Ch 22- The Shoulder Complex
Muscles of the Shoulder Complex -Origin: Transverse processes of upper four cervicle vertebrae -Insertion: Vertebral border of scapula, above spine of scapula -Muscle action: Elevation of scapula and lateral flexion of neck when scapula fixed -Innervation/Nerve root: Dorsal scapular (C5) -Acts on humerus/scapula: Scapula
Levator scapulae
With the patient in a seated or supine position, examiners grasp the head of the humerus and apply a stress load and anterior/posterior translation to the humeral head while stabilizing the scapula. The humeral head should ride up with stress. Excessive translation of >3/8 inch (1 cm) is a positive finding.
Load and Shift test
What are the four major articulations/joints of the shoulder complex?
-Sternoclavicular (SC) -Acromioclavicular (AC) -Glenohumeral (GH) -Scapulothoracic
What are the four muscles of the rotator cuff?
-Subscapularis -Supraspinatus -Infraspinatus -Teres minor
How long should a sternoclavicular joint be immobilizied after a grade 3 sprain?
3-5 weeks
Name this articulation: -This is a gliding articulation of the lateral end of the clavicle with the acromion process. It is a rather weak junction.
Acromioclavicular (AC) joint
Anterior or Posterior GH Dislocation? -Patient will carry the affected arm in slight abduction and external rotation; will be unable to touch the opposite shoulder with the hand of affected arm. Moderate pain and disability. There will be a flattened deltoid contour.
Anterior GH dislocation
Anterior, Posterior, Middle, or Inferior GH joint ligament: -Tense when shoulder is in extension, abduction, or external rotation
Anterior GH joint ligament
Anterior/inferior vs Posterior GH dislocation: -May result from direct impact to posterior or posterolateral aspect of the shoulder. Most common MOI is forced abduction, external rotation, and extension. Account for 95% of shoulder dislocations. Head of humerus is forced anterior. Healing of this injury is usually slow, and the detached labrum and capsule can produce a permanent anterior defect to the labrum. Moderately frequent occurance result from instability in primary dislocations would be a bony Bankart lesion.
Anterior/inferior GH dislocation
This test is used to determine if a patient has GH instability. Patients lie supine while the examiners ER their arm. Patients with anterior GH instability will show great apprehension.
Apprehension/Crank test
Muscles of the Shoulder Complex -Origin: Coracoid process of the scapula -Insertion: Middle of the humerus; medial surface -Muscle action: Flexion and adduction of arm -Innervation/Nerve root: Musculocutaneous (C5 & C6) -Acts on humerus/scapula: Humerus
Coracobrachialis
Name this articulation: -This is an enarthrodial, or ball-and-socket, joint in which the round head of the humerus articulates with the shallow glendoid cavity of the scapula. It is maintained by both a passive (glenoid labrum and capsular ligaments) and active mechanism (deltoid and rotator cuff).
Glenohumeral (GH) joint
Grade 1, 2, 3, 4, 5, or 6 AC Joint sprain? -This indicates tearing or rupture of AC ligaments, with associated stretching of coracoclavicular ligaments. Partial displacement and prominence of lateral end of clavicle when compared bilaterally. There is point tenderness during palpation of injury site, and athlete is unable to fully abduct through a full ROM or horizontal adduction.
Grade 2
Grade 1, 2, 3, 4, 5, or 6 AC Joint sprain? -This occurs less frequently, but this involves a complete rupture of the AC and coracoclavicular ligaments.
Grade 3
Grade 1, 2, 3, 4, 5, or 6 AC Joint sprain? -This exhibits posterior separation of the clavicle, with complete disrupton of the AC ligament. In some sprains, the coracoidclavicular ligament will remain intact.
Grade 4
Muscles of the Shoulder Complex -Origin: Infraspinatus fossa of scapula -Insertion: Greater tubercle of humerus (posterior to supraspinatus) -Muscle action: Externally rotates the arm; slight adduction -Innervation/Nerve root: Suprascapular (C5 & C6) -Acts on humerus/scapula: Humerus
Infraspinatus
Muscles of the Shoulder Complex -Origin: Anterior surface of 3rd-5th ribs -Insertion: Coracoid process of scapula -Muscle action: Draws the scapula anteriorly (protraction) and downward -Innervation/Nerve root: Medial pectoral (C8 & T1) -Acts on humerus/scapula: Scapula
Pectoralis minor
Anterior or Posterior GH Dislocation? -This produces severe pain and disability. Arm is often held in adduction and internal rotation. The anterior deltoid muscle is flattened, acromion and coracoid process are prominent, and head of humerus alos may be seen posteriorly. Limited external rotation and elevation.
