THE SHOULDERChapter 21

The Shoulder Girdle Complex

3 joints make up the shoulder girdle The

Sternoclavicular joint

The Acromioclavicular joint

The Glenohumeral joint

The Sternoclavicular Joint Formed through the articulation of the

sternum and the clavicle. Also called the SC joint Injuries to this joint can be very debilitating,

but are very rarely seen in athletics.

Acromioclavicular Joint Formed by the

articulation of the acromion process of the scapula and the distal end of the clavicle. Also called the AC joint

Its is located superiorly to the glenohumeral joint and is commonly exposed to injury in contact sports.

Glenohumeral Joint Formed by the Humerus

and the scapula The head of the humerus

is attached to the glenoid fossa of the scapula Shallowness of the socket

allows for a great deal of movement

Supported by several muscles ligaments Soft tissue

Structure and Function

Dynamic Stability refers to mobility with stability Shoulder accomplishes this through the

coordinated movement of the scapula in concert with the humerus

Several muscle groups work together synergistically to create the dynamic stability of the shoulder.

Rotator Cuff A set of 4 deep

muscles of the glenohumeral joint They originate on the

scapula and insert onto the superior aspect of the humerus

Will often be referred to as the SITS muscles Supraspinatus Infraspinaus Teres Minor Subscapularis

Muscles of the Shoulder Girdle Muscle Force Coupe

Formed by the actions of the deltoid and rotator cuff muscles

Allows the humeral head to spin while remaining in place on the glenoid

Scapulothoracic Mechanics Allows the scapula to move in several places using the following muscles

Trapezius Rhomboids Serratus Pectoralis Minor

Muscles that move the Scapula There are several muscles that move the

scapula Levator scapulae Rhomboids

Major and Minor Pectoralis Minor Serratus Anterior Trapezius

Muscles that move the Scapula

Muscles that move the Arm (Humerus)

There are several muscles that move the Humerus Coracobrachialis Pectoralis Major Teres Major/Minor Deltoid Supraspinatus Infraspinatus Latissimus Dorsi

Muscles that move the Arm (Humerus)

Overuse Injuries to the Shoulder Overuse injuries of the shoulder are usually limited to

the soft tissues. Usually caused by repetitive activity to the point of

causing tissue damage and inflammation Common among athletes that participate in overhead

movements Many athletes are unaware that an injury is occurring until

symptoms manifest Overuse Injuries include

Impingement syndrome Tendonitis Bursitis Muscle strains

Impingement Syndrome Impingement syndrome describes a situation

causing injury when the space between the humeral head and acromion becomes narrowed. The bones “impinge” or squeeze structures within

the space Structures affected are the joint capsule, tendons of

the rotator cuff, and a bursa Impingement causes mechanical irritation of the

cuff tendons, resulting in hemorrhage and swelling Commonly called tendonits of the rotator cuff

Supraspinatus is the muscle usually involved If the bursa is involved, bursitis is the result.

Impingement Syndrome - Symptoms Symptoms

Pain and tenderness in GH area

Pain and/or weakness with ABD in midrange

Limited IR + results from special

tests Hawkin’s impingement

Tenderness to palpation in subacromial area

Impingement Syndrome - Treatment Treatment options

Correction of improper sport technique

Preseason conditioning

Specialized taping Rehabilitation and

Prevention Most rehab

techniques involve strengthening the weakened muscles of the shoulder girdle

Shoulder Impingement Exercises

Rotator Cuff Tears Could be partial tear or full thickness of the tendon

Can happen to people of any age In younger people often caused by more traumatic injuries

Falling on outstretched arm Unusual demands on the joint

Older people Usually caused by degeneration of the muscle and tendon tissues

Treatment Usually determined by severeity of injury and how it

responds to rehab Small and partial tears respond well to non-operative rehab

program Moderate to large tears, and small tears that are non-

responsive to rehab, require surgery

Rotator Cuff tears (cont’d) Symptoms

Pain Full ROM with

partial tears Loss of ROM with

full tears Athlete will not be

able to lift the arm overhead, and often when they try, the can be observed to hike or shrug

Muscle Strains Can be caused by excessive

overuse or traumatic injury Symptoms

Pain Tenderness in muscle belly

caused by Palpation RROM Stretch

There could be a delay of a day or two before symptoms actually show

Treatment PRICE Gentle stretching Strengthening program

Biceps (long head) Tendonitis

Can cause discomfort in the front of the shoulder and will often be confused with rotator-cuff tendonitis.

