The Shoulder

1. What are the 4 main ligaments of the sternoclavicular joint? 1b. Which of the sternoclavicular ligaments prevents upward displacement of the clavicle and which prevents lateral displacement of the clavicle? 2. What are the 3 main ligaments of the acromioclavicular joint? What is result of the clavicle's motion on one of the acromioclavicular ligaments?

1. Anterior sternoclavicular, posterior sternoclavicular, interclavicular, and the costoclavicular ligaments are the 4 main ligaments of the sternoclavicular joint; interclavicular prevents upward displacement of the clavicle and costoclavicular prevents lateral displacement of the clavicle. 2. 1.) Acromioclavicular ligaments that consists of 4 portions (anterior, posterior, superior, and inferior), the 2.) coracoacromial ligament (which forms with the acromion, the coracoacromial arch), and the 3.) coracoclavicular ligament that consists of the conoid and trapezoid are the ligaments of the acromioclavicular joint; because the motion of the clavicle, the coracoclavicular becomes a bit loose which permits movement of the scapula at the AC joint.

1. What is the furrow that lies in between the greater and lesser tubercles? 1b. What holds and secures the long tendon of the biceps brachii? 2. What are the 4 major articulations of the shoulder? 3. What is a feature of the sternoclavicular and acromioclavicular joint?

1. Bicipital groove, which secures the long tendon of the biceps brachii, is the furrow that lies in between the greater and lesser tubercles. 2. Sternoclavicular joint, acromioclavicular joint, glenohumeral joint, and scapulothoracic joint are the 4 major articulations of the shoulder. --> Sternoclavicular joint is the articulation of the clavicle and manubrium. 3. Fibrocartilaginous disc (like the intervertebral disk) are placed b/t the articulating surface of the sternum to clavicle and acromion to clavicle and that allows the clavicle to move on the sternum/disk meaning a function of the fibrocartilage disk to is help produce movement of the clavicle against fixed objects (sternum, acromion).

1. What is the main artery for the shoulder and arm muscles? 2. What artery provides blood supply to the upper limbs as well as parts of the neck and brain and what is the path of this artery? What does this artery branch into? 3. What muscles insert into the greater tubercle of the humerus? 4. What muscles insert into the lesser tubercle of the humerus?

1. Brachial artery is the main artery for the shoulder and arm muscles. 2. Subclavian artery provides blood supply to the upper limbs as well as parts of the neck and brain; (brachial artery arises from the subclavian artery), subclavian artery is located distal to the SC joint, arches up and out, passes the anterior scalene muscle, and moves downward laterally behind the clavicle and in front of the first ribs (by the manubrium). 2b. The subclavian becomes the axillary artery at the 1st rib margin and becomes the brachial artery around the teres major muscle (shoulder). 3. Pectoralis major, supraspinatus, infraspinatus, and teres minor are the muscles that insert on the greater tubercle (lateral side of the humerus) 4. Subscapularis and teres major are the muscles that insert on the lesser tubercle (medial side of the humerus).

1. What is the MOI for shoulder impingement? 1b. What condition is closely related to shoulder impingement? 2. Where is the site for rotator cuff tears and what is the MOI? 2b. What is the demographic for rotator cuff tears? 3. What are the signs and symptoms of shoulder impingement?

1. Chronic compression of the supraspinatus tendon, subacromial bursa, and long head biceps tendon due to the decreased space under the coracoacromial arch (which they are all underneath) as a result of shoulder abduction is the MOI for shoulder impingement. (1b.) Shoulder impingement is closely related to shoulder instability in which individuals involved in overhead sports typically have hypermobile shoulders which can increase the chance or severity of shoulder impingement. 2. Near their insertion on the greater tubercle is the site for rotator cuff tears with the MOI being acute trauma or shoulder impingement. 2b. Complete tears are seen in individuals with a long history of shoulder issues and are relatively uncommon in young people. 3. Diffuse pain around the acromion that is aggravated during overhead activities, ERG (increased external rotation) and GIRD (decreased internal rotation) in the throwing arm are the signs and symptoms of shoulder impingement.

