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Chapter 10 Shoulder Injuries Chapter Objectives • Understand the basic anatomy of the shoulder. • Explain how shoulder injuries occur. • Describe the various types of injuries to the shoulder. • Explain treatment procedures fro common shoulder injuries. Anatomy • Bones • Humerus • Clavicle • Scapula Humerus Scapula Clavicle Anatomy • Ligaments • Coracoclavicular Ligaments • Trapezoid • Conoid • Acromioclavicular ligament • Corocoacromial Muscles • Rotator Cuff • Subscapularis • internal rotator • Infraspinatus • external rotator • Teres Minor • external rotator • Supraspinatus • primarily an abductor of the arm Muscles • Deltoid • Attaches to acromion process and lateral humerus • 3 portions • Anterior, posterior, and medial • Abducts, flexes, and extends the shoulder Muscles • Pectoralis minor • Pectoralis major • Primarily responsible for horizontal adduction and protraction • Biceps brachii • • • • • • Muscles 2 heads Originates at supraglenoid tubercle and corocoid process Inserts at radius Bicep tendon/bicipital groove Held in place by transverse ligament Flexes elbow, abducts and supinates forearm Muscles • Triceps brachii • • • • 3 heads-long, lateral, and medial Originate posterior humerus Insert at ulna Extend elbow, humeral adduction Joints • Acromioclavicular (AC) joint • One of most common injured areas of shoulder • Consists of acromion process and distal clavicle • Held together by the ac ligament Injured AC joint Joints • Glenohumeral joint • Articulation of the humerus and glenoid fossa • Very susceptible to injury due to fossa being shallow • Humeral head covered with articular cartilage • Capsular ligament surrounds the entire joint which aids in joint stability Injuries- prevention • Shoulder injury causes • Muscle weakness • Postural problems • Nature of the joint Addressing muscular weakness • Often weak in posterior (back) muscles • Signs- rounded shoulders, tight pectoralis muscles, weak posterior shoulder muscles • All predispose athlete to injury • Proper technique in throwing, swimming, etc. prevent injury • Proper padding important Common shoulder injuries • Acromioclavicular ligament sprain • Aka-separated shoulder • most common mechanism of injury occurs when the athlete falls onto the point of the shoulder or receives a direct blow to the tip of the shoulder or falls on an outstretched arm • graded according to the degrees of severity AC sprain (cont.) • Mild (1st degree) • stretching or slight tearing of the ligament fibers • Mild joint tenderness, mild swelling, and little or no disability of the shoulder • Moderate (2nd degree) • partial disruption of the supporting ligaments • pain and tenderness directly over and around the joint, local swelling, and an increase in pain on forced motion • Severe (3rd degree) • total disruption of one or more of the supporting ligaments • varying degrees of tenderness, swelling, instability, and an increase in pain with any effort to stress the joint • often exhibit a piano key sign; that is, the clavicle can be pushed down but will spring back up when pressure is released. AC sprain treatments • PRICE • Refer if 2nd or 3rd degree to r/o fracture • 3rd degree may require surgery or harness immobilization Glenohumeral ligament sprain • sprains of the shoulder joint seldom occur unless there is a subluxation or dislocation • Vulnerable in abduction and external rotation • Pain with any motion • PRICE and refer to physician Rotator cuff strain • Injuries to rotator cuff muscles are difficult to detect and isolate because these muscles, which reinforce the joint capsule, lie deep in the shoulder • MOI• ballistic arm activities • forceful concentric contraction of the muscles that accelerate and decelerate limb activities • improper warm ups • muscle fatigue Rotator cuff injuries (cont) • Signs and symptoms • anterior-lateral shoulder pain • point tenderness • decreased range of motion • loss of strength consistent with the severity of the injury • Pain may radiate down the lateral arm but usually stops at mid-humerus • Pain is often increased at night while the individual is lying on the affected side Rotator cuff injuries (cont) • Treatment • PRICE • Gentle strengthening and flexibility exercises • See handout for examples Impingement sydrome • common injury involving the soft tissues of the shoulder comprising of the subacromial space (often involves the supraspinatus and biceps) • Usually result of repetitive overhead types of movement • Treatment • Modified activity • Strengthening posterior shoulder muscles • Improving flexibility (especially in pecs) Bicipital tendinitis • Common with overhead activities (swimming, throwing, etc) • Tendon becomes irritated in bicipital groove • May feel crepitis (grinding) • Rest and immobilization may be required • Treat with Ultrasound and N-SAIDS Bicep tendon rupture • Caused by direct blow or severe contracture forces • Athlete will have inability to flex the elbow • Noticeable deformity as bicep muscle will roll up under skin • Treat- ice, immobilized, refer to physician • Surgical repair necessary Clavicular fracture • Most often fractures occur in distal 1/3 of bone • Usually caused by direct blow or falling on the tip of the shoulder • Restrict motion with sling and ice • Refer for x-ray • Most fractures take 6 weeks to heal Humeral fracture • Not difficult to find if fractured at midshaft • Shoulder can sometimes hide humeral head fractures • Pain on all sides of bone when palpated (around circumference) is good indicator of fracture • Splint and refer for immediate care • Check pulse before and after splinting to check circulation Epiphysis injury • Can be caused by • Blow to humeral head • Falling on elbow and driving humerus into glenoid fossa • Signs/symptoms-same as humeral fx • Treat with ice, splint, sling • Refer, can cause growth impairment • Young pitchers prone to epiphyseal injury from excessive throwing Avulsion fracture • Can accompany a glenohumeral or AC sprain • Capsular ligament pulls away from scapula when humerous dislocates from glenoid fossa • Only revealed or ruled out by x-ray • Treat with splint and ice Glenohumeral dislocations and subluxations • Head of humerous is out of the socket • Sublux- head was out, then back in • Cause-excessive abduction and external rotation Glenohumeral dislocations and subluxations • Dislocation can cause tear of the capsular ligament • Anterior dislocation most common • Deformity usually seen at deltoid muscle (shoulder flat) • X-ray needed to determine extent of injury Glenohumeral dislocations and subluxations • Dislocations and subluxations need to strengthen adductors and internal rotators • Can wear restrictive harness • Surgery sometimes required to repair capsular ligament Adhesive capsulitis • frozen shoulder • inflammation about the rotator cuff and capsular area that can result in dense adhesions and capsular contractures causing restriction of motion and pain • exact cause remains unknown • The main feature is a lack of passive range of motion Brachial plexus injury • normally involves the cervical spine, but the symptoms are exhibited in the shoulder and upper extremity • Usually caused by forced rotation or lateral flexion • Is a stretching or pinching of brachial plexus Brachial plexus injury • result in transitory paralysis of the arm • numbness or a burning sensations radiating down the arm and sometimes into the hand • Weakness or numbness lasting more than an hour should be referred to a physician Thoracic Outlet Syndrome • a group of symptoms resulting from compression of the thoracic neurovascular bundle • . This neurovascular bundle emerges from the thorax though an outlet or triangle formed by the scalene muscles and the first rib • Narrowing of the outlet can cause a variety of symptoms Thoracic Outlet Syndrome • Possible causes • hypertrophy of one of the scalene muscles • shape of the first rib • scar tissue formation around the nerve roots • cervical ribs • excess callus formation as a result of a fractured clavicle • hyperabduction or stretching of the brachial plexus Thoracic Outlet Syndrome • Symptoms • aching pain across the shoulder • pain in the side of the neck and down the arm • sensation of weakness, heaviness, and easily fatigability when using the arm • Athletes exhibiting TOS often have a history of trauma to the head, neck, or shoulder area