The Shoulder Complex
• Its mobility compromises stability.
• Structurally, the shoulder is an
unstable joint
–
relies on a large network of ligaments and muscles to
provide stability without restricting mobility.
• Functional movement involves
integration of bones, joints, ligaments,
and muscles.
Shoulder Motion
• Glenohumeral
–
–
–
–
–
–
Flexion
Extension
Abduction
Adduction
Internal Rotation
External Rotation
• Shoulder Girdle
–
–
–
–
–
–
Protraction
Retraction
Elevation
Depression
Upward Rotation
Downward Rotation
Functional Anatomy
• Bones
– Humerus
• Angle of inclination
– 130-150o
• Angle of torsion
– Varies
– Scapula
– Clavicle
Functional Anatomy
• Four Joint System
– Glenohumeral Joint
– Scapulothoracic Joint
– Acromioclavicular Joint
– Sternoclavicular Joint
Rhythm between the joints
Functional Anatomy
• Glenohumeral joint
– Ball and socket –
• glenoid fossa is 2/3 size of the humeral head.
– Static stabilizers
• What are these?
– Dynamic stabilizers
• What are these?
Static Stabilizers
• Glenohumeral
Ligaments
– Circle Stability
• The anterior, inferior,
superior, and posterior
glenohumeral
ligaments act together
to force the articular
surface of the humeral
head against the
glenoid.
• As one is stretched the
other develops tension.
Static Stabilizers
• Glenoid labrum
– Cartilage
• Thicker on outside and
thinner on inside
• Circle stability
– Acts like tee for a golf
ball
• Complimented by
ligaments and long
head of biceps tendon
Circle Stability
Functional Anatomy
• Coracoacromial Arch
– Coracoacromial Ligament
• Roof
–
–
–
–
Supraspinatus
Long head of Biceps Tendon
Superior/Anterior Labrum
Bursa = Subacromial (aka
Subdeltoid)
Dynamic Stabilizers
•
Glenohumeral dynamic stabilizers
1. Originate on axial skeleton and attach to
humerus
•
Latissimus dorsi, serratus anterior, pectoralis minor,
and pectoralis major
2. Originates on scapula/clavicle and attach to
humerus
•
•
Deltoid, teres major, coracobrachialis, biceps and
triceps.
Rotator Cuff - SITS
Shoulder Musculature
• Rotator cuff
– Supraspinatus
– Infraspinatus
– Teres Minor
– Subscapularis
What is the
function of
the rotator
cuff?
Rotator Cuff
Dynamic Stabilizers
•
•
Force couples - Circle stability
Co-contraction – compresses
the humeral head within the
glenoid fossa = minimizes
humeral head displacement
1.
2.
Adducted position – rotator cuff
vs. anterior deltoid
Abducted position –
rotator cuff and long head of
biceps vs. deltoids
Functional Anatomy
• Scapulothoracic joint – not a true joint
– Upward rotation, downward rotation, protraction, and
retraction
• When do these occur in throwing motion?
– It is essential to maintain positioning of humeral head
relative to glenoid and for glenoid to adjust relative to
movement while maintaining stable base.
– Scapulohumeral Rhythm
• Is often the key to shoulder pathology
• 180 degrees of motion – flexion or abduction
– 120o Glenohumeral
– 60o Scapulothoracic – Upward rotation/Tilt
Scapulohumeral Rhythm
• Humeral to Scapular ratio (
– Humeral Elevation to Upward Rotation
Scapular Stabilizers
• Dynamic stabilizers
– Trapezius, levator scapulae,
pectoralis minor, serratus
anterior, and major and minor
rhomboids.
– Which are upward and which
are downward rotators?
– Which are protractors and
retractors?
– Serratus anterior
• Very important especially
deceleration/follow-through of
throwing
Functional Anatomy
• Sternoclavicular joint
– Must have motion here to achieve full humeral
abduction
• Interclavicular, Sternoclavicular ligaments
• Acromioclavicular joint
– Must have posterior rotation of clavicle so
scapula can rotate to allow full elevation.
• Trapezoid and Conoid ligaments
Kinetic Chain
• Interaction of the sternoclavicular,
acromioclavicular, scapulothoracic, and
glenohumeral joints.
– To get overhead motion:
• Scapula must rotate.
• Clavicle elevates.
Mechanisms of Injury
• Direct Trauma
Mechanisms of Injury
• Indirect Trauma
Mechanisms of Injury
• Shoulder Dyskinesis
Sternoclavicular Injuries
– MOI:
• Direct contact
• Transfer through kinetic chain – longitudinal force through
clavicle – FOOSH or Traction
– Grades 1, 2, 3 - (sprain to dislocation)
• Painful motions – Retraction, Protraction, Elevation
– Dislocation
• Anterior more common.
