Shoulder Complex PP #6

Painful Arc

-120- 180 range-cleared -Impingement is between the 60 - 120 degree range -Pain is the result of pinching inflamed or tender structures under the Acromion process. -Subacromial Bursitis -Calcium Deposits -Tendonitis of rotator cuff muscles -Think Scapulohumeral rhythm

Characteristics of a Glenohumeral Joint Shoulder Dislocations

-95% are Anterior -Bankart lesion/Hill Sacks lesion/ rotator cuff tear -Axillary nerve- numbness

What are some indications for surgery to repair sternoclavicular joint? Potential benefits.

-Absolute indications for surgery include open fractures and neurovascular injury requiring repair or exploration. The strongest relative indication for surgery is a displaced clavicle with 2 cm or more of shortening -Potential benefits- Shorter healing time Less risk of non union More strength in the upper limb after surgery

Rotator Cuff Pathology & Impingement Syndrome: Partial Tear

-Affect supraspinatus first -Can progress to full tear -May heal with conservative treatment -Re-injury is common -Classic symptom is "painful arc" -Very common in older adults Internal and external causes contribute -Internal = age-related changes in area with poor vascularity -External = repeated impingement -May also occur from acute injury or repetitive strain injury -As pathology progresses, load is transferred to smaller tendon area, weaker tendon less effective at seating HH to prevent impingement, etc. -If partial tear- strengthen above 120 degrees of elevation- isometrics or below- 60 degrees -Painful arc: Movement between about 70 and 120 degrees is painful -Reduce inflammation Avoid overhead postures

RC Tear: Conservative Tx

-Anti-inflammatory modalities -Early ROM exercises to maintain ROM Pendula or wand exercises -Strengthen scapular stabilizer muscles Be sure normal scapulohumeral rhythm is maintained -After inflammation is gone and mm is healed, strengthen RC mm

What is the characteristics of the Acrominoclavicular Joint?

-Attaches scapula to clavicle from the acromion process (Acts like a shelf over the shoulder joint). -Synovial joint with 3 planes of movement- (winging, tipping, rotation terms) -Primary function (Binds the scapula and the clavicle together forcing them to perform similar motions). (Allow scapula additional range of rotation in later stages of movement) (Dependent on ligamentous and joint capsule for stability (first injured is the joint capsule/ acromioclavicular ligaments)) (Coracoclavicular ligament is the primary ligament for support 2 portions (Conoid and Trapezoid)) -Acts like a shelf- Greek Akros- meaning topmost hightest -Maintain relationship btn scapula and clavicle during flex/abd of UE during early stages of movement -Super strong ligaments- that are then reinforced with the attachments of the deltoid and trapezius -The goal of the A-C joint: keep the gleniod fossa aligned with the humeral head during motions of flexion and abduction. -All movement accompanied by movement at the scapulothoracic joint

RC & Deltoid: Force Couple #2

-Axis of rotation and Arthrokinematics -Maintains congruity-the rotator cuff muscles maintain the head of the humerus in the glenoid fossa (approximately 1 mm from the axis of rotation) at all times during arm elevation

G-H Stability cont. with Rotator Cuff muscles & Dynamic Stability vs. Static Stability: Characteristics of each.

-Bony , ligamentous, and labrum (static) structures are inadequate for supporting the HH -Dynamic stability is crucial (Through force couple of rotator cuff and deltoid) -Hard working RC is subject to "wear & tear" (Supraspinatous tendon is relatively avascular) (Stretched when arm at rest, compressed when arm is moving) -Biceps (long head) assists with G-H flexion (Slides under transverse ligament)

Describe the complex motion of the G-H Joint:

-Combined movement at G-H and other shoulder girdle joints -About 2/3rds of flexion & abduction occur at the G-H joint -Need ER to abduct fully -IR and ER ROM vary depending on UE position -Amount of motion attributed to the GH joint is controversial -About 120 degrees of flex and abd occur at the GH joint -Need ER rotation at about 60 degrees to move GT out of the way of the over-hanging acromion -IR/ER rotation more limited with arm at side (LT hits the edge of the glenoid during IR and GT hits the acromion during ER)

Subacromial Space Coracoacromial Arch: Name the tissues that might get compression under the arch.

