Shoulder
Chapter 12
5 Articulations of the shoulder:
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SC (sternoclavicular jt.), surrounded by a jt. capsule; thickened anteriorly
and posteriorly by four ligaments, jt. motions are superior, inferior, anterior
and posterior. Some forward and backward rotation.
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AC (acromioclavicular jt.), enclosed by a thinner capsule than the SC jt.;
strong superior and inferior AC ligaments cross the jt. providing stability,
coracoacromial ligament (“arch”) attaches to the AC jt. to serve as a buffer
between the rotator cuff and acromion process, limited motion in all three
planes.
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CC (coracoclavicular jt.), syndesmosis where coracoid process of scapula and
the inferior surface of the clavicle are joined by the CC ligament, CC
ligament w/ conoid and trapezoid resist independent upward movement of
the clavicle, downward movement of the scapula and anteroposterior
movement of clavicle and scapula, movement is very limited.
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GH (glenohumeral jt.), very unstable due to the head of the humerus which is
3-4x surface area of the glenoid fossa, glenoid fossa is somewhat deepened
(perimeter) by the glenoid labrum (fibrocartilage), GH capsule joined by the
superior, middle, and inferior GH ligaments (anterior) coracohumeral
ligament (superior), displacements could occur in anterior, posterior,
inferior; strong coracohumeral ligament protects against superior
displacement, rotator cuff tendons join the capsule (helps w/stability)
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ST (scapulothoracic jt.), scapula permits motion w/respects to trunk and
thorax, 90% of muscles of the shoulder attaches to the scapula, scapula
perform two function: 1) stabilization of shoulder 2) facilitate movement.
Muscles of the shoulder and movements:
 Deltoid- Anterior, Lateral, Posterior
 Pectoralis Major- Clavicular( Upper), Sternal
 Latissimus Dorsi
 Teres Major
 Rhomboideus Major/ Minor
 Rotator Cuff- Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis
 Biceps Brachii- Long/ Short Head
 Triceps Brachii
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ROM:
Flexion GH: Anterior Deltoid, Upper Pec, w/assistance from the short head of bicep
Extension GH: Sternal Pec, Latissimus dorsi, and Teres major, w/assistance post deltoid
and long head of bicep.
Abduction GH: Lateral deltoid and supraspinatus, 90-180’- Infraspinatus, subscapularis,
teres minor.
Adduction GH: Latissimus dorsi, teres major, sternal pec, w/assistance long/short head
of bicep, and tricep. Above 90’ subscapularis assist.
Lateral/External Rotation: Infraspinatus, teres minor, w/assistance post deltoid.
Medial/ Internal Rotation: Subscapularis, teres major, w/assistance pec major, anterior
deltoid, latisssimus dorsi, and short head of the bicep.
Bursae
 Subcoracoid
 Subscapularis
 Subacromial (palpate)
Nerves
 Brachial Plexus- C5-C8, T1
Artery
 Subclavin
 Axillary
Throwing Action:
1. Preparatory/cocking phase: Arm and hand are drawn behind the body (90’ of
abduction and 15’ of horizontal abduction) external rotation, motion causes
heavy eccentric loading of the horizontal adductors/internal rotators.
2. Acceleration/ delivery phase: Horizontal adduction, elbow extension, and
rapid internal rotation.
3. Deceleration: Occurs after ball release, max internal rotation, wrist flexion and
pronation, infra/supraspinatus, teres major/minor, latisssimus dorsi, and
posterior deltoid play a major role in resisting shoulder distraction and anterior
subluxation forces.
Degree’s of shoulder movement and Scapulohumeral Rhythm
Movements of the shoulder involve some rotation at the SC, AC, and GH jt. Shoulder
past 30’ of abduction or 45/60’ of flexion, the scapula will begin to rotate. The
Scapulohumeral rhythm will begin at a 2:1 ratio until the shoulder reaches 110-180’
which will make the ratio a 1:1.
S.O.A.P’s
Referred pain, change in techniques, alter in posture, overuse, regular questions,
dominant hand, sensation of slipping or popping out?
Injuries
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Acromioclavicular Joint Sprain (AC): The AC joint is weak and easily injured
by a direct blow, fall on the point of the shoulder, or force transmitted up the long
axis of the humerus during a fall on an outstretched arm. Ac sprains often are
classified as Type I to VI based on the extent of ligamentous damage, degree of
instability, and the direction in which the clavicle displaces relative to the
acromion and coracoid process.
