The Shoulder

• Shoulder complex:

  • scapula
  • humerus
  • glenohumeral joint
  • scapulothoracic joint
  • acromioclavicular joint
  • sternoclavicular joint
• Shoulder girdle:

  • connects upper limb to axial skeleton
  • 2 bones = clavicle and scapula
• Sternoclavicular joint:

  • only 25% surface area
  • least bony stability
  • integrity of joint comes from ligaments
  • disc for shock absorption
  • only direct contact between upper extremity and trunk
• S/C:

  • for all movements
  • mainly for abduction
  • also for forward, backward, upward, and rotation
  • arm in flexion and abduction, clavicle elevates, posteriorly rotates, and retracts
• S/C injury:

  • MVA and sports
  • direct = someone/something hits you
  • indirect = through arm or shoulder
  • with dislocation, clavicle goes up and forward
  • dangerous if posterior
• Anterior dislocations:

  • due to indirect trauma
  • anterolateral force with posterior shoulder rotation
• Posterior dislocation:

  • due to direct trauma
  • anteromedial force
  • posterolateral force with anterior shoulder rotation
• S/C dislocation grading:

  1. no deformity, pain
  2. deformity, subluxation, pain, swelling, unable to abduct or bring arm across chest
  3. completely displacement of clavicle
• S/C management:

  • posterior = ER
  • anterior = lateral traction, POLI/PEACE/LOVE
• Clavicle:

  • protects neurovasculature
  • attachment site for muscles
  • bony attachment for shoulder
• Clavicle:

  • one of the most common fractures
  • injured with force that brings shoulder to midline
  • injured with direct force from superior or anterior direction
  • fall on point of shoulder
  • fall on outstretched arm
• Clavicle fractures:

  • middle third or distal tip
  • pain
  • localized pain and swelling
  • loss of function
  • spasm of trapezius and SCM
  • arm held to body and shoulder elevated
  • scapula is protracted
• Clavicle fracture management:

  • pain relief
  • sling (B tube)
  • figure 8 brace
  • heals within 4-6 weeks
  • keep arm moving below 90°
• Acromioclavicular joint:

  • stability provided by 3 mechanisms.
  • coracoclavicular ligaments (conoid and trapezoid)
  • acromioclavicular ligament
  • capsule
• A/C separations:

  • MOI = direct or indirect
  • direct = point of shoulder with arm adducted
  • indirect = FOOSH
  • graded 1-6
• Grades 1-3:

  Grade 1:

  • small tear of AC
  • no instability
  • pain

  Grade 2:

  • complete AC tear
  • partial CC tear
  • instability (anterior and posterior)

  Grade 3:

  • all three tear
  • complete instability
  • step deformity
• AC separation tests:

  • shear test
  • cross flexion test
• Grade 4-6:

  Grade 4:

  • clavicle pushes back
  • pierces trapezius

  Grade 5:

  • clavicle goes up
  • pierces trapezius and deltoid

  Grade 6:

  • clavicle goes down
  • pierces neurovasculature
• AC management:

  Grade 1:

  • stable but painful
  • return them to sport ASAP
  • tape for comfort
  • decrease pain
  • POLICE/PEACE/LOVE
  • keep shoulder moving
  • maintain ROM and strength
• AC management:

  Grade 2/3:

  • POLICE/PEACE/LOVE
  • stabilize with tape
  • gentle AROM and AAROM
  • shoulder isometrics; work to concentric
  • strengthen scapular stabilizers
  • full strength
  • good scapulothoracic mechanics
  • full function
• Return to play criteria:

  • medical clearance
  • full ROM
  • strength within 90% of the other arm
  • full function
  • ability to protect themself
  • ability to protect joint
• Shoulder complex:

  • increase mobility = decrease stability
  • glenohumeral and scapulothoracic joints help with mobility
  • they work with musculature, ligaments, and capsules to maintain Instantaneous Centre of Motion of GH joint
  • boney structures maintain articulation
  • scapular stabilizers stabilize the scapula
  • rotator cuff muscles centralize and compress humeral head
• GH joint:

  • humeral head is 3x larger than glenoid
  • labrum deepens socket
  • humeral head coordinates movement with scapula and scapular stabilizers
  • scapula rotates under the humeral head to support it
• Shoulder support:

  • static = labrum, capsule, GH ligaments
  • dynamic = RC, SS
• Shoulder support:

  posterior and superior:

  • spine of scapula and acromion
  • RC muscles
  • thick capsule

  anterior:

  • minimal bony support
  • biceps
  • joint capsule and ligaments
• Static stabilizers:

  • capsule has thickenings
  • thickenings = ligaments
  • there are 4
  • the anterior inferior glenohumeral ligament fans out (superior and anterior rotation) when arm is abducted and externally rotated to prevent humeral head subluxation
• Dynamic stabilizers:

  • RC muscles have a downward pull on humerus to keep it from being pinched under the actinium
  • they compress and centralize humeral head
  • they rotate the humerus
  • they originate on the scapula
• Normal movement patterns:

  • scapula is a stable base for the first 30° of arm abduction
  • after 30° it moves with the humerus and is no longer stable
  • ratio = 2:1
• Force couple:

  • two muscles stabilize something on opposite sides
  • 0-90° = upper trapezius and serratus anterior control abduction
  • 90° - on = lower trapezius and serratus anterior
• Dislocated shoulder:

  Torn loose:

  • TUBS
  • traumatic
  • unilateral
  • bankart
  • surgery

  Born loose:

  • AMBRI
  • atraumatic
  • multidirectional
  • bilateral
  • rehab
  • no need for inferior capsular shift
• Traumatic:

  • single force applies overload to passive restraints
  • damages glenoid (bankart) and humeral head (Hill-Sachs lesion)

  Atraumatic:

  • multidirectionally lax individuals
  • secondary to repetitive microtrauma
  • loose capsule
• Torn - Anterior dislocation:

  • 95%
  • MOI: forced external rotated with arm abducted or FOOSH
  • arm held externally rotated and abducted
  • restricted ROM
  • altered shoulder contour (subcoracoid dislocation)
• Torn - Inferior dislocation:

  • 1%
  • MOI = arm in excessive abduction, force applied to humeral head which pushes it down and out of the glenoid
  • similar signs and symptoms as anterior
• Torn - Posterior dislocation:

  • 4%
  • easily missed
  • due to seizures or electric shock
  • MOI = arm adducted and flexed, force taken on hand which causes humerus to push out glenoid posteriorly
  • elbow held at side of body with hand on stomach
  • cannot externally rotate or abduct
• Born - Subluxation:

  • chronic instability
  • can be acquired from repetitive trauma or poor stretching through joint
  • dead arm = humeral head pinches neurocasculature
  • numb/weak
• Management of Torn and Born Loose:

  • POLICE/PEACE/LOVE
  • protect
  • gentle ROM
  • isometric strength
  • keep elbow and wrist moving
  • gain ROM to above shoulder
  • continue functional strengthening
  • begin proprioceptive training
  • prepare for return to play
  • idealize strength
  • add power