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The shoulder Chapter 21
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The Shoulder Girdle Complex
3 joints make up the shoulder girdle The Sternoclavicular joint The Acromioclavicular joint The Glenohumeral joint
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The Sternoclavicular Joint
Formed through the articulation of the sternum and the clavicle. Also called the SC joint Injuries to this joint can be very debilitating, but are very rarely seen in athletics.
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Acromioclavicular Joint
Formed by the articulation of the acromion process of the scapula and the distal end of the clavicle. Also called the AC joint Its is located superiorly to the glenohumeral joint and is commonly exposed to injury in contact sports.
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Glenohumeral Joint Formed by the Humerus and the scapula Supported by
The head of the humerus is attached to the glenoid fossa of the scapula Shallowness of the socket allows for a great deal of movement Supported by several muscles ligaments Soft tissue
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Structure and Function
Dynamic Stability refers to mobility with stability Shoulder accomplishes this through the coordinated movement of the scapula in concert with the humerus Several muscle groups work together synergistically to create the dynamic stability of the shoulder.
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Rotator Cuff A set of 4 deep muscles of the glenohumeral joint
They originate on the scapula and insert onto the superior aspect of the humerus Will often be referred to as the SITS muscles Supraspinatus Infraspinaus Teres Minor Subscapularis
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Muscles of the Shoulder Girdle
Muscle Force Coupe Formed by the actions of the deltoid and rotator cuff muscles Allows the humeral head to spin while remaining in place on the glenoid Scapulothoracic Mechanics Allows the scapula to move in several places using the following muscles Trapezius Rhomboids Serratus Pectoralis Minor
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Muscles that move the Scapula
There are several muscles that move the scapula Levator scapulae Rhomboids Major and Minor Pectoralis Minor Serratus Anterior Trapezius
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Muscles that move the Scapula
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Muscles that move the Arm (Humerus)
There are several muscles that move the Humerus Coracobrachialis Pectoralis Major Teres Major/Minor Deltoid Supraspinatus Infraspinatus Latissimus Dorsi
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Muscles that move the Arm (Humerus)
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Overuse Injuries to the Shoulder
Overuse injuries of the shoulder are usually limited to the soft tissues. Usually caused by repetitive activity to the point of causing tissue damage and inflammation Common among athletes that participate in overhead movements Many athletes are unaware that an injury is occurring until symptoms manifest Overuse Injuries include Impingement syndrome Tendonitis Bursitis Muscle strains
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Impingement Syndrome Impingement syndrome describes a situation causing injury when the space between the humeral head and acromion becomes narrowed. The bones “impinge” or squeeze structures within the space Structures affected are the joint capsule, tendons of the rotator cuff, and a bursa Impingement causes mechanical irritation of the cuff tendons, resulting in hemorrhage and swelling Commonly called tendonits of the rotator cuff Supraspinatus is the muscle usually involved If the bursa is involved, bursitis is the result.
