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The Shoulder

The Shoulder. Chapter 21. Shoulder Girdle Complex. Glenohumeral joint Acromioclavicular joint Scapulothoracic joint. Glenohumeral Joint. Glenoid fossa Head of humerus. Acromioclavicular Joint. Acromion process of scapula Clavicle. Scapulothoracic Joint. Scapula Posterior ribcage.

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The Shoulder

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  1. The Shoulder Chapter 21

  2. Shoulder Girdle Complex • Glenohumeral joint • Acromioclavicular joint • Scapulothoracic joint

  3. Glenohumeral Joint • Glenoid fossa • Head of humerus

  4. Acromioclavicular Joint • Acromion process of scapula • Clavicle

  5. Scapulothoracic Joint • Scapula • Posterior ribcage

  6. Bony Landmarks • Sternum • Clavicle • Humerus • Head of humerus • Greater tubercle • Lesser tubercle • Bicipital groove Lesser tubercle Greater tubercle

  7. Bony Landmarks • Scapula • Acromion • Coracoid process • Glenoid fossa • Spinous process

  8. Shoulder Girdle

  9. Muscles of the Shoulder • Deltoid • Trapezius • Pectoralis Major • Pectoralis Minor • Serratus anterior • Rhomboid major • Rhomboid minor • Levator scapulae • Coracobrachialis • Latissimus dorsi

  10. Deltoid • Abducts shoulder

  11. Trapezius • Rotates scapula

  12. Shoulder depression • Scapular depression • Punching • Flex shoulder • Adduct shoulder • IR shoulder

  13. Levator Scapulae • Elevates scapula • Rhomboid Major/Minor • Retract scapula • Elevate scapula

  14. Flexes shoulder • Adducts shoulder

  15. Biceps Brachii • Weakly flexes shoulder • Two proximal heads • Long head—supraglenoid tubercle of scapula • Short head—coracoid process of scapula

  16. Rotator Cuff Muscles Collective set of four deep muscles of the GH joint • Supraspinatus • Inserts into humerus anteriosuperiorly • Infraspinatus • Inserts onto the humerus posterosuperiorly • Teres Minor • Inserts onto the humerus posteriorly • Subscapularis • Inserts onto humerus anteriorly

  17. Rotator Cuff Muscles

  18. Rotator Cuff Muscles

  19. Ligaments of the Shoulder • Coracoclavicular • Coracoacromial • Coracohumeral • Glenohumeral • Acromioclavicular

  20. Common Injuries of the Shoulder Overuse injuries to the shoulder

  21. Impingement Syndrome • Widely used term to describe pain occurring when space between humeral head and acromion become narrowed • Bones “impinge” or squeeze structures that occupy the subacromial space • Three structures: • Joint capsule • Tendons of rotator cuff • Bursa

  22. Impingement Syndrome • Overhead sports • Baseball, tennis, swimming, volleyball • Signs & Symptoms • Pain and tenderness in GH • Pain and/or weakness with active abduction in mid-range • Limited IR • Confirmation with special tests • Point tenderness in subacromial area

  23. Impingement Syndrome—Treatment • Address biomechanics • Substitute with cross-training until condition resolves • Limit excessive overhead movement • Rehab exercises & stretching

  24. Rotator-Cuff Tears • Traumatic injury • i.e. FOOSH • Unusual demands on young athlete • Repetitive use leads to chronic condition • Ultimately tear in tendons • Partial thickness tear • Not completely sever tendon • May respond well to non-op treatment • Full thickness tear • Require surgery

  25. Rotator-Cuff Tears—Signs & Symptoms • Vague pain in shoulder area • “Catching” sensation when arm moved • Inability to sleep on affected side • Varying degrees of disability

  26. Muscle Strains • Caused by overuse or traumatic injuries • Signs & Symptoms • Pain, tenderness in muscle belly • Symptoms provoked by: • Direct palpation • Stretch • Contraction against resistance • Mild strains can resolve within few days • Severe strains can take several months to heal

  27. Muscle Strains—Treatment • PRICE • Gentle stretching • Strengthening program • Cross-train • Functional progression

  28. Biceps Tendonitis • Discomfort in anterior shoulder • Often confused with RC tendonitis • Can be caused by impingement

