The Shoulder Complex

• Its mobility compromises stability.

• Structurally, the shoulder is an unstable joint– relies on a large network of ligaments and muscles to

provide stability without restricting mobility.

• Functional movement involves integration of bones, joints, ligaments, and muscles.

Shoulder Motion

• Glenohumeral– Flexion– Extension– Abduction– Adduction– Internal Rotation– External Rotation

• Shoulder Girdle– Protraction– Retraction– Elevation– Depression– Upward Rotation– Downward Rotation

Functional Anatomy

• Bones– Humerus

• Angle of inclination– 130-150o

• Angle of torsion– Varies

– Scapula– Clavicle

Functional Anatomy

• Four Joint System– Glenohumeral Joint– Scapulothoracic Joint– Acromioclavicular Joint– Sternoclavicular Joint

Rhythm between the joints

Functional Anatomy

• Glenohumeral joint– Ball and socket –

• glenoid fossa is 2/3 size of the humeral head.

– Static stabilizers• What are these?

– Dynamic stabilizers• What are these?

Static Stabilizers

• Glenohumeral Ligaments– Circle StabilityCircle Stability

• The anterior, inferior, superior, and posterior glenohumeral ligaments act together to force the articular surface of the humeral head against the glenoid.

• As one is stretched the other develops tension.

Static Stabilizers

• Glenoid labrum– Cartilage

• Thicker on outside and thinner on inside

• Circle stabilityCircle stability– Acts like tee for a golf

ball

• Complimented by ligaments and long head of biceps tendon

Circle Stability

Functional Anatomy

• Coracoacromial Arch– Coracoacromial Ligament

• Roof

– Supraspinatus– Long head of Biceps Tendon– Superior/Anterior Labrum– Bursa = Subacromial (aka

Subdeltoid)

Dynamic Stabilizers

• Glenohumeral dynamic stabilizers1. Originate on axial skeleton and attach to

humerus• Latissimus dorsi, serratus anterior, pectoralis minor,

and pectoralis major

2. Originates on scapula/clavicle and attach to humerus• Deltoid, teres major, coracobrachialis, biceps and

triceps.• Rotator Cuff - SITS

Shoulder Musculature

• Rotator cuff– Supraspinatus– Infraspinatus– Teres Minor– Subscapularis

What is the function of the rotator cuff?

Rotator Cuff

Dynamic Stabilizers

• Force couples - Circle stabilityCircle stability• Co-contraction – compresses

the humeral head within the glenoid fossa = minimizes humeral head displacement

1. Adducted position – rotator cuff vs. anterior deltoid

2. Abducted position – rotator cuff and long head of biceps vs. deltoids

Functional Anatomy

• Scapulothoracic joint – not a true joint– Upward rotation, downward rotation, protraction, and

retraction• When do these occur in throwing motion?

– It is essential to maintain positioning of humeral head relative to glenoid and for glenoid to adjust relative to movement while maintaining stable base.

– Scapulohumeral Rhythm• Is often the key to shoulder pathology • 180 degrees of motion – flexion or abduction

– 120o Glenohumeral– 60o Scapulothoracic – Upward rotation/Tilt

Scapulohumeral Rhythm

• Humeral to Scapular ratio (– Humeral Elevation to Upward Rotation

Scapular Stabilizers

• Dynamic stabilizers– Trapezius, levator scapulae,

pectoralis minor, serratus anterior, and major and minor rhomboids.

– Which are upward and which are downward rotators?

– Which are protractors and retractors?

– Serratus anterior • Very important especially

deceleration/follow-through of throwing

Functional Anatomy

• Sternoclavicular joint– Must have motion here to achieve full humeral

abduction• Interclavicular, Sternoclavicular ligaments

• Acromioclavicular joint– Must have posterior rotation of clavicle so

scapula can rotate to allow full elevation.• Trapezoid and Conoid ligaments

Kinetic Chain

• Interaction of the sternoclavicular, acromioclavicular, scapulothoracic, and glenohumeral joints.– To get overhead motion:

• Scapula must rotate. • Clavicle elevates.

Mechanisms of Injury

• Direct Trauma

Mechanisms of Injury

• Indirect Trauma

Mechanisms of Injury

• Shoulder Dyskinesis

Sternoclavicular Injuries– MOI:

• Direct contact • Transfer through kinetic chain – longitudinal force through clavicle

– FOOSH or Traction

– Grades 1, 2, 3 - (sprain to dislocation)• Painful motions – Retraction, Protraction, Elevation

– Dislocation• Anterior more common. • Posterior is very serious – Why?