-Compression : glenohumeral joint capsule coracohumeral ligament Supraspinatus muscle tendon unit tendon from the long head of the biceps brachii subacromial bura Compression coming from the acromion process or coracoacromial ligament -Decompression surgery with rotator cuff repairs

Is it hard to localize the difference of the subacromial & coracoacromial arch?

-Difficult to localize the difference due to the interconnection -Very broad area of signs and symptoms -Rx. Ultrasound guided cortisone shot.

Sternoclavicular joint: What happens during elevation?

-Elevation is usually about 45 degrees and depression about 15 -Elevation associated with elevation and upward rotation of the scapula- ligamentous attachment- yanks it along-Conoid/ Trapezoid/ AC joint lig

Sternoclavicular Joint: Saddle Shaped...Synovial joint w/ movment in what 3 planes...

-Elevation/Depression -Protraction (protrusion)/Retraction -Rotation

Scapulothoracic Force Couple #1:

-Force coupling with the upper and lower trapezius. -Force Couple definition- synergy of 2-3 forces that work on opposite sides of an axis and pull in opposite directions to produce rotation. 2 important force couples #1 Trapezius (upper and lower) with the Serratus muscle #2 force couple Rotator cuff muscles/ deltoid

Scapulotheracic "Joint" is formed by...

-Formed by the articulation of the scapula with the thorax (posterior rib cage) -Not a true anatomic joint..."false joint

Thawing Phase:

-Gradual return of motion -Pain diminishes -Takes up to 26 months -30% will have some permanent residual loss of ROM -Loss with internal rotation -Increase aggressiveness of stretching exercises -Reduce use of AE -Introduce strengthening ex's -Overall timeline = 18 months to 3 years from onset -Watch for substitution patterns and retrain to restore normal scapulohumeral rhythm

GH joint: the humerus has what role?

-Humerus- upward angle medially- 130 degree inclination and rotates posteriorly about 40 degrees= retroversion -Interestingly- Base Ball pitchers- their shoulder in actually more retroversion- because of the torsional forces placed on the humeral head.

Problems with Clavicle ORIF (tremendous forces on the clavicle)

-Incisional numbness and hardware irritation are real complications -Studies support the risk of surgical complications. In one study, 53 percent of surgical patients required plate removal. -In another study of 125 patients who underwent ORIF, 12 percent needed reoperation, 4 percent had plate breakage, and 3.2 percent had loosening. -Other complications included infection and frozen shoulders.

Why is scapulohumeral rhythm important?

-Increases possible ROM -Maintains G-H joint congruity -Supports optimal length-tension relationship in shoulder muscles

Labrum will deepen the glenoid cavity by -%. What is the significance?

-Labrum will deepen the glenoid cavity by 50% -Labrum -deepens the joint/ socket and forms a cup for the humeral head (ball) to move within and makes the shoulder joint much more stable.

Glenohumeral Joint has a large - head & small - fossa?

-Large humeral head & small glenoid fossa -Incongruent joint Great mobility, sacrifices stability Glenoid labrum deepens the socket "Golf ball on a tee"

G-H Joint Structures: Joint capsule

-Large, loose, taut superiorly, slack anteriorly -Provides little stability to allow great motion

Fractures of the Shoulder continued, Proximal Humeral Fracture Patterns: Most common fractures of the humerus & typical fall pattern:

-Most common fractures of the humerus Articular surface (humeral head) Greater tuberosity Lesser tuberosity Surgical neck (different from the anatomical neck) -Typically from fall on outstretched UE Common in the elderly -Usually heal well, but may be with significant residual loss of ROM

Plane of the Scapula: sagital, scapular plane, frontal: What are some characteristics of these planes together?

