of shoulder flexion, internal rotation and 30 degrees of horizontal adduction  Downward pressure is applied  Weakness and pain are assessed bilaterally

26. Compression Test Compress the clavicle and spine of the scapula together + if increased movement is felt or pain is experienced Clavicle and AC joint

27. © 2007 McGraw-Hill Higher Education. All rights reserved. Recognition and Management of Specific Injuries Clavicular Fractures  Cause of Injury  Fall on outstretched arm/hand (FOOSH)  Fall on tip of shoulder or direct impact  Occurs primarily in middle third  (greenstick fracture often occurs in young athletes)  Signs of Injury  Generally presents supporting arm, head tilted towards injured side w/ chin turned away  Clavicle may appear lower or displaced  Palpation reveals pain, swelling, deformity and point tenderness

28. © 2007 McGraw-Hill Higher Education. All rights reserved. Clavicle Fractures  Care  Immobilaize with sling ; Referral for X-Ray  Possible Sx Occasionally requires operative management  Closed reduction - sling and swathe, immobilize w/ figure 8 brace for 6-8 weeks  Removal of brace should be followed w/ joint mobes, isometrics and use of a sling for 3-4 weeks

29. © 2007 McGraw-Hill Higher Education. All rights reserved. Clavicle Fx

30. © 2007 McGraw-Hill Higher Education. All rights reserved. Fractures of the Humerus  Cause of Injury  Humeral shaft fractures occur as a result of a direct blow, or fall on outstretched arm  Proximal fractures occur due to direct blow, dislocation, fall on outstretched arm  Signs of Injury  Pain, swelling, point tenderness, decreased ROM  X-ray is positive for fracture  Care  Immediate application of splint, treat for shock and refer  Athlete will be out of competition for 2-6 months depending on location and severity of injury

31. © 2007 McGraw-Hill Higher Education. All rights reserved.

32. Sternoclavicular (SC) Sprain  Cause of Injury  Indirect force- FOOSH  blunt trauma (may cause displacement)  Signs of Injury  Grade 1 - pain and slight disability  Grade 2 - pain, subluxation w/ deformity, swelling and point tenderness and decreased ROM  Grade 3 - gross deformity (dislocation), pain, swelling, decreased ROM Possibly life-threatening if dislocates posteriorly  Care  PRICE, immobilization  Immobilize for 3-5 weeks followed by graded reconditioning

33. http://www.youtu be.com/watch?v=f kGtNkBsXkE

34. © 2007 McGraw-Hill Higher Education. All rights reserved. Acromioclavicular Sprain  Cause of Injury  Result of direct blow (from any direction), upward force from humerus, fall on outstretched arm  Signs of Injury  Grade 1 - point tenderness and pain w/ movement; no disruption of AC joint  Grade 2 - tear or rupture of AC ligament, partial displacement of lateral end of clavicle; pain, point tenderness and decreased ROM (abduction/adduction)  Grade 3 - Rupture of AC and CC ligaments with dislocation of clavicle; gross deformity, pain, loss of function and instability

36. © 2007 McGraw-Hill Higher Education. All rights reserved. AC Sprain

37. © 2007 McGraw-Hill Higher Education. All rights reserved.  Care  Ice, stabilization, referral to physician  Grades 1-3 (non-operative) will require 3-4 days (grade 1) and 2 weeks of immobilization ( grade 3) respectively  Aggressive rehab is required w/ all grades Joint mobilizations, flexibility exercises, & strengthening should occur immediately Progress as athlete is able to tolerate w/out pain and swelling Padding and protection may be required until pain-free ROM returns

38. © 2007 McGraw-Hill Higher Education. All rights reserved.

39. Glenohumeral Dislocations  Cause of Injury  Head of humerus is forced out of the joint  Anterior dislocation is the result of an anterior force on the shoulder, forced abduction, extension and external rotation  Occasionally the dislocation will occur inferiorly  Signs of Injury  Flattened deltoid, prominent humeral head in axilla; arm carried in slight abduction and external rotation; moderate pain and disability  Care  RICE, immobilization and reduction by a physician  Begin muscle re-conditioning ASAP  Use of sling should continue for at least 1 week  Progress to resistance exercises as pain allows

40. © 2007 McGraw-Hill Higher Education. All rights reserved. http://www.youtube.com/watch?v=-Hv8FM78I7I http://www.youtube.com/watch?v=plquoz_mKiQ

41. © 2007 McGraw-Hill Higher Education. All rights reserved. Shoulder Dislocation

42. © 2007 McGraw-Hill Higher Education. All rights reserved. Shoulder Impingement Syndrome  Cause of Injury  Mechanical compression of supraspinatus tendon, subacromial bursa and long head of biceps tendon due to decreased space under coracoacromial arch  Seen in over head repetitive activities  Signs of Injury  Diffuse pain, pain on palpation of subacromial space  Decreased strength of external rotators compared to internal rotators; tightness in posterior and inferior capsule  Positive impingement and empty can tests

43. © 2007 McGraw-Hill Higher Education. All rights reserved.  Care  Restore normal biomechanics in order to maintain space  Strengthening of rotator cuff and scapula stabilizing muscles  Stretching of posterior and inferior joint capsule  Modify activity (control frequency and intensity)

44. © 2007 McGraw-Hill Higher Education. All rights reserved.  Rotator cuff tear  Involves supraspinatus or rupture of other rotator cuff tendons  Primary mechanism - acute trauma (high velocity rotation)  Occurs near insertion on greater tuberosity  Full thickness tears usually occur in those athletes w/ a long history of impingement or instability (generally does not occur in athlete under age 40)  Signs of Injury  Present with pain with muscle contraction  Tenderness on palpation and loss of strength due to pain  Loss of function, swelling  With complete tear impingement and empty can test are positive

45. © 2007 McGraw-Hill Higher Education. All rights reserved.  Care  RICE for modulation of pain  Progressive strengthening of rotator cuff  Reduce frequency and level of activity initially with a gradual and progressive increase in intensity

46. © 2007 McGraw-Hill Higher Education. All rights reserved. Shoulder Bursitis  Etiology  Chronic inflammatory condition due to trauma or overuse - subacromial bursa  May develop from direct impact or fall on tip of shoulder  Signs of Injury  Pain w/ motion and tenderness during palpation in subacromial space; positive impingement tests  Management  Cold packs and NSAID’s to reduce inflammation  Remove mechanisms precipitating condition  Maintain full ROM to reduce chances of contractures and adhesions from forming

47. © 2007 McGraw-Hill Higher Education. All rights reserved. Bicipital Tenosynovitis  Cause of Injury  Repetitive overhead athlete - ballistic activity that involves repeated stretching of biceps tendon causing irritation to the tendon and sheath  Signs of Injury  Tenderness over bicipital groove, swelling, crepitus due to inflammation  Pain when performing overhead activities  Care  Rest and ice to treat inflammation  NSAID’s  Gradual program of strengthening and stretching

48. © 2007 McGraw-Hill Higher Education. All rights reserved. Contusion of Upper Arm  Cause of Injury  Direct blow  Repeated trauma could result in development of myositis ossificans  Signs of Injury  Pain and tenderness, increased warmth, discoloration and limited elbow flexion and extension  Management  RICE for at least 24 hours  Provide protection to contused area to prevent repeated episodes that could cause myositis ossificans  Maintain ROM