1. What is the MOI for thoracic outlet compression syndrome? 2. What are the signs and symptoms of thoracic outlet syndrome? What are the tests that can indicate thoracic outlet syndrome?

1. Compression of the brachial plexus, subclavian artery, and subclavian vein at either the infrasternal notch (space b/t first ribs and clavicle/image), b/t anterior and middle scalenes (under sternocleidomastoid), by the pec minor as the neurovascular bundle passes under the coracoid process or infrasternal notch, or the presence of a cervical rib. 2. Paresthesia, radiating pain, sensation of cold, Raynaud's syndrome (decrease circulation to fingers), muscle weakness and atrophy, and radial nerve paralysis are the signs and symptoms of thoracic outlet syndrome; anterior scalene test, hyperabduction test, military brace test (passively extended the shoulder and turning the neck to the opposite side), and costoclavicular tests can indicate thoracic outlet syndrome.

1. What is the MOI for contusions of the upper arm and what could multiple contusions of the upper arm lead to? 2. What are the signs and symptoms of contusions of the upper arm?

1. Compression via direct blow is the MOI for contusions of the upper arm with multiple contusions leading to myositis ossificans of the upper arm known as "linebacker's arm" or "blockers exostosis." 2. Bruise (obvious) as well as possible transitory arm paralysis and inability to use extensor forearm muscles as a result of the radial nerve also being possibly contused against the humerus are the signs and symptoms of contusions of the upper arm.

1. What is the MOI of shoulder bursitis? 2. What are the signs and symptoms of shoulder bursitis?

1. Direct impact, fall on the acromion, or shoulder impingement is the MOI for subacromial (main bursa) bursitis that is either chronic or acute. 2. Pain when moving the shoulder, tenderness to palpation in the subacromial space, and a positive impingement test are the signs and symptoms of shoulder bursitis.

1. What is the MOI for scapular fractures? What are the sites for scapular fractures? 1b. What is the prevalence of scapular fractures? 2. What are the signs and symptoms of scapular fractures?

1. Direct trauma or indirect trauma through the transmission of force through the humerus to the scapula is the MOI for scapular fractures; the scapular body, glenoid, acromion, and coracoid are the sites for scapular fractures. 1b. Fractures of the scapula are uncommon as the scapula is well protected by a heavy outer bony border and a cushion of muscle above and below. 2. Obvious deformity, location of disability, pain during shoulder movement, as well as swelling and point tenderness are the signs and symptoms of scapular fractures.

1. What is the MOI for clavicular fractures? 1b. What is the prevalence of clavicular fractures? 2. What are the signs and symptoms of clavicular fractures? 3. What is the treatment for clavicular fractures? 3b. What is a closed reduction?

1. FOOSH, falling on the acromion, or direct impact is the MOI for clavicular fractures. 1b. Clavicular fractures are among the most frequent fracture in sports. 2. Patient supporting the arm on the injured side while also tilting their head to the injured side, the injured clavicle appearing slightly lower than the healthy side, swelling, point tenderness, and mild deformity are the signs and symptoms of clavicular fracture. 3. X-ray leading to nonsurgical (closed) reduction, sling and swathe bandage where immobilization is maintained for 6-8 weeks, as well as initial treatment for shock and gentle isometric/mobilization exercises is the treatment for clavicular fractures.

1. What is the MOI for glenohumeral joint sprain? 1b. What are the muscles affected in glenohumeral joint sprains? 2. What are the signs and symptoms of glenohumeral joint sprain?

1. Forced abduction (seen in arm tackles in football) or forced external rotation is the MOI for glenohumeral joint sprains. 1b. Infraspinatus-teres minor, as a result of being responsible for external rotation, are the muscles affected in glenohumeral joint sprains. 2. Pain during arm movement especially when the MOI (abduction or external rotation) is reproduced along with decreased ROM and pain during palpation are the signs and symptoms of glenohumeral joint sprain.