-Movement in the plane of the scapula puts less stress on the glenohumeral joint capsule and surrounding musculature. -It is the position in which most of the functions / activities of daily living are performed. ( statue of liberty) -Occurs 30-40 degrees anterior to the frontal plane. -Most of our activities are not performed in cardinal planes of movement. -Start AROM/ PROM in plane of the scapula for increased motion and less pain (examples- frozen shoulder, hemiparesis) -After frozen shoulder start in this plane for most return

Movements of the scapula joint are mechanically linked to the - and - joint.

-Movements of the scapula thoracic joint are mechanically linked to the acromioclavicular and the sternoclavicluar joint Via strong ligaments and joint capsules -The shoulder movement is referring to all three joints -A weakened or painful one "joint" will significantly effect the other joints function

Scapulohumeral rhythm muscles:

-Muscles important for motion of scapula Trapezius Serratus Anterior -Muscles important for the motion of the Glenohumeral joint Deltoid Rotator Cuff Supraspinatus, Infraspinatus, Teres minor, Subscapularis 3 phases

Shoulder Pathology

-Musculoskeletal Pathology Intrinsic disease- disease of the glenohumeral joint, periarticular structures -Difficult to assess secondary to a lot of structures in a very small space. -Remember Cyriax history and selective tissue testing -True shoulder pain rarely extends beyond the elbow. -Pain in the AC joint and SC joint tend to be very loalized (Extrinsic disease- not related to the shoulder) -Shoulder will have pain -Etiology can be: cervical spine, thoracic spine, lungs, chest, visceral structures ( heart, gall bladder, diaphragm, spleen)

Scapulothoracic Joint: Primary functions:

-Orient the glenoid fossa for optimal contact with the humeral head -Add ROM to flexion and abduction of the arm -Provide a stable base of support for movement at the glenohumeral joint Think crane with a heavy stable base. Maintains good length tension relationships of the deltoid muscle when working past 90 degrees.

What is functional role of our clavicles?

-Our clavicles act like a crankshaft for overhead movements -Only articular connection to the skeleton is via the sternoclavicular joint -It is otherwise suspended by muscles that are the primary mechanism for securing the shoulder girdle to the rest of the body -This allows for a lot of mobility, but conflicts with the UE's need for a stable base

What is the role of coracoacromial arch?

-Protects top of HH and sensitive tissues below (mm, tendon, bursa) -Trauma, e.g. blow during sports, carring a heavy bag

Overall the G-H Joint Strutures provide passive or active support against gravity?

-Provides passive support against the weight of gravity- inferior translation -Hurts with Post CVA- Hemiparesis (stroke) shoulder -Excessive overhead Throwing with external rotation- may lead to "stretching out the anterior capsule" and cause instability of the GH joint.

Frozen Phase:

-ROM restrictions in capsular pattern -Tries to substitute ST -"Hiking the shoulder" to compensate for loss of GH motion -Pain reduced Only in stretching at end range -Lasts up to a year -Add more aggressive stretching exercises to initial program. -Differentiate stretch to GH joint -Reduce use of adaptive equipment, where possible -Watch for: Signs of a return to the inflammatory (freezing) stage Substitution patterns

Rotator Cuff Pathology & Impingement Syndrome: Complete Tear

-Requires surgical repair -Most often progresses from partial tear -Including Acromioplasty

The sternoclavicular joint is separated by an - disc.

-Separated by an articular disc. -Serves as a hinge, shock absorber. Can have degeneration over time-but not common

What is a bursa/bursitis?

-Several, but most important is the subacromial bursa (subacromial and subdeltoid) -Separates supraspinatus tendon and the head of the humerus from structures above (acromion, coracoid process, coracohumeral ligament, and deltoid) -Extremely painful with bursitis Pain with elevation of the arm -Cyriax testing

Adhesive Capsulitis (Frozen Shoulder)

-Shoulder Decide App -GH joint capsule thickens and there is a loss of the axillary "pouch" Typical age of onset: 30's, 40's, & 50's -Mainly women Primary: cause unknown (insidious onset) Secondary: Precipitating event, e.g., trauma, surgery, or other pathology (rotator cuff tear, Mastectomy, bursitis, etc.) -Loss of ROM in a "capsular pattern" ER most limited, then Abduction, and Int. Rotation 3 Phases discussed in literature Idiopathic Primary cause unknown May be inflammatory, immunologic, endocrinal alterations, or biochemical Incidence is 3 times higher in people with diabetes Capsular pattern: ER most limited, then abd, then IR

What happens during A-C Joint Seperations?

