THE SHOULDER

Anatomy

Separations

Fractured Clavicle

Dislocations

Supraspinatus Tendonitis

THE SHOULDER

Scapulothoracic

Acromioclavicular

Sternoclavicular

Glenohumeral

Shoulder (Anterior View)

Acromioclavicular Separation

Mechanisms of Injury:

Fall on the tip of the unprotected shoulder.

Fall on the outstretched hand.

Downward force on the acromion from above.

Grade of Injury of A/C

Grade 1:

Small tear of the capsule of the AC joint. No instability of joint.

P.O.P.

Grade 2: Tear of the A/C joint capsule and a small tear of the coraco-clavicular ligaments.

Degree of Injury of A/C

Grade 3: Tear of the acromio-clavicular ligament and the coraco-clavicular ligament.

Distal End of Clavicle

GRADE 3 A-C

SEPARATION

INSTABILITY OF A-C Jt.

Grade 1: No instability of acromio-clavicular joint.

Grade 2: Slight instability of A-C joint. ‘Springy’ clavicle.Grade 3: Total separation of A-C joint. The clavicle goes superiorly.

ACTIVE MOVEMENTS TO ASSESS A-C Jt.

Abduction

Cross Flexion

CROSS FLEXION

Active Abduction of the Shoulder Joint

Grade 1: Full R.O.M. with pain at end of range.

Grade 2: Has over 45º of motion but not 90º.

Grade 3: less than 45º.

Return Time Estimates

Grade 1: One week to ten days.

Grade 2: Two to three weeks.

Grade 3: Four to six weeks.

CRITERIA FOR RETURN

Medical clearance.

Full Range of Motion.

Strength with 90%

Able to do “high five”

Protect the joint.

CLAVICLE

• ‘S’ shape bone.

• Protects neuro-vascular bundle and for muscle attachment.

• Securely anchored at either end.

CLAVICLE FRACTURE

Any force that brings the shoulder to the midline of the body.

Direct impact to clavicle from superior or anterior direction.

Clavicle Fracture: Signs & Symptoms

Pain and loss of function of shoulder.

Spasm of trapezius and SCM (sternocliedomastoid) m.

Arm held to body, shoulder elevated.

Clavicle Fracture: Signs & Symptoms

May be palpable deformity when palpating the clavicle.

In a pre-pubescent person, they may get a ‘greenstick’ fracture.

MEDICAL REFERRAL!

Clavicle

1st RibSternum

Sternocavicular Ligament

Costoclavicular Ligament

Sternoclavicular Joint

STERNOCLAVICULAR JOINT SEPARATION

Very stable joint. Major ligaments are the sternoclavicular and costo-clavicular ligaments.

Mechanism of Injury is the same as for the A.C. joint.

Pain. Loss of motion. The unaffected side looks higher.

PENDULAR EXERCISES

Flexion

Adduction Abduction

Extension

CW RotationCCW Rotation

ANATOMICAL PREDISPOSITION TO

DISLOCATION

• Glenoid Defects

• Labral Defects

• Neuromuscular Disorders

LUX = DISLOCATE

SUBLUX = PARTIAL DISLOCATION

TERMINOLOGY

TRAUMATIC

Single force applies excessive overload to the soft tissues of the joint and often damages the Glenoid Labrum (Bankart Lesion) and the joint capsule.

ATRAUMATICAthlete who has multiple joint laxities, who had frequent episodes of sub-luxations before and a relatively minor one results in dislocation. (Congenital hypermobility and/or muscle weakness)

ACQUIRED

Sports such as swimming, gymnastics and baseball where repetitive micro-trauma, poor stretching and motion lead to capsular stretching. Eventual feeling of instability.

Bones of Shoulder Joint

Acromion Process

Clavicle

Posterior Anterior

Glenoid

LABRUMCartilage ring around the glenoid. Deepens the socket of the G-H Joint.

Superior, Middle and Inferior Glenohumeral Ligament

Coracoclavicular Acromioclavicular

Coraco-acromial Lig.

Pectoralis Major

Long Head of Biceps

Deltoid

1 23

4

1. Subscapularis

2. Supraspinatus

3. Infraspinatus

4. Teres Minor

Supraspinatus

Infraspinatus

Teres Minor

Posterior Musculature

PRIMARY MOVERS

DeltoidPectoralis Major

(Latissimus Dorsi is posterior)

TYPES OF DISLOCATIONS

Anterior (85%)

Inferior (5%)

Posterior (10%)

Subcoracoid Dislocation

ANTERIOR DISLOCATION

Arm in abduction and external rotation. Force is taken on the hand or arm which increases the external rotation of the arm causing the head of the humerus to dislocate.

INFERIOR DISLOCATION

Arm is in excessive abduction and a force is taken on the hand pushing the head of the humerus inferiorly out of the glenoid.

Subcoracoid Dislocation

Subcoracoid Dislocation

Anterior Dislocation

Subcoracoid Dislocation

The elbow is held away from the side and the hand can not turn onto the stomach.

POSTERIOR DISLOCATION

The arm is in flexion and adduction. Force is taken on the hand, causing the head of the humerus to be push out the glenoid posteriorly.

POSTERIOR DISLOCATION

The coracoid process may be prominent. The elbow will be at the side and the hand on the stomach. Attempting to turn the arm out causes shoulder pain.

For any dislocated shoulder, do not try to reduce the joint. Do not pull on the arm.

Try to immobilize as best you can (difficult).

Medical referral!

Recurrent dislocations have nothing to do with the treatment after the first dislocation.

Recurrent dislocations are dependent upon the damage that happens during the first dislocation.

APPREHENSIVE SHOULDER TEST

When an athlete subluxes the glenohumeral joint, they experience a Dead Arm.

We do an Apprehension Test for the shoulder to determine if they subluxed the shoulder.

Apprehension Test

• Tell you to stop

• Roll their body towards the arm.

• Fight what you are doing

• Pull the arm to the body

OVERUSE INJURIES OF THE SHOULDER

SUPRASPINATUS IMPINGEMENT

OF THE SHOULDER

IMPINGEMENT

To impinge is to pinch.

The supraspinatus gets pinched between the humerus and the acromion and/or the coracoacromial ligament.

SUPRASPINATUS MUSCLE

FLEXION IMPINGEMENT

SIGNS AND SYMPTOMS

• Painful Arc (Abduction)

• Hand Behind Back decreased.

• Weakness of external rotators of the

shoulder.

INITIAL TREATMENT

• Stretch into internal rotation.

• Strengthen external rotators.

• Modify activity.

Hand Behind Back

• One arm at a time.

• Thumb to middle of back.

• Move up back.

STRETCH INTERNAL ROTATION

Arm with limited internal rotation.

EXTERNAL ROTATION STRENGTHENING

MEDICAL REFERRAL

PHYSIOTHERAPY