1. Understanding Athletic-Related Injuries to the Upper Extremity
Shoulder Injuries
David Smith

2. Anatomy of the Shoulder
Ball and Socket Joint
Great degree of mobility, therefore it is highly susceptible to injury
Many sports activities, in particular those that involve repetitive overhead movements place a great deal of stress on the supporting structures
Throwers, swimmers, football, serving in tennis or volleyball

4. Major bones of shoulder joint
Humerus
Scapula
Clavicle
Sternum

5. HUMERUS
Head of the humerus articulates with the scapula’s shallow glenoid fossa Bicipital groove for biceps tendon. It fits between the greater and lesser tuberosity

6. SCAPULA Glenoid Cavity
Situated laterally on the scapula inferior to the acromion and is relatively shallow
The glenoid labrum increases the depth of the articulation

7. SCAPULA Three prominent projections Spine
Divides the posterior scapula unequally
Supraspinatus fossa and Infraspinatus fossa
Acromion
Sits at the lateral tip of the spine of the scapula. Tip of the shoulder
Coracoid Process
“Hooklike Projection” arises anteriorly from the scapula. Curves upward, forward, and outward in front of the glenoid fossa

10. CLAVICLE S- shaped bone Supports the anterior portion of the shoulder
Articulates at tip of shoulder with the acromion and at the sternum near throat

11. CLAVICLE
Medial 2/3 bends convexly forward, and the lateral 1/3 is concave
The point at which the clavicle changes shape and contour presents a structural weakness
Fractures occur at this point (The Middle 1/3)

12. Anatomy of the Shoulder cont…
Scapula
Serves mainly as an articulating surface for the head of the humerus
Glenoid Cavity
Situated laterally on the scapula inferior to the acromion and is relatively shallow
The glenoid labrum increases the depth of the articulation
Serves as the site for many muscle attachements

13. Bony Components Clavicle: Collarbone Scapula: Shoulder blade
Humerus: Upper arm

15. Anatomy of the Shoulder cont…
Articulations
Sternum and Clavicle
Acromion and Clavicle
Glenoid cavity and Humerus
Scapula and Thoracic cage

16. Anatomy of the Shoulder cont…
Joints
Acromioclavicular Joint (AC)
Acromion Process of Scapula and distal end of Clavicle
Weak junction

17. Anatomy of the Shoulder cont…
Glenohumeral Joint (GH Joint)
Head of humerus and glenoid fossa
Ball and socket, very mobile
Very shallow, very susceptible to injury
Deepend by the glenoid labrum

18. Anatomy of the Shoulder cont…
Sternoclavicular Joint (SC Joint)
Clavicle articulates with the manubrium of the sterum
Allows the clavicle to move up and down, forward and backward, in combination, and in rotation

19. Anatomy of the Shoulder cont…
Scapulothoracic Joint
Not a true joint- movement of the scapula on the wall of thoracic cage is critical to shoulder joint motion
Scapular muscles attach the scapula to the axial skeleton is critical to stabilizing the scaupla

20. F. Major Joints of the Shoulder Region
Sternoclavicular joint (SC): Sternum articulates with the clavicle
Acromioclavicular joint (AC): Scapulas acromion process and clavicle articulate. Very weak joint

21. Coracoclavicular Joint (CC): Clavicle and the scapulas coracoid process articulate
Glenohumeral joint: ball and socket joint, humerus articulates with the scapulas glenoid cavity. Glenoid labrum deepens the joint so the humerus can move. The joint is surrounded by synovial capsule

22. Other Anatomy

23. Anatomy of the Shoulder cont…
Muscles Acting on the Glenohumeral Joint
Originating on the scapula and attaching to the humerus
Rotator Cuff (Decelerator Muscles)
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
All responsible for internally and externally rotating the arm, as well as abduction

25. Muscles: see handout for location of rotator cuff muscles
Four muscles of the rotator cuff: SITS
Supraspinatus: abduction of the arm
Infraspinatus: external rotation of the arm
Teres Minor: external rotation of the arm
Subscapularis: internal rotation of the arm

27. Anatomy of the Shoulder cont…
Deltoid
Abducts, flexes, and extends the shoulder
Pectoralis Major and Minor
Biceps and Triceps

29. Major Movements of the Shoulder
Flexion
Extension IR ER
Abduction
Adduction

31. Preventing Shoulder Injuries
Most often caused by:
Weakness
Postural problems
Nature of game (overhead movements)

32. Muscular Weakness and Postural Problems can cause injuries
Out of sight, out of mind
Weakness on posterior side
Rotator Cuff (Decelerators)!!
Rounded shoulders
Tight pectorals and weak posterior muscles
Constant use of one muscle
Swim, baseball, volleyball…etc
Balancing out the use
Proper techniques

33. Ligament Injuries Sternoclavicular Ligament Sprain (SC)
Separation of SC Joint
Injured by falling on lateral side of shoulder
Hit in sternum with violent force
Acromioclavicular Ligament Sprain (AC)
Shoulder separation, 1-3° sprain
Injured by impact to the top of shoulder or by falling on an outstretched arm
Glenohumeral Ligament Sprain (GH)
Vulnerable when in abduction and external rotation
Dislocation and subluxation

35. Sprains to Joint-can occur in 3 major joints
Sternoclavicular Sprain: Uncommon injury, occurs when the Medial end of clavicle is displaced. A 3rd degree is life threatening due to pressure placed on blood vessels, esophagus, or trachea

36. Grades of an SC sprain

37. Acromioclavicular Sprain (separated shoulder): AC joint is extremely vulnerable to sprains. Caused by a direct blow to tip of the shoulder or landing on an outstretched arm or elbow, may also occur with a blow from behind the shoulder

38. 1st degree: Minor stretching and tearing, AC has point tenderness

39. 2nd degree: Partial tearing, cannot fully abduct arm

40. 3rd degree: complete rupture of ligament, dislocation.

