(2) Lecture 8: The Athlete's Shoulder Flashcards
Shoulder Complex
Humerus + scapula (articulation w/ Ac, SC jts and thoracic wall)
- great mobility b/c of minimal bony congruity
- works with musculature and ligaments to maintain instantaneous centre of motion of GH jt.
Shoulder Girdle
CLAVICLE + SCAPULA
- connects upper limb to axial skeleton
- clavicle attaches medially to manubrium of sternum and laterally to acromion of scapula
Shoulder Separation
affects ACROMIOCLAVICULAR (AC) jt.
Shoulder Dislocations
affect
- glenohumeral jt.
- sternoclavicular (SC) jt.
usually blowing a ligament
Shoulder Fractures
affect
- clavicle
- humerus
- scapula
Shoulder Tendonitis/osis
affects rotator cuff
common in overhead athletes
Shoulder Strains
affect
- rotator cuff
- scapular stabilizers
Sternoclavicular joint
- clavicle articulates w/ manubrium to form SC jt.
- only 25% of clavicle’s surface area in contact = LEAST bony stability in chain
- integrity of jt. is from strong ligament attachment
- shock absorber (disc)
- only direct connection btwn. upper extremity and trunk
SC jt movement
- important for all movements, especially ABDUCTION
- clavicle moves freely fwd/bwd and up and rotate
When arm moves thru flexion/abduction, the clavicle retracts, elevates and rotates posteriorly
SC jt stability
Strong ligaments maintain integrity
Sternoclavicular lig: stops from popping fwd
Interclavicular lig: helps w/ depression
Costoclavicular lig: stops from popping up
Articular disk: shock absorber
SC injury
- MVA and sports injuries are common causes
MOI
- direct blow to clavicle
- indirect through arm or shoulder (lands on one of them)
- clavicle usually moves UPWARD/FORWARD
- if posterior, it is a medical emergency b/c it can affect the subclavian v. + a., trachea, esophagus
Anterior dislocations of SC jt.
rarely occur as a result of direct trauma
- force applied to ANTEROLATERAL clavicle = shoulder rolls backward
- usually caused by INDIRECT force
Posterior dislocations of SC jt.
typically due to DIRECT force to ANTEROMEDIAL clavicle
can also happen when a force is applied to posterolateral shoulder, making the shoulder roll fwd
Grade 1 SC injury
- Slight pain and tenderness
- no deformity
- little to no laxity
Grade 2 SC injury
- sublux (some laxity)
- defomity
- swelling and pain
- unable to abduct or bring arm across chest
Grade 3 SC injury
complete displacement of clavicle
- gross laxity
- NO endpoint
Management of SC injury
- posterior injury = send to ER
- anterior injuries are reduced w/ LATERAL TRACTION
- POLI? Peace + Love (minus compression and elevation)
- high incidence of re-injury
Clavicle
- S shaped bone
Functions
- protects neurovascular bundle (brachial plexus)
- muscle attachment
- bony attachment of shoulder
Clavicle fractures
- one of most common sport fractures
MOI
- can be injured w/ any force that brings SHOULDER TO MIDLINE
- or direct force from superior or anterior direction
- or indirect force (fall on point of shoulder OR fall on outstretched arm)
Signs and Symptoms of clavicle fractures
- usually MIDDLE 1/3 (NOT medial 1/3) w/ outer fragment dropping down
- can be distal tip
- lots of pain
- localized tenderness and swelling
will have
- loss of function
- spasm of trapezius + SCM
- arm held to body w/ shoulder elevated
- scapula is protracted
Management of clavicle fractures
- pain relief
- POLICE
- sling : B-TUBE (NOT A-tube b/c sling hangs over clavicle = weight on clavicle)
- figure 8 brace to avoid foreshortening (less common now)
- usually heals in 4-6 weeks
- keep arm moving BELOW 90 degrees (nothing above shoulder height until healed)
Acromioclavicular jt. stability
Provided by different structures:
1. Coracoclavicular ligs (VERTICAL stability)
- conoid
- trapezoid
- Acromioclavicular ligs (ANT.-POST. stability)
- Capsule
AC separations
MOI
- direct: point of shoulder w/ arm abducted (MOST COMMON)
- indirect: fall out on outstretched hand (force comes up through)
Graded 1-6
- 1-3 are most common
- 4-6 are surgical
Grade 1 AC separation
- small tear of capsule of AC jt
- NO instability of jt./NO laxity
- pain on palpation
- A-P + vertical stability present
- no anatomic changes
- full ROM w/ pain near EOR (end of range)
Grade 2 AC separation
- complete tear of AC jt capsule + ligaments
- small tear of coracoclavicular lig
- slight A-P spring
- no ant-post stability (still have vertical stability)
Grade 3 AC separation
complete tear of AC ligament and coracolavicular lig.