– S/S: Dizziness, nausea, neurovascular changes, or dysphagia

– Testing – Joint play and palpation– Tx:

• Ice, Sling, and Referral• Figure 8 immobilization – 3-5 weeks

– Rehabilitation

Acromioclavicular Injuries• Ligaments:

– Acromioclavicular ligament

– Coracoclavicular ligaments – Trapezoid and Conoid

• MOI:– Direct trauma

• FOOSH or tip of elbow• Top of shoulder• Clavicle

– Chronic degeneration - overuse

• Classification– Type I, II, III, IV, V, VI

– Step-off deformity

• S/S: – PAIN, laxity, deformity– Radiating pain –

neck/scapula

Acromioclavicular Injuries

• Special tests: – AC Glide -Piano Key Sign– Pain above 90o and with

horizontal adduction– Traction, Compression

• Tx:– Conservative – 1-4 weeks

• Ice, sling, corticosteroid injections, leukotape

• Rehabilitation/Padding

– Surgical – at least 4 months• Resection of distal clavicle• Wires for stability

Shoulder Instability vs. Laxity

• Is there a difference?• Descriptions

– Laxity – Capsular weakening and stretching that allows humeral head to have large glide motion in one or more directions

• Puts many structures at risk by demanding more effort to control motion.

– Instability – Humeral head displacement with elevation

• Many causes – laxity, weakness, neurological

Glenohumeral Sprain

• Damage to capsular ligaments– MOI:

• forceful movement – abduction and rotation

– S/S: • Pain/tenderness• Limited ROM – end ranges• Laxity tests

– Apprehension

– Glenohumeral Glide

– Potential for chronic problems• Importance of immobilization and strengthening

Glenohumeral Dislocations• Dislocations and Subluxations

– What’s the difference?• MOI: Dislocation

– Direct trauma (laxity) - FOOSH• 85-90% will reoccur if MOI was direct trauma

– Indirect trauma (instability)• General S/S:

– Joint dislocation – not functioning– Pain– Vascular or Neurological problems?

• When do athletes need surgery?• What are complications?

Glenohumeral Dislocations

• Classification– Anterior Glenohumeral - most common

• MOIs• Bankart lesion and Hills-Sachs lesion

– Posterior Glenohumeral• MOIs• Reverse Hills-Sachs lesion

– Inferior Glenohumeral - very uncommon• MOIs

Glenohumeral Dislocations• S/S:

– classic deformities for each direction• Special Tests:

– Glide tests, Apprehension, Load and Shift, Relocation, and Sulcus Sign

– Clunk (R/O Labral Tear)• Tx: No surgery

– Who reduces?– Ice/Modalities– Immobilization – 3-4 weeks– Strengthening

• Rotator cuff and scapular

Chronic Shoulder Subluxation• MOI: Traumatic, Atraumatic, or Microtraumatic• Types:

– Anterior – • clicking or pain; complain of dead arm during cocking phase (when

throwing); pain posteriorly; possible impingement; positive apprehension test

– Posterior – • possible impingement, loss of internal rotation; crepitation; increased

laxity; pain anteriorly and posteriorly

– Multidirectional (MDI)– • inferior laxity; positive sulcus sign; pain and clicking w/ arm at side;

possible signs and symptoms associated w/ anterior and posterior instability

Chronic Shoulder Subluxation

• Tests: Clunk and O’Brien’s

• S.L.A.P. lesions = complication– Superior labrum anterior to posterior– Long Head of Biceps Brachii– Types I, II, III, IV

Chronic Shoulder Instability or Laxity

• Management– Conservative

• strengthening (rotator cuff and scapula stabilizers)

– Various harnesses and restraints can be used to limit motion

– Surgical stabilization may be required to improve function and comfort

• Usually not chosen unless had two traumatic dislocations ornon-traumatic dislocations

• 6 to 8 weeks immobilization

Shoulder Injuries

• Fractures of the Humerus– Shaft or Proximal fracture

• MOI: Direct blow or FOOSH

– Epiphyseal fractures • MOI: Direct blow or indirect loading• common in young athletes

