THE SHOULDER
Chapter 21
The Shoulder Girdle Complex

3 joints make up the
shoulder girdle
 The
Sternoclavicular joint
 The Acromioclavicular
joint
 The Glenohumeral joint
The Sternoclavicular Joint

Formed through the articulation of the sternum and
the clavicle.
 Also
called the SC joint
 Injuries to this joint can be very debilitating, but are
very rarely seen in athletics.
Acromioclavicular Joint

Formed by the
articulation of the
acromion process of the
scapula and the distal
end of the clavicle.


Also called the AC joint
Its is located superiorly
to the glenohumeral joint
and is commonly
exposed to injury in
contact sports.
Glenohumeral Joint

Formed by the Humerus
and the scapula
 The
head of the humerus is
attached to the glenoid
fossa of the scapula
 Shallowness
of the socket
allows for a great deal of
movement

Supported by
 several
muscles
 ligaments
 Soft tissue
Structure and Function

Dynamic Stability refers to mobility with stability
 Shoulder
accomplishes this through the coordinated
movement of the scapula in concert with the humerus
 Several muscle groups work together synergistically to
create the dynamic stability of the shoulder.
Rotator Cuff

A set of 4 deep muscles of
the glenohumeral joint
 They
originate on the scapula
and insert onto the superior
aspect of the humerus
 Will often be referred to as
the SITS muscles
 Supraspinatus
 Infraspinaus
 Teres
Minor
 Subscapularis
Muscles of the Shoulder Girdle

Muscle Force Coupe
Formed by the actions of the deltoid and rotator cuff
muscles
 Allows the humeral head to spin while remaining in place on
the glenoid


Scapulothoracic Mechanics

Allows the scapula to move in several
places using the following muscles
Trapezius
 Rhomboids
 Serratus
 Pectoralis Minor

Muscles that move the Scapula

There are several muscles that move the scapula
 Levator
scapulae
 Rhomboids
 Major
and Minor
 Pectoralis
Minor
 Serratus Anterior
 Trapezius
Muscles that move the Scapula
Muscles that move the Arm (Humerus)

There are several muscles that move the Humerus
 Coracobrachialis
 Pectoralis
Major
 Teres Major/Minor
 Deltoid
 Supraspinatus
 Infraspinatus
 Latissimus Dorsi
Muscles that move the Arm (Humerus)
Overuse Injuries to the Shoulder

Overuse injuries of the shoulder are usually limited to
the soft tissues.

Usually caused by repetitive activity to the point of causing
tissue damage and inflammation
Common among athletes that participate in overhead movements
 Many athletes are unaware that an injury is occurring until
symptoms manifest


Overuse Injuries include
Impingement syndrome
 Tendonitis
 Bursitis
 Muscle strains

Impingement Syndrome

Impingement syndrome describes a situation causing
injury when the space between the humeral head
and acromion becomes narrowed.
The bones “impinge” or squeeze structures within the
space
 Structures affected are the joint capsule, tendons of the
rotator cuff, and a bursa


Impingement causes mechanical irritation of the cuff
tendons, resulting in hemorrhage and swelling

Commonly called tendonits of the rotator cuff


Supraspinatus is the muscle usually involved
If the bursa is involved, bursitis is the result.
Impingement Syndrome - Symptoms

Symptoms
 Pain
and tenderness in GH
area
 Pain and/or weakness with
ABD in midrange
 Limited IR
 + results from special tests
 Hawkin’s
impingement
 Tenderness
to palpation in
subacromial area
Impingement Syndrome - Treatment

Treatment options
 Correction
of
improper sport
technique
 Preseason conditioning
 Specialized taping

Rehabilitation and
Prevention
 Most
rehab techniques
involve strengthening
the weakened muscles
of the shoulder girdle
Shoulder Impingement Exercises
Rotator Cuff Tears

Could be partial tear or full thickness of the tendon

Can happen to people of any age

In younger people often caused by more traumatic injuries



Older people


Falling on outstretched arm
Unusual demands on the joint
Usually caused by degeneration of the muscle and tendon tissues
Treatment



Usually determined by severeity of injury and how it responds to
rehab
Small and partial tears respond well to non-operative rehab
program
Moderate to large tears, and small tears that are non-responsive
to rehab, require surgery
Rotator Cuff tears (cont’d)

Symptoms
 Pain
 Full
ROM with partial
tears
 Loss of ROM with full
tears
 Athlete will not be
able to lift the arm
overhead, and often
when they try, the
can be observed to
hike or shrug
Muscle Strains


