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Chapter 22 The Shoulder Complex
Chapter 22
Extended Lecture Outline
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Introduction:
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The shoulder complex has a great degree of mobility, which requires some compromise
in stability, thus leaving the shoulder highly susceptible to injury
Anatomy of the Shoulder
o Bones
 Clavicle
 Supports the anterior portion of the shoulder, keeping it free from the thoracic
cage
 The point where the clavicle changes shape and contour presents a structural
weakness (Largest number of fractures to the clavicle occur at this point)
 Sternum
 Divided into three parts (manubrium, body and xiphoid process)
 Provides attachment for clavicle at SC joint – only axial skeleton attachment of
upper extremity
 Scapula
 Articulating surface for the head of the humerus
 The spine, the acromion and the coracoid process
 The glenoid labrum increases the depth of the glenoid fossa
 Humerus
 Articulates with the glenoid fossa of the scapula
 Anatomical neck is the attachment for the articular capsule of the GH joint
 Lying between the lesser and greater tubercles is the bicipital groove
o Articulations (four major articulations)
 Sternoclavicular Joint: (SC Joint)
 Only direct connection between the upper extremity and the trunk
 Acromioclavicular Joint: (AC Joint)
 Glenohumeral Joint: (GH Joint)
 Ball-and-socket joint
 Maintained by both static (capsule and ligaments) and dynamic stabilizers
(muscles)
 Scapulothoracic Joint: (ST Joint)
 Not a true joint
 Scapular stabilization is critical in providing a stable base for GH motion
o Ligaments (Figure 22-3)
 Sternoclavicular Joint Ligaments
 Anterior sternoclavicular: prevents upward displacement of the clavicle
 Posterior sternoclavicular: prevents upward displacement of the clavicle
 Interclavicular: prevents lateral displacement of the clavicle
 Costoclavicular: Prevents lateral and upward displacement of the clavicle
 Acromioclavicular Joint Ligaments
 Consists of anterior, posterior, superior and inferior portions
 Coracoclavicular ligament: (Conoid and Trapezoid) maintains the position of the
clavicle in relation to the acromion
 Glenohumeral Joint Ligaments
 Superior glenohumeral ligament
 Middle glenohumeral ligament
 Inferior glenohumeral ligament
 Coracohumeral ligament
o Shoulder Musculature (See Table 22-1)
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Chapter 22 The Shoulder Complex
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Muscles acting on the Humerus: Pectoralis Major, Latissimus dorsi, Deltoid,
Supraspinatus, infraspinatus, Subscapularis, Teres Major, Teres Minor, and
Coracobrachialis
 Scapula Muscles: Trapezius, Rhomboid Major, Rhomboid Minor, Levator Scapulae,
Pectoralis Minor and Serratus Anterior
o Bursae (Figure 22-3)
 Most important bursa is the subacromial bursa (subdeltoid); located between the
coracoacromial arch and the glenohumeral capsule
 In overhead positions the subacromial bursa can become compressed under the
coracoacromial arch
o Nerve Supply (Chapter 25, Figure 22-6)
 Axillary (C5 – C6), Musculocutaneous (C5-C7), Subscapular (C5-C6), Suprascapular
(C5-C6), Dorsal Scapular (C5), Pectoral (C5-T1) and Radial (C5-T1) Nerves
o Blood Supply (Figure 22-7)
 Subclavian Artery becomes the axillary artery at outer border of the first rib and which in
turn becomes the brachial artery in the region of the teres major muscle in the upper arm
Functional Anatomy
 Critical to maintain the position of the humeral head in the glenoid fossa especially with
overhead motions
 The RTC muscles along with the long head of the biceps provide dynamic stability of
humeral head in the glenoid
 Supraspinatus compresses the humeral head in the glenoid, while cocontraction of the
infraspinatus, teres minor and subscapularis, depress the humeral head during overhead
movements
 Dynamic movement as well as stabilization of the shoulder complex requires all four
joints acting together