1. What is the MOI for biceps brachii ruptures and where is the site for bicep brachii ruptures? 2. What are the signs and symptoms of a bicep brachii rupture?

1. Powerful eccentric or concentric contraction is the MOI for biceps brachii fractures which occur most commonly near the bicipital groove. 2. Obvious deformity, hearing of a snap, and weakness in flexion and supination are the signs and symptoms of a bicep brachii rupture.

1. What is the MOI for scapular dyskinesis? 2. What are the signs and symptoms of scapular dyskinesis?

1. Scapular dyskinesis is abnormal movement of the scapula caused by chronic overuse; SICK is an acronym for the MOI for scapular dyskinesis which is scapular malposition, inferior scapular winging, coracoid tenderness, and kinesis abnormalities of the scapula. 2. Affected shoulder is inferior and tipped forward compared to the other shoulder in what appears as a slouched position, winging, and prominence of the inferior medial border of the scapula (due to scapula muscle weakness or overactive pecs) are the signs and symptoms of scapular dyskinesis.

1. What is the scapulohumeral rhythm? 2. What are the components of an anterior shoulder observation? 2b. What is a step deformity? 3. What are the components of a posterior shoulder observation?

1. Scapulohumeral rhythm is the ratio between the glenohumeral muscles and scapula muscles in relation to shoulder joint movement; for example, 180° of abduction is 60° protraction, 25° scapular upward rotation, and 95° shoulder abduction. The ratio of scapulohumeral rhythm is 2:1 for every 2° of glenohumeral movement, there is 1° of scapular movement. 2. Observing whether the acromions are even with each other or if one is depressed, if one shoulder is higher than the other due to muscle spasm or guarding, if the acromion is especially prominent (which may indicate a step deformity), if the clavicular shaft appears deformed, if there is loss of deltoid definition, if the deltoid muscles are symmetrical, and if there is an indentation in the upper biceps region are the components of a shoulder observation. 2b. Step deformity is the abnormal prominence of the acromion indicative of ligament tear of the AC joint. 3. If one scapula is higher than the other (indicative of Sprengel's deformity which is congenital), if the scapula is protracted because of constricted pectoral muscles, if there is winged scapula, and if there is normal scapulohumeral rhythm.

1. What is the only axial skeleton attachment for the entire upper extremity? 2. What is the scapula's function? Where is it located? 3. What are the three prominent projections of the scapula?

1. Sternum is the only axial skeleton attachment (e.g., skull, rib cage, spine) for the entire upper extremity. 2. Scapula's function is to serve as an articulating surface for the head of the humerus; the scapula is located on the dorsal aspect (back) of the thorax. 3. The scapula has 3 prominent projections: the spine (of scapula), the acromion, and the coracoid process.

1. What muscle compresses the humeral head into the glenoid fossa? 2. What muscles depress the humeral head during overhead movements? 3. What tissue also helps control humeral head movement and what is the mechanism for its stabilization of the humeral head? 4. What muscles, besides the rotator cuff muscles, stabilize the shoulder joint?

1. Supraspinatus stabilizes the humeral head by compressing it into the glenoid fossa. 2. Infraspinatus, teres minor, and subscapularis are the muscles that depress the humeral head during overhead movements. 3. Glenohumeral joint capsule itself helps control humeral head movement as the tendons of the rotator cuff merges into the glenohumeral joint capsule; as the rotator cuff muscles contract, they tighten the joint capsule which helps center the humeral head relative to the glenoid. 4. The scapula muscles (levator scapula, traps, serratus anterior..) also help stabilize the position of the glenoid fossa relative to the moving humerus.

1. What is the landmark on the superior (above the spine of scapula) dorsal aspect of the scapula? 2. What is the landmark on the inferior (below the spine of scapula) dorsal aspect of the scapula? 3. Which of these two are located medially: the greater tubercle or lesser tubercle?

