Week 11: The Shoulder

Question 1

The Shoulder (Pectoral) Girdle (4 Joints)

Answer 1

1. Glenohumeral
2. Acromioclavicular
3. Sternoclavicular
4. Scapulothoracic

Question 2

Glenoid Labrum

Answer 2

-Helps to deepen socket, gives more surface area so head of humorous doesn’t slip out as easily

Question 3

Ligaments, Tendons and Bursa

Answer 3

-Ligaments provide support
-Many muscles/tendons within the shoulder that help with ROM and act on humorous and scapula, a lot more ROM than hip
-Bursa lies flat (when normal) and helps reduce friction

Question 4

Muscles Acting on the Scapula (4)

Answer 4

-Levator scapulae, trapezius, rhomboid major, latissimus dorsi

Question 5

Rotator Cuff (4 Muscles)

Answer 5

1. Supraspinatus
   -Note orientation/location
2. Infraspinatus
3. Teres Minor
4. Subscapularis

*Major dynamic stabilizer of the shoulder

Question 6

Dislocations vs. Subluxations of the GH Joint

Answer 6

-Dislocation: head of humerus translates completely out of the glenoid
-Subluxation: a partial or incomplete dislocation of the GH joint
-Dislocation more damage (more tissues, causes more instability)
-Anterior dislocation most common

Question 7

Shoulder Dislocations

Answer 7

-Anterior *most common
-Posterior
-Inferior *rare

-MOI:
-Anterior: force from behind + hyperextension, *abducted and elbow flexed both to 90 degrees with external rotation, head of humorous goes forward
-Posterior: FOOSH (fall on outstretched hand)
-Inferior: Hyperabduction + flexion ?

-S&S: Reduced ROM, “pop”, pain, uneven shoulders/scapula, shock, possible tingling/numbness if nerves affected, unwilling or unable to move
-Acute Management: Reassurance, treat for shock, brachial plexus and A/V affected, stabilize in position of comfort or sling, EMS for dislocations, decrease inflammation and secondary complications (also in treatment)
-Treatment: Sling, relocate (certified person), rest, improve ROM and strength with time, PIER, accessory movements, proprioception, sport-specific movements

Question 8

Special Test for Anterior GH Dislocation

Answer 8

Apprehension Test

Question 9

SLAP Lesions/Tears- Superior Labrum Anterior and Posterior:

Answer 9

-Injury to superior aspect of labrum from ant → post
-Biceps tendon can also be injured
-MOI: repetitive overhead movements (eg/ throwing), FOOSH (Fall On Out Stretched Hand), sudden traction to the arm, dislocation of GH
-S&S: clicking/catching/popping, pain moving arm overhead, pain lifting heavy objects, pain deep in joint or in back of joint, anterior shoulder pain if biceps involved.

Question 10

Bankart Lesion

Answer 10

-An injury to the anterior-inferior glenoid labrum
-Secondary to anterior dislocation
-S&S: Pain & limited ROM with most shoulder movements, clicking, catching, grinding, popping, subluxation

Question 11

Hills-Sachs Lesion

Answer 11

-A divot-type fracture of the head of the humerus following a dislocation
-Head of humerus gets compressed against the rim of the glenoid

Question 12

Rotator Cuff Injuries (3)

Answer 12

1. Impingement
   -MOI: overuse, poor mechanics
2. Tendonitis→osis
   -MOI: overuse, poor mechanics
3. Rotator Cuff Tears
   -MOI: acute or overuse

*One can lead to the next, or they can happen independently
*Certain referred pain patterns (see notes)

Question 13

Acromioclavicular (AC) Sprains

Answer 13

-MOI: FOOSH (Fall On Outstretched Hand), fall/tackle – landing on side of shoulder, checked into boards
-S&S: pain, step deformity at AC, weakness in shoulder/arm
-Athlete often supporting arm against body
-Acute management: PIER, sling, swath, severe deformities need to be referred
-AC tape job to support healing & decrease pain

Question 14

Rockwood Classification of AC Injuries

Answer 14

AC = acromioclavicular
CC = coracoclavicular

*Indicates which ligaments affected (AC & CC) and clavicle displacement position

Question 15

Treatment of Acute Shoulder Injuries

Answer 15

-PIER, sling for support
-Once diagnosed, AC tape job to help approximate joint/any remaining ligaments to support healing
-Rehab to promote tissue healing & regain mobility & stability

Surgery considered for:
-Middle third clavicle fractures
-Type III AC sprains in active people
-Types IV, V & VI AC sprains *type 6 not as common
-First-time GH dislocation in young athletes
-Full-thickness rotator cuff tears
-Displaced or unstable proximal humerus fractures
-Urgent surgical referral for posterior sternoclavicular dislocations – why?

Question 16

Few Reasons a Posterior SC Dislocation is a Concern

Answer 16

-Many arteries, veins and nerves that can be affected
-Many other structures that can cause issues

Question 17

Subacromial Impingement Syndrome A.K.A Shoulder Impingement

Answer 17

-MOI: overuse, biomechanical imbalances
-Pinching and subsequent inflammation of structures under the coracoacromial ligament

May include one or all of:
-Supraspinatus tendon
-Long head of biceps tendon
-Subacromial bursa

-S&S: pain & weakness in painful arc of abduction e.g./reaching (especially with a weight away from body), catching/clicking, pain with sleeping on affected side, pain putting jacket/sweaters on

-Special test: Painful arc
-Positive test: Pain during GH abduction between 60°-120°
-Pain clears beyond 120°
-Referred pain often reported in supraspinatus pattern down middle deltoid
-Common in swimmers, overhead athletes (tennis, pitchers, quarterbacks)

Question 18

Humerus Fractures

Answer 18

-MOI: high-energy direct blow
-S&S: pain, swelling, bruising, unable to move arm or grinding when they do
-Surgical neck – most common fracture site on humerus
-Approx 80% are non-displaced = non-surgical
-Acute management: PIER, sling, treat for shock, send to emerge if stable – otherwise call EMS
-Management: sling, pain management, start treatment early (7-10 days) to avoid frozen shoulder (even though bone callous not formed for 3 weeks)

Question 19

Scapula Fractures

Answer 19

-MOI: high-energy blunt trauma, fall from height
-S&S: extreme pain with arm movements, localized swelling, bruising/trauma to the area
-Management: sling
(Most cases are non-surgical)

Surgery indicated for:
-Displaced fractures of glenoid
-Displaced fracture at neck of scapula
-Acromion fractures causing impingement

Question 20

Clavicle Fractures

Answer 20

-MOI: force to lateral shoulder (tackle, check into boards), FOOSH (less commonly), direct trauma
-S&S: severe pain & swelling over site, deformity, unwillingness to move arm
-Acute management: tube sling (to avoid pressure on clavicle), PIER
-Treatment:
-Sling or figure 8 brace (although these are quite uncomfortable and studies show equal results for speed and quality of healing – preference of ortho)
-PIER
-Pain management
-Alleviate assoc. spasm

Question 21

Treating the Shoulder Girdle

Answer 21

-Consider the anatomy and how complex it is
-3 joints
-Muscles spanning multiple joints

Important considerations (and often overlooked!):
-Thoracic spine mobility
-Scapular mobility
-Scapular stability
-Upper limb proprioception