The Shoulder

Shoulder Girdle Complex

Glenohumeral jointAcromioclavicular jointScapulothoracic joint

Glenohumeral JointGlenoid fossaHead of humerus

Acromioclavicular JointAcromion process of

scapulaClavicle

Scapulothoracic JointScapulaPosterior ribcage

Bony Landmarks

SternumClavicleHumerus

◦ Head of humerus◦ Greater tubercle◦ Lesser tubercle◦ Bicipital groove◦ Epicondyles

Greater tubercle

Lesser tubercle

Scapula ◦ Acromion◦ Coracoid process◦ Glenoid fossa◦ Spine

Bony Landmarks

Shoulder Girdle

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Bones & Markings

Ready, Set, Go

Muscles of the ShoulderDeltoidTrapeziusPectoralis MajorPectoralis MinorSerratus anterior

Rhomboid majorRhomboid minorLevator scapulaeCoracobrachialisBiceps brachii

Deltoid◦ Abducts shoulder

Trapezius◦ Rotates scapula

Shoulder depressionScapular depression

Punching

Flex shoulderAdduct shoulder IR shoulder

Rhomboid Major/Minor◦ Retract scapula◦ Elevate scapula

Levator Scapulae◦ Elevates scapula

Flexes shoulderAdducts shoulder

Coracobrachialis

Biceps BrachiiWeakly flexes

shoulderTwo proximal

heads◦ Long head—

supraglenoid tubercle of scapula

◦ Short head—coracoid process of scapula

Rotator Cuff Muscles

Collective set of four deep muscles of the GH joint

Supraspinatus◦Abduction of the arm

Infraspinatus◦External Rotation of the shoulder

Teres Minor◦External rotation of the shoulder

Subscapularis◦Internal rotation of the shoulder

Rotator Cuff Muscles

Ligaments of the Shoulder

CoracoclavicularCoracoacromialCoracohumeralGlenohumeralAcromioclavicula

r

Levator Scapula

Rhomboids Minor

Rhomboids Major

Acromioclavicular (AC) joint

Serratus Anterior

Trapezius

Deltoids

Infraspinatus

Teres Minor

Pectoralis Major

Pectoralis Minor

Biceps (short & long head)

OVERUSE INJURIES TO THE SHOULDER

Common Injuries of the Shoulder

Shoulder Impingement SyndromeWidely used term to describe

pain occurring when space between humeral head and acromion become narrowed

Bones “impinge” or compress structures that occupy the subacromial space

Three structures:◦Joint capsule◦Tendons of rotator cuff◦Bursa

Impingement SyndromeOverhead sports

◦Baseball, tennis, swimming, volleyballSigns & Symptoms

◦Pain and tenderness in GH◦Pain and/or weakness with

active abduction in mid-range◦Limited IR◦Confirmation with special tests

Empty can

◦Point tenderness in subacromial area

Impingement Syndrome—TreatmentAddress biomechanicsSubstitute with cross-training

until condition resolvesLimit excessive overhead

movementRehab exercises & stretching

Rotator-Cuff Strain/Tears

Traumatic injury◦i.e. FOOSH

Unusual demands on young athleteRepetitive use leads to chronic

condition◦Ultimately tear in tendons

Partial thickness tear◦Not completely severe tendon◦May respond well to non-op treatment

Full thickness tear◦Require surgery

Rotator-Cuff Strains/Tears- Signs & SymptomsPain with muscle contraction“Catching” sensation when arm

movedInability to sleep

on affected sideVarying degrees

of disabilityDecreased

strengthSwelling

Rotator-Cuff Strains/Tears-TreatmentRICELimit activity - asymptomaticShoulder strengtheningProgressive RTP throwing

program

Biceps TendonitisDiscomfort in

anterior shoulderOften confused

with RC tendonitisCan be caused by

impingement

TRAUMATIC SHOULDER INJURIES

Common Injuries of the Shoulder

Glenohumeral DislocationForced abduction,

external rotation of shoulder

Signs and Symptoms◦ Flattened deltoid◦ Pain and Swelling ◦ Disability

Requires immediate care by physician

Additionally injuries include:◦ Fractures◦ Glenoid labral

tears◦ Axillary nerve

damage

Glenoid LabrumCartilaginous ring that acts to

keep the humeral head positioned on the glenoid by blocking unwanted movement

Glenoid Labrum InjuriesInjury occur with :

