The Shoulder Complex

1. The Shoulder Complex

2. General Knowledge • 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

3. 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.asp?vidid=849

4. Basic Anatomy

5. Anatomy

6. Anatomy

7. Muscular Anatomy

8. Muscular Anatomy

9. Muscular Anatomy

10. Movements • http://www.youtube.com/watch?v=FHq3K6J3Wq8 • http://www.youtube.com/watch?v=RPRJPNCVRdE

11. 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. Prevention of Shoulder Injuries • 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

13. Throwing Mechanics Instruction in proper throwing mechanics is critical for injury prevention

14. 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. Throwing Mechanics • 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

16. Throwing Mechanics • 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

17. 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. 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. 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. Assessment of the Shoulder Complex • 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

21. Assessment of the Shoulder Complex • 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

22. Assessment of the Shoulder Complex • 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

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

27. 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. 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. Clavicle Fx

30. 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

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.youtube.com/watch?v=fkGtNkBsXkE

34. 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. AC Sprain

37. 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

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. http://www.youtube.com/watch?v=-Hv8FM78I7I • http://www.youtube.com/watch?v=plquoz_mKiQ

41. Shoulder Dislocation

42. 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. 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. 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. 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. 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. BicipitalTenosynovitis • 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. 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