1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 12 Shoulder Conditions

2. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy Extremely mobile; minimal stability Joints –Sternoclavicular joint –Acromioclavicular joint –Coracoclavicular joint –Scapulothoracic joint –Glenohumeral joint

3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d) Skeletal features of the shoulder and chest

4. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d)

5. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d) Sternoclavicular joint –Superior sternum with the proximal clavicle Joint capsule and ligaments Ball-and-socket joint

6. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d) Acromioclavicular joint (AC) –Acromion process of scapula with distal end of clavicle –Irregular joint; permits movement in all 3 planes –Capsule; minimal stability ligaments; strong stabilizers Superior and inferior AC ligament Coracoclavicular ligament

7. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d) Coracoclavicular joint –Coracoid process of scapula with the inferior surface of clavicle Coracoclavicular ligament –Minimal movement permitted

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d) Glenohumeral joint –Glenoid fossa of scapula with the head of the humerus –Most ROM of any joint in body, but poor stability Head has greater surface area than fossa Shallow fossa (glenoid labrum)

9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d)

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d) Glenohumeral joint (cont’d) –Joint capsule and ligaments –Rotator cuff muscles (SITS) Tendons form a collagenous cuff around joint Tension helps hold the head against the glenoid fossa

11. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d) Scapulothoracic joint –Muscles attached to scapula permit its motion with the trunk and thorax –Functions of scapular muscles Stabilization of shoulder region Facilitate movement of upper extremity through appropriate positioning of glenohumeral joint

12. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d) Bursa –Subacromial bursa Lies in subacromial space Cushions rotator cuff muscles from acromion (especially supraspinatus) Compressed during overhead arm action –Subcoracoid; subscapularis

13. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d) Nerves –Brachial plexus innervates upper extremity

14. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Shoulder Anatomy (cont’d) Subclavian; axillary— several branches Blood supply to the shoulder

15. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions Muscles of the shoulder and chest

16. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Muscles of the shoulder and upper back

17. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Action (cont’d) MUSCLEPRIMARY ACTION Deltoid *Anterior *Middle *Posterior *Flexion, horizontal adduction *Abduction, horizontal abduction *Extension, horizontal abduction Pectoralis major *Clavicular *Sternal *Flexion, horizontal adduction *Extension, adduction, horizontal adduction SupraspinatusAbduction, stabilizes shoulder joint CoracobrachialisHorizontal adduction Latissimus dorsiExtension, adduction Teres majorExtension, adduction, medial rotation InfraspinatusLateral rotation, horizontal abduction

18. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) MUSCLEPRIMARY ACTION Teres minorLateral rotation, horizontal abduction SubscapularisMedial rotation Biceps brachii Long head Short head *Assists with abduction *Assists with flexion, adduction, medial rotation, and horizontal adduction Triceps brachii (long head) Assists with extension and adduction

19. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Movement in Three Planes –Sagittal Flexion and extension –Frontal Abduction and adduction –Transverse Medial rotation and lateral rotation Movements of the arm at the shoulder

20. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Shoulder ROM –Loose structure of GH –Proximity of other articulations and their movement capabilities Movement at the shoulder typically involves some rotation of the SC, AC, & GH joints Scapulohumeral rhythm –Coordinated movement of the scapula that accompanies abduction & adduction of humerus

21. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Prevention of Shoulder Conditions Physical conditioning –Flexibility –Strength Protective equipment –Shoulder pads Proper skill technique –Throwing motion –Proper falling technique

22. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex Sternoclavicular (SC) Joint Sprain –MOI Indirect force through humerus Blow to the clavicle –Displacement: superior and anterior

23. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Sternoclavicular (SC) Joint Sprain (cont’d) –S&S 2: unable to horizontally adduct; holds arm forward and close to body 3: prominent displacement of proximal clavicle Management: cold; sling; physician referral

24. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Posterior SC sprain –MOI Blow to the posterolateral aspect of the shoulder with the arm adducted and flexed –Concern: structures involved

25. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Posterior SC sprain (cont’d) –S&S Unable to perform shoulder protraction Numbness & weakness of upper extremity Difficulty swallowing Diminished pulse –Management: activate EMS

26. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Acromioclavicular (AC) Joint Sprain –MOI Direct blow Fall on point of shoulder Fall on outstretched arm

27. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Acromioclavicular (AC) Joint Sprain (cont’d) –Type I: mild stretching of ligaments Minimal swelling & pain over the joint line Discomfort on abduction >90

28. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Acromioclavicular (AC) Joint Sprain (cont’d) –Type II – rupture of AC ligaments + displacement; step off deformity Pain with horizontal adduction Pain with downward pressure on distal clavicle Stability: vertical maintained; sagittal plane compromised

29. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Acromioclavicular (AC) Joint Sprain (cont’d) –Type III – rupture of AC ligaments and coracoclavicular ligament Visible prominence of the distal clavicle Depression or drooping of the shoulder girdle

30. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Acromioclavicular (AC) Joint Sprain (cont’d) –Types IV–VI Caused by more violent forces Extensive mobility due to tear of deltoid and trapezius attachment at distal clavicle –Management Type I – cold; sling; physician referral II- VI – referral to emergency medical facility

31. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d)

32. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Glenohumeral Sprain –MOI Forceful abduction Forceful abduction and external rotation –Joint capsule stretches or tears; humeral head moves in anterior inferior direction

33. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Glenohumeral Sprain –S&S 1: AROM – slight limitation 2: swelling, ecchymosis, decreased ROM, especially abduction –Management Cold; sling; physician referral

34. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) GH sprains

35. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Glenohumeral Dislocation –Anterior Intense pain; recurrent: less painful Tingling and numbness down arm Arm held in slight abduction and external rotation; stabilized against body by opposite hand

36. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Glenohumeral Dislocation (cont’d) –Anterior (cont’d) Deformity – sharp contour and a prominent acromion process Attempt to bring arm across chest horizontal adduction or internal rotation - severe pain

37. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Glenohumeral Dislocation –Posterior MOI – fall on or blow to the anterior shoulder S&S: Arm is carried tightly against chest & front of the trunk (rigid adduction and internal rotation)

38. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Glenohumeral Dislocation (cont’d) –Posterior (cont’d) S&S: (cont’d) Deformity: anterior shoulder appears flat, the coracoid process is prominent, Individual will not allow the arm to externally rotate & abduct produces severe pain; unable to supinate the forearm

39. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Glenohumeral Dislocation –Management – Acute Injury Immobilize in comfortable position Apply cold Immediate physician referral If deficits with pulse or sensation, activate emergency plan, including EMS

40. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Glenohumeral Dislocation –Chronic dislocations Problem of reoccurrence Less force needed Less spasm, pain, swelling Sensation of arm going “dead”

41. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains to the Shoulder Complex (cont’d) Glenohumeral Dislocation (cont’d) –Chronic dislocations (cont’d) S&S: pain with crepitus and clicking after reduction; reduction often self-induced Management: cold; sling & swathe; physician referral

42. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions Rotator cuff (primarily supraspinatus) –Partial tear more likely in young; total tear: adults over age 30 Impingement syndrome –Abutment of rotator cuff and subacromial bursa against coracoacromial ligament and greater tubercle of the humerus

43. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Supraspinatus tendon during abduction

44. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Rotator cuff/Impingement syndrome –Contributing factors (refer to Box 12.2) –S&S “Deep” pain – initially at night Becomes progressively worse Painful arc: between 70° and 120° Unable to sleep on involved side –Management: do not permit to continue activity until seen by a physician

45. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Bursitis – Subacromial bursa –MOI: impinged during overhead motion –S&S Sudden shoulder pain: initiation and acceleration phase of throwing Point tenderness on anterior & lateral edges of acromion process

46. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Bursitis – Subacromial bursa (cont’d) –S&S (cont’d) Painful arc during passive abduction Pain sleeping on involved side –Management: do not permit to continue activity until seen by a physician

47. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Bicipital tendinitis –MOI Repetitive overhead activities involving excessive elbow flexion and supination; tendon passes back and forth in groove Direct blow Subsequent to impingement syndrome

48. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Bicipital tendinitis (cont’d) –S&S Pain and tenderness at bicipital groove with internal and external shoulder rotation Pain with passive stretch in extreme shoulder extension with elbow extended and forearm pronated –Management: do not permit to continue activity until seen by a physician

49. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Biceps tendon rupture –Prolonged tendinitis makes tendon vulnerable –MOI: forceful flexion against resistance –S&S Hear and feel a snap Intense pain

50. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Biceps tendon rupture (cont’d) –S&S (cont’d) Visible palpable defect in muscle belly during flexion; “Popeye” appearance if mass moves distally Weakness: flexion and supination of forearm –Management: cold; sling; immediate referral to a physician or emergency care facility

51. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Thoracic outlet compression syndrome –Nerves and/or vessels become compressed in the proximal neck or axilla Location and etiology of thoracic outlet syndrome

52. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Thoracic outlet compression syndrome (cont’d) Neurologic syndrome –Stretch or compression involving lower trunk brachial plexus –S&S Aching pain, pins-and-needles sensation, or numbness in the side or back of the neck extends across the shoulder down the medial arm to the ulnar aspect of the hand Weakness in grasp and atrophy of the hand

53. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Thoracic outlet compression syndrome (cont’d) Vascular syndrome –Compression of subclavian artery or vein –S&S Vein: edema, hand stiffness, venous engorgement of arm with cyanosis, symptoms may present several hours after exercise Artery: rapid onset of coolness, numbness entire arm, fatigue after overhead activity Management: immediate referral to a physician

54. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures Clavicular fracture –MOI: direct or indirect force –S&S Swelling, ecchymosis, and a deformity may be visible and palpable Pain with any shoulder motion Greenstick fracture –Management: cold; sling & swathe; immediate referral to a physician or emergency care facility

55. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Scapular fracture –MOI: direct or indirect force –S&S Localized pain and hemorrhage Reluctant to move injured arm; prefers to maintain adduction; abduction – very painful –Need to rule out pulmonary injury –Management: cold; sling & swathe; immediate referral to a physician or emergency care facility

56. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Epiphyseal fracture –Little league shoulder – proximal humerus; due to repetitive medial rotation & adduction –S&S Acute shoulder pain with throwing hard Pain with deep palpation in axilla –Management Cold; sling & swathe; immediate referral to a physician or emergency care facility

57. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Epiphyseal fracture Epiphyseal fracture to the proximal humeral growth center

58. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Avulsion fracture –MOI Coracoid process due to forceful throwing Greater and lesser tubercles: associated with dislocation –S&S: pain with deep palpation at site –Management: Cold; sling & swathe; immediate referral to a physician or emergency care facility

59. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Humeral fracture –MOI Direct blow Fall on upper arm Fall on outstretched hand with elbow extended

60. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Humeral fracture (cont’d) –S&S Pain, swelling, hemorrhage, discoloration Inability to move arm Inability to supinate forearm Possible paralysis

61. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Humeral fracture (cont’d) –Management Cold; sling & swathe; immediate referral to a physician or emergency care facility

62. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Humeral fracture Fracture to the surgical neck of the humerus

63. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Coach and Onsite Assessment S &S that require activation of emergency plan, including summoning EMS –Obvious deformity suggesting a suspected fracture, separation, or dislocation –Significant loss of motion or weakness in the myotomes –Joint instability

64. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Coach and Onsite Assessment (cont’d) S &S that require activation of emergency plan, including summoning EMS (cont’d) –Abnormal sensation in the shoulder, arm, or hand –Absent or weak pulse distal to the injury –Any significant, unexplained pain Refer to Application Strategy 12.3