• Posterior is very serious – Why?
– S/S: Dizziness, nausea, neurovascular changes, or
dysphagia
– Testing – Joint play and palpation
– Tx:
• Ice, Sling, and Referral
• Figure 8 immobilization – 3-5 weeks
– Rehabilitation
Acromioclavicular Injuries
• Ligaments:
– Acromioclavicular ligament
– Coracoclavicular ligaments –
Trapezoid and Conoid
• MOI:
– Direct trauma
• FOOSH or tip of elbow
• Top of shoulder
• Clavicle
– Chronic degeneration overuse
• Classification
– Type I, II, III, IV, V, VI
– Step-off deformity
• S/S:
– PAIN, laxity, deformity
– Radiating pain –
neck/scapula
Acromioclavicular Injuries
• Special tests:
– AC Glide -Piano Key Sign
– Pain above 90o and with
horizontal adduction
– Traction, Compression
• Tx:
– Conservative – 1-4 weeks
• Ice, sling, corticosteroid
injections, leukotape
• Rehabilitation/Padding
– Surgical – at least 4 months
• Resection of distal clavicle
• Wires for stability
Shoulder Instability vs. Laxity
• Is there a difference?
• Descriptions
– Laxity – Capsular weakening and stretching
that allows humeral head to have large glide
motion in one or more directions
• Puts many structures at risk by demanding more
effort to control motion.
– Instability – Humeral head displacement with
elevation
• Many causes – laxity, weakness, neurological
Glenohumeral Sprain
• Damage to capsular ligaments
– MOI:
• forceful movement – abduction and rotation
– S/S:
• Pain/tenderness
• Limited ROM – end ranges
• Laxity tests
– Apprehension
– Glenohumeral Glide
– Potential for chronic problems
• Importance of immobilization and strengthening
Glenohumeral Dislocations
• Dislocations and Subluxations
– What’s the difference?
• MOI: Dislocation
– Direct trauma (laxity) - FOOSH
• 85-90% will reoccur if MOI was direct trauma
– Indirect trauma (instability)
• General S/S:
– Joint dislocation – not functioning
– Pain
– Vascular or Neurological problems?
• When do athletes need surgery?
• What are complications?
Glenohumeral Dislocations
• Classification
– Anterior Glenohumeral - most common
• MOIs
• Bankart lesion and Hills-Sachs lesion
– Posterior Glenohumeral
• MOIs
• Reverse Hills-Sachs lesion
– Inferior Glenohumeral - very uncommon
• MOIs
Glenohumeral Dislocations
• S/S:
– classic deformities for each direction
• Special Tests:
– Glide tests, Apprehension, Load and Shift,
Relocation, and Sulcus Sign
– Clunk (R/O Labral Tear)
• Tx: No surgery
–
–
–
–
Who reduces?
Ice/Modalities
Immobilization – 3-4 weeks
Strengthening
• Rotator cuff and scapular
Chronic Shoulder Subluxation
• MOI: Traumatic, Atraumatic, or Microtraumatic
• Types:
– Anterior –
• clicking or pain; complain of dead arm during cocking phase (when
throwing); pain posteriorly; possible impingement; positive
apprehension test
– Posterior –
• possible impingement, loss of internal rotation; crepitation; increased
laxity; pain anteriorly and posteriorly
– Multidirectional (MDI)–
• inferior laxity; positive sulcus sign; pain and clicking w/ arm at side;
possible signs and symptoms associated w/ anterior and posterior
instability
Chronic Shoulder Subluxation
• Tests: Clunk and O’Brien’s
• S.L.A.P. lesions = complication
– Superior labrum anterior to posterior
– Long Head of Biceps Brachii
– Types I, II, III, IV
Chronic Shoulder Instability or
Laxity
• Management
– Conservative
• strengthening (rotator cuff and scapula stabilizers)
– Various harnesses and restraints can be used to limit
motion
– Surgical stabilization may be required to improve
function and comfort
• Usually not chosen unless had
two traumatic dislocations or
non-traumatic dislocations
• 6 to 8 weeks immobilization
Shoulder Injuries
• Fractures of the Humerus
– Shaft or Proximal fracture
• MOI: Direct blow or FOOSH
– Epiphyseal fractures
• MOI: Direct blow or indirect loading
• common in young athletes
– May pose danger to nerve and
blood supply
Shoulder Injuries
• Fractures of the Humerus
– Signs and Symptoms
• Pain, swelling, point tenderness, decreased ROM
– Management
• Immediate application of splint, treat for shock and
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– Humeral fractures- remove from activity for 3-4 months
– Proximal fracture - incapacitation 2-6 months
– Epiphyseal fracture - quick healing - 3 weeks
Shoulder Injuries
• Contusion of Upper Arm
– Etiology
