the shoulder complex

The Shoulder Complex

© 2007 McGraw-Hill Higher Education. All rights reserved.

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

General Knowledge


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)

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Basic Anatomy


Anatomy


Muscular Anatomy


Movements

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Prevention of Shoulder Injuries

Proper physical conditioning is keyDevelop body relative to sport – Sport

SpecificStrengthen 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


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

Prevention of Shoulder Injuries


Throwing Mechanics

Instruction in proper throwing mechanics is critical for injury prevention


Throwing Mechanics

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N8Drew Brees – Sport Sciencehttp://www.youtube.com/watch?v=tVoqA-LKG

b4Pitching Biomechanicshttp://www.youtube.com/watch?v=h53qlkHve

QAPitching Tipshttp://www.youtube.com/watch?v=qvNMvOe

HUL8

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Windup Phase First movement until ball leaves gloved hand Lead leg strides forward while both shoulders

abduct, externally rotate and horizontally abductCocking 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

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

Throwing Mechanics


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.


Pitch Count Recommended limits for 9-10 year old pitchers:

50 pitches per game 75 pitches per week 1000 pitches per season 2000 pitches per year

Recommended limits for 11-12 year old pitchers: 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


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?


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



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



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



Apprehension test (Crank test)

Apprehension test used for anterior glenohumeral instability This motion should

not be forced Easier to have the

athlete lay down


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 grimaceNeer’s

Hawkins-Kennedy


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

Compression Test

Compress the clavicle and spine of the scapula together

+ if increased movement is felt or pain is experienced

Clavicle and AC joint


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


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


Clavicle Fx


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


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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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


AC Sprain


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 immediatelyProgress as athlete is able to tolerate

w/out pain and swellingPadding and protection may be required

until pain-free ROM returns


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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Shoulder Dislocation


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


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)


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


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


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


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


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

the shoulder complex

Documents

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