Shoulder Complex

Glenoid Labrum Tear

MOI: degeneration or trauma can be asymptomatic SLAP lesion S/S: pain, catching, weakness in over head motions, instability. Tx: rest, NSAIDS, arthroscopic repair

SC Joint

Sternoclavicular Joint (posterior =911)

Bursa

Subcoracoid Subscapularis Subacromial (most common)

Internal Rotation

Subscapularis, teres major

Shoulder Muscles

Superficial (see) Latissimus Dorsi Pec major Deltoid Trapezius

Thoracic Outlet Syndrome

TOS= nerves/ vessels become compressed in neck/axilla = narrowed space between 1st rib & clavicle due to anterior scalene muscles compress compression by pec minor presence of cervical rib Mechanism = overhead rotational stresses aggravates condition (weight lifting, swimming)

AC Joint Sprain

"Separated Shoulder" FOOSH

Rotator Cuff (info)

-Act to rotate the humerus -tendons merge to form "cuff" around the joint -contraction of these muscles - stabilize the humeral head in the glenoid fossa

Scapulohumeral Rhythm

0-30 - setting - glenohumeral moves, no scapular movement 30-90 - scapula abducts and up rot 1 deg for every 2 deg GH abd 2:1 ratio of glenohumeral to scapulothoracic movement 90-full abd, 1:1 ratio

NATA position statement Ped Athlete

6-18 -1 overhead sport at a time 2-3 months between -9-14 year olds 75 pitches/game, 600/season, 2-3000 year 1-2 days of a week no more 16 hours week vigorous activity

AC Joint

Acromioclavicular Joint -limited motion

Shoulder Nerve Supply

Brachial Plexus C5-T1

Impingement s/s & tx

Deep pain, pain at night (unable to sleep on side)"painful arc" = 70-120 of active abduction, overhead movements cause pain RICE, refer, NSAIDs, activity modification resists motion to less than 90 degrees if needed if impinged find out why heat/us or EMS can supplement treatment ice after activity strengthen RC and scapular muscles stretching

SC Joint Sprain Mechanism

Direct blow, FOOSH (drives clavicle superior, medial , and anterior)

Throwing Motion Table

Early cocking- abduction/ER - supraspinatus very active Late cocking- more ER - anterior structures stretched scapula must be stable Acceleration - large muscle groups to IR stable scapula Deceleration - all posterior muscles active to slow down especially teres minor Follow-Through - scapula protracts (abducts) serratus anterior

FOOSH

Falling on out streched hand

GH

Glenohumeral Joint (between glenoid fossa & head of the humerus)

AC Joint Sprain S/Sx

Grade 1: minimal swelling/pain, pain w/ ABD > 90 degrees stretch AC joint ligament Grade 2: step off deformity (raised) clavicle rises about level of acromion, tenderness, pain with horiz ADD - ruptured AC joint ligament and sprain to rupture of coracoclavic lig. Grade 3: visible deformity at joint, swelling, bruising, step deformity and depression/drooping of shoulder - tearing of deltoid and trap facia

SC Joint Sprain S/SX:

Grade 1: point tenderness/pain over SC joint, no deformity Grade 2: bruising, swelling, pain; cannot horiz ADD w/out pain Grade 3: Prominent displacement of clavicle, significant pain

Extension

Latissimus dorsi, pectoralis major (lower), teres major

GH joint Sprain (nothing tears & joint has been jolted)

MOI: foosh (arm behind self) S/s: pain with arm movement, esp. with reproduction of MOI TX: RICE, sling if needed, begin PROM/AROM after pain subsides, then RROM

GH dislocations

Majority = anterior combination - of ABD, ER, Ext -Posterior combination of Flex, IR and posterior -Inferior mechanism = ABD with a inferior directed force on humerus (rare)

Bicipital Tenosynovitis (ant. humerous front)

Mechanism repetitive overuse during rapid overhead movements involving excessive elbow flexion and supination activites (weightlifting) s/sx: pain, tenderness over bicipital groove pain/ weakness with resisted should flexion (flair) Managment: activity modification, RICE NSAIDS, heat/us or ems to control inflammation; graston/friction massage strengthing stretching program