◦ Acute trauma (dislocation)

◦ Repeated trauma Degenerated tear

(baseball pitchers)

◦ Repetitive subluxation Labral rim degenerate

over time

Signs & Symptoms◦ Pain◦ Catching or

popping sensation◦ Limited ROM◦ Varying degrees

of weakness◦ Special Tests◦ MRI

SLAP TearSuperior Labrum

from Anterior to Posterior

Occurs at point where biceps tendon inserts on labrum

Area of relatively poor blood supply

FOOSHRepetitive

overhead actionsLifting a heavy

object

Acromioclavicular Separation

Direct blow to tip of shoulder◦ FB player falling on

tip of shoulder or FOOSH

Signs & Symptoms◦ Pain in vicinity of

AC joint◦ Possible deformity

of joint depending on degree of sprain

AC Separation—Treatment RICERehab

◦ ROM & strengthening as tolerated

◦ Overhead exs not recommended

2nd degree◦ 3-4 weeks immob◦ Most painful

3rd degree◦ 6-8 weeks immob◦ May leave

permanent deformity

Acromioclavicular Separation

Clavicle Fracture• Fall on tip of shouldero FOOSH

• Direct impact• Signs and Symptomso Pain, deformity, and swelling

• Refer to physician

Brachial Plexus Injury

StingerBurnerOccurs when

head and neck forcibly moved/hit to one side

Nerves and brachial plexus compressed on that side

Painful and disabling

Brachial PlexusGroup of

peripheral nervesLeave spinal cord

& extend from vertebrae into shoulder

Give arm ability to function

Brachial Plexus Injury—Signs & SymptomsIntense pain from neck down to armArm will feel like it’s on fire or have

pins-and-needles sensationArm/hand may be weak and numbIntense pain in area of brachial

plexusSymptoms last several minutes to

several hours or moreWeakness may last for several days

◦ depends on severity of injury

Brachial Plexus Injury—TreatmentResting neck/arm until pain &

symptoms go awayIce pack 20 minutes every 3-4

hoursAnti-inflammatoriesStrengthening exercisesRTP determined by sports

medicine staffSubsequent stingers cause for

further testing

Brachial Plexus Injury—TreatmentChronic stingers may

eliminate athlete from contact sports

Scar tissue develops around nerve◦ ® Causes nerves to

become entrapped If athlete receives

another blow, brachial plexus may not be able to flex◦ shatters instead,

tearing major nerves of arm

◦ Causes permanent neurological damage

Avoid by:◦ Keeping neck and

shoulders as strong as possible

◦ Properly fitted equipment

◦ Proper tackling & blocking techniques

SPECIAL TESTS

Special Tests for ShoulderHawkin’s-Kennedy

ImpingementAnterior ApprehensionPiano SignApley’s ScratchEmpty CanDrop-arm Sign

Hawkin’s-Kennedy• Seated

• Shoulder in 90 degrees of flexion, slight horizontal adduction, & maximal internal rotation

• (+) reproduction of pain• Subacromial

Impingement

Drop Arm Sign

Apprehension-relocation

• Supine with are @ 90 degrees of abduction & external rotation

• 1 had placed as a fulcrum just posterior to humeral head then passively move shoulder into maximal external rotation against fulcrum of other hand

• (+) reproduction of shoulder pain, or apprehension with movement• Glenohumeral

subluxlation

Piano Key/Sign – AC Separation

• Seated or standing

• Clinician presses downward on elevated end of clavicle

• (+) pain or excessive movement of clavicle• AC separation

Empty Can Test—Supraspinatus

• Seated

• Elevate UE to 30-45 degrees in plane of scapula with internal rotation (thumb down); resist elevation

• (+) pain & weakness

Apley’s Scratch – shoulder mobility

• Sitting

• 3 part test1. Reach across

chest & place hand on opposite sholder

2. Reach overhead to place hand between scapula

3. Reach behind back as high as possible

*compare bilaterally

• (+) asymetrical motion1. Restriction in horizontal adduction, IR, scapular protraction2. Restriction I abduction, ER, scapular upward rotation and

elevation3. Restriction in adduction, IR, scapular downward rotation and

retraction

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