-Shoulder decide app 3 Different Grades of Tears -Shoulder Decide AC separation (Bloody) surgery -The A-C joint is hard to palpate "clearly" due to the very dense Acromioclavicular ligament / joint capsule.- palpate with arm movement-extension- feel the clavicle rotate -Acromioclavicular disc Degeneration common, but typically asymptomatic Horizontal Adduction testing with overpressure stresses the AC joint. -Coracoclavicular Ligaments- Coracoid process to the clavicle (trapezoid and conoid) -AC joint seperation is sometimes called a shoulder seperation. -Scale 1-3 same as ligamentous tearing scale. -Grade 4-6 describe the degree of clavicle separation superiorly from the scapula resulting in a step deformity.

Humeral Fx: Nonoperative Tx:

-Sling immobilization and early controlled motion for non-articular fractures -Gripping exercises and AROM to hand, wrist, forearm, & elbow to maintain ROM -When cleared by MD (usually 1-3 wks), start PROM to AAROM shoulder Pendulum exercises Table top exercises (enable the patient to move through AROM without the resistance of gravity or other external force) Wear sling when not exercising -Begin stretching and AROM exercises at 4-6 weeks Discontinue sling -Begin strengthening exercises at 8-12 weeks. Open chain -Exercise bands, weights Closed chain (helps to increase dynamic stability) -Wall & chair push-ups, quadruped, prone-on-elbows -Stable humeral fxs are usually treated non-operatively -Distal ex's -Maintain ROM and a little bit of strength -Helps manage distal edema -Do more aggressive stretching exercises when approved by MD, usually about 6 weeks after injury -Look at scapulohumeral rhythm and prevent substitution patterns of premature scapular elevation and trunk leaning when raising the arm. Substitution patterns discourage proper recruitment of the RC mm

Glenohumeral Instability: start w/ isometric then progress to -. Exercising will enhance -.

-Start with isometric, then progress to concentric -Try to use exercises that enhance proprioception, e.g., close chain -Vary speed of movement during exercise.

Surgery to fix the SLAP often involves:

-Surgery to fix the SLAP often involves Biceps tenodesis- A biceps tenodesis is a procedure that cuts the biceps tendon from where it attaches to the labrum, and reattaches it to another area. The idea behind a biceps tenodesis is that by decreasing the forces that pull on the SLAP region, the symptoms will be alleviated. A biceps tenodesis is most often performed on patients over 40 years of age or patients with extensive biceps tendonitis or tearing.

Reasons for Impingement:

-The line of pull of the deltoid muscle for elevating the arm is directly superior. The head of the humerus moves vertically and strikes the acromion. -Normally counteracted by the rotator cuff tendons (esp. the supraspinatus and long head of the biceps) -External Rotation of the Humerus with rolling in the glenoid fossa List of reasons for impingement: -Glenohumeral Instability wit joint hypermobility -Muscle weakness /Fatigue with overuse syndrome -Micro-trauma with Rotator Cuff tendon Degeneration -Repeated stress with arm in abducted position -Poor scapula position or movement with abnormal arthrokinematics glenohumeral joint (scapulohumero rhythm) -Inflammation in subacromial space -Scarring -Bone spurs, Osteophytes, and or -Hooked Acromion -Capsular Tightness with slouched posture

Factoids of the Biceps Tendon (2 Tendons)

-The long head of the biceps is more likely to get damaged because it travels through the shoulder joint to the supraglenoid tubercle. (long head - subject to wear & tear, impingement injuries) -Slides 1 ½ inches up down the bicipital groove between the two tuberosities. Can slide out of the groove (different anatomical variations.) Transverse humeral ligament -Good to depress the humeral head when carrying something heavy with elbows at 90 degrees flexion. -Intra-articular, but extra- synovial. Coracohumeral ligament forms a tunnel for the biceps tendon -Tendonitis, partial, full thickness tears or avulsion

The rotator cuff muscles are important in shoulder movements in maintaining what joint stability?