  29. Proximal Biceps Tendon Rupture • Not common in athletics • Sudden onset of pin in front of shoulder • Associated with a “pop” during vigorous activity • Drooping biceps muscle at distal arm • “Popeye” muscle

  30. Proximal Biceps Tendon Rupture

  31. Common Injuries of the Shoulder Traumatic Shoulder injuries

  32. Shoulder Dislocation • Direction depends on nature of injury • Antero-inferiorly (most common direction) • Inferiorly • Posteriorly • Requires immediate care by physician • Additionally injuries include: • Fractures • Glenoid labral tears • Axillary nerve damage

  33. Glenoid Labrum • Cartilaginous ring that acts to keep the humeral head positioned on the glenoid by blocking unwanted movement

  34. Glenoid Labrum Injuries • Injury occur with : • Acute trauma (dislocation) • Repeated trauma • Degenerated tear (baseball pitchers) • Repetitive subluxation • Labral rim degenerate over time • Signs & Symptoms • Pain • Catching or popping sensation • Limited ROM • Varying degrees of weakness • Special Tests • MRI

  35. SLAP Tear • Superior Labrum from Anterior to Posterior • Occurs at point where biceps tendon inserts on labrum • Area of relatively poor blood supply • FOOSH • Repetitive overhead actions • Lifting a heavy object

  36. Multidirectional Instabilities • Hyper-elastic or overly flexible individuals, often can sublux shoulder voluntarily • May have problems with overhead sports • Positive Sulcus sign • Weight-bearing exercises & weight training helpful • Condition normally not improved with surgery

  37. Acromioclavicular Separation • Direct blow to tip of shoulder • FB player falling on tip of shoulder or FOOSH • Signs & Symptoms • Pain in vicinity of AC joint • Possible deformity of joint depending on degree of sprain

  38. AC Separation—Treatment • PRICE • Rehab • ROM & strengthening as tolerated • Overhead exs not recommended • 2nd degree • 3-4 weeks immob • Most painful • 3rd degree • 6-8 weeks immob • May leave permanent deformity

  39. Acromioclavicular Separation

  40. Brachial Plexus Injury • Stinger • Burner • Occurs when head and neck forcibly moved/hit to one side • Nerves n brachial plexus compressed on that side • Painful and disabling

  41. Brachial Plexus • Group of peripheral nerves • Leave spinal cord & extend from vertebrae into shoulder • Give arm ability to function

  42. Brachial Plexus Injury—Signs & Symptoms • Intense pain from neck down to arm • Arm will feel like it’s on fire or have pins-and-needles sensation • Arm/hand may be weak and numb • Intense pain in area of brachial plexus • Symptoms last several minutes to several hours or more • Weakness may last for several days • depends on severity of injury

  43. Brachial Plexus Injury—Treatment • Resting neck/arm until pain & symptoms go away • Ice pack 20 minutes every 3-4 hours • Anti-inflammatories • Strengthening exercises • RTP determined by sports medicine staff • Subsequent stingers cause for further testing

  44. Brachial Plexus Injury—Treatment • Chronic stingers may eliminate athlete from contact sports • Scar tissue develops around nerve • ® Causes nerves to become entrapped • If athlete receives another blow, brachial plexus may not be able to flex • shatters instead, tearing major nerves of arm • Causes permanent neurological damage • Avoid by: • Keeping neck and shoulders as strong as possible • Properly fitted equipment • Proper tackling & blocking techniques

  45. Fractures of Shoulder • Usually caused by impact or blow to shoulder • Common areas: clavicle & humerus • Scapular fx not show on x-ray; use bone scan • Clavicleobvious deformity • Ecchymoses may be present • Consider injury to joints, muscles, ligaments, vessels, and nerves

  46. Special Tests

  47. Special Tests for Shoulder • Neer’s Impingement • Hawkin’s-Kennedy Impingement • Cross-over Impingement • Speed’s test • Empty Can • Drop-arm Sign • Shoulder Hike • Cross-arm adduction • Anterior apprehension • Posterior glide • Feagin’s Test • Sulcus sign • Clunk test • AC Shear Test • Roos Test • Piano Sign

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