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Chapter 12
Shoulder Conditions
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Shoulder Anatomy
• Extremely mobile; minimal stability
• Joints
– Sternoclavicular joint
– Acromioclavicular joint
– Coracoclavicular joint
– Scapulothoracic joint
– Glenohumeral joint
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Shoulder Anatomy (cont’d)
Skeletal features of the shoulder and chest
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Shoulder Anatomy (cont’d)
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Shoulder Anatomy (cont’d)
• Sternoclavicular joint
– Superior sternum
with the
proximal clavicle
• Joint capsule and
ligaments
• Ball-and-socket
joint
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Shoulder Anatomy (cont’d)
• Acromioclavicular joint (AC)
– Acromion process of scapula with distal end of
clavicle
– Irregular joint; permits movement in all 3 planes
– Capsule; minimal stability ligaments; strong
stabilizers
• Superior and inferior AC ligament
• Coracoclavicular ligament
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Shoulder Anatomy (cont’d)
• Coracoclavicular joint
– Coracoid process of scapula with the inferior
surface of clavicle
• Coracoclavicular ligament
– Minimal movement permitted
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Shoulder Anatomy (cont’d)
• Glenohumeral joint
– Glenoid fossa of scapula
with the head of the humerus
– Most ROM of any joint in body, but poor stability
• Head has greater surface area than fossa
• Shallow fossa (glenoid labrum)
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Shoulder Anatomy (cont’d)
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Shoulder Anatomy (cont’d)
• Glenohumeral joint (cont’d)
– Joint capsule and ligaments
– Rotator cuff muscles (SITS)
• Tendons form a collagenous cuff around joint
• Tension helps hold the head against the
glenoid fossa
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Shoulder Anatomy (cont’d)
• Scapulothoracic joint
– Muscles attached to scapula permit its motion
with the trunk and thorax
– Functions of scapular muscles
• Stabilization of shoulder region
• Facilitate movement of upper extremity
through appropriate positioning of
glenohumeral joint
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Shoulder Anatomy (cont’d)
• Bursa
– Subacromial bursa
• Lies in subacromial space
• Cushions rotator cuff muscles from acromion
(especially supraspinatus)
• Compressed during overhead arm action
– Subcoracoid; subscapularis
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Shoulder Anatomy (cont’d)
• Nerves
– Brachial plexus
innervates upper
extremity
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Shoulder Anatomy (cont’d)
• Subclavian; axillary—
several branches
Blood supply to the shoulder
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Kinematics and Major Muscle Actions
Muscles of the shoulder and chest
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Kinematics and Major Muscle Actions
(cont’d)
Muscles of the shoulder and upper back
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Kinematics and Major Muscle Action
(cont’d)
MUSCLE
PRIMARY ACTION
Deltoid
*Anterior
*Middle
*Posterior
*Flexion, horizontal adduction
*Abduction, horizontal abduction
*Extension, horizontal abduction
Pectoralis major
*Clavicular
*Sternal
*Flexion, horizontal adduction
*Extension, adduction, horizontal adduction
Supraspinatus
Abduction, stabilizes shoulder joint
Coracobrachialis
Horizontal adduction
Latissimus dorsi
Extension, adduction
Teres major
Extension, adduction, medial rotation
Infraspinatus
Lateral rotation, horizontal abduction
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Kinematics and Major Muscle Actions
(cont’d)
MUSCLE
PRIMARY ACTION
Teres minor
Lateral rotation, horizontal abduction
Subscapularis
Medial rotation
Biceps brachii
•Long head
•Short head
*Assists with abduction
*Assists with flexion, adduction, medial rotation,
and horizontal adduction
Triceps brachii (long
head)
Assists with extension and adduction
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Movement in Three Planes
– Sagittal
Movements of the arm
at the shoulder
• Flexion and
extension
– Frontal
• Abduction and
adduction
– Transverse
• Medial rotation and
lateral rotation
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Kinematics and Major Muscle Actions
(cont’d)
• Shoulder ROM
– Loose structure of GH
– Proximity of other articulations and their movement
capabilities
• Movement at the shoulder typically involves some
rotation of the SC, AC, & GH joints
• Scapulohumeral rhythm
– Coordinated movement of the scapula that
accompanies abduction & adduction of humerus
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Prevention of Shoulder Conditions
• Physical conditioning
– Flexibility
– Strength
• Protective equipment
– Shoulder pads
• Proper skill technique
– Throwing motion
– Proper falling technique
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Sprains to the Shoulder Complex
• Sternoclavicular (SC) Joint Sprain
– MOI
• Indirect force through humerus
• Blow to the clavicle
– Displacement: superior and anterior
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Sprains to the Shoulder Complex (cont’d)
• Sternoclavicular (SC) Joint Sprain (cont’d)
– S&S
• 2: unable to horizontally adduct; holds arm
forward and close to body
• 3: prominent displacement of proximal
clavicle
• Management: cold; sling; physician referral
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Sprains to the Shoulder Complex (cont’d)
• Posterior SC sprain
– MOI
• Blow to the posterolateral aspect of the
shoulder with the arm adducted and flexed