-The rotator cuff muscles are important in shoulder movements and in maintaining glenohumeral joint stability. -These muscles arise from the scapula and connect to the head of the humerus, forming a cuff at the shoulder joint. They hold the head of the humerus in the small and shallow glenoid fossa of the scapula. - 1 mm displacement from axis of rotation

Abnormal movements & the "likely" pathology:

-Watching the Scapulohumeral movement- both concentric and eccentric in abduction -You notice one side has abnormal movements compared to the "good side" Probably: -Altered Scapula and Glenohumeral Rythym from muscle weakness (lower trap) or muscle "tightness" (pectoralis) -Hyper or Hypo mobility of the Glenohumeral Joint Capsule. Usually hyper in the anterior capsule and hypo in the posterior capsule- Check the patient's internal and external rotation supine with the gh joint at 90 degrees of abduction -Pathology of the rotator cuff muscles or labrum -Pathology of the Biceps tendon long head

Preventing Scapular Elevation (Hiking) during Active Shoulder Exercises technique:

-Work in the plane of the scapula to put the RC mm in the optimal length-tension relationship for coordinated movement -ROM exercise w/ client mirroring the therapist while the therapist stabilizes the shoulder to prevent early scapular elevation -Wall walking exercise w/ the client self-stabilizing to prevent early scapular elevation

Labrum slap tear- further subdivide it into the displacement of the tear. (pealing back) The Biceps tendon is affected: Type 3 SLAP

-bucket handle tear may pinch in the joint

Labrum slap tear- further subdivide it into the displacement of the tear. (pealing back) The Biceps tendon is affected: Type 4 SLAP

-bucket handle tear with extension into the biceps tendon allowing the tendon to sublux into the joint

Sternoclavicular joint: Ant/Post ligaments check involvement in clavicle fracture:

-check anterior and posterior movement of the head of the clavicle

Labrum slap tear- further subdivide it into the displacement of the tear. (pealing back) The Biceps tendon is affected: Type 1 SLAP

-frayed by still attached

What are the 2 major synergies in the shoulder complex?

-shoulder complex- scapula/ thoracic synergy and deltoid rotator cuff synergy -If one of the synergies is off- we will not have arm elevation

Labrum slap tear- further subdivide it into the displacement of the tear. (pealing back) The Biceps tendon is affected: Type 2 SLAP

-small tear with instability of biceps labrum complex (common )

Sternoclavicular joint: Costoclavicular ligaments check involvement in clavicle fracture:

-very strong, checks clavicular elevation, e.g., during shoulder abduction

Shoulder Complex is comprised of 20 muscles & 3 bones, what are the three bones?

1-Scapula 2-Clavicle 3-Humerus

What are the 3 plans of movement of the glenohumeral joint?

1. Abduction/adduction 2. Flexion/extension 3. Internal rotation/external rotation

Sternoclavicular joint extremely strong connective tissue for stability: Name the 3 ligaments.

1. Anterior and Posterior Sternoclavicular ligaments 2. Costoclavicular ligament 3. Interclavicular ligament

What are three joint in the shoulder complex? Other components to the shoulder complex:

1. Glenohumeral joint 2. Acromioclavicular joint 3. Sternoclavicular joint -False or functional joints Scapulothoracic and Subacromial Space Ligamentous stability and dynamic stability muscles - Mobility vs. Stability.

Scapulohumeral rhythm 2 main points:

1. Scapula seeks stability / setting phase -Most of the motion at the Glenohumeral Joint -Humerus 30 degrees of abduction -Clavicle 0-5 degrees elevation 2 Next 60 degrees of motion Humerus 40 degrees abduction and external rotation - Scapula begins upward rotation to 20 degrees, (ST to GH motion is about 1:2) -Clavicle 15 degrees of elevation with post. rotation

What are the A-C Ligaments?

