The shoulder
Shallow G-H jtglenoid labrum
deepens capsule;also
requires strong
muscle force to
stabilize the jointRTC (rotator cuff
muscles) SITS ms.
Ligaments of shoulder joint:
A-C ligament-sup and inf reinforce the
joint capsule and prevent post
dislocation of the clavicle
G-H ligaments-originate from labrum
and attach to lesser tubercle and anat
neck (reinforce capsule) sup, mid and
inf bands
Coracoclavicular lig.- lat(trapezoid) and
med(conoid) Both prevent backward
mvmt of the scapula and ind they limit
scap rotation
Acromioclavicular Joint
A-C joint capsule
Coracoclavicular
ligaments
Clavicular Ligaments
A-C Joint
Conoid ligament
Common Glenohumeral
Problems
Rotator cuff tendinitis
Rotator cuff tears
Bicipital tendinitis, rupture
Glenohumeral dislocation/subluxation
Labral Tears
Frozen shoulder syndrome
Arthritis
Rotator Cuff Problems
Rotator Cuff Impingement
Rotator Cuff Tear (RCT)
Phase 1 (0 to 6 weeks)
Phase 2 (6 to 12 weeks)
• Passive range of motion
exercises only for almost
all tears.
• Active-assisted range of
motion for very small
tears or repairs with
exceptionally good tissue
• Full passive motion
• Begin active-assisted
motion
• Strengthen intact cuff
muscles
• Begin to strengthen the
muscles that stabilize the
shoulder blade
Phase 3 (12 to 16 weeks)
Phase 4 IV (> 16 weeks)
•Passive stretching beyond
the patient's own range of
motion
•Strengthening the repaired
cuff muscles
•More strengthening of the
stabilizers of the shoulder
blade
•Functional strengthening
•Rehabilitation for sports
Normal Cuff, Torn
Supraspinatus on MRI
Bicipital Tendinitis
Impingement
Shear in bicipital groove
Long biceps tendon in
intimate with joint
capsule.
May be impinged
beneath acromion, or
sheared within
bicipital groove.
Bony Structures
Avascular Necrosis of
Humeral Head
May be seen with
chronic corticosteroid
use.
(GENTLY handle
patients with history
of steroid use.)
Can lead to total
shoulder
replacement.
Glenohumeral Arthritis
Glenohumeral Arthritis
Frozen Shoulder Syndrome
“Freezing” shoulder
“Frozen” shoulder
“Thawing” shoulder
Freezing Shoulder
“Freezing” shoulder
Usually starts with inflammatory process,
such as impingement syndrome.
Subscapularis trigger points limit external
rotation, abduction
Shoulder becomes painful, then stiff
Best opportunity for intervention is here!
Frozen Shoulder
Capsule undergoes fibrotic changes
(“Adhesive capsulitis”)
PT intervention alone is of questionable
help.
May benefit from manipulation under
anesthesia, followed by PT care.
Thawing Shoulder
Shoulder spontaneously becomes less painful,
less stiff.
If in rehab, take credit for result, but probably
little effect from treatment.
Nearly all frozen shoulders spontaneously
resolve in 6 to 18 months
May recur on opposite side
Rare in African-Americans
Glenohumeral/Scapulothor
acic Rhythm
Occur in 2:1 ratio GH/ST, but not in
constant ratio.
GH joint moves first, with stabilized
scapula
Then, move in 1:1 ratio.
Then finish with mostly GH motion
FINAL ratio is 2:1
Glenohumeral Dislocation
Usually caused by violent abduction/external
rotation of humerus.
Humerus dislocates in anterior, inferior direction.
Causes disruption of anterior labrum (Bankart
lesion)
If repeated, posterior aspect of humerus strikes
labrum, producing indentation in humerus (Hill
Sachs lesion.)