- looks physically different from Grade 1/2
- step deformity: raised distal end of clavicle + depressed acromion
- clavicle pops up + shoulder pops down
- 45 degrees or less ROM
Cross Flexion
like throwing a scarf over shoulder
- lots of pain if AC jt. is affected
AC shear
pushing AC jt. fwd + back
Grade 5 AC separation
like type 3
- deltoid + trapezial fascia stripped off
clavice points STRAIGHT UP
Grade 6 AC separation
DOWNward displacement of clavicle
C5-6/Brachial plexus at risk
Management of Grade 1 AC separation
- clinically stable but very painful
- tape for comfort
- get them out of sling
- POLICE/PEACE&LOVE
- can go back as soon as pain allows
Goal: keep shoulder moving for return to play ASAP
- maintain ROM, strength and function
Management of Grade 2/3 AC separation
Inflammation/Destruction phase
- POLICE/PEACE&LOVE
- stabilize w/ tape
Repair Phase
- gentle AROM then progress to full ROM
- shoulder isometrics, progress to concentric
- scapular stabilizer strengthening
Remodeling Phase
- full strength at shoulder
- good scapulothoracic mechanics
Criteria for return from shoulder girdle injuries
- medical clearance
- full ROM
- strength within 90% of unaffected side
- full function
- able to PROTECT THEMSELVES
Return time after AC jt. injury
Grade 1: 7-10 days
Grade 2: 2-3 weeks
Grade 3: 4-12 weeks
Grades 4-6: Surgical
ICOM
Instantaneous Centre of Motion of GH jt
- maintained by shoulder complex working w/ musculature and ligaments
- Boney structures keep articulation in contact
- Rotator cuff muscles compress and centralize humeral head (move thru space)
- Scapular stabilizers help position for scapula for max stability
Glenohumeral Jt.
- humeral head is 3x the size of laterally facing glenoid
- labrum deepens the socket
- scapula must rotate UNDER to support humerus during movement
Static and Dynamic Shoulder Support
Static support
- labrum
- capsule
- glenohumeral ligaments
- shape of bones
Dynamic support
- rotator cuff (MOST)
- scapular stabilizers
Posterior + Superior Shoulder Support
- spine of scapula + acromion
- thick capsule
- RC (rotator cuff) muscles crossing posterior jt
Anterior Shoulder Support
- minimal bony support
- biceps (long head attaches to labrum)
- jt. capsule and ligaments
Static stabilizers capusle/ligaments
- capsule around shoulder jt. has THICKENINGS
Thickenings are the ligaments
- Superior (SGHL), middle (MGHL), inferior (IGHL)
- IGHL is commonly inured
- ligaments rotate w/ movement
- in abduction + external rotation, anterior IGHL “fans out” and rotates anteriorly + superiorly to prevent subluxation of shoulder
Most commonly injured GH ligament
Anterior IGHL
- main stopping force for anterior movement
Rotator Cuff muscles
- subscapularis (internal rotation)
- supraspinatus (abduction)
- infraspinatus
- teres minor
maintain humeral head in glenoid + help w/ movement
Normal GH jt Movement Patterns
- Setting Phase
- initial 30 degrees, the scapula does NOT move as it establishes a stable base
- rotator cuff muscles drive movement - After setting phase, there is a 2:1 ratio btwn the humerus and scapula
Force Couple - Scapulothoracic jt.
0-90 degrees of shoulder abduction: UPPER fibres of trap + serratus anterior drive motion
above 90 degrees of shoulder abduction: LOWER fibres of trap + serratus anterior drive motion
Dislocated Shoulder
Traumatic - TORN loose (TUBS)
Atraumatic - BORN loose (AMBRI)
Traumatic dislocated shoulder
TORN loose (TUBS)
Traumatic
Unilateral lesion
Bankart (torn labrum)
Surgery required
- single force applies excessive overload to passive restraints
- often damages the glenoid (Bankart) and humerus (Hill-Sachs lesion)
Atraumatic dislocated shoulder
BORN loose (AMBRI)
Atraumatic
Multidirectional
Bilateral (frequently)
Rehabilitation (responds well)
Inferior capsular shift needed
- born lax ppl or functionally lax secondary to repetitive microtrauma
- loose capsule
Torn Loose - Anterior dislocation
95% of dislocations happen ANTERIORLY
MOI
- forced external rotation usually ABDUCTED or FOOSH
Signs + symptoms
- arm held slightly externally rotated + abducted
- restricted ROM
- altered contour of shoulder
Subcoracoid dislocation
Flat looking shoulder
Apprehension Test
For shoulder instability
- for previous dislocations not recent
Hand overhead and pull forearm out away from shoulder
Patient will:
TELL you to stop
ROLL their body towards the arm
FIGHT what you are doing
PULL the arm to the body
Inferior Dislocations
accounts for 1%
MOI
- arm in excessive ABDUCTION and a force is taken pushing humeral head inferiorly out of glenoid
Signs and symptoms
- similar to anterior dislocation
- arm held slightly externally rotated + abducted
- restricted ROM
- altered contour of shoulder
Posterior dislocations
EASILY MISSED (need side view X-ray)
- accounts for 4%
- often due to seizure or electric shock
MOI
- arm in FLEXION + ADDUCTION
- force is taken on hand = humeral head pushes out glenoid posteriorly
- elbow held at side w/ hand or stomach
CANNOT externally rotate or abduct
Born loose - Subluxing shoulders
- seen in individuals w/ chronic instability
- AMBRI: multiple jt laxities in multiple directions w/ frequent subluxations
- can be acquired from repetitive trauma + poor stretching of a jt
may experience DEAD ARM w/ humeral subluxation
- due to traction/`impingement of neurovascular structures causing weakness/numbness
Management of Traumatic/Atraumatic Injuries
Inflammatory phase
- POLICE/PEACE&LOVE
- PROTECT
- exercise: gentle ROM (NO ext. rot./abd)
- isometric strength
- keep elbow + wrist moving
- sling is probably not best b/c of slight external rotation
Management of Traumatic/Atraumatic Injuries
Repair/Fibroblastic phase
- gain ROM, slowly working to abov shoulder height
- continue functional strengthening + work thru range
- begin proprioception exercise
- subluxers/born loose patients may start here
Management of Traumatic/Atraumatic Injuries
Remodeling phase
Functional training for return to play
- idealize strength through range
- add in power (strength+speed)
- bracing/taping