1.Anterior and posterior ligaments of the joint. 2.More proximal coracoclavicular ligaments. Sharp edge- like a knife to the rotator cuff muscles/long head of the biceps (conoid and trapazoid) - limit clavicle elevation 3.Coracoacromial ligament.

Only about -% of the surface is in contact w/ the glenoid fossa.

25

Give an example of a acute traumatic event.

Acute traumatic event would be a fall onto an outstretched arm

Glenohumeral stability: Atraumatic or microtrauma

Atraumatic or microtrauma (not including a labral tear) may be treated conservatively -Strengthen RC and scapular muscles (problem is laxity combined with impingement)

What type of joint is the genohumeral joint?

Ball & socket joint

Humeral Fx: Operative Tx:

Complex or unstable fxs require open reduction & internal fixation (ORIF) -Hardware -Hemiarthroplasty (replace the humeral head)/ Total Shoulder Post-op treatment -Follows same course as non-operative -Timelines will vary depending on the stability of the fixation -Prognosis for ultimate movement/function should be considered when establishing goals (biomechanical, rehab, or both??)

The shoulder complex is connected to the skeleton ONLY by the what joint? What is the shoulder more dependent on then joints?

Connected to skeleton ONLY by the sternoclavicular joint -The shoulder is more dependent on muscles than on joint structures to maintain alignment and stability -Muscles work in teams to produce highly coordinated movement/ actions that are expressed over several joints

- process of the GH joint has multiple attachments for ligaments & muscles?

Coracoid process-means "crows beak"- multiple attachments for ligaments and muscles

Do degenerative tears become for brittle with age?

Degenerative tears- becomes more brittle with age, this will cause it can fray and tear as part of the aging process.

Will the clavicle fracture before the ligament tears?

Depends on ligaments for stability...so strong that usually the clavicle fractures before a ligament tears (dislocation).

Sternoclavicular joint: What happens during depression?

Depression associated with depression and downward rotation

Muscles that act as depressors for the scapulotheracic joint?

Depressors Lower Traps, Lats Dorsi, Pectoralis Minor, Subclavius

Dislocations at the GH joint occur - % of the time.

Dislocations- 95% of the time is anterior- posterior dislocations require additional forces/ seizures MVA

During abduction of the arm, what happens to the rotator cuff?

During abduction of the arm, the rotator cuff compresses the glenohumeral joint, a term known as concavity compression, in order to allow the large deltoid muscle to further elevate the arm. In other words, without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle.

Scapulohumeral rhythm: what is external rotation very important?

EXTERNAL ROTATION IS VERY IMPORTANT FOR THE GREATER TUBEROSITY TO CLEAR THE ACROMION- ESP WITH ABDUCTION If there is not external rotation - shoulder abduction is limited to 120 degrees with 60 degrees GH joint and 60 degrees scapulothoracic joint

Muscles that act as elevators for the scapulotheracic joint?

Elevators Upper Traps, Levator Scapula, Rhomboids

Impingement and Instability quite a couple in the athlete: Grade 1

Grade 1- Usually (older patients) have straight forward impingement with no instability

Impingement and Instability quite a couple in the athlete: Grade 2

Grade 2- Secondary Impingement and instability from chronic overuse and microtears of capsule and labrum (swimmers)

Impingement and Instability quite a couple in the athlete: Grade 3

Grade 3- Secondary impingement and instability from general ligament laxity throughout body. Hypermobile other joints as well.

Impingement and Instability quite a couple in the athlete: Grade 4

Grade 4- Primary instability with no impingement. Look for a sulcus sign.

Labral tears symptoms include:

Labral tears symptoms include: -pain deep in the front of the shoulder, popping or clicking in the shoulder, and a decreased range of motion or strength. -The symptoms are often made worse with shoulder movements, most often overhead activities such as throwing. -Patients may also have feelings of instability "the shoulder is going to pop out of place".

G-H Joint Structures: Capsular Pattern for the GH joint

Loss of ROM with out trauma in a capsular pattern then something is wrong the joint capsule ER most limited, then Abduction, and Int. Rotation (substitute Hiking movements)

The GH joint provides...

