The Shoulder

Shoulder Girdle Complex

Glenohumeral joint

Acromioclavicular joint

Scapulothoracic joint

Glenohumeral Joint

Glenoid fossa

Head of humerus

Acromioclavicular Joint

Acromion process of scapula

Clavicle

Scapulothoracic Joint

Scapula

Posterior ribcage

Bony Landmarks

Sternum

Clavicle

Humerus

◦ 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

Muscles of the Shoulder

Deltoid

Trapezius

Pectoralis Major

Pectoralis Minor

Serratus anterior

Rhomboid major

Rhomboid minor

Levator scapulae

Coracobrachialis

Biceps brachii

Deltoid

◦ Abducts shoulder

Trapezius

◦ Rotates scapula

Shoulder depression

Scapular depression

Punching

Flex shoulder

Adduct shoulder

IR shoulder

Rhomboid Major/Minor

◦ Retract scapula

◦ Elevate scapula

Levator Scapulae

◦ Elevates scapula

Flexes shoulder

Adducts shoulder

Biceps Brachii

Weakly flexes

shoulder

Two 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

Coracoclavicular

Coracoacromial

Coracohumeral

Glenohumeral

Acromioclavicular

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 Syndrome

Widely 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 Syndrome

Overhead sports

◦ Baseball, tennis, swimming, volleyball

Signs & 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—

Treatment

Address biomechanics

Substitute with cross-training until

condition resolves

Limit excessive overhead movement

Rehab exercises & stretching

Rotator-Cuff Strain/Tears

Traumatic injury

◦ i.e. FOOSH

Unusual demands on young athlete

Repetitive 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 & Symptoms Pain with muscle contraction

“Catching” sensation when arm moved

Inability to sleep on affected side

Varying degrees of disability

Decreased strength

Swelling

Rotator-Cuff Strains/Tears-

Treatment RICE

Limit activity - asymptomatic

Shoulder strengthening

Progressive RTP throwing program

Biceps Tendonitis Discomfort in

anterior shoulder

Often confused with RC tendonitis

Can be caused by impingement

TRAUMATIC SHOULDER INJURIES

Common Injuries of the Shoulder

Glenohumeral Dislocation

Forced 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 Labrum

Cartilaginous ring that acts to keep the

humeral head positioned on the glenoid

by blocking unwanted movement

Glenoid Labrum Injuries

Injury 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 Tear

Superior Labrum

from Anterior to

Posterior

Occurs at point

where biceps tendon

inserts on labrum

Area of relatively

poor blood supply

FOOSH

Repetitive overhead

actions

Lifting 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

RICE

Rehab

◦ 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 shoulder

o FOOSH

• Direct impact

• Signs and Symptoms

o Pain, deformity, and swelling

• Refer to physician

Brachial Plexus Injury

Stinger

Burner

Occurs when head

and neck forcibly

moved/hit to one

side

Nerves and brachial

plexus compressed

on that side

Painful and disabling

Brachial Plexus Group of peripheral

nerves

Leave spinal cord & extend from vertebrae into shoulder

Give arm ability to function

Brachial Plexus Injury—

Signs & Symptoms

Intense pain from neck down to arm

Arm will feel like it’s on fire or have pins-

and-needles sensation

Arm/hand may be weak and numb

Intense pain in area of brachial plexus

Symptoms last several minutes to several

hours or more

Weakness may last for several days

◦ depends on severity of injury

Brachial Plexus Injury—

Treatment Resting neck/arm until pain & symptoms

go away

Ice pack 20 minutes every 3-4 hours

Anti-inflammatories

Strengthening exercises

RTP determined by sports medicine staff

Subsequent stingers cause for further

testing

Brachial Plexus Injury—

Treatment Chronic 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 Shoulder

Neer’s Impingement

Hawkin’s-Kennedy

Impingement

Speed’s test

Empty Can

Drop-arm Sign

Cross-arm adduction

Anterior apprehension

Posterior glide

Sulcus sign

AC Shear Test

Piano Sign

Apley’s Scratch

Neer’s Impingement

• Seated; stabilize

scapula

• Passively take UE

into full shoulder

flexion with

humerus in

internal rotation

• (+) pain

• Subacromial

Impingement

Hawkin’s-Kennedy • Seated

• Shoulder in 90

degrees of flexion,

slight horizontal

adduction, & maximal

internal rotation

• (+) reproduction of

pain

• Subacromial

Impingement

Review and practice with partner

Hawkin’s-Kennedy test

◦ Technique

◦ Identify what injury

Speed’s Test

• Seated

• shoulder elevated

75-90 degrees in

sagittal plane, elbow

extended, & forearm

supinated. Resist

elevation

• (+) pain

• Biceps

tendonitis

• Labral instability

Drop Arm Sign

• Sitting/standing

• Passively abduct

shoulder to 90

degrees, then slowly

lowers arm to the

waist

• (+) arm drop to side

or athlete is unable

to slowly lower arm

Review and practice with partner

Drop Arm Sign

◦ Technique

◦ Identify what injury

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

Clunk Test

• Sitting or supine

• Place one hand on

arm above elbow &

other hand on the

posterior aspect of

the humerus; bring

arm into full

abduction; push

humeral head

anterior while other

hand laterally rotates

the humerus

• (+) grind or clunk

• Labrum

instability

Review and practice with partner

Apprehension-relocation test

◦ Technique

◦ Identify what injury

AC Shear Test

• Seated

• Upper extremity at

side, clinician

interlaces fingers &

surrounds AC joint;

squeeze hands

together to

compress AC joint

• (+) pain or

excessive

movement at AC

joint

• AC impairment

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

Review and practice with partner

Piano Key & Empty Can test

◦ Technique

◦ Identify what injury

Lift Off Test—Subscapularis

• Seated

• Hand in the curve of the lumbar spine; lift hand off back &

maintain internal rotation against resistance

• (+) pain or weakness, inability to lift hand off back

Apley’s Scratch – shoulder mobility

• Sitting

• 3 part test

1. 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 motion

1. Restriction in horizontal adduction, IR, scapular protraction

2. Restriction I abduction, ER, scapular upward rotation and elevation

3. Restriction in adduction, IR, scapular downward rotation and retraction

Questions?

Find a partner and let’s practice