1. Supraspinous fossa, where the supraspinatus originates, is the superior (above the spine of scapula) dorsal aspect of the scapula. 2. Infraspinous fossa, where the infraspinatus originates, is the inferior (below the spine of scapula) dorsal aspect of the scapula. 3. Lesser tubercle is located medially whereas the greater tubercle is located higher and laterally.

1. What is the MOI for bicipital tendinitis (or tenosynovitis)? 2. What are the signs and symptoms of long head bicep tendinitis? 3. What is the treatment for bicipital tendinitis (or tenosynovitis)?

1. Tenosynovitis of the long head of the biceps can occur from repetitive stretching of the biceps tendon under the transverse humeral ligament in the bicipital groove. 2. Tenderness of the bicep over the bicipital groove, some swelling, increased warmth, crepitus, along with pain when performing dynamic overhead throws (dodgeball, baseball, etc.). 3. Complete rest for several days if possible with cryotherapy and ultrasound is the treatment for bicipital tendinitis (or tenosynovitis).

1. Where does the majority of recurrent shoulder instabilities occur and why? 2. What is the MOI for recurrent shoulder instabilities? 3. What are the signs and symptoms of recurrent shoulder instabilities?

1. The majority of recurrent shoulder instabilities occur anteriorly as a result of the major of shoulder dislocations occur anteriorly. 2. Traumatic (macrotraumatic), chronic overuse (microtraumatic), birth defect/congenital, or neuromuscular are the MOIs for recurrent shoulder instabilities. 3. Dead arm syndrome (pain experienced during a throwing motion), clicking, and pain at the back of the shoulder (anterior instability) or both in the front and back (posterior instability) are the signs and symptoms of recurrent shoulder instability;

1. What are the muscles acting on the glenohumeral joint divided into? 2. What is the most important bursa of the shoulder and where is it? When is this bursa most likely to be injured and why? 3. What is the nerve root for the musculocutaneous nerve? 4. What is the ROM that the supraspinatus affects shoulder abduction?

1. The muscles acting on the glenohumeral joint are divided into two groups: the first group consists of muscles that originate on the trunk (axial) i.e., pectoralis muscles and latissimus dorsi; the second group is the muscles that originate on the scapula i.e., deltoids, teres major, and coracobrachialis. --> There are also rotator cuffs 2. Subacromial bursa is the most important bursa of the shoulder; subacromial bursa is located in the subacromial space (underneath the coracoacromial ligament and acromion) (image). 2b. Subacromial bursa is most likely to be injured when the humerus is in an overhead position because the subacromial bursa becomes compressed as it moves up against the acromion. 3. C5-C7 is the nerve root for the musculocutaneous nerve. 4. The initiation of the first 30° of abduction is the ROM that the supraspinatus affects.

1. What is the MOI for brachial plexus injuries? 2. What are the signs and symptoms for brachial plexus injuries?

1. Blunt trauma or excessive stretch is the MOI for brachial plexus injuries. 2. Depending on what nerve was injured, muscle weakness of the rotator cuffs, shoulder girdle, shoulder joint, and upper arm muscles are the signs and symptoms of brachial plexus injuries.

1. What are the nerve roots for the pectoral nerve? 2. What are nerve roots for the radial nerve? 3. What are nerve roots for the brachial plexus?

1. C5-T1 are the nerve roots for the pectoral nerve. 2. C5-T1 are the nerve roots for the radial nerves too. 3. C5-T1 are the nerve roots for the brachial plexus.

1. What are the bones that make up the shoulder? 2. What part of the clavicle presents a structural weakness and is the site of the largest number of fractures to the clavicle? 3. What is protecting the clavicle?

1. Clavicle, sternum, scapula, and humerus are the bones that make up the shoulder. 2. The point at which the clavicle changes shape/contour is the part of the clavicle that presents a structural weakness and is the site of the largest number of fractures to the clavicle. 3. Just skin as the clavicle lies superficially with no muscle or fat protection making it a subject to direct blows.