Mainly Muscle for dynamic support and ligaments for static support instead of bone/ joint

Fractures of the Shoulder continued, Proximal Humeral Fracture Patterns Characteristics:

Most are stable one-part fractures involving the surgical neck of the humerus -Stable fxs are not displaced or only very minimally displaced and do not disrupt the articular surfaces. -The anatomical neck is the narrow area just distal to the articular surface of the humeral head. -Fractures tend to occur at the surgical neck just below the tubercles Look at the bicipital groove... Pts. can have problems with bicipital tendonitis later in RX. If the groove is altered.

Most sublaxations occur during what type of motions?

Most subluxations- excessive movement occurs in the anterior and inferior motions.

Scapulotheracic "Joint" motions:

Motions are described as if it were an anatomic joint Lacks usual joint characteristics: Crunching- need to stretch out the fascia under the scapula Motions are -Elevation...superiorly 60 degrees -Depression... 5-10 degrees-stabilizes the scapula with closed chain activities -Protraction (abduction)..5-6 inches from midline -Retraction (adduction)..midline -Up/Down rotation (inferior angle of scapula)...60 degrees

Muscles of the scapula that attach:

Muscles: Serratus Anterior: Supraspinatus, Subscapularis Trapezius: Teres Major, Teres Minor, Triceps Brachii long head, Biceps Brachii Rhomboid Major: Rhomboid Minor: Coracobrachialis, Lattisimus Dorsi, Deltoid Levator Scapula: Infraspinatus, Pectoralis Minor

Primary purpose of the sternoclavicular joint is to...

Primary purpose is to place the scapula in an optimal position for the humerus to function

Primary support of the glenohumeral joint is muscular or ligaments?

Primary support of the Glenohumeral joint is actually muscular- rotator cuff "dynamic stabilizers"

Muscles that act as protractors for the scapulotheracic joint?

Protractors Serratus Anterior

Muscles that act as retractors for the scapulotheracic joint?

Retractors Middle Trap, Rhomboids, Lower Trap

Sternoclavicular joint: What happens during rotation?

Rotation -Spins in one direction -> posteriorly, bringing inferior surface of clavicle to face anteriorly -ROM is about 30-45 degrees rotation -Important motion b/c shape of the clavicle, rotation results in elevation of the AC joint

What does a SLAP lesion stand for?

SLAP lesion stands for superior labral anterior posterior with biceps tendon involvement

What does it mean that the shoulder joint looks like a golf ball on a tee analogy?

Shoulder joint looks like a golf ball on a tee - the ball (humeral head) is not held in place by the tee (socket). The labrum is the extra support needed to stabilize the ball.

Scapulotheracic Joint: Slouching affects the scapula's ability to...

Slouching affects the scapula's ability to upward rotate and keep the glenoid fossa in proper alignment with humerus, decreases the deltoids length tension curve at the shortened range.

Factoids: G-H Stability cont. with Rotator Cuff muscles & Dynamic Stability vs. Static Stability

Static stabiity not enough -Mm are "silent" when arm at side without a load -Gravity is countered by superior joint capsule, coracohumeral lig, and passive tension of supraspinatous mm -With a load, supraspinatous kicks in -Without supraspinatous, sustained load on sup capsule and Coracohumeral lig regults in stretching/subluxation Rotator cuff mm -Supraspinatous -Infraspinatous -Teres minor -Subscapularis -Supra, infra, and TM work as joint compressors -Deltoid has superior pull -Together they create pure rotation In addition: -Subscap provides anterior stability

What joint is the only structural attachment of shoulder girdle to body?

Sternoclavicular Joint

What is a subacromial role?

Subacromial -Often described as 2 bursa: subacromial and subdeltoid -Separates supraspinatous tendon and head of humerus from the structures above (acromion, coracoid process, coracohumeral ligament, and deltoid) -Permits smooth gliding btn HH and supraspinatous tendon Interruption is common and results in pain and limited GH motion

How is the subacromial space formed and why is it important?