– May pose danger to nerve and blood supply

Shoulder Injuries

• Fractures of the Humerus– Signs and Symptoms

• Pain, swelling, point tenderness, decreased ROM– Management

• Immediate application of splint, treat for shock and refer

– Humeral fractures- remove from activity for 3-4 months– Proximal fracture - incapacitation 2-6 months– Epiphyseal fracture - quick healing - 3 weeks

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Shoulder Injuries

• Contusion of Upper Arm– Etiology

• Direct blow

– Signs and Symptoms• Transitory paralysis and inability to use

extensor muscles of forearm• Ecchymosis

– Management• RICE for at least 24 hours• Provide protection to contused area to prevent repeated

episodes that could cause myositis ossificans• Maintain ROM

Shoulder Injuries

• Clavicular Fractures– MOIs:

• FOOSH, fall on tip of shoulder or direct impact• Occur primarily in middle third (greenstick fracture often

occurs in young athletes)– Signs and Symptoms

• Supporting of arm, head tilted towards injured side w/ chin turned away

• Clavicle may appear lower• Pain, swelling, deformity and point tenderness

– Management• Closed reduction - sling and swathe, immobilize w/ figure 8

brace for 6-8 weeks• Rehabilitation and use of a sling for 2-4 weeks

Shoulder Injuries• Biceps Rupture

– MOI: • Result of a powerful

contraction• Generally occurs near

origin of muscle at bicipital groove

– Signs and Symptoms• “Snap” and intense pain• Protruding bulge–

“popeye”• Definite weakness with

elbow flexion and supination

• Management– Ice, Sling, and refer – Athletes will require

surgery– Older individual will be able

to rely on brachialis which serves as primary elbow flexor

Shoulder Injuries• Repetitive Throwing or Overhead Motion

Injuries– Rotator Cuff Pathology

• Rotator Cuff Impingement Syndrome– Compressive vs. Tensile

• Rotator Cuff Tendinitis

– Overhead Athlete and Instability Continuum• Instability = unwanted humeral translation as

a result of ineffective muscle contraction

Overhead Athlete and Instability Continuum

Microtrauma = Inflammation

Overuse

Instability

Subluxation

Rotator Cuff Tendinitis

Impingement

Pink and Jobe, 1991 Rotator Cuff TEAR

Rotator Cuff Impingement

• MOI– 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

– Exacerbating factors - laxity and inflammation, postural mal-alignments

Rotator Cuff Impingement

• Primary compression– Irregularly shaped acromion or

ligament, enlarged bursa, inflammed tendons

• Secondary compression– Instability, poor posture,

repetitive overhead

• Primary tensile– Overuse, Posterior capsule

tightness, and rotator cuff weakness

• Secondary tensile– Scapular dyskinesis, rotator

cuff weakness, instability

Impingement

Inflammation

Rotator Cuff Impingement

– Signs and Symptoms• Diffuse pain, pain on palpation of subacromial

space, bicipital groove, supraspinatus insertion• Limited ROM – active and passive – above 90o

• Painful arc – 70-120o

• Decreased strength of external rotators compared to internal rotators; tightness in posterior and inferior capsule

– Special Tests: Neer’s and Hawkins-Kennedy Tests. Empty Can

– Tx: Rehabilitation – rotator cuff and scapular stabilizers

Rotator Cuff Tendinitis• Supraspinatus most likely• Etiology either Insidious or Acute• MOI: Overuse; Instability; Impingement; acromion spurs;

poor vascularization (“wringing out”)• 3 Stages - I - inflammation; II - degeneration; III – tear• S/S: pain deep in shoulder and radiating down lateral

arm; pain w/ follow –through or overhead, supraspinatus tenderness, decreased strength – abd, ER, IR

• Special tests – Empty Can and Drop test; Impingement tests

Rotator Cuff Pathology– Stage I –

• Supraspinatus or biceps tendon injury

• Pain w/ abduction and resisted supination w/ external rotation;

• Edema and thickening of rotator cuff and bursa

– Occurs in athlete < 25 years old

– Stage II – • Permanent thickening and

fibrosis of supraspinatus and biceps tendon; pain w/ motion

• Aching during activity that worsens at night

– Stage III – • History of shoulder problems

and pain• Limited active and full passive

ROM• Tendon defect (3/8 “) or tear –

partial thickness tear• Permanent scar tissue and

thickening of rotator cuff– Athletes 25-40 years old

– Stage IV- • Infraspinatus and

supraspinatus wasting• Pain during abduction and ER• Tendon defect greater than

3/8” – full thickness tear• Limited active and full passive

ROM

Rotator Cuff Pathologies• Management

– Rest – Ice, Analgesics, and,electrical stimulation for pain– NSAID’s and ultrasound for inflammation– Restore appropriate mechanics and strengthen rotator

cuff to depress and compress humeral head to restore space

• Flexibility of posterior structures• Strengthening of scapular, rotator cuff, and other shld. muscles