1. What is the MOI for an acromioclavicular sprain? 2. What are the signs and symptoms for each grade of an acromioclavicular sprain (there are 6)? 3. What is the immediate care for an AC sprain?

1. Direct blow on the acromion or indirect force from FOOSH are the MOIs for an acromioclavicular sprain. 2. Grade 1 AC sprain sees point tenderness and mild pain during movement at the AC with no disruption; Grade 2 AC sprain sees a partial tear of the AC ligaments with stretching of the coracoclavicular ligament, subluxation and prominence of the lateral end of the clavicle, point tenderness, and inability to fully abduct or horizontally a-d-duct; Grade 3 AC sprain (uncommon) sees complete rupture of both AC ligaments and coracoclavicular ligaments; Grade 4 AC sprain sees posterior fracture of the clavicle with complete disruption of AC ligament (though the coracoclavicular ligaments tend to remain intact; Grade 5 AC sprain sees complete loss of both AC and CC ligaments as well as tearing of the trapezius and deltoids and consequent severe pain and shoulder instability; Grade 6 is very uncommon and sees the clavicle displaced inferior to the coracoid behind the coracobrachialis tendon. 3. The protocol for AC joint immediate treatment is cold application and compression to control local hemorrhage, slight and swathe bandage to stabilize AC joint, and referral to physician.

1. What are the ligaments of the glenohumeral joint? 1b. What movements do the glenohumeral ligaments restrict? 2. What ligament secures the long bicep tendon within the bicipital groove by passing over the lesser and greater tubercles? 3. What movements do the glenohumeral ligaments restrict?

1. Glenohumeral ligaments (divided into superior, middle, and inferior), coracoacromial ligament (also), and the coracohumeral ligaments are for the glenohumeral joint. 1b. Shoulder flexion, extension, and rotation are the movements restricted by the glenohumeral ligaments. 2. Transverse ligament is the ligament that secures the long bicep tendon within the bicipital groove by passing over the lesser and greater tubercles. 3. Superior glenohumeral ligament is tight in full a-DDuction and limits anterior inferior translation of the shoulder; middle glenohumeral ligament is tight in external rotation and limits anterior translation; inferior glenohumeral ligament becomes tight in aBduction/external rotation logically (anterior), aBduction/internal rotation logically (posterior). Anterior inferior glenohumeral ligament restricts anterior inferior glenohumeral motion and in the same way posterior inferior glenohumeral ligament restricts posterior inferior glenohumeral motion

1. What is the MOI for a sternoclavicular sprain? 1b. What is the prevalence of sternoclavicular sprains? 2. What are the signs and symptoms for each grade of sternoclavicular sprain? 2b. When can a sternoclavicular sprain become a life-or-death situation? 3. What is the immediate treatment for a sternoclavicular sprain?

1. Indirect force transmitted from the arm, direct blow on the clavicle, and torsion of a posteriorly extended arm are the MOIs for a sternoclavicular sprain. 1b. Sternoclavicular sprain is relatively uncommon. 2. Grade 1 sternoclavicular sprain sees little pain and disability, point tenderness, and no joint deformity; grade 2 sternoclavicular sprain sees subluxation of the sternoclavicular with visible deformity, pain, point tenderness and swelling, and an inability to abduct the shoulder in full ROM or horizontally a-d-duct; grade 3 sternoclavicular sprain sees a complete dislocation with gross displacement of the clavicle at the sternal end indicating rupture of the sternoclavicular and costoclavicular ligaments. 2b. If the clavicular is displaced posteriorly it can place pressure on the blood vessels of the neck and become a life-or-death situation. 3. POLICE is the immediate treatment for a sternoclavicular sprain.

1. What is a unique feature of the clavicle? 2. How is the glenohumeral joint stabilized? 3. What is a feature of the scapulothoracic joint? 4. What is the characterization of the sternoclavicular joint and why; what is the sternoclavicular joint's redeeming quality?