41. Acromioclavicular Seperation

42. AC Joint Separation

43. Clinical appearance of AC Separation

44. Muscle and Tendon Injuries
Most caused by overuse
Throwing, shooting, or repeating a swim stroke

45. Muscle and Tendon Injuries
Rotator Cuff Strain
1°- pain with no loss of ROM or stability
2°- pain with some loss of ROM and stability
3°- pain with partial or complete loss of ROM and stability

46. Muscle and Tendon Injuries cont…
Rotator Cuff Strain
Occur because of excessive motion beyond the normal range
Most often, Supraspinatus
Repetitive motions -> result in crepitus and impingement syndrome
Rehab- RICE and gentle strengthening and flexibility exercises

47. Muscle and Tendon Injuries cont…
Impingement Syndrome
Repetitive overhead types of movement
freestyle swimmers, throwers, and tennis players
Supraspinatus and biceps run through space beneath acromion process
Rehab- strengthening posterior muscles, modifying activity, and improving flexibility of pectorals

48. Impingement Syndrome

49. Rotator Cuff Impingement Syndrome: Impression of supraspinatus tendon between head of the humerus and the acromion process.
Symptoms: Aching and pain when abducting the arm above 90 degrees.

50. Muscle and Tendon Injuries cont…
Bicipital Tendonitis
Very common
Repetitive nature causes irritation of tendon in bicipital groove
Rehab- stop repetitive action, immobilization, heat, anti-inflammatory medications

51. Bicipital Tendonitis: Irritation of the long head of the biceps tendon in the bicipital groove

52. Muscle and Tendon Injuries cont…
Biceps tendon rupture
Direct blow or severe contractile forces
Unable to flex elbow
Looks like a golf ball under skin
Rehab- ice and immobilization, refer to physician for surgical repair

55. Clavicle Fracture At weakest pt- middle 1/3
Bone Injuries
Clavicle Fracture
At weakest pt- middle 1/3
Immobilization and Ice, physician will set clavicle in place using a harness
May need surgery if displaced

56. Clavicle Fracture: Nearly 80% of all clavicle fractures occur in the middle 1/3 of clavicle. Caused by direct blow or fall on outstretched arm. Athlete will hold arm and tilt head toward clavicle and chin is turned the opposite side.

57. Clavicle fracture

58. Clavicle fracture

59. Clavicle surgery repair

60. Humeral Fractures- May be hard to detect because of musculature
unable to move arm and experiencing pain, most likely felt or heard a pop
Splint, and check distal pulse

62. Epiphysis Injury Bone Injuries cont… Growth plate in young athlete
Direct or indirect blow
Mimic humeral fx- pain, inability to use arm, guarding, feeling/hearing pop
Can cause permanent growth impairment
Rehab- ice, splint, and refer to physician

63. Avulsion Fracture Tearing bone off with ligament
Bone Injuries cont…
Avulsion Fracture
Tearing bone off with ligament
May accompany a AC or GH sprain
P! associated with fx
Almost IMPOSSIBLE to detect unless r/o by x-ray
Splint and ice, refer to MD

64. GH Dislocations and Subluxations
Bone Injuries cont…
GH Dislocations and Subluxations
Dislocation: Head of humerus is out of the socket
Complete disruption of joint
Subluxation: Head of humerus went out of socket and then back in
Partial disruption of joint

65. Dislocations and subluxations
Excessive abduction and external rotation
Anterior is most common
Pain and inability to use shoulder, deformity at deltoid muscle

66. GH Dislocations and Subluxations
X-ray is necessary to determine extent of injury
Permanent changes to the nerves, cartilage, and blood vessels
Rehab:
strengthen muscles of adduction and internal rotation, restrict abduction and external rotation,
Harness and Surgery is likely

67. Dislocation to the Glenohumeral Joint: Anterior displacement of the humerus is caused by forced abduction and external rotation. Dislocation can tear the capsule, ligaments and labrum. Displays a flattened deltoid and severe pain and disability. Injury is beyond the scope of an athletic trainer’s duties, athlete needs a referral for x-rays and reduction.

68. Shoulder dislocation

69. Questions What are the bones of the shoulder joint? (4 Bones)
What are the 4 joints of the shoulder girdle? (4)
What are the 4 muscles of the rotator cuff?
What is the rotator cuff known as? (Think function)
What are the differences in rotator cuff strains?
What is the difference b/n dislocation and subluxation?

70. END OF SHOULDER ANATOMY

71. Hands on…. Point to each bones in the shoulder girdle
Locate each joint in the shoulder girdle
Demonstrate special tests?