Both can be caused by impingement and will have the same treatment

Biceps Tendon Rupture Not common in

athletics, but results from vigorous activity Described as a sudden

onset of pain in the front of the shoulder and an associated “pop”

Symptoms Drooping of the biceps

muscle near the distal upper arm

Ecchymosis

Biceps Tendon Rupture (cont’d)

This injury is considered a Grade III injury and usually affects the biceps tendon long head.

People who have a prior history of tendonitis may be more prone to this injury

Treatment Surgery is usually not needed PRICE Gradual return to strengthening and

activity Athletes can usually return to full

activity after a period of conservative care

There may be a small loss of shoulder flexion in the long term, but not enough to result in loss of high-level functioning

Traumatic Shoulder Injuries Usually are caused by a sudden onset

Blow to arm or shoulder Shoulder joint being forced beyond

physiologic limits Common Injuries

Glenohumeral dislocation Acromioclavicular separation Fractures Tendon Ruptures

Anterior Shoulder Dislocation

Results in the head of the humerus being completely out of the glenoid fossa Usually caused by shoulder being forced into

abduction, extension and external rotation. Most common means of dislocation is

anterioinferiorly Immediate transport to a physician is

required Physician should also check for other

injuries Fractures Glenoid labial tears Axillary nerve damage Hill-Sachs lesions can occur if the head of

the humerus hits the front of the glenoid hard enough to cause an indentation

Anterior Shoulder Dislocation (cont’d)

If the injury is not properly managed and fully rehabilitated, there is a high risk for recurrent dislocations. Immobilization may be as long as 8 weeks

Glenoid Labrum Injuries These injuries involve the deepest soft

tissue in the shoulder Can often occur along with dislocations Happens commonly with baseball pitchers

when degenerative changes in the labrum cause it to become loose Permits humeral head to slip forward

Symptoms Pain Popping sensation Limited use of the arm Varying degrees of weakness Special tests and MRI will confirm diagnosis

Treatment includes specialized rehab program Suspected tears must be referred to a

physician

Multidirectional Instability Refers to the ability of the

athlete to voluntarily dislocate their shoulders usually due to athlete being

hyperelastic or overly flexible This causes problems with

athlete playing overhead sports.

Weight bearing exercises can be helpful in dealing with this problem Push-ups Plyometrics Weight training

Acromioclavicular Separation

This injury is a traumatic sprain of the AC joint Usually caused by a blow to the

tip of the shoulder Symptoms

Pain near the AC joint Obvious deformity

Treatment Physician referral 1st degree sprains

PRICE 2nd / 3rd degree sprains

Require 6-8 weeks of immobilization

Brachial Plexus Injury Is often called a stinger or burner

Usually caused by a stretching of the brachial plexus on the opposite side Symptoms

Intense pain from the neck down to the arm On-fire or pins-and-needles sensation Weakness Numbness

Treatment Referral to specialist Rest Ice Anti-inflammtory meds Strengthening exercises for neck and shoulders

Prevention Keeping neck and shoulders strong Wearing properly fitted equipment that distributes forces during collision Using proper technique

Fractures Fractures of the

shoulder girdle most commonly involve the clacivle and humerus

Scapular fractures may not be seen on standard x-rays Present on bone scans

Any suspected fracture should be referred to an emergency room physician

Is it a Shoulder Injury Often times pain in the shoulder can be

referred pain from another injury. Pain in the shoulder does not always indicate a

shoulder problem Cardiac problems or Heart attack

Referred pain to the left shoulder, neck and arms Spleen Injury

Refer pain to the left shoulder and down the upper portion of the left arm Kehr’s sign