Subacromial space: -Formed by the coracoacromial arch and the superior aspect of the head of the humerus. -It is important in function/dysfunction, but it is not really a "linkage"

G-H Joint Structures: Corachohumeral ligament

Superior limits adduction, inferior limits abduction, all 3 limit ER and anterior glide with horizontal abduction and/or extension)

G-H Joint Structures: Glenohumeral ligaments

Superior, middle, & inferior form a "Z" on the anterior capsule (more like a thickening of the capsule) middle ligament is missing in 30% of the population

Rotator cuff tests these muscles: S.I.T.S

Supraspinatus Infraspinatus Teres Minor Subscapularis

Freezing Phase: Treatment & Symptoms:

Symptoms -Shoulder pain -Sleep (pain interrupts sleep) -ADLs -At or near end range -ROM may be near normal initially, decreasing over time -Pain at end range.(capsular) -Client restricts use of the UE -Strength is usually close to normal Lasts 2-9 months Treatment (sleep on back or unaffected side w/ affected UE supported) -Precaution: Don't overstretch capsule!! -Positioning for comfort -Postural exercises -ADL "coaching" -Maximize function while respecting pain -Compensatory strategies for OP -Cortisone shots are common..to decrease inflammatory response of synovial tissue

Symptoms of a tear in the shoulder are & is dependent on:

Symptoms - depend on where the tear is located: -An aching vague pain in the front or top of the shoulder. -Clicking or catching sensation during certain movements. -Pain with specific overhead activities.

Sternoclavicular joint: the "S" shape of the bone is responsible for:

The "S" shape of the bone is responsible increases strength. CRANK SHAFT

The joint capsule at the shoulder is thick or thin and supported by what?

The joint capsule is relatively thin and supported by the thickenins in the glenohumeral ligaments.

The potential volume in the glenohumeral joint is about how many times the size of the humeral head?

The potential volume in the glenohumeral joint is about twice the size of the humeral head- very lax. Also potential for dislocations

The radial spiral groove will run obliquely across the posterior of the surface of...

The radial spiral groove will run obliquely across the posterior surface of the humerus- Radial nerve runs in this groove- if a high humeral fracture - traction on the Radial nerve with wrist drop

What muscle out of the S.I.T.S is most used of the rotator cuff?

The supraspinatus is the most used muscle of the rotator cuff.-small muscle with about a 20 times disadvantage- the deltoid does help out after about 20 degrees of abduction.

Can trauma tear the labrum?

Trauma can tear the Labrum- superior part is only loosely attached and the 50% biceps longhead has attachments to the superior labrum- pulling on it

Glenohumeral stability: Traumatic laxity

Traumatic laxity usually requires surgery -Be sure you know post-op precautions -Take care to prevent re-stretching the repaired capsule -Determine what stage the patient is in (acute, subacute, settled, chronic)

T or F: Impairments of the shoulder interfere w/ TOTAL UE movement.

True

T or F: Normally the slope or plane of the fossa is 4 degrees inclined upward relative the horizontal axis and facing about 35 degrees forward in the anterior frontal plane- lines up for the plane of the scapula motion- most normal way to elevate the upper extremity

True

T or F: The cause of a SLAP tear can generally be divided into acute traumatic events or chronic repetitive injuries that lead to failure.

True

T or F: The long axis of the clavicle is lightly above horizontal plane an about 20 degrees posterior to the frontal plane- changes with individuals

True

T or F: The movement of the scapula and the humerus as the patient upward flexes and abducts their arm 180 degrees Roughly a 2:1 ratio GH joint to Scapula rotation. 120 degrees at the GH joint and 60 degrees at the scapula.

True

T or F: the shoulder complex has the greatest movement of any area of the body.

True

What shape would predispose a person to a rotator cuff tear: Type I, II, III Neer Classification?

Type 3 (39 % of the population) 70% of torn rotator cuffs are Type 3

Sternoclavicular joint: Interclavicular ligaments check involvement in clavicle fracture:

check downward glide of the clavicle, maintaining the space between the clavicle and the first rib to protect the brachial plexus and subclavian artery that run between the two

Scapulothoracic Joint: Key muscles for scapula mobility:

serratus anterior, trapezius (upper, middle, and lower) , levator, & rhomboids