S/S: Type I- No disruption of the AC or Coracoclavicular ligaments, minimal
swelling and pain over the joint line and pain increase w/abduction past 90'. Type
II- The Ac ligaments are torn but the Coracoclavicular ligament is only sprained.
The clavicle rides above the level of the acromion (Step), at the jt line. Type IIIComplete disruption of the AC and Coracoclavicular ligament, resulting in visible
dislocation of the AC jt, obvious swelling, and bruising and mild elevation of the
distal clavicle and drooping of the shoulder girdle. Type IV-VI- Extensive
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mobility and pain signify tearing of the deltoid and trapezius muscle attachments
at the distal clavicle.
Management: Type I-II- Rest, Ice, NSAID's, ROM exercises, Immobilization in
a sling when pain is present. Type III-VI- Physician will determine if surgical
repair is necessary.
Sternoclavicular Joint Sprain (SC): The majority of injuries result from
compression related to a direct blow or more commonly by indirect forces
transmitted from a direct blow to the shoulder or a fall on an outstretched arm.
S/S: Grade I- Mild pain, point tenderness over the SC jt, no visible deformity.
Grade II- Pain, swelling, jt subluxation leading to bruising, person is unable to
horizontally adduct w/o pain. Grade III- Prominent displacement of the sternal
end of the clavicle and may involved a fracture, complete rupture of the
sternoclavicular and costoclavicular ligaments, severe pain, a posterior
displacement is a more serious injury because of the potential injury to the
esophagus, trachea and subclavin artery.
Management: Grade I/II: Ice Rest, NSAID’s, and immobilization (I) 1-2
weeks and (II) 3-6 weeks. Followed by ROM exercises. Grade III- Required
immediate reduction of the dislocation and immobilized for 4-6 weeks
Glenohumeral Joint Sprain (GH): Damage to the GH jt can occur when the arm
is forcefully abducted; its more commonly is caused by excessive shoulder
external rotation and extension, a direct blow or a forceful movement that pushes
the humerus posteriorly.
S/S: Grade I- anterior shoulder is painful to palpate, pain occurs when injury is
reproduced. Grade II- some jt laxity, pain, swelling, and bruising (Severe), ROM
(abduction) is limited.
Management: Ice, rest, NSAID’s, sling for 12-24 hours, ROM exercises (painfree), No full external rotation or abduction for 3 weeks in order to promote
capsular healing.
Glenohumeral Instability: GH instability is base on jt play movement or relative
displacement of the humeral head and is classified as Anterior, Posterior, Inferior,
or Multidirectional. (Anterior, most common and Posterior is second most).
Anterior- MOI= Blow to the posterolateral aspect of the shoulder, excessive
force that push the arm into abduction, external rotation and extension. This force
causes the inferior GH ligament to fail and let the humerus to slide against the
labrum causes damage (Bankart Lesion).
Posterior- MOI= When the humerus is flexed and internally rotated and a
posterior force is directed along the long axis of the humerus. Most of posterior
instabilities occur with microtraumatic episodes.
Inferior- This injury is rare, because of the strong superior GH ligament. Note:
Superior translation is limited by the coracoacromial arch and acromion process.
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Multidirectional- Occurs when damage takes place in more than one plane.
Acutely, if not all anterior and posterior dislocations are associated with some
pre-existing inferior laxity or laxity in the opposite direction.
Management: All treatment is initially conservative with 50-70% responding
favorably to rehabilitation and activity modification. Surgical repair is indicated
for individuals who do not respond to conservative measures.
Glenohumeral Dislocation/Subluxations: Acute dislocation have an associated FX
or nerve damage, therefore the individual show go to the physician for reduction
and follow up. Physician should be looking for a Hill-Sachs lesion- small defect
in the articular cartilage on the humeral head (MRI)
S/S: Intense pain (recurrent dislocation less pain), tingling and numbness down
the arm, sharp contour w/a prominent acromion process compared w/ a smooth
deltoid outline. Humeral head may be palpated in the axilla. `
Management: Sling for 3-6 weeks or when pain has subsided remove from sling
to begin ROM and strengthen exercises. All treatment is initially conservative
with 50-70% responding favorably to rehabilitation and activity modification.
Surgical repair is indicated for individuals who do not respond to conservative
measures.
Chronic Dislocations: Called “trick shoulder” is when the shoulder dislocations
increases and the force to dislocate decrease. Person feels the dislocation because
the arm goes dead (dead arm syndrome).
S/S: Pain is the major complaint w/crepitation and/or clicking after the arm shifts
back into place.