Superior Labral Tear Anterior and
Posterior to Biceps Attachment
(SLAP)
Biceps tendon
Posterior tear
Anterior tear
Bicipital Tear (Longhead)
Scapulothoracic Problems
Winging scapula from poor posture, habit.
Common in tall, early developing females, swimmers
Correlated with G-H problems
May be from long thoracic nerve palsy, taking
out serratus anterior.
Results in inability to raise arm above 120 degrees
(ever.)
Serratus Anterior Loss
Winging
120 degrees abduction
Suprascapular Nerve Palsy
Suprascaular nerve
innervates supra- and
infraspinatus.
Injury results in
selected weakness.
What’s the sensory
pattern??
Coracoacromial lig- provides roof over
the humeral head - acts as a protective
arch
Scapular movements must be
accompanied by shoulder joint
movements therefore if you have
impairment at G-H joint, must look at
scapula
Kinematics of shoulder jointscapulohumeral rythym
external rotation with abduction
scapular plane
Muscles-RTC(rotator cuff muscles) SITS
supraspinatus-imp to keep head of
humerus in glenoid fossa along with
other ms.
Infra, teres minor, subscap-act to
depress head during flexion and
abduction-counteract strong deltoid
long head of biceps becomes very
active in shld flex and abd past 90
Ms. named from areas they originate
and insert-grouping as follows:
Scapulohumeral:deltoid, supraspinatus,
infraspinatus, teres minor,
subscapularis, teres major,
coracobrachialis
Axioscapular:pect minor, trapezius,
rhomboids, lev scap, serr ant
Axiohumeral: pect major, lat dorsi
Deltoid-ant, mid and post portion
Origin: ant portion-lateral 1/3rd of
clavicle
mid-acromion, post-spine of scapula
Insertion-deltoid tuberosity of humerus
and med rotate, post fibers extend and
laterally rotate
innervation-axillary (C5,6)
supraspinatus:
origin-supraspinatus fossa of scapula
insertion-greater tubercle of humerus
action- stabilizes head of humerus in
capsule, assists in abduction-acts as
force couple with deltoid to assist with
abd
innervation-suprascapular (C4,5,6)
Infraspinatus-origin-infra fossa
insertion-greater tubercle and shld
capsule
innervaton-suprascap nerve
action-ext rotation of shoulder and
depression of humeral head and
stabilizes head during movement
Teres minor-origin-upper lateral border
of scapula
insertion-greater tub and shoulder
capsule
action-lat rotation and add of humerus
Subscapularis-origin-subscapular fossa
insertion-lesser tubercle of humerus
and capsule
action-int rotation of humerus and
works with other ms.
Innervation-subscapular (C5-7)
Teres major-origin-acillary border of inf
angle of scap
insertion-med tip of inter groove
action-med rotation, adduction and
shouler ext
Innervation-lower subscapular(C5-7)
Axioscapular-pect minor:
origin-ribs 3,4,5 and fascia of intercostal
ms
insert-coracoid process
action-elevation and downward rot of
scap
innervation-medial pect (C8-T1)
trapezius-origin-upper from occ
protuberance, nuchal line and spinous
porcess of C7, middle from spinous
process T1-5 and lower from T6-12
insertion- upper from lat clav and
Rhomboid major-origin-spinous process
T2-5
insertion-vertebral border
action-down rotation, elevation and
adduction of scap
innervation-dorsal scapular (C4-5)
rhomboid minor-origin-spinous
processes C7-T1
insert-root of spine of scap
action-same as major
inn-same as major
Levator scapula-origin-transverse
processes C1-4
insertion-sup med border of scap
action- elevation, down rotation and
add of scap
innervation-dorsal scapular
Serratus anterior-origin-upper 8-9 ribs
ant surface
insertion -medial, inf surf of scap
action-up rot, elevation and abduction
inn-long thoracic (C5-7)
AxiohumeralPectoralis major-origin:clavicle, sternum
and cartilage of first 6-7 ribs
insert-lat inter. Groove