Posterior GH dislocation
Anterior, Posterior, Middle, or Inferior GH joint ligament: -Tense when shoulder is in abduction and internal rotation
Posterior GH joint ligament
This test is used to check for posterior glenohumeral instability. Patients area supine with the arm abducted to 90 degrees and horizontally adducted 20 degrees, with the elbow flexed to 90 degrees. Scapula is stabilized while examiner the humerus is IR and glided posteriorly. Positive test indicates insufficiency of posterior capsule and possible damange to posterior labrum.
Posterior drawer test
Humeral shaft, Proxmial humerus, or Epiphyseal fracture? -This fracture poses considerable danger to the nerve and vessels of the area. Can result from direct blow, dislocation, or impactreceived by falling onto outstretch arm. Anatomical neck, tuberositities, or surgical neck may be involved. Most occur at surgical neck.
Proximal humerus fracture
Muscles of the Shoulder Complex -Origin: Spinous processes of C7 and T1 vertebrae -Insertion: Vertebral border of scapula, below spine of scapula -Muscle action: Adduction, stabilization, and rotation of scapula (lowering lateral/inferior angle) -Innervation/Nerve root: Dorsal scapular (C5) -Acts on humerus/scapula: Scapula
Rhomboid majar
Muscles of the Shoulder Complex -Origin: Spinous processes of T2-T5 vertebrae -Insertion: Vertebral border of scapula, at base of spine of scapula -Muscle action: Adduction, stabilization, and rotation of scapula (lowering lateral/inferior angle) -Innervation/Nerve root: Dorsal scapular (C5) -Acts on humerus/scapula: Scapula
Rhomboid minor
What is the test used to determine pathology to the SC joint? Pressure is applied, anteriorly, superiorly, inferiorly to proximal clavicle. Instability to increased pain are a positive test.
SC Joint play
Bankart, Hill-Sachs, Reverse Hill-Sachs, or SLAP lesion: -This defect is cause by an injury to the superior aspect of the labrum that be posteriorly, extends anteriorly, and affects the attachment of the long head of the biceps to the superior labrum.
SLAP lesion
Do the following muscles act on the humerus or the scapula? -Trapezius -Rhomboid major -Rhomboid minor -Leveator scapulae -Pectoralis minor -Serratus anterior
Scapula
This describes the movement of scapula relative to the movement of the humerus throughout a full range of abduction.
Scapulohumeral rhythm
Name this articulation: -This joint is not a true joint; the movement of the scapula on the wall of the thoracic cage is critical to shoulder joint motion. The scapula serves as the origin for the muscles of the rotator cuff, and this joint allows for upward/downward rotation, IR/ER, and anterior/posterior tilting.
Scapulothoracic joint
Bankart, Hill-Sachs, Reverse Hill-Sachs, or SLAP lesion: -This defect occurs with a posterior GH dislocation; it can occur on the anteromedial portion of the humeral head following a posterior shoulder dislocation.
Reverse Hill-Sachs
A winged scapula on both sides could indicate a general weakness of what muscle?
Serratus anterior
Muscles of the Shoulder Complex -Origin: Outer surface of first nine ribs -Insertion: Entire length of the ventral surface of vertebral/anterior border of scapula -Muscle action: Stabilization, abduction, and rotation of scapula -Innervation/Nerve root: Long thoracic (C5-C7) -Acts on humerus/scapula: Scapula
Serratus anterior
One scapula being unusually high may indicate _________________, which is a congenital deformity in which the scapula does not descend.
Sprengel's deformity
Name this articulation: -The clavicle articulates with the manubrium of the sternum to from this articulation; which is the only direct connection between the upper extremity and the trunk.
Sternoclavicular (SC) joint
Muscles of the Shoulder Complex -Origin: Subscapular fossa of scapula -Insertion: Lesser tubercle of humerus -Muscle action: Internally rotates the arm -Innervation/Nerve root: Subscapular (C5 & C6) -Acts on humerus/scapula: Humerus
Subscapular fossa
This test is used to check for inferior instability, due to laxity of superior GH ligament and coracohumeral ligament. Patients are seated with their arms hanging to the side. Examiners grasp the elbow while applying an inferior translation. A sulcus will appear.