Clavicular Fractures

Mechanism: direct blow, fall on point of shoulder, FOOSH s/sx: swelling, ecchymosis, visible/palpable deformity over clavicle pain w/ any shoulder motion supports arm, head tilted toward the side Management :RICE, immobilize (sling), 4-6 weeks puts in retraction figure 8 brace after immobilization, progressive rehabilitation program (gradual motion ex's, gradual motion ex's gradual strengthening)

Biceps Brachii Rupture

Mechanism: prolonged tendinitis; forceful flexion against excessive resistance s/sx: hear/feel snapping sensation, intense pain, ecchymosis, visible palpable defect can be seen over muscle belly pain, weakness in elbow flexion and supination management: rice, refer to MD; conservative txt recommended for older, non-competitive patients (ROM, strengthening program); surgical treatment for competitive athletes

Abduction

Middle Deltoid, Supraspinatus

AC Joint Sprain Management:

RICE, NSAIDS, immobilization (if needed due to pain or in severe cases); protect area upon return to play.

SC Joint Sprain Management:

RICE, NSAIDS, immobilization with sling (grade 1 or 2), reduction of displacement (grade 3), refer, EMS posterior displacement (breathing probs)

Impingement

Related to instability postural changes - slouching acromion shape is hooked from mictrotrauma decreased subacromial space - supraspinatus, subacromial bursa, long head of biceps tendon

Rotator cuff Muscles

SITS Muscles -supraspinatus (back) -infraspinatus -teres minor -subscapularis (front)

ST Joint

Scapulothoracic Joint -not a true joint -scapula and rib cage -Scapular Muscles control (stabilization of the shoulder region)

Flexion

anteior deltoid and pectoralis major (upper)

GH Dislocation Management :

assess sensation and circulation treat for shock immediate referral to MD, EMS if no circulation immobilize shoulder (sling)

Humeral Fractures

direct blow, fall on upper arm, FOOSH s/sx: pain, swelling, dicoloration, inability to move arm, inability to supinate forearm, arm is held close to body (splinted) management: immobilize (sling or splint, depending on location) RICE, refer to md, rehab begins after fx is healed

Scapular Fractures

direct trauma s/sx: pain, tenderness localized to fx site painful with shoulder motion, esp ABD management: RICE, immobilize, refer to MD, rehab ex's begin after 2 weeks (to minimize scarring, loss of ROM) rare in sports

Difference between Impingement, rotator cuff injury, and TOS

impingament- bursa sac shoulder compression in tendon & muscle instability superspinatus rotator = torn or just muscles overhead injury Tos = kneck, artery, nerves, veins, numbness tingling swelling loss of blood flow

Bursae (info)

in subacromial space -can become inflamed when repeatedly compressed during overhead arm actions

External Rotation

infraspinatus, teres minor

GH Dislocations S/sx:

intense pain, tingling/numbness into hand injured arm held in slight ABD (20-30 degrees) and slight ER, stabilized against body by opposite hand Deformity Humeral head is palpable in axilla

Rotator Cuff Injury/tears

often associated with impingement often supraspinatous but could be other 3 similar s/s as impingement - night pain, rest doest make pain away.

Shoulder Bursitis

often seen with impingement Mechanism: repetitive overhead activities, fall on shoulder S/SX: pain at start and acceleration phases of throwing motion inability to sleep on affected side Management: refer to MD; cortisone injection; NSAIDS, rule out underlying conditions otherwise same as impingement

Thoracic Outlet Syndrome (s/sx & management)

s/sx: aching pain, pins-needles numbness on side or back of neck, extend down into shoulder, elbow , hand, weakness if vessels is compressed see edema and stiffness in forearm/hand, a cold arm, fatigue after activity Management: referral to MD, NSAIDS, activity modification muscle strengthening and postural correction = key!

Chronic Instabilities

s/sx: pain, crepitus/clicking after arm relocates Management: RICE, immobilization, restore shoulder motion and strength; surgery if persistent instability occurs if injury does not reduce immobilize and refer to MD for reduction