– Strengthen lower extremity and trunk to reduce stress on shoulder

– Stage III and IV cases may require immobilization and rest and potentially surgery

Shoulder Bursitis

• MOI – Subacromial (Subdeltoid) bursa– Chronic inflammatory condition due to trauma or overuse -– Fibrosis, fluid build-up resulting in constant inflammation

• Signs and Symptoms– Pain w/ motion and tenderness during palpation in subacromial

space; positive impingement tests

• Management– Ice, ultrasound and NSAID’s to reduce inflammation– Remove mechanisms precipitating condition– Maintain full ROM to reduce chances of contractures and

adhesions from forming

Bicipital Tendinitis

• MOI– Repetitive overhead athlete – rotator cuff dysfunction– Ballistic activity that involves repeated stretching of biceps

tendon causing irritation to the tendon, sheath, and transverse humeral ligament

• Forceful extension and external rotation

• Signs and Symptoms– Tenderness over bicipital groove, swelling, crepitus due to

inflammation– Pain when performing overhead activities– Positive: Speed’s and Yergason’s Tests

• Management– Rest, ice and ultrasound to treat inflammation– NSAID’s– Gradual program of strengthening and stretching

Frozen Shoulder

• MOI– Contracted and thickened joint capsule w/ little synovial fluid– Chronic inflammation w/ contracted inelastic rotator cuff muscles– Generalized pain w/ motions (active and passive) resulting in

resistance of movement

• Signs and Symptoms– Pain in all directions both w/ active and passive motion

• Management– Aggressive joint mobilizations and stretching of tight musculature– Electric stimulation for pain and ultrasound for deep heating

Neurovascular Entrapment

• Brachial Plexus Injury– Compression or Traction

• Suprascapular Nerve Injury– Supraspinatus and Infraspinatus waste away

• Thoracic Outlet Syndrome– Pressure on trunks and medial cord of

brachial plexus and the subclavian artery or vein

Thoracic Outlet Syndrome

• MOI– Poor posture, prolonged pressure, acute trauma– 1) decreased space between clavicle and first rib, 2)

scalene compression, 3) compression by pect. minor, or 4) presence of cervical rib

• Signs and Symptoms– Neural – numbness, pain, paresthesia, atrophy– Arterial – coldness, pallor, cyanosis, atrophy– Venous – muscle/joint stiffness, edema, venous

enlargement, thrombophlebitis

Thoracic Outlet Syndrome

• Tests:– Adson’s (anterior scalene test) – subclavian artery– Allen’s (pectoralis minor test) - neurovascular– Military Brace (costoclavicular test) – subclavian

artery

• Management– Conservative treatment

• correct anatomical condition through stretching (pec minor and scalenes) and strengthening (trapezius, rhomboids, serratus anterior, erector spinae)

Shoulder Assessment

Putting it together with

Case studies

Case Study #1

• A 23 year old comes to you complaining of shoulder pain. He says that 2 days ago he was playing catch with a football; when his friend threw the ball, he reached for it above his head, lost his balance, and fell on an outstretched hand out to the side. He felt the shoulder “slip” a little and then pain. He complains of pain in his upper/anterior shoulder and upper chest region. Also reports a “clicking” sensation.

Case Study #2

• A female competitive swimmer comes to you complaining of diffuse shoulder pain. She notices the problem most when she does the butterfly. She complains that her shoulder sometimes feels unstable and weak when doing this stroke, she has even felt it “pop” once. She reports some changes in sensation along the outside of her arm – near her deltoid.

Case Study #3

• A 30 year old tennis player complains of pain throughout shoulder and into arm. Notices increased episodes of hands “falling asleep” during the night. Also notices that hands are often cold. Notices that discomfort increases with overhead serving and returns. Also, has problems in the weight room and with ADLs when arms are overhead.

Case Study #4

• A major league baseball pitcher reports to athletic training room with increasing pain in shoulder on follow-through of pitching. Pain increases when he has pitched more than 70 pitches. He localizes pain to area by greater tubercle. It is point tender and slightly swollen. He has excessive external rotation and limited internal rotation.