Can be caused by excessive
overuse or traumatic injury
Symptoms


Pain
Tenderness in muscle belly
caused by





Palpation
RROM
Stretch
There could be a delay of a day
or two before symptoms actually
show
Treatment



PRICE
Gentle stretching
Strengthening program
Biceps (long head) Tendonitis


Can cause
discomfort in the
front of the
shoulder and will
often be confused
with rotator-cuff
tendonitis.
Both can be
caused by
impingement and
will have the
same treatment
Biceps Tendon Rupture

Not common in athletics,
but results from vigorous
activity
 Described
as a sudden
onset of pain in the front
of the shoulder and an
associated “pop”

Symptoms
 Drooping
of the biceps
muscle near the distal
upper arm
 Ecchymosis
Biceps Tendon Rupture (cont’d)



This injury is considered a Grade III
injury and usually affects the biceps
tendon long head.
People who have a prior history of
tendonitis may be more prone to this
injury
Treatment





Surgery is usually not needed
PRICE
Gradual return to strengthening and
activity
Athletes can usually return to full
activity after a period of conservative
care
There may be a small loss of shoulder
flexion in the long term, but not enough
to result in loss of high-level functioning
Traumatic Shoulder Injuries

Usually are caused by a sudden onset
 Blow
to arm or shoulder
 Shoulder joint being forced beyond physiologic limits

Common Injuries
 Glenohumeral
dislocation
 Acromioclavicular separation
 Fractures
 Tendon Ruptures
Anterior Shoulder Dislocation

Results in the head of the humerus being
completely out of the glenoid fossa

Usually caused by shoulder being forced into
abduction, extension and external rotation.



Most common means of dislocation is
anterioinferiorly
Immediate transport to a physician is
required
Physician should also check for other
injuries




Fractures
Glenoid labial tears
Axillary nerve damage
Hill-Sachs lesions can occur if the head of the
humerus hits the front of the glenoid hard
enough to cause an indentation
Anterior Shoulder Dislocation (cont’d)

If the injury is not properly managed and fully
rehabilitated, there is a high risk for recurrent
dislocations.
 Immobilization
may be as long as 8 weeks
Glenoid Labrum Injuries

These injuries involve the deepest soft tissue
in the shoulder


Can often occur along with dislocations
Happens commonly with baseball pitchers
when degenerative changes in the labrum
cause it to become loose


Symptoms






Permits humeral head to slip forward
Pain
Popping sensation
Limited use of the arm
Varying degrees of weakness
Special tests and MRI will confirm diagnosis
Treatment includes specialized rehab
program

Suspected tears must be referred to a
physician
Multidirectional Instability

Refers to the ability of the
athlete to voluntarily dislocate
their shoulders

usually due to athlete being
hyperelastic or overly flexible


This causes problems with athlete
playing overhead sports.
Weight bearing exercises can
be helpful in dealing with this
problem
Push-ups
 Plyometrics
 Weight training

Acromioclavicular Separation

This injury is a traumatic sprain
of the AC joint


Usually caused by a blow to the
tip of the shoulder
Symptoms
Pain near the AC joint
 Obvious deformity


Treatment
Physician referral
 1st degree sprains



PRICE
2nd / 3rd degree sprains

Require 6-8 weeks of immobilization
Brachial Plexus Injury

Is often called a stinger or burner


Symptoms





Intense pain from the neck down to the arm
On-fire or pins-and-needles sensation
Weakness
Numbness
Treatment






Usually caused by a stretching of the brachial plexus on the opposite side
Referral to specialist
Rest
Ice
Anti-inflammtory meds
Strengthening exercises for neck and shoulders
Prevention



Keeping neck and shoulders strong
Wearing properly fitted equipment that distributes forces during collision
Using proper technique
Fractures


Fractures of the shoulder
girdle most commonly
involve the clacivle and
humerus
Scapular fractures may
not be seen on standard
x-rays
 Present

on bone scans
Any suspected fracture
should be referred to an
emergency room
physician
Is it a Shoulder Injury

Often times pain in the shoulder can be referred
pain from another injury.
 Pain
in the shoulder does not always indicate a shoulder
problem

Cardiac problems or Heart attack
 Referred

pain to the left shoulder, neck and arms
Spleen Injury
 Refer
pain to the left shoulder and down the upper
portion of the left arm
 Kehr’s
sign