Shoulder: Anatomy, Related Injuries, Assessments, and Treatments

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Shoulder Anatomy, Related Injuries, Assessments,
and Treatments
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Overview

• Anatomy of the shoulder bones, muscles, and
  ligaments
• Related injuries Contusions, strains, sprains,
  dislocation, and fractures.
• Assessment History, observation, and physical
  examination.
• Evaluation of findings.

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Anatomy of the Shoulder

• Sternoclavicular Joint
• Acromioclavicular Joint
• Glenohumeral Joint
• Shoulder Muscles
• Brachial plexus

• Composed of the sternal end of the clavicle, the
  cartilage of the first rib, and the manbrium.
• Articulation between the lateral end of the
  clavicle and the medial margin of the acromion
  process of the scapula.
• Shoulder joint is a synovial joint--ball and
  socket.
• Many muscles--refer to Table 17-1.
• Shoulder nerves are part of the brachial plexus.

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Sternoclavicular Joint

• This joint is surrounded by a loose articular
  capsule which is reinforced by the anterior and
  posterior sternoclavicular ligaments.
• The interclavicular ligament strengthens the
  superior aspect of the joint capsule--this is the
  stablizing factor for the right and left
  sternoclavicular joints.
• Although injuries occur to this joint
  infrequently, this synovial joint is very
  important because it is the only bony attachment
  between the upper limb and the axial skeleton.
• The articulation between the clavicle and the
  sternum is the pivot point which movements of the
  shoulder as a whole occur.

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Acromioclavcular Joint

• This synovial joint permits a limited amount of
  rotation and numerous gliding movements.
• This is surrounded by a loose-fitting articular
  capsule, which is strengthened by the
  acromioclavicular ligament.
• Together the joint and the acromioclavicular
  ligament play a small role in holding the
  clavicle and the scapula together--which is a
  sight for injury because of the high amount of
  sensory nerves contained here.
• The coracoclavicular ligament plays a role in
  preventing separation of the clavicle from the
  scapula.
• The coracoclavicular ligament is divided into two
  sections the trapezoid and conoid ligaments.
• The concoid ligament restrains backward movement
  of the scapula where the trapezoid ligament
  prevents excessive forward displacement.
• If the coracoclavicular ligament tears, it can
  cause the acromion to be forced down and away
  from the clavicle.

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Glenohumeral Joint

• Our most moveable joint--has three axes which
  allows transverse (flexion and extension),
  anteriorpostior (abduction and adduction), and
  vertical (medial and lateral rotation) to occur.
• Components head of the humerus, adjacent
  glenoidal surface of the scapula, the glenoid
  labrum, the articular capsule, and the
  coracohumeral, glenohumeral, transverse, and
  coracoacromial ligament.
• Static stabilizers ligaments, joint capsule, and
  glenoid labrum
• Disruption of the glenoid labrum is commonly
  associated with recurrently dislocating
  shoulders.
• Dynamic stabilizers rotator cuff and adjacent
  muscles.
• The SITS muscles (supraspinatus, infraspinatus,
  teres minor, and subscapularis) blend with and
  strengthen the articular capsule to form the
  rotator cuff.

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Glenohumeral Joint cont

• The supraspinatus is the primary abductor of the
  arm.
• The infraspinatus and the teres minor are
  external rotators which are attached to the
  greater tuberosity.
• The subscapularis is the internal rotator which
  is attached to the lesser tuberosity.
• The rotator cuff provides strength to help
  prevent anterior, superior, and posterior
  displacement of the humeral head during activity.

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Muscles of the shoulder(Table 17-1)

• Trapezius
• Levator scapulae
• Rhomboids
• Serratus anterior
• Supraspinatus
• Infraspinatus
• Teres minor
• Subscapularis
• Teres major

• Deltoid
• Pectoralis major (upper fibers)
• Pectoralis major (lower fibers)
• Pectoralis minor
• Latissimus dorsi
• Biceps
• Coracobrachialis
• Triceps

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Brachial Plexus(Figure 17-13)

• Complex network consisting of nerves, trunks,
  divisions, and main branches that ultimately
  provide motor and sensory innervation to the
  entire upper extremity.
• When pressure is put on this nerve plexus or the
  blood vessels that are along this area, serious
  injury can occur.

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Injuries to the shoulder

• Injuries to the shoulder occur because there is
  an extensive range of motion that can occur, but
  there is a lack of stability of the shoulder
  joint.
• Mechanisms causing most of the trauma direct
  trauma, indirect trauma, and throwing movements.
• Direct trauma tackling in football or checking
  in ice hockey.
• Indirect trauma athlete lands on an
  outstretched hand and an athlete landing on the
  point of a flexed elbow.
• These injuries can be acute, and chronic.

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Contusions

• Most common contusion is to the acromion process
  (fig 17-16) called a shoulder pointer, which does
  not involve ligaments.
• Trainer must be aware of contusions to the
  acromioclavicular joint, the deltoid muscle, the
  shaft of the clavicle
• Complications with repeated blows to the point of
  attachment of the deltoid muscle and on the
  lateral humerus is a painful periostitis, which
  can develop into an irritative exostosis referred
  to as a blockers spur.

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Strains

• Mechanisms for a strain injury overstretching,
  violent contractions, and repetitive use.
• Strains are common in sports that require the
  athlete to propel an object pitching and
  swimming.
• Nature of the strain depends on several factors
  that the athletic trainer must take into
  consideration age and maturity of the athlete,
  the type and weight of the object being
  propelled, the type of delivery, the presence of
  weakness, fatigue, incoordination, fibrous
  scarring or degenerative changes from previous
  injuries, and microtrauma from repetitive
  activity.