action: med rotation, flexion and
horizontal adduction
Latissimus dorsi-origin-sp processes of
T6-12, last 3 ribs, thoracolumbar fascia
and iliac crest
insert-inter groove
action-med rotation, adduction and ext
of shld, ext of L spine, flex of T spine
Disorders of PNSneuropraxia-local blockage interfering
with conduction , it’s OK above and
below-commonly caused by
compression-Saturday night palsy-radial
nerve or Bell’s palsy, no disruption of
axon
Axonotmesis-nerve injury characterized
by disruption of the axon and myelin
sheath but with preservation of
supporting CT resulting in axonal
degeneration distal to the injury site-the
deficit depends on the # of axons
neurotmesis- partial or complete
severance of a nerve with disruption of
axons, myelin sheaths and supporting
connective tissue resulting in
degeneration of axons distal to the injury
site (worst of the 3)
Disorders of PNS
Erb’s palsy-compression or stretching of
upper BP nerve roots (C5,6)-results in
“waiter’s tip” sign
Klumpke’s paralysis-compression or
stretching of lower BP (C8,T1)-results in
functionless hand
Bursae-fluid filled sac which can be
inflammed-bursitis-most common in
shoulder-subdeltoid and subacromialleast likely subscapular bursitis
Signs-warm, edematous with
tenderness over area
Pain quality-intense, dull, throbbing all
movements painful
Tendonitis-inflammation of the tendon
RTC tendonitis-supraspinatus most
involved-results from overuse, tennis,
baseball, carpenters, plumbers-can also
be poor blood supply causing scarring
or Ca deposits-can bring about tears,
bursitis or impingements; local steroids
can relieve symptoms but may cause
structural wknss of tendon
Pain quality-sharp twinges ie. Donning
jacket, reaching OH, abd or IR arm
Onset-gradual. May sometimes refer to
C5-6 dermatome
RTC tears-acute, chronic, full, partial
thickness tears;<1cm. Small, >5cm.
Massive-usually traumatic but may be
degenerative
pain-not always severe but pt con’t
raise arm and has severs atrophy lat
and ant deltoid region-may require
surgery
Adhesive capsulitis-frozen shld.-trauma,
disuse, immobilization, RTC lesions
pain-dull-severe with activity, pain at
Onset-gradual, will see increase activity
of upper traps
Impingement syndrome-supra, long
head biceps, subacro bursa most
affected-pt. will exhibit painful arc of
motion b/w 70-120 degrees
3 stages:
I-edema-athlete or poor posture, young
person with no recollection of injury
II-fiborsis and tendinitis (20-40
yo)recurrent pain with activity
III-bone spurs and tendon ruptureslong history (50-60yo)
G-H instability-hum head dislocates
through ant capsule, RTC ms. Can be
weak
Brachial plexus lesions-numbness
and burning entire arm, hand,
fingers, sensory loss over 2 or
more dermatomes, paralysis of
arm, may be transcient tenderness over BP with increased
symptoms with movement of head
to opposite side
Thoracic outlet syndrome-often called
neurovascular compression-symptoms
resulting from injury at upper border of
thorax where BP and subclavian a are
located-can be caused from a C-rib
treatment-postural correction ex to bring
back shoulders
Brach plex lesions-numbness and burning
entire arm, hand, fingers-sensory los over
2 or more derm-paralysis of arm-may be
transcient-tenderness over BP with
increase symptoms when turning head
opp. side
Diagnostic testsX-ray-for bony defects, alignment,
exostosis (bone spurs), osteophytes and
diseases
C-T scans-specific for bone
MRI-magnetic resonance imaging-soft
tissue-no radiation as in X-ray
angiography-contrast mat injected into
vascular system
myelograpy-inject dye into SA space
EEG-records brain electrical activity
EMG and NVC-see if diseases are
neuromuscular in origin
arthrogram-injects dye and air-views jt
space, cartilage, ligs