– Concern: structures involved
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Sprains to the Shoulder Complex (cont’d)
• Posterior SC sprain (cont’d)
– S&S
• Unable to perform shoulder protraction
• Numbness & weakness of upper extremity
• Difficulty swallowing
• Diminished pulse
– Management: activate EMS
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Sprains to the Shoulder Complex (cont’d)
• Acromioclavicular (AC) Joint Sprain
– MOI
• Direct blow
• Fall on point of shoulder
• Fall on outstretched arm
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Sprains to the Shoulder Complex (cont’d)
• Acromioclavicular (AC) Joint Sprain (cont’d)
– Type I: mild stretching of ligaments
• Minimal swelling & pain over the joint line
• Discomfort on abduction >90
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Sprains to the Shoulder Complex (cont’d)
• Acromioclavicular (AC) Joint Sprain (cont’d)
– Type II – rupture of AC ligaments
• + displacement; step off deformity
• Pain with horizontal adduction
• Pain with downward pressure on distal clavicle
• Stability: vertical maintained; sagittal plane
compromised
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Sprains to the Shoulder Complex (cont’d)
• Acromioclavicular (AC) Joint Sprain (cont’d)
– Type III – rupture of AC ligaments and
coracoclavicular ligament
• Visible prominence of the distal clavicle
• Depression or drooping of the shoulder girdle
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Sprains to the Shoulder Complex (cont’d)
• Acromioclavicular (AC) Joint Sprain (cont’d)
– Types IV–VI
• Caused by more violent forces
• Extensive mobility due to tear of deltoid and
trapezius attachment at distal clavicle
– Management
• Type I – cold; sling; physician referral
• II- VI – referral to emergency medical facility
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Sprains to the Shoulder Complex (cont’d)
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Sprains to the Shoulder Complex (cont’d)
• Glenohumeral Sprain
– MOI
• Forceful abduction
• Forceful abduction and external rotation
– Joint capsule stretches or tears;
humeral head moves in
anterior inferior direction
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Sprains to the Shoulder Complex (cont’d)
• Glenohumeral Sprain
– S&S
• 1: AROM – slight limitation
• 2: swelling, ecchymosis, decreased ROM,
especially abduction
– Management
• Cold; sling; physician referral
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Sprains to the Shoulder Complex (cont’d)
GH sprains
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Sprains to the Shoulder Complex (cont’d)
• Glenohumeral Dislocation
– Anterior
• Intense pain; recurrent: less painful
• Tingling and numbness down arm
• Arm held in slight abduction and
external rotation; stabilized against body by
opposite hand
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Sprains to the Shoulder Complex (cont’d)
• Glenohumeral Dislocation (cont’d)
– Anterior (cont’d)
• Deformity – sharp contour and a
prominent acromion process
• Attempt to bring arm across chest
horizontal adduction or internal rotation severe pain
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Sprains to the Shoulder Complex (cont’d)
• Glenohumeral Dislocation
– Posterior
• MOI – fall on or blow to the anterior shoulder
• S&S:
• Arm is carried tightly against chest & front
of the trunk (rigid adduction and internal
rotation)
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Sprains to the Shoulder Complex (cont’d)
• Glenohumeral Dislocation (cont’d)
– Posterior (cont’d)
• S&S: (cont’d)
• Deformity: anterior shoulder appears flat,
the coracoid process is prominent,
• Individual will not allow the arm to
externally rotate & abduct produces severe
pain; unable to supinate the forearm
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Sprains to the Shoulder Complex (cont’d)
• Glenohumeral Dislocation
– Management – Acute Injury
• Immobilize in comfortable position
• Apply cold
• Immediate physician referral
• If deficits with pulse or sensation, activate
emergency plan, including EMS
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Sprains to the Shoulder Complex (cont’d)
• Glenohumeral Dislocation
– Chronic dislocations
• Problem of reoccurrence
• Less force needed
• Less spasm, pain, swelling
• Sensation of arm going “dead”
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Sprains to the Shoulder Complex (cont’d)
• Glenohumeral Dislocation (cont’d)
– Chronic dislocations (cont’d)
• S&S: pain with crepitus and clicking after
reduction; reduction often self-induced
• Management: cold; sling & swathe; physician
referral
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Overuse Conditions
• Rotator cuff (primarily supraspinatus)
– Partial tear more likely in young;
total tear: adults over age 30
• Impingement syndrome
– Abutment of rotator cuff and subacromial bursa
against coracoacromial ligament and greater
tubercle of the humerus
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Overuse Conditions (cont’d)
Supraspinatus tendon during abduction
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Overuse Conditions (cont’d)
• Rotator cuff/Impingement syndrome
– Contributing factors (refer to Box 12.2)
– S&S
• “Deep” pain – initially at night
• Becomes progressively worse
• Painful arc: between 70° and 120°
• Unable to sleep on involved side
– Management: do not permit to continue activity until
seen by a physician
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Overuse Conditions (cont’d)
• Bursitis – Subacromial bursa
– MOI: impinged during overhead motion
– S&S
• Sudden shoulder pain: initiation and
acceleration phase of throwing
• Point tenderness on anterior & lateral edges of