o Scapulohumeral Rhythm
 As humerus elevates to 30º there is no movement of the scapula (Setting Phase)
 From 30º to 90º scapula abducts and upwardly rotates 1 degree for every 2 degrees of
humeral elevation
 From 90º to full abduction the scapula abducts and upwardly rotates 1 degree for each 1
degree of humeral elevation
Prevention of Shoulder Injuries
 Strengthening through full range of motion of all the muscles involved in movement of
the shoulder complex is essential
 Perform a proper warm-up prior to explosive movements
 Prethrowing warm-up routine (external rotation at 90 degrees, abduction, throwing
deceleration, humeral flexion, humeral extension, low scapular rows, throwing
acceleration and scapular punch)
 Athlete’s should be instructed and drilled on how to fall properly
 Wear protective padding in collision sports
 Teach proper techniques and biomechanics related to sport specificity
Assessment of the Shoulder Complex
o History
o Observation (anterior, lateral and posterior)
o Palpation (bony and soft tissue)
o Special Tests
 Active and Passive ROM
 Muscle Testing
 Tests for Sternoclavicular Joint Instability (Figure 22-9A)
 Tests for Acromioclavicular Joint Instability (Figure 22-9B)
 Tests for Glenohumeral Instability
 Glenohumeral translation (Load and Shift Test Figure 22-10)
 Anterior and Posterior Drawer Tests (Figures 22-11A and B)
 Sulcus Test (Figure 22-12)
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Chapter 22 The Shoulder Complex
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Clunk Test (Figure 22-13)
O’Brien Test (Active Compression Test Figure 22-14)
Apprehension Test (crank test) Posterior apprehension and Relocation Test
(Figures 22-15A, 22-15B, 22-15C)
 Tests for Shoulder Impingement
 Neer’s Test (Figure 22-16A)
 Hawkins-Kennedy Test (Figure 22-16B)
 Tests for Supraspinatus Muscle Weakness
 Drop Arm Test (Figure 22-17A)
 Empty Can Test (Figure 22-17B)
 Tests for Serratus Anterior Muscle Weakness (22-18)
 Push-up movement against the wall – winging of one scapula can indicate injury
to long thoracic nerve
 Tests for Biceps Tendon Irritation
 Yergason’s Test (Figure 22-19A)
 Speed’s Test (Figure 22-19B)
 Ludington’s Test (Figure 22- 19C)
 Circulatory Assessment
 Pulse rates obtained over the axillary, brachial and radial arteries
 Assess skin temperature
 Tests for Thoracic Outlet Compression Syndrome
 Anterior Scalene Syndrome Test (Adson’s Test) – (Figure 22-20A)
 Hyperabduction Syndrome Test (Allen Test) – (Figure 22-20D)
 Military Brace Position Test (Figure 22-20C)
 Costoclavicular Syndrome Test (Roo’s Test) – (Figure 22-20B)
 Sensation Testing (See Dermatomes Figure 13-5)
o Subjective Shoulder Scale Assessment
 American Shoulder and Elbow Surgeons (ASES) Subjective Shoulder Scale: contains
patient derived subjective assessment and a physician derived objective assessment
 Subjective patient self-report section consists of pain and function (function based on ten
questions)
Recognition and Management of Specific Injuries
 Clavicular Fractures
 Scapular Fractures
 Fractures of the Humerus
 Humeral Shaft
 Proximal Humerus
 Epiphyseal Fracture
 Sternoclavicular Sprain
 Acromioclavicular Sprain (Grade 1-5, Figure 22-26)
 Contusions to the distal end of the clavicle
 Glenohumeral Joint Sprain
 Acute Subluxations and Dislocations
 Subluxations
 Anterior Glenohumeral Dislocation
 Bankart Lesion: Anterior defect on the labrum
 Hill-Sachs Lesion: Defect on the posterior lateral aspect of the humeral head
 SLAP Lesion: Defect caused by an injury to the superior aspect of the labrum
 Posterior Glenohumeral Dislocation
 Reverse Hill-Sachs lesion: Occurs on the anteromedial portion of humeral head
following posterior shoulder dislocation
 Recurrent Instabilities of the Shoulder
 Recurrent Anterior Instability
 Recurrent Posterior Instability
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Chapter 22 The Shoulder Complex
 Multidirectional Instability
Shoulder Impingement
 Swimmers and throwers develop increased glenohumeral external rotation ERG