1. It can move up/down, forward/backward, in combination, and in rotation. 2. Both actively (through the deltoid and rotator cuff muscles) and passively (via the ligaments) is how the glenohumeral joint is stabilized. 3. Scapulothoracic is not a true joint, however, shoulder movement would not be possible without the gliding movement of the scapula against the back of the ribcage. 4. Sternoclavicular joint is extremely weak because of its bony structure but it is stable due to strong ligaments that tend to pull the sternal end of the clavicle downward and toward the sternum which in effect anchors it.

1. What is the MOI for shoulder dislocations and subluxations? 1b. What is the most common kind of shoulder displacement? 1c. What structures could possibly be injured in a shoulder dislocation? 2. What are the glenoid labrum lesions that can form from a shoulder dislocation? 3. What are the signs and symptoms of a shoulder dislocation? 4. Why should a dislocation be reduced by a physician and what is the Milch technique?

1. Forced abduction/external rotation/and extension or direct impact to the back of the shoulder/shoulder blade is the MOI for anterior shoulder dislocations (as well as inferior dislocations); forced adduction and internal rotation is the MOI for a posterior shoulder dislocation. 1b. Anterior displacement is the most common kind of shoulder displacement. 1c. Glenoid labrum, shoulder ligaments, tendons of the rotator cuff muscles or long head of the biceps, as well as possible injury to the brachial plexus are the structures that could be injured in a shoulder dislocation. 2. SLAP lesion (anterior or posterior to the superior labrum that can affect the long bicep tendon), Bankart lesion (glenoid tear from anterior dislocation), Hill-Sachs lesion (lesion behind the greater tubercle of humerus leading to divot of the humeral head), and reverse Hill-Sachs lesion from posterior dislocation (lesion around the lesser tubercle) are the glenoid labrum lesions that can form from a shoulder dislocation. 3. Obvious deformity, flattened deltoid shape, and the arm in either slight abduction and external (for anterior displacement) or limited external rotation and elevation (for posterior displacement) are the signs and symptoms of shoulder dislocation. 4. Shoulders should be reduced by a physician because first-time shoulder dislocations may be associated with a fracture; the Milch technique is a method of reduction in which the arm is elevated then abducted and externally rotated.

1. What is the colloquial term for adhesive capsulitis? 2. What is the MOI for adhesive capsulitis and what group is it most prevalent in? 3. What are the signs and symptoms of adhesive capsulitis? 4. What tool can be used to treat adhesive capsulitis?

1. Frozen shoulder is the colloquial term for adhesive capsulitis. 2. Adhesive capsulitis is more common in older persons, but can occasionally occur in younger patients; exact cause of frozen shoulder is unclear but involves tight/inelastic rotator cuff muscles and thickened joint capsule around the humeral head. 3. Complaints of a stiff/frozen shoulder, pain in all directions of movement with restriction/limitation in the both active and passive movement are the signs and symptoms of frozen shoulder/adhesive capsulitis. 4. Ultrasound can be especially useful in treating adhesive capsulitis.

1. What are the sites of humeral fractures and what is the distinct MOI for each site of a humeral fracture? 1c. What could a humeral fracture be misdiagnosed as? 1d. Which of humeral fractures is the most prevalent and what condition does this humeral fracture predominate? 2. What are the sign and symptoms of humeral fractures?

1. Humeral shaft, proximal humerus, and head of the humerus (epiphyseal) are the sites of humeral fractures. 1b. Direct blow or a fall on the arm is the MOIs for a humeral shaft fracture; direct blow, dislocation, or impact from falling on an outstretched arm are the MOIs for a proximal humeral fracture (1c. can be misdiagnosed as a shoulder dislocation); direct trauma or indirect trauma along the long axis of the humerus equally is the MOIs for epiphyseal/humeral head fracture. 1d. Epiphyseal/humeral head fracture is the most prevalent sign and symptoms of humeral fracture are even more common than bone fractures. 2. X-ray is needed to make a conclusive diagnosis, pain, inability to move the arm, swelling, point tenderness, and discoloration of the superficial tissue are the signs and symptoms of humeral fractures.