The Shoulder Complex
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
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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.as
p?vidid=849
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Basic Anatomy
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Anatomy
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Anatomy
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Muscular Anatomy
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Muscular Anatomy
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Muscular Anatomy
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Movements
 http://www.youtube.com/watch?v=FHq3K6J3Wq8
 http://www.youtube.com/watch?v=RPRJPNCVRdE
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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
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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
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Throwing Mechanics
Instruction in proper throwing mechanics is critical for
injury prevention
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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
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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
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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
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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.
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Pitch Count

Recommended limits for 9-10 year old pitchers:





Recommended limits for 11-12 year old pitchers:





50 pitches per game
75 pitches per week
1000 pitches per season
2000 pitches per year
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
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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?
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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
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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
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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
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Apprehension test (Crank test)
 Apprehension test
used for anterior
glenohumeral
instability


This motion should
not be forced
Easier to have the
athlete lay down
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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
HawkinsKennedy
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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
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Clavicle and AC joint
Compression Test
 Compress the clavicle
and spine of the
scapula together
 + if increased
movement is felt or
pain is experienced
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

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 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

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Clavicle Fx
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 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

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© 2007 McGraw-Hill Higher Education. All rights reserved.
 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

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http://www.youtu
be.com/watch?v=f
kGtNkBsXkE
 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

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AC Sprain
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
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
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© 2007 McGraw-Hill Higher Education. All rights reserved.
 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

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 http://www.youtube.com/watch?v=-Hv8FM78I7I
 http://www.youtube.com/watch?v=plquoz_mKiQ
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Shoulder Dislocation
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 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

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
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)

© 2007 McGraw-Hill Higher Education. All rights reserved.

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

© 2007 McGraw-Hill Higher Education. All rights reserved.

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

© 2007 McGraw-Hill Higher Education. All rights reserved.
 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

© 2007 McGraw-Hill Higher Education. All rights reserved.
 Bicipital Tenosynovitis
 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

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 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

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