• Direct blow
– Signs and Symptoms
• Transitory paralysis and inability to use
extensor muscles of forearm
• Ecchymosis
– Management
• RICE for at least 24 hours
• Provide protection to contused area to prevent repeated
episodes that could cause myositis ossificans
• Maintain ROM
Shoulder Injuries
• Clavicular Fractures
– MOIs:
• FOOSH, fall on tip of shoulder or direct impact
• Occur primarily in middle third (greenstick fracture often
occurs in young athletes)
– Signs and Symptoms
• Supporting of arm, head tilted towards injured side w/ chin
turned away
• Clavicle may appear lower
• Pain, swelling, deformity and point tenderness
– Management
• Closed reduction - sling and swathe, immobilize w/ figure 8
brace for 6-8 weeks
• Rehabilitation and use of a sling for 2-4 weeks
Shoulder Injuries
• Biceps Rupture
– MOI:
• Result of a powerful
contraction
• Generally occurs near
origin of muscle at
bicipital groove
– Signs and Symptoms
• “Snap” and intense pain
• Protruding bulge–
“popeye”
• Definite weakness with
elbow flexion and
supination
• Management
– Ice, Sling, and refer
– Athletes will require
surgery
– Older individual will be able
to rely on brachialis which
serves as primary elbow
flexor
Shoulder Injuries
• Repetitive Throwing or Overhead Motion
Injuries
– Rotator Cuff Pathology
• Rotator Cuff Impingement Syndrome
– Compressive vs. Tensile
• Rotator Cuff Tendinitis
– Overhead Athlete and Instability
Continuum
• Instability = unwanted humeral translation as
a result of ineffective muscle contraction
Overhead Athlete and
Instability Continuum
Overuse
Microtrauma = Inflammation
Instability
Subluxation
Impingement Rotator Cuff Tendinitis
Pink and Jobe, 1991
Rotator Cuff TEAR
Rotator Cuff Impingement
• MOI
– 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
– Exacerbating factors laxity and inflammation,
postural mal-alignments
Rotator Cuff Impingement
• Primary compression
– Irregularly shaped acromion or
ligament, enlarged bursa,
inflammed tendons
• Secondary compression
– Instability, poor posture,
repetitive overhead
• Primary tensile
– Overuse, Posterior capsule
tightness, and rotator cuff
weakness
Impingement
• Secondary tensile
– Scapular dyskinesis, rotator
cuff weakness, instability
Inflammation
Rotator Cuff Impingement
– Signs and Symptoms
• Diffuse pain, pain on palpation of subacromial
space, bicipital groove, supraspinatus insertion
• Limited ROM – active and passive – above 90o
• Painful arc – 70-120o
• Decreased strength of external rotators compared
to internal rotators; tightness in posterior and
inferior capsule
– Special Tests: Neer’s and Hawkins-Kennedy
Tests. Empty Can
– Tx: Rehabilitation – rotator cuff and
scapular stabilizers
Rotator Cuff Tendinitis
• Supraspinatus most likely
• Etiology either Insidious or Acute
• MOI: Overuse; Instability; Impingement; acromion spurs;
poor vascularization (“wringing out”)
• 3 Stages - I - inflammation; II - degeneration; III – tear
• S/S: pain deep in shoulder and radiating down lateral
arm; pain w/ follow –through or overhead, supraspinatus
tenderness, decreased strength – abd, ER, IR
• Special tests – Empty Can and Drop test; Impingement
tests
Rotator Cuff Pathology
– Stage I –
• Supraspinatus or biceps
tendon injury
• Pain w/ abduction and
resisted supination w/
external rotation;
• Edema and thickening of
rotator cuff and bursa
– Occurs in athlete < 25
years old
– Stage II –
• Permanent thickening and
fibrosis of supraspinatus
and biceps tendon; pain w/
motion
• Aching during activity that
worsens at night
– Stage III –
• History of shoulder problems
and pain
• Limited active and full passive
ROM
• Tendon defect (3/8 “) or tear –
partial thickness tear
• Permanent scar tissue and
thickening of rotator cuff
– Athletes 25-40 years old
– Stage IV• Infraspinatus and
supraspinatus wasting
• Pain during abduction and ER
• Tendon defect greater than
3/8” – full thickness tear
• Limited active and full passive
ROM
Rotator Cuff Pathologies
• Management
–
–
–
–
Rest
Ice, Analgesics, and,electrical stimulation for pain
NSAID’s and ultrasound for inflammation
Restore appropriate mechanics and strengthen
rotator cuff to depress and compress humeral head to
restore space
• Flexibility of posterior structures
• Strengthening of scapular, rotator cuff, and other shld.