(external rotation gain), and significantly decreased glenohumeral internal
rotation (GIRD)
 Neer’s Stage I, Stage II, Stage III, Stage IV
 Scapular Dyskinesis
 Shoulder Bursitis
 Adhesive Capsulitis (Frozen Shoulder)
 Thoracic Outlet Compression Syndrome
 Compression of neurovascular bundle between the first rib and clavicle
(costoclavicular syndrome)
 Compression between the anterior and middle scalene muscles
 Compression by the pectoralis minor muscle as the neurovascular bundle passes
beneath the coracoid process or between the clavicle and first rib
 Presence of cervical rib
 Biceps Brachii Ruptures
 Bicipital Tenosynovitis
 Contusions of the Upper Arm
 Peripheral Nerve Injuries (Table 22-2)
Throwing Mechanics
o Wind-Up Phase
 From first movement until the ball leaves the gloved hand
o Cocking Phase
 Begins when the hands separate and ends when maximum external rotation of the
humerus has occurred
o Acceleration Phase
 From maximal external rotation until ball release
 Velocities approach 7,000 degrees per second with a force approaching 800 N
 Scapula elevates, abducts and rotates upward
o Deceleration Phase
 Lasts from ball release until the shoulder reaches maximal internal rotation
 External rotators of RTC contract eccentrically to slow down the humerus
 Rhomboids contract eccentrically to slow down the scapula
o Follow-Through Phase
 Lasts from maximum shoulder internal rotation until the end of motion – when athlete is
in a balanced position
Rehabilitation of the Shoulder Complex
o Immobilization after Injury
 Immobilization will vary depending on the structures injured, the severity of the injury
and whether the injury is treated conservatively or surgically
 Isometric exercises begin while the upper extremity is still immobilized
 Progression of ROM and strengthening exercises will be dictated by the physiological
healing process
o General Body Conditioning
o Shoulder Joint Mobilization (Figure 22-33)
 Normal joint arthrokinematics must be maintained to regain normal full range
physiological movement
 Mobilizations should be used when the limitation in motion is from tightness of the joint
capsule or surrounding ligaments rather than tightness of the musculotendinous units
 Include inferior, anterior, and dorsal humeral glides, anterior-posterior and inferior glides
of the clavicle at both the AC and SC joints and generalized ST mobilizations
o Flexibility (Figure 22-34 to Figure 22-38)
 Gentle ROM exercises should be started early (Codman’s pendulum exercises, sawing
motion, Rope and pulley, wall climbing exercises)
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Chapter 22 The Shoulder Complex
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Muscular Strength (Figure 22-39 to Figure 22-44)
 Isometrics started while immobilized
 Isotonics can be incorporated with a variety of resistance (Tubing, dumbbells, barbells or
manual resistance)
 Resistance exercises should include all cardinal plane movements and should also include
the RTC as well as the scapular stabilizers
 Isokinetic exercises do not approach functional speeds of throwing
 Exercises should emphasize eccentric and concentric components of exercise
 Plyometric exercises are useful in the later stages of rehabilitation
Neuromuscular Control (Figure 22-45)
 Following injury or surgery, the athlete must regain strength and ROM and must also
develop a firing sequence for the specific muscles necessary to perform
 Closed kinetic chain exercises emphasize co-contraction of antagonistic muscle groups
thus providing neuromuscular control of opposing muscle groups and promoting stability
of the shoulder joint
Functional Progressions and Return to Activity
 Usually incorporate sport-specific skills required for an athlete’s return to sport
 Throwing programs are utilized as a progression back to activity (See Focus Box 22-1 –
Throwing Progression)
 Progressions to advanced stages are based on symptoms from previous stages
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