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Impingement Syndrome - Symptoms
Pain and tenderness in GH area Pain and/or weakness with ABD in midrange Limited IR + results from special tests Hawkin’s impingement Tenderness to palpation in subacromial area
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Impingement Syndrome - Treatment
Treatment options Correction of improper sport technique Preseason conditioning Specialized taping Rehabilitation and Prevention Most rehab techniques involve strengthening the weakened muscles of the shoulder girdle
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Shoulder Impingement Exercises
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Rotator Cuff Tears Could be partial tear or full thickness of the tendon Can happen to people of any age In younger people often caused by more traumatic injuries Falling on outstretched arm Unusual demands on the joint Older people Usually caused by degeneration of the muscle and tendon tissues Treatment Usually determined by severeity of injury and how it responds to rehab Small and partial tears respond well to non-operative rehab program Moderate to large tears, and small tears that are non-responsive to rehab, require surgery
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Rotator Cuff tears (cont’d)
Symptoms Pain Full ROM with partial tears Loss of ROM with full tears Athlete will not be able to lift the arm overhead, and often when they try, the can be observed to hike or shrug
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Muscle Strains Can be caused by excessive overuse or traumatic injury
Symptoms Pain Tenderness in muscle belly caused by Palpation RROM Stretch There could be a delay of a day or two before symptoms actually show Treatment PRICE Gentle stretching Strengthening program
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Biceps (long head) Tendonitis
Can cause discomfort in the front of the shoulder and will often be confused with rotator-cuff tendonitis. Both can be caused by impingement and will have the same treatment
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Biceps Tendon Rupture Not common in athletics, but results from vigorous activity Described as a sudden onset of pain in the front of the shoulder and an associated “pop” Symptoms Drooping of the biceps muscle near the distal upper arm Ecchymosis
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Biceps Tendon Rupture (cont’d)
This injury is considered a Grade III injury and usually affects the biceps tendon long head. People who have a prior history of tendonitis may be more prone to this injury Treatment Surgery is usually not needed PRICE Gradual return to strengthening and activity Athletes can usually return to full activity after a period of conservative care There may be a small loss of shoulder flexion in the long term, but not enough to result in loss of high-level functioning
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Traumatic Shoulder Injuries
Usually are caused by a sudden onset Blow to arm or shoulder Shoulder joint being forced beyond physiologic limits Common Injuries Glenohumeral dislocation Acromioclavicular separation Fractures Tendon Ruptures
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Anterior Shoulder Dislocation
Results in the head of the humerus being completely out of the glenoid fossa Usually caused by shoulder being forced into abduction, extension and external rotation. Most common means of dislocation is anterioinferiorly Immediate transport to a physician is required Physician should also check for other injuries Fractures Glenoid labial tears Axillary nerve damage Hill-Sachs lesions can occur if the head of the humerus hits the front of the glenoid hard enough to cause an indentation
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Anterior Shoulder Dislocation (cont’d)
If the injury is not properly managed and fully rehabilitated, there is a high risk for recurrent dislocations. Immobilization may be as long as 8 weeks
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Glenoid Labrum Injuries
These injuries involve the deepest soft tissue in the shoulder Can often occur along with dislocations Happens commonly with baseball pitchers when degenerative changes in the labrum cause it to become loose Permits humeral head to slip forward Symptoms Pain Popping sensation Limited use of the arm Varying degrees of weakness Special tests and MRI will confirm diagnosis Treatment includes specialized rehab program Suspected tears must be referred to a physician
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Multidirectional Instability
Refers to the ability of the athlete to voluntarily dislocate their shoulders usually due to athlete being hyperelastic or overly flexible This causes problems with athlete playing overhead sports. Weight bearing exercises can be helpful in dealing with this problem Push-ups Plyometrics Weight training
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Acromioclavicular Separation
This injury is a traumatic sprain of the AC joint Usually caused by a blow to the tip of the shoulder Symptoms Pain near the AC joint Obvious deformity Treatment Physician referral 1st degree sprains PRICE 2nd / 3rd degree sprains Require 6-8 weeks of immobilization
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Brachial Plexus Injury
Is often called a stinger or burner Usually caused by a stretching of the brachial plexus on the opposite side Symptoms Intense pain from the neck down to the arm On-fire or pins-and-needles sensation Weakness Numbness Treatment Referral to specialist Rest Ice Anti-inflammtory meds Strengthening exercises for neck and shoulders Prevention Keeping neck and shoulders strong Wearing properly fitted equipment that distributes forces during collision Using proper technique
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Fractures Fractures of the shoulder girdle most commonly involve the clacivle and humerus Scapular fractures may not be seen on standard x-rays Present on bone scans Any suspected fracture should be referred to an emergency room physician
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Is it a Shoulder Injury Often times pain in the shoulder can be referred pain from another injury. Pain in the shoulder does not always indicate a shoulder problem Cardiac problems or Heart attack Referred pain to the left shoulder, neck and arms Spleen Injury Refer pain to the left shoulder and down the upper portion of the left arm Kehr’s sign
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