Chapter 18:
The Shoulder Complex
© 2007 McGraw-Hill Higher Education. All rights reserved.
Shoulder Joint-Anatomy (1)
 Sternum
 Clavicle
 Scapula- acromion process and coracoid
process, glenoid fossa and glenoid labrium,
spine of scapula
 Humerus- Greater tubercle, Lesser tubercle,
head of humerus,
 http://www.readingshoulderunit.com/shoulder
_anatomy.htm
© 2007 McGraw-Hill Higher Education. All rights reserved.
Anatomy
© 2007 McGraw-Hill Higher Education. All rights reserved.
© 2007 McGraw-Hill Higher Education. All rights reserved.
Sternoclavicular (SC) Joint **
 ___________________________________
 Allows for rotation during movements like
shrugging the shoulders and reaching above
the head.
 Supported by 4 ligaments __________________________________
 Costoclavicular ligament
 Interclavicular ligament
© 2007 McGraw-Hill Higher Education. All rights reserved.
Acromioclavicular (AC) Joint**
 Lies between the acromion process and the
clavicle
 ______________________
 Primary ligament: ________________
 Secondary ligaments


Coracoacromial ligament
Coracoclavicular ligaments
© 2007 McGraw-Hill Higher Education. All rights reserved.
Glenohumeral (GH) Joint**(1)
 ___________________________
 Glenoid fossa of the scapula

____________________
 Head of the humerus (3-4 x larger than
glenoid)-plunger/volleyball example
 _________________________
© 2007 McGraw-Hill Higher Education. All rights reserved.
GH joint** (2)
 Joint is deepened by a meniscus like
structure called the glenoid labrum

functions to add stability to the joint
 Stabilized by two types of stabilizers

Static stabilizers


joint capsule
several glenohumeral ligaments
© 2007 McGraw-Hill Higher Education. All rights reserved.
GH joint** (3)
 Dynamic stabilizers

rotator cuff muscles (SITS)




_______________
_______________
_______________
_______________
© 2007 McGraw-Hill Higher Education. All rights reserved.
© 2007 McGraw-Hill Higher Education. All rights reserved.
© 2007 McGraw-Hill Higher Education. All rights reserved.
Other shoulder anatomy (3)
 Bursa

_______________ (clinically most important)
 Nerve supply

brachial plexus (________)
 Blood supply

_____________________________
© 2007 McGraw-Hill Higher Education. All rights reserved.
Shoulder movements
 Flexion (180) and Extension (80-90)
 Abduction (180) and Adduction
 Horizontal Adduction/Flexion (130)
 Horizontal Abduction/Extension (60)
 External rotation (90)
 Internal rotation (90)
© 2007 McGraw-Hill Higher Education. All rights reserved.
ROM/Muscle Testing





Shoulder flexion- __________________
Shoulder extension-Post Delt
Shoulder abduction-____________________
Shoulder adduction- ___________________
Shoulder internal rotation-Ant Delt/
Subscapularis
 Shoulder external rotation____________________________________
 Horizontal ADD/Flex- ________________
 Horizontal ABD/Ext- _________________
 Scapula elevation, depression, protraction,
and retraction
© 2007 McGraw-Hill Higher Education. All rights reserved.
•Apprehension test (Crank test)
 Apprehension test
used for anterior
glenohumeral
instability

This motion should
not be forced
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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
© 2007 McGraw-Hill Higher Education. All rights reserved.
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
© 2007 McGraw-Hill Higher Education. All rights reserved.
Special Test Continue
 Yerguson’s
 Drop Arm
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Prevention of Shoulder Injuries
 Proper physical conditioning is key
 Develop body and specific regions relative to
sport
 Warm-up should be used before explosive
arm movements are attempted
 ____________________________________
_________________________________
 Protective equipment
 ________________________________
© 2007 McGraw-Hill Higher Education. All rights reserved.
Preventing shoulder problems
 General muscle strengthening
 Try and avoid exercises above 90 degrees in the beginning
 Stretching for shoulder capsule, but be careful
 Strengthening rotator cuff muscles
 including eccentric work
 http://www.asmi.org/SportsMed/throwing/thrower10.html
 Throwing Program
 Strengthen scapular stabilizers
 push-ups
 press-ups
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Throwing Mechanics
•Instruction in proper throwing
mechanics is critical for injury prevention
© 2007 McGraw-Hill Higher Education. All rights reserved.
 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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 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
© 2007 McGraw-Hill Higher Education. All rights reserved.
Recognition and Management of
Specific Injuries
 Clavicular Fractures

Cause of Injury



____________________________, fall on tip of
shoulder or direct impact
Occur primarily in middle third (greenstick fracture
often occurs in young athletes)
Signs of Injury



_______________________________________
______________________________________
Clavicle may appear lower
Palpation reveals pain, swelling, deformity and
point tenderness
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 Clavicular Fractures (continued)

Care



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
Occasionally requires operative management
© 2007 McGraw-Hill Higher Education. All rights reserved.
© 2007 McGraw-Hill Higher Education. All rights reserved.
 Sternoclavicular Sprain

Cause of Injury


Indirect force, 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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 Acromioclavicular Sprain

Cause of Injury


Result of direct blow (from any direction), upward
force from humerus, FOOSH
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 (Step
deformity);+ Piano Key Test, pain, loss of function
and instability
© 2007 McGraw-Hill Higher Education. All rights reserved.

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)
Aggressive rehab is required w/ all grades
 __________________________________________
____________________________________
 Progress as athlete is able to tolerate w/out pain and
swelling
 __________________________________________
_______________________________
© 2007 McGraw-Hill Higher Education. All rights reserved.
© 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
(Hill-Sachs Lesion vs Bankart Lesion vs SLAP Tears)



Signs of Injury
 Flattened deltoid, prominent humeral head in axilla;
arm carried in slight abduction and external rotation;
moderate/severe 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
© 2007 McGraw-Hill Higher Education. All rights reserved.
 Shoulder Impingement Syndrome

Cause of Injury



Mechanical compression of supraspinatus
tendon, Glenoid labrum, subacromial bursa and
long head of biceps tendon due to decreased
space under coracoacromial ligament
_______________________________________
__________________________________
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
_______________________________________
© 2007 McGraw-Hill Higher Education. All rights reserved.

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- degrees per sec??????)
Occurs near insertion on greater tuberosity
Full thickness tears usually occur in those
athletes w/ a long history of impingement or
instability
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



Signs of Injury


_______________________________________
____________________________________
May develop from direct impact or fall on tip of
shoulder
_______________________________________
____________________________________
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 Tendonitis

Cause of Injury


Signs of Injury




Repetitive overhead athlete - ballistic activity that
involves repeated stretching of biceps tendon
causing irritation to the tendon and sheath
_______________________________________
_______________________________
___________________________________
____________________________
Care



Rest and ice to treat inflammation
NSAID’s
Gradual program of strengthening and stretching
© 2007 McGraw-Hill Higher Education. All rights reserved.