Ch. 14 - Shoulder Conditions

What are the scapular muscles 2 functions?

1) stabilization of shoulder region 2) facilitate movement of the upper extremity through appropriate positioning of the glenohumeral joint

Normal ROM: horizontal abduction/adduction

130

Normal ROM: shoulder flexion

160 - 180

Normal ROM: shoulder abduction

170 - 180

Normal ROM: adduction

50 - 70

Normal ROM: shoulder extension

50 -60

There are __ articulations of the shoulder. Name all of them.

5; sternoclavicular joint, coracoclavicular joint, glenohumeral joint, scapulothoracic joint, and acromioclavicular joint

Normal ROM: external rotation

80 - 90

Major nerve arising from the brachial plexus that supply the shoulder region: axillary nerve

C5, C6

Major nerve arising from the brachial plexus that supply the shoulder region: subscapular nerve

C5, C6

Major nerve arising from the brachial plexus that supply the shoulder region: suprascapular nerve

C5, C6

Why is the motion of the clavicle in the inferior direction restricted?

The first rib is joined by its cartilage to the manubrum just inferior to the joint, motion of the clavicle in the inferior directions is therefor restricted.

Sternoclavicular Sprain: third degree

*Deformity: gross prominence of medial end of the clavicle *Swelling: severe *Palpable pain: severe *Movement: limited as in second degree, but pain is more severe *Treatment: apply a figure eight immobilizer with scapulas retracted. Immediately refer to a physician. Check radial pulse, respiration, and ability to swallow. If significant findings are present, activate the emergency action plan

Sternoclavicular Sprain: first degree

*Deformity: none *Swelling: slight *Palpable pain: mild *Movement: usually unlimited, but may have discomfort with movement *Treatment: ice, rest, and immobilization with sling/swather

Acromioclavicular Sprain: type 1

*Deformity: none *Swelling: slight *Palpable pain: mild over joint line *Movement: usually unlimited, but may have some discomfort on abduction greater than 90 degrees *Stability: no instability *Treatment: ice, NSAIDs, regain full ROM and strength; return to activity as tolerated, with protection

Acromioclavicular Sprain: type 3

*Deformity: prominent elevation of clavicle AC ligaments and coracoclavicular ligaments are disrupted *Swelling: severe *Palpable pain: severe on palpation and depression of acromion process; definite palpable step deformity present *Movement: limited as in type 2, but pain is more severe *Stability: demonstrable instability *Treatment: ice, immobilize, and immediately refer to physician; if treated conservatively, deformity remains, but function should be within normal limits

Acromioclavicular Sprain: type 2

*Deformity: slight elevation of lateral clavicle; AC ligaments are disrupted, but coracoclavicular is still intact *Swelling: moderate *Palpable pain: moderate with downward pressure on distal clavicle; palpable gap or minor step present; snapping may be felt on horizontal adduction *Movement: unable to abduct the arm or horizontally adduct the arm across the chest without noticeable pain *Stability: some instability *Treatment: ice, NSAIDs, immobilize with sling; TENS, interferential EMS for pain relief; ultrasound;strengthening and stability exercises; return to activity with protection

Sternoclavicular Sprain: second degree

*Deformity: slight prominence of medial end of the clavicle *Swelling: moderate *Palpable pain: moderate *Movement: unable to abduct the arm or horizontally adduct the arm across the chest without noticeable pain *Treatment: ice, rest, immobilization with a sling for 3-4 weeks; initiate strengthening program after that

What are 2 common ways to injure you bicipital tendon?

1) direct blow to the tendon or tendon sheath 2)anterior impingement syndrome associated with overhead rotational activities

What are the two clearly defined forms of thoracic outlet compression syndrome?

1) neurological syndrome (90%); involves the lower trunk of the brachial plexus and ins caused by abnormal nerve stretch or compression 2) vascular form that involves the subclavian artery and vein and is more common in men than in women

What are 2 critical instances that increase the potential for shoulder injury in the throwing motion?

1) when the arm has not yet reached maximum lateral rotation and a large internal rotation torque develops at the shoulder, heightening the possibility of a glenoid labral tear 2) when both a large compression force and a large horizontal abduction torque are generated at the shoulder, crating the potential for rotator cuff tension failure and subacromial impingement

Normal ROM: internal rotation

60 - 100

Major nerve arising from the brachial plexus that supply the shoulder region: dorsal scapular nerve

C5

Major nerve arising from the brachial plexus that supply the shoulder region: pectoral merve

C5 - T1

Major nerve arising from the brachial plexus that supply the shoulder region: musculocutaneous nerve

C5-C7

Anterior Instability

Cause: excessive indirect forces that push the arm into abduction, external rotation, and extension Signs and symptoms: the head of the humerus lodges under the anteroinferior portion of the glenoid fossa adjacent to the coracoid process

Most common mechanism of injury in a sprain to the sternoclavicular joint

a blow to the posterolateral aspect of the shoulder with the arm adducted and flexed

Hill-Sachs lesion

a small defect in the articular cartilage of the humeral head caused by the impact of the humeral head on the glenoid fossa and the humerus dislocates

What joint injury accounts for nearly half of all athletic shoulder injuries and how does it happen?

acromioclavicular joint (AC joint); falling on an outstretched arm

Atraumatic osteolysis of the distal clavicle is ________.

an overuse injury resulting from repetitive microtraumas

What direction is the most acute dislocation of the glenohumeral joint?

anterior with posterior dislocations being the second most frequent

When is the biceps brachii able to exert more force?

because the biceps brachii also crosses the elbow joint, it is capable of exerting more force at the shoulder when the elbow is in full extension