Sulcus test
Muscles of the Shoulder Complex -Origin: Supraspinatus fossa of scapula -Insertion: Greater tubercle of humerus -Muscle action: Abduction of arm; slightly externally rotates arm -Innervation/Nerve root: Suprascapular -Acts on humerus/scapula: Humerus
Supraspinatus
Muscles of the Shoulder Complex -Origin: Dorsal surface of the inferior angle of the scapula -Insertion: Lesser tubercle of the humerus -Muscle action: Adduction, extension, and internally rotation of arm -Innervation/Nerve root: Subscapular (C5 & C6) -Acts on humerus/scapula: Humerus
Teres major
Muscles of the Shoulder Complex -Origin: Axillary boarder of the scapula -Insertion: Greater tubercle of humerus (posterior to infraspinatus) -Muscle action: Externally rotates the arm -Innervation/Nerve root: Axillary (C5 & C6) -Acts on humerus/scapula: Humerus
Teres minor
Grade 1, 2, 3, 4, 5, or 6 AC Joint sprain? -Point tenderness and discomfory during movement at junction between acromion process and outer end of clavicle. No disruption of AC and coracoclavicular ligaments.
Grade 1
Grade 1, 2, 3, 4, 5, or 6 AC Joint sprain? -There is a complete loss of both the AC and coracoclavicular ligaments. In addition to tearing of trapezius and deltoid attachment of clavicle and acromion. Reflects gross deformity and prominence of distal clavicle, severe pain, loss of movement, and instability of shoulder complex.
Grade 5
Grade 1, 2, 3, 4, 5, or 6 AC Joint sprain? -This is very rare and involves the clavicle being displaced inferior to coracoid behind the coracobrachialis tendon.
Grade 6
Bankart, Hill-Sachs, Reverse Hill-Sachs, or SLAP lesion: -This is a defect that is found on the posterior lateral aspect of the humeral head.
Hill-Sachs lesion
Humeral shaft, Proxmial humerus, or Epiphyseal fracture? -This fracture occurs occasionally from direct blow of fall on arm. Typically comminuted or transverese.
Humeral shaft fracture
Do the following muscles act on the humerus or the scapula? -Pectoralis major -Latissimus dorsi -Deltoid -Supraspinatus -Infraspinatus -Teres major -Teres minor -Coracobrachialis
Humerus
Anterior, Posterior, Middle, or Inferior GH joint ligament: -Tense when shoulder is abducted, extended, or externally rotated
Inferior GH joint ligament
Muscles of the Shoulder Complex -Origin: Spinous processes of the lower six thoracic and lumbar vertebrae, sacrum, and posterior iliac crest (all via lumbodorsal fascia) -Insertion: Medial margin of intertubercular groove of humerus -Muscle action: Extension, adduction and internal rotation of arm; pulls shoulder downward -Innervation/Nerve root: Thoracodorsal (C6-C8) -Acts on humerus/scapula: Humerus
Latissimus dorsi
If only one side is winged, what nerve may be injured?
Long thoracic nerve
This test can determine if a patient has a rupture of the biceps tendon. Patients are seated with both hands grasping the top of their head. They are instructed to alternately contract and relax their bicpes while examiners palpate the muscle. No contraction is indicative of a positive test.
Ludington's test
Anterior, Posterior, Middle, or Inferior GH joint ligament: -Tense when shoulder is in flexion and external rotation
Middle GH joint ligament
Most clavicle fractures occur at what point?
Middle third
What is the criteria for progression to the next distance on a throwing progression?
No increased pain or soreness the following day
This test is used to asses a patient for a SLAP lesion. Patients will be seated or standing. The GH joint is flexed to 90 degrees and horizontally adduct 15 degrees, IR, elbow extension and forearm pronated. Patients are instructed to isometrically resist the examiners downward force at distal forearm. If pain is felt with hand pronated, patients are instructed to supinate the forearm and go again. If pain is relieved with supination, the test is positive. Pain in AC joint is indicative of AC pathology.
O'Brein's/Active Compression Test
Muscles of the Shoulder Complex -Origin: Medial half of clavicle, sternum, costal cartilages of upper six ribs, and aponeurosis of external oblique muscle -Insertion: Greater tubercle of humerus -Muscle action: Flexion, adduction, internal rotation of arm -Innervation/Nerve root: Medial and lateral pectoral (C5-C8, T1) -Acts on humerus/scapula: Humerus
Pectoralis major
Scapular dyskinesis shows the inferior medial border of the scapula being prominent, especially during cocking phase of throwing. This can be due to anterior tightness of the _________ & _________ and weakness of the ____________ & ___________.
-Pectoralis major and minor -Lower trapezius and serratus anterior
The ____________ compresses the humeral head into the glenoid, while cocontraction of the __________, __________, and ____________ depress the humeral head during overhead movements.
-Supraspinatus -Infraspinatus, Teres minor, subscapularis
What are the three structures mostly involved in shoulder impingement under the coracoacromial arch?
-Supraspinatus tendon -Subacromial bursa -LHBT
What two muscle of the rotator cuff are extremly important to eccentrically decelerate the humerus during the deceleration phase of throwing?