acromion process
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Overuse Conditions (cont’d)
• Bursitis – Subacromial bursa (cont’d)
– S&S (cont’d)
• Painful arc during passive abduction
• Pain sleeping on involved side
– Management: do not permit to continue activity
until seen by a physician
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Overuse Conditions (cont’d)
• Bicipital tendinitis
– MOI
• Repetitive overhead activities involving
excessive elbow flexion and supination;
tendon passes back and forth in groove
• Direct blow
• Subsequent to impingement syndrome
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Overuse Conditions (cont’d)
• Bicipital tendinitis (cont’d)
– S&S
• Pain and tenderness at bicipital groove with
internal and external shoulder rotation
• Pain with passive stretch in extreme shoulder
extension with elbow extended and forearm
pronated
– Management: do not permit to continue activity
until seen by a physician
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Overuse Conditions (cont’d)
• Biceps tendon rupture
– Prolonged tendinitis makes tendon vulnerable
– MOI: forceful flexion against resistance
– S&S
• Hear and feel a snap
• Intense pain
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Overuse Conditions (cont’d)
• Biceps tendon rupture (cont’d)
– S&S (cont’d)
• Visible palpable defect in muscle belly during
flexion; “Popeye” appearance if mass moves
distally
• Weakness: flexion and supination of forearm
– Management: cold; sling; immediate referral to
a physician or emergency care facility
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Overuse Conditions (cont’d)
• Thoracic outlet
compression syndrome
Location and etiology of
thoracic outlet syndrome
– Nerves and/or
vessels become
compressed in the
proximal neck or
axilla
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Overuse Conditions (cont’d)
• Thoracic outlet compression syndrome (cont’d)
• Neurologic syndrome
– Stretch or compression involving lower trunk brachial
plexus
– S&S
• Aching pain, pins-and-needles sensation, or
numbness in the side or back of the neck extends
across the shoulder down the medial arm to the
ulnar aspect of the hand
• Weakness in grasp and atrophy of the hand
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Overuse Conditions (cont’d)
• Thoracic outlet compression syndrome (cont’d)
• Vascular syndrome
– Compression of subclavian artery or vein
– S&S
• Vein: edema, hand stiffness, venous engorgement
of arm with cyanosis, symptoms may present
several hours after exercise
• Artery: rapid onset of coolness, numbness entire
arm, fatigue after overhead activity
• Management: immediate referral to a physician
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Fractures
• Clavicular fracture
– MOI: direct or indirect force
– S&S
• Swelling, ecchymosis, and a deformity may be
visible and palpable
• Pain with any shoulder motion
• Greenstick fracture
– Management: cold; sling & swathe; immediate
referral to a physician or emergency care facility
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Fractures (cont’d)
• Scapular fracture
– MOI: direct or indirect force
– S&S
• Localized pain and hemorrhage
• Reluctant to move injured arm; prefers to
maintain adduction; abduction – very painful
– Need to rule out pulmonary injury
– Management: cold; sling & swathe; immediate
referral to a physician or emergency care facility
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Fractures (cont’d)
• Epiphyseal fracture
– Little league shoulder – proximal humerus;
due to repetitive medial rotation & adduction
– S&S
• Acute shoulder pain with throwing hard
• Pain with deep palpation in axilla
– Management
• Cold; sling & swathe; immediate referral to a
physician or emergency care facility
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Fractures (cont’d)
• Epiphyseal fracture
Epiphyseal fracture to the proximal
humeral growth center
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Fractures (cont’d)
• Avulsion fracture
– MOI
• Coracoid process due to forceful throwing
• Greater and lesser tubercles: associated with
dislocation
– S&S: pain with deep palpation at site
– Management:
• Cold; sling & swathe; immediate referral to a
physician or emergency care facility
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Fractures (cont’d)
• Humeral fracture
– MOI
• Direct blow
• Fall on upper arm
• Fall on outstretched hand with
elbow extended
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Fractures (cont’d)
• Humeral fracture (cont’d)
– S&S
• Pain, swelling, hemorrhage,
discoloration
• Inability to move arm
• Inability to supinate forearm
• Possible paralysis
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Fractures (cont’d)
• Humeral fracture (cont’d)
– Management
• Cold; sling & swathe;
immediate referral to a physician or
emergency care facility
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Fractures (cont’d)
• Humeral fracture
Fracture to the surgical neck
of the humerus
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Coach and Onsite Assessment
• S &S that require activation of emergency plan,
including summoning EMS
– Obvious deformity suggesting a suspected
fracture, separation, or dislocation
– Significant loss of motion or weakness in the
myotomes
– Joint instability
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Coach and Onsite Assessment (cont’d)
• S &S that require activation of emergency plan,
including summoning EMS (cont’d)
– Abnormal sensation in the shoulder, arm, or
hand
– Absent or weak pulse distal to the injury
– Any significant, unexplained pain
• Refer to Application Strategy 12.3
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