Signs/Symptoms of a glenoid labrum tear

complain of pain, catching or weakness when the arm is overhead in an abducted and externally rotated position; pain often is associated with clicking or popping withing the joint

Ligamentous injuries to the SC, AC, and GH joints can result from _______________.

compression, tension, and shearing forces occurring in a single episode or from repetitive overload

Why does the AC joint have limited motion?

due to a diarthrodial joint

When does the largest translations take place in the glenohumeral joint?

during passive movement of the arm at the extremes of the ROM

What causes adduction when there is no resistance?

in the absence of resistance results from gravitational force, with the abductors controlling the speed of motion

As the number of chronic dislocations _________, the forces that are needed to produce the injury ________.

increases, decreases

Primary muscles producing movement at the glenohumeral joint: lateral rotation

infraspinatus, teres major

What are the 4 ligaments in the joint capsule of the SC joint?

interclavicular, costoclavicular, anterior SC ligament, and posterior SC ligament

Primary muscles producing movement at the glenohumeral joint: abduction

middle deltoid, supraspinatus

About 85% of proximal humeral fractures can be treated ________.

noneperatively

Signs/Symptoms of osteolysis of the distal clavicle

palpable pain, crepitus, and swelling are present over the distal clavicle

In managing a glenohumeral dislocation, you would ____________.

prevent unnecessary movement of the humerus, a rolled towel or thin pillow can be placed between the thoracic wall and humerus before applying a sling

Which blood vessel provides the major blood supply to the shoulder?

subclavian artery passes beneath the clavicle to become the axillary artery

Primary muscles producing movement at the glenohumeral joint: medial rotation

subscapularis, teres major

What does the strong coracohumeral ligament protect against in the glenohumeral joint?

superior dislocation

What is the most common site for proximal humeral fractures?

surgical neck

Signs/Symptoms of traumatic clavicular fractures

swelling, ecchymosis, and a deformity may be visible and palpable at the fracture site

The subacromial bursa lies in ___________________.

the subacromial space, where it is surrounded by the acromion process of the scapula and the coracoacromial ligament above and the GH joint below

When does the subacromial bursa become irritated?

when it is repeatedly compressed during overhead arm action

Innervation of the upper extremity arises from _______.

the brachial plexus, branching primarily from C5-C8 and T1

Thoracic outlet compression syndrome is

a condition in which nerves and/or vessels become compressed in the proximal neck or axilla

Little League Shoulder

an epiphyseal fracture to the proximal humeral epiphysis; often is cause by repetitive medial rotation and adduction traction forces placed on the shoulder during pitching

Primary muscles producing movement at the glenohumeral joint: flexion

anterior deltoid, pectoralis major (clavicular)

Bankart lesion

as the humerus slides forwar, the inferior GH ligament may be avulsed from the anterior lip of the labrum or in combination with a portion of the labrum; tearing of the labrum and inferior GH ligaments

Disorders associated with thoracic outlet syndrome

compression of the medial cord of the brachial plexus compression of the subclavian artery and vein cervical rib syndrome scalenus anterior syndrome hyperabduction syndrome costoclavicular space syndrome poor posture with drooping houlders

Factors Contributing to Impingement Syndrome

excessive amount of overhead movement limited subacromial space under the coracoacromial arch limited flexibility of the coracoacromial ligament Thickness of the supraspinatus and biceps brachii tendon Lack of flexibility/strength of the supraspinatus and biceps brachii weakness of the posterior cuff muscles tightness of the posterior cuff muscles hypermobility of the shoulder joint imbalance in muscle strength, coordination, and endurance shape of the acromion training devices

What is the most frequently dislocated major joint in the body?

glenohumeral joint

SLAP lesion

glenoid labrum tear; an injury to the superior labrum may being posteriorly and extend anteriorly, disrupting the attachment of the long head of the biceps tendon to the superior glenoid tubercle

What causes extension when there is no resistance?

gravity; eccentric contraction of the flexor muscles serve as a controlling or braking mechanism

The substantial fibrocartilaginous disk is is found _______ of the SC joint and is significant because _________.

in the middle; it provides strength and prevents medial displacment

Signs/Symptoms of biceps tendon rupture

individual often hears and feels a snapping sensation and experiences intense pain; ecchymosis and a visible, palpable defect can be seen in the muscle belly; marked weakness with flexion and supination

Primary muscles producing movement at the glenohumeral joint: adduction

latissimus dorsi, pectoralis major (sternal), teres major

Primary muscles producing movement at the glenohumeral joint: extension

latissimus dorsi, pectoralis major (sternal), teres major

80% of traumatic clavicular fractures occur in what portion?

middle third of the clavicle

Signs/Symptoms of a scapular fracture

minimal displacement and exhibit localized hemorrhage, pain, and tenderness

The loose structure of the shoulder complex enables extreme ________, but provides little ________.

mobility; stability

Multidirectional Instability

most anterior and posterior dislocations are associated with some preexisting, inferior laxity or laxity in the opposite direction

Posterior Instability

most often occurs when the humerus is flexed and internally rotated and a posterior force is directed along the long axis of the humerus; more commonly results from a seies of accumulated microtraumatic episodes

What causes a biceps tendon rupture?

occurs as a result of the avascular portion of the proximal long head of the biceps tendon constantly passing over the head of the humerus during arm motion

Chronic rotator cuff tears to the SITS muscles results from __________________.

repetitive microtraumatic episodes that primarily impinge on the supraspinatus tendon just proximal to the greater tubercle of the humerus

The coracoclavicular ligaments resist __________.

resists independent upward movement of the clavicle, downward movement of the scapula, and anterioposterior movement of the clavicle or scapula

treatment of a glenoid labrum tear

rest, anti-inflammatory drugs, and rehabilitation exercises; arthroscopic debridement may be necessary