-Teres minor -Infraspinatus
Winging of the entire medial border of the scapula at rest is caused by fatigue of the __________ and ___________.
-Trapezius -Rhomboids
How long should a patient with a clavicular fracture be immobilized?
6-8 weeks
What is the test used to determine pathology to the AC joint? Pressure is applied to the distal clavicle in all four directions. Instability and associated increase in pain are a positive test.
AC joint play
This is a condition more characteristically of old people. It involves a contracted and thickened joint capsule that is tight around the humeral head, with little synovial fluid. Pain is reported in all directions of movement about the shoulder, with restriction or limitation of both active and passive movement.
Adhesive Capsuilitis (Frozen shoulder)
What is another name for the Anterior Scalene Syndrome test (testing subclavian artery/TOS) in which patient are seated, arm extended, with chin elevated, head turned up to face side being tested? Positive test is pulse depressed or stopped completely.
Adson's test
What is another name for the Hyperabduction Syndrome test (subclavian/axilliary artery/ TOS), in which patient are seated, arm extended, with chin elevated, head turned up and away from the side being tested? Positive test is pulse disappears.
Allen test
This test is used to check for anterior glenohumeral instability. Patients are supine with their arms abducted to 45 degrees, horizontally adducted 10 degrees, and externally rotated 10 degrees. The scapula is stabilized as a slight distraction is applied to the GH joint. Increased laxity is a postive test of insufficiency of the anterior joint capsule and integrity of the anterior labrum.
Anterior drawer test
Bankart, Hill-Sachs, Reverse Hill-Sachs, or SLAP lesion: -This is a permanent anterior defect on the labrum.
Bankart lesion
This test is used to asses a patient for a possible labrum tear. Patient will lie supine. Examiners will passively abduct and externally rotate the humerus while apply an anterior force to the humeral head while also circumducting the arm checking for a clunking sensation.
Clunk test
Muscles of the Shoulder Complex -Origin: Lateral 1/3 of clavicle, acromion process, and spine of scapula -Insertion: Deltoid tuberosity of humerus -Muscle action: Abduction of arm; anterior fibers flex and internally rotate arm; posterior fibers extend and externally rotate the arm -Innervation/Nerve root: Axillary (C5 & C6) -Acts on humerus/scapula: Humerus
Deltoid
Humeral shaft, Proxmial humerus, or Epiphyseal fracture? -This is much more common in young patients. Causes by direct blow or indirect force traveling along length of axis of humerus. Causes shortening of arm, disability, swelling, point tenderness, and pain. May also present with false joint.
Epiphyseal fracture
Muscles of the Shoulder Complex -Origin: Occipital bone, ligamentum nuchae, and spinous processes of 7th cervical and all thoracic vertebrae -Insertion: Lateral 1/3 of clavicle, acromion process, and spine of scapula -Muscle action: Elevation (upper portion) or depression (lower portion); rotation, adduction, and stabilization of scapula -Innervation/Nerve root: Spinal accessory (CN 11) -Acts on humerus/scapula: Scapula
Trapezius
What is commonly found in the following muscles? -Levator scapulae -Rhomboid minor -Supraspinatous -Infraspinatous -Scalenes -Deltoid -Subscapularis -Teres major -Trapezius -Serratus anterior -Pectoralis major and minor
Trigger points
The following seven exercises are beneficial for throwers during what? -External rotation at 90 degrees of abduction -Throwing deceleration -Humeral flexion -Humeral extension -Low scapular rows -Throwing acceleration -Scapular punch
Warm-up
This condition involves compression of the brachial plexus, subclavian artery, and subclavian vein (neurovascular bundle) in the neck and shoulder. Can result from compression of neurovascular bundle in narrowed space between 1st rib and clavicle, compression between the anterior and middle scalene muscles, compression by the pectoralis minor muscle as neurovascular bundle passes beneath the coracoid process or between clavicle and rib, and the presence of a cervical rib (abnormal rib originating from a cervical vertebra and thoracic rib). Signs and symptoms include paresthesia and pain, sensation of cold, impaired circulation in fingers, muscle weakness, muscle atrophy, and radial nerve palsy.
Thoracic Outlet Syndrome
What are the distances that should be used during a throwing progression?
-45 feet -60 feet -90 feet -120 feet -150 feet -180 feet
What are the four bones that make up the shoulder complex?
-Clavicle -Sternum -Scapula -Humerus
What the 9 movements produced by the GH joint?
-Flexion/Extension -Abduction/Adduction -Horizontal abduction/adduction -Internal/External rotation -Circumduction
What are the three division of the sternum?
-Manubrium -Body -Xiphoid process
The shoulder complex has the greatest degree of ________; which compromises its _________.
-Mobility -Stability