muscles
– Strengthen lower extremity and trunk to reduce stress
on shoulder
– Stage III and IV cases may require immobilization and
rest and potentially surgery
Shoulder Bursitis
• MOI – Subacromial (Subdeltoid) bursa
– Chronic inflammatory condition due to trauma or overuse – Fibrosis, fluid build-up resulting in constant inflammation
• Signs and Symptoms
– Pain w/ motion and tenderness during palpation in subacromial
space; positive impingement tests
• Management
– Ice, ultrasound and NSAID’s to reduce inflammation
– Remove mechanisms precipitating condition
– Maintain full ROM to reduce chances of contractures and
adhesions from forming
Bicipital Tendinitis
• MOI
– Repetitive overhead athlete – rotator cuff dysfunction
– Ballistic activity that involves repeated stretching of biceps
tendon causing irritation to the tendon, sheath, and transverse
humeral ligament
• Forceful extension and external rotation
• Signs and Symptoms
– Tenderness over bicipital groove, swelling, crepitus due to
inflammation
– Pain when performing overhead activities
– Positive: Speed’s and Yergason’s Tests
• Management
– Rest, ice and ultrasound to treat inflammation
– NSAID’s
– Gradual program of strengthening and stretching
Frozen Shoulder
• MOI
– Contracted and thickened joint capsule w/ little synovial fluid
– Chronic inflammation w/ contracted inelastic rotator cuff muscles
– Generalized pain w/ motions (active and passive) resulting in
resistance of movement
• Signs and Symptoms
– Pain in all directions both w/ active and passive motion
• Management
– Aggressive joint mobilizations and stretching of tight musculature
– Electric stimulation for pain and ultrasound for deep heating
Neurovascular Entrapment
• Brachial Plexus Injury
– Compression or Traction
• Suprascapular Nerve Injury
– Supraspinatus and Infraspinatus waste away
• Thoracic Outlet Syndrome
– Pressure on trunks and medial cord of
brachial plexus and the subclavian artery or
vein
Thoracic Outlet Syndrome
• MOI
– Poor posture, prolonged pressure, acute trauma
– 1) decreased space between clavicle and first rib, 2)
scalene compression, 3) compression by pect. minor,
or 4) presence of cervical rib
• Signs and Symptoms
– Neural – numbness, pain, paresthesia, atrophy
– Arterial – coldness, pallor, cyanosis, atrophy
– Venous – muscle/joint stiffness, edema, venous
enlargement, thrombophlebitis
Thoracic Outlet Syndrome
• Tests:
– Adson’s (anterior scalene test) – subclavian artery
– Allen’s (pectoralis minor test) - neurovascular
– Military Brace (costoclavicular test) – subclavian
artery
• Management
– Conservative treatment
• correct anatomical condition through stretching (pec minor
and scalenes) and strengthening (trapezius, rhomboids,
serratus anterior, erector spinae)
Shoulder Assessment
Putting it together with
Case studies
Case Study #1
• A 23 year old comes to you complaining of
shoulder pain. He says that 2 days ago he
was playing catch with a football; when his
friend threw the ball, he reached for it
above his head, lost his balance, and fell
on an outstretched hand out to the side.
He felt the shoulder “slip” a little and then
pain. He complains of pain in his
upper/anterior shoulder and upper chest
region. Also reports a “clicking” sensation.
Case Study #2
• A female competitive swimmer comes to
you complaining of diffuse shoulder pain.
She notices the problem most when she
does the butterfly. She complains that her
shoulder sometimes feels unstable and
weak when doing this stroke, she has
even felt it “pop” once. She reports some
changes in sensation along the outside of
her arm – near her deltoid.
Case Study #3
• A 30 year old tennis player complains of
pain throughout shoulder and into arm.
Notices increased episodes of hands
“falling asleep” during the night. Also
notices that hands are often cold. Notices
that discomfort increases with overhead
serving and returns. Also, has problems in
the weight room and with ADLs when arms
are overhead.
Case Study #4
• A major league baseball pitcher reports to
athletic training room with increasing pain
in shoulder on follow-through of pitching.
Pain increases when he has pitched more
than 70 pitches. He localizes pain to area
by greater tubercle. It is point tender and
slightly swollen. He has excessive external
rotation and limited internal rotation.