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Strains cont

• Rotator cuff strains difficult to detect
  because the muscles lie deep in the shoulder.
• Biceps strain common in skiing, throwing
  overhand, and tennis.
• Repetitive motion of the shoulder causes the
  biceps tendon to slide up and down causing an
  inflammatory reaction called bicipital
  tenosynovitis.
• Impingement syndrome occurs when there is
  injury to the soft tissues of the shoulder that
  make up the subacromial space swimmers
  shoulder.

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Sprains

• Acromioclavicular sprain the most common
  sprain.
• Occur as a result of a blow to the tip of the
  shoulder or falling on an outstretched arm which
  can cause a sprain to the supporting ligaments
  shoulder separation.
• Glenohumeral sprain seldom occur
• Sternoclavicular sprain result when force is
  directed along the long axis of the clavicle
  toward the sternal end and stress is applied to
  the sternoclavicular and costoclavicular
  ligaments.

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Dislocations

• Glenohumeral dislocation athlete usually has
  the shoulder in an abducted, externally rotated
  position and receives a blow somewhere along the
  extremity.
• Complication of an anterior shoulder dislocation
  is the axillary nerve injury. The athlete may
  have loss of sensation over the lateral aspect of
  the shoulder and decreased function of the
  deltoid muscle.

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Fractures

• Clavicle fracture the medial fragment is
  normally pulled upward by the contractions of the
  sternocleidomastoid and trapezius muscles,
  whereas the lateral portion is displaced downward
  by the contraction of the pectoralis major muscle
  and the weight of the arm.
• Humerus Fracture resembles a glenohumeral
  dislocation and most often is the result from
  falling on an outstretched arm.
• Proximal humerus epiphyseal fracture uncommon,
  but a dislocated shoulder can lead to this in a
  young athlete.

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Assessment Process

• The shoulder girdle is the most frequently
  injured area of the upper extremity.
• The glenohumeral joint has an extensive ROM, it
  is relatively unstable compared to other major
  joints of the body.
• The trainer must take the following factors into
  consideration when assessing the shoulder
  unique anatomic features, intricate functional
  characteristics, various mechanisms of injury,
  and associated signs and symptoms.

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Secondary Survey, History, and Observation

• Secondary survey depend on the position and
  status of the athlete at time of injury. The
  athlete will more than likely be moving around.
• History question the athlete.
• Are the symptoms of the current injury similar to
  those of any previous injuries?
• When did the onset of symptoms occur?
• Observation Look before you touch
• Is the athlete favoring one side of his shoulder?
• Do not remove articles of clothing covering the
  shoulder right away--instead, palpate underneath.

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Physical Examination

• Easy to palpate due to the fact that most of the
  structures are subcutaneous.
• Conduct palpation of the shoulder girdle with the
  area as relaxed as possible.
• Normally have the athlete sit on a table or
  stand.
• The clavicle is a good reference point to begin
  because it is subcutaneous along its entire
  length.
• Next palpate distally to the lateral end of the
  clavicle where it articulates with the acromion
  to form the cromioclavicular joint. Expressed
  tenderness means injury.

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• To check for a injury referred to as the
  shoulder pointer palpate the acromion process
  at the tip of the shoulder.
• The vertebral border is the point of reference
  for the muscles attached along its
  length--palpate the spine of the vertebral or
  medial borders of scapula.
• For greater and lesser tuberosities, palpation
  should be as follows with the humerus
  externally rotated, the bicipital groove and
  lesser tuberosity are exposed--to expose the
  greater tuberosity, internal rotation causes the
  structure to be more prominent.
• Deltoid muscle must be carefully palpated
  tenderness related to touch may indicate
  tenosynovitis of the biceps tendon or an injury
  to the deltoid muscle--tenderness deep in the
  deltoid, is associated with subdeltoid bursitis
  or rotator cuff problems.

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Movement procedures

• Painful arc pain is absent at beginning of ROM
  but develops near midrange of movement and then
  stops as this point is passed.
• Apleys scratch test instruct athlete to place
  each hand in two different places to determine
  the active ROM of the shoulder while you compare
  bilaterally.
• Drop arm test instruct athlete to abduct the
  arm past 90 and then slowly lower it to the
  side. A positive test is indicated if the
  athlete is unable to return the arm to the side
  slowly or has pain when attempting the movement.

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• Empty can position the arm is horizontally
  abducted 30 with the arm internally rotated and
  the thumb pointing downward. Ask athlete to hold
  this position and if there is a tear in the
  supraspinatus muscle, the arm will again drop
  because of weakness or pain.
• Yergason test test determines if the tendon of
  the long head of the biceps is stable in the
  bicipital grove or if a tenosynovitis exists.
  Have athlete flex the elbow on the involved side
  90, then ask them to hold this position while
  outwardly rotating the arm. If no discomfort in
  the bicipital groove, then there is no related
  injury.
• Apprehension tests have athlete in supine
  position and passively move the arm to 90 of
  abduction and then gently outwardly rotate. If
  the athlete has had prior complications with the
  glenohumeral joint, then they will express
  apprehension and resist further movement.

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• Shoulder injuries require frequent reevaluations
  so you can monitor and determine when the athlete
  can return to activity.
• When to refer the athlete
• Suspected fracture, separation, or dislocation
• Gross deformity
• Significant loss of motion
• Significant or continued pain
• Joint instability
• Abnormal sensations that do not quickly go away,
  such as weakness or numbness
• Absent or weak pulse distal to the point of
  injury
• Any doubt regarding the severity or nature of the
  injury