Management: Ice, sling and surgical repair is indicated for individuals who do
not respond to conservative measures.
Glenoid Labrum Tears: Glenoid labrum is a fibrocartilaginous rim that lines the
glenoid fossa. The capsule and inferior glenohumeral ligament are adjacent with
the labrum at their attachment to the glenoid. Tearing of the labrum and inferior
glenohumeral ligament (Bankart Lesion) is associated with anterior instability.
Labrum tears also are associated with degeneration and aging or trauma. When a
labrum is injured to the superior aspect, starting posteriorly and extends anteriorly
and disrupting the long head of the biceps tendon (SLAP lesion).
S/S: Individual may C/O pain, catching, or weakness when arm is overhead. Pain
is associated with clicking or popping within the jt.
Management: Treatment is based on tear pattern and presence or absence of GH
instability. Rest, ice, NSAID’s, Rehab exercises. Physician will determine if
surgical repair is necessary.
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Impingement Injuries: Chronic rotator cuff injuries will cause impingement of
the supraspinatus tendon. Impingement syndrome: Implies an actual mechanical
abutment of the rotator cuff and the subacromial bursa against the coracoacromial
ligament and acromion. This injury is caused from the force overload to the
rotator cuff and bursa, during overhead activities and throwing. (Swimmers
shoulder)
S/S: Pain is described as deep in the shoulder and present at night and activity
increases pain. In the worse stages pain is palpated in the subacromial space.
Management: Rest, restricting movements above 90’, ice, NSAID’s, exercises
when pain has diminished.
Bursitis: Bursitis is not generally an isolated condition, but rather is associated
with other injuries, such as an impingement syndrome, or in older individuals
with pre-existing degenerative changes in the rotator cuff. The subacromial bursa
is commonly injured in swimmers, baseball, softball, and tennis players.
S/S: Pain is reported during the initiation and acceleration of the throwing motion.
Point tenderness on anterior and lateral edges of the acromion process.
Management: Ice, rest, stretching, and refer to physician for further treatment.
Bicipital Tendinitis: Injury to the biceps tendon often occurs from repetitive
overuse during rapid overhead movements, such as racquet sports, shot-putters,
baseball/softball pitchers, quarterbacks, swimmers, and javelin throwers. Irritation
occurs as the tendon passes back and forth in the bicipital groove of the humerus
or a sublux of the tendon because of a lax humeral ligament, also a direct blow
could lead to swelling.
S/S: Pain and tenderness is present over the bicipital groove. Pain could be
elicited by passively stretched in shoulder extension w/elbow extended and
forearm pronated.
Management: Rest, Ice, restriction from activities, NSAID’s, Ultrasound,
stretching, strengthening when pain subsides, and immobilized when individual is
in extreme pain.
Biceps Tendon Rupture: Prolonged tendinitis can make the tendon vulnerable to
forceful rupture during repetitive overhead motions (swimming), or in forceful
flexion activities against excessive resistance (weightlifting, gymnastics, water
skiing). The rupture occurs as a result of the avascular portion of the proximal
long head of the biceps tendon constantly passing over the head of the humerus.
S/S: Individual often hears and feels a snapping sensation and experiences intense
pain. Ecchymosis and a visible, palpable defect can be seen in the muscle belly
when flexing the bicep (“Popeye arm”), and weakness in flexion and supination.
Management: Ice, rest, immobilization and immediate referral to a physician,
surgical repair will be performed for those who are in competitive sports.
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Clavicular Fractures: The clavicle is highly susceptible to compressive forces
caused by a blow or fall on the point of the shoulder, a direct blow to the bone or
falling on an outstretched arm. High incidences include hockey, football, martial
arts, lacrosse, gymnastics, weight lifting, wrestling, racquet sports, and bicycling.
Most of the FX occurs in the middle 1/3 of the clavicle.
S/S: Swelling, ecchymosis and a deformity may be visible and palpable at the FX
site.
Management: Immobilization, referred to a physician, individual will be place in
a figure-eight brace for 4-6 weeks.
Humeral Fractures: Humeral FX results from violent compressive forces from a
direct blow, a fall on an outstretched hand w/elbow extended.
S/S: Pain, swelling, discoloration, an inability to move the arm, an inability to
supinate the forearm, and possible paralysis may be present.
Management: Immobilization, Ice, and immediate referral to a physician, Note:
Fortunately, these FX often are impacted which facilitates closed reduction and
allows early mobilization after 3-4 weeks of immobilization.