1. The shoulder
Chapter 21

2. The Shoulder Girdle Complex
3 joints make up the shoulder girdle
The Sternoclavicular joint
The Acromioclavicular joint
The Glenohumeral joint

3. 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.

4. 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.

5. 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

6. 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.

7. 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

8. 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

9. Muscles that move the Scapula
There are several muscles that move the scapula
Levator scapulae
Rhomboids
Major and Minor
Pectoralis Minor
Serratus Anterior
Trapezius

10. Muscles that move the Scapula

11. 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

12. Muscles that move the Arm (Humerus)

13. 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

14. 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.

15. 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

16. 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

17. Shoulder Impingement Exercises

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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