IntroductionIntroduction

The function of the shoulder The function of the shoulder allows the greatest range of allows the greatest range of motion of any joint in the motion of any joint in the body. body.

This great range of motion This great range of motion can also lead to several can also lead to several common problems affecting common problems affecting the shoulder joint. the shoulder joint.

In other words, the shoulder In other words, the shoulder is built for motion, not is built for motion, not stabilitystability

ConsiderationsConsiderations

What happens to the ROM during flexion if What happens to the ROM during flexion if the arm is externally and internally rotated? the arm is externally and internally rotated? Why?Why?

Which arm can you reach furthest up your Which arm can you reach furthest up your back with?back with?

Why?Why?

BonesBones

The The bonesbones of the of the shoulder include the shoulder include the humerus, the scapula, humerus, the scapula, and the clavicle.and the clavicle.

A “roof” of the shoulder A “roof” of the shoulder is formed by a part of is formed by a part of the scapula called the the scapula called the acromion.acromion.

JointsJoints

There are actually two There are actually two jointsjoints around the around the shoulder shoulder

The glenohumeral joint The glenohumeral joint or the shoulder joint or the shoulder joint

The acromioclavicular The acromioclavicular (AC) joint where the (AC) joint where the clavicle meets the clavicle meets the acromion. acromion.

Joint CapsuleJoint Capsule

The The joint capsulejoint capsule is made by is made by a group of ligaments that a group of ligaments that connect the humerus to the connect the humerus to the socket of the shoulder joint socket of the shoulder joint on the scapula.on the scapula.

Three ligaments are the main Three ligaments are the main source of stability for the source of stability for the shoulder, and help to keep shoulder, and help to keep the shoulder from dislocating. the shoulder from dislocating. Coracohumeral ligamentCoracohumeral ligament Middle glenohumeral Middle glenohumeral

ligamentligament Inferior glenohumeral Inferior glenohumeral

ligamentligament

BursaBursa

Sandwiched between Sandwiched between the rotator cuff muscle the rotator cuff muscle layer and the outer layer and the outer layer of large bulky layer of large bulky muscles is a structure muscles is a structure known as a known as a bursabursa. .

A A bursabursa is simply a is simply a closed space between closed space between two moving surfaces two moving surfaces that has a small amount that has a small amount of lubricating fluid insideof lubricating fluid inside

LigamentsLigaments Ligaments are soft tissue Ligaments are soft tissue

structures that connect structures that connect bones to bones. bones to bones.

The The acromioclavicularacromioclavicular ligaments that attach the ligaments that attach the clavicle to the acromionclavicle to the acromion

The The coracoclavicular coracoclavicular (2)(2) ligaments connects the ligaments connects the clavicle to the coracoid clavicle to the coracoid process.process.

The The coracoacromialcoracoacromial ligament ligament connects the coracoid connects the coracoid process and the acromion process and the acromion processprocess

Coracoacromial ligament

coracoacromial

coracoclavicular

A Guide to Shoulder A Guide to Shoulder Problems Problems

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Shoulder InjuriesShoulder Injuries

1.1. Impingement/BursitisImpingement/Bursitis

2.2. Rotator Cuff TearRotator Cuff Tear

3.3. Acromioclavicular(ACAcromioclavicular(AC) Joint Separation) Joint Separation

4.4. Shoulder InstabilityShoulder Instability

5.5. LabralLabral Tear Tear

Impingement SyndromeImpingement Syndrome

Impingement SyndromeImpingement Syndrome

The The supraspinatus tendonsupraspinatus tendon connects the humerus with connects the humerus with the scapula (shoulder the scapula (shoulder blade) and helps blade) and helps raiseraise and and rotate the arm. rotate the arm.

As the arm is raised, the As the arm is raised, the supraspinatus tendon also supraspinatus tendon also keeps the keeps the humerushumerus tightly tightly in the socket (glenoid) of in the socket (glenoid) of the scapula.  the scapula. 

Impingement SyndromeImpingement Syndrome

The part of the scapula that The part of the scapula that makes up the roof of the shoulder makes up the roof of the shoulder is called the is called the acromion processacromion process. . 

Between the acromion process Between the acromion process and the supraspinatus tendon and the supraspinatus tendon there is a bursa.  there is a bursa. 

The The bursabursa is a lubricated sac of is a lubricated sac of tissue that protects the muscles tissue that protects the muscles and tendons as they move and tendons as they move against one another.  against one another. 

The bursa simply allows the The bursa simply allows the moving parts to slide against one moving parts to slide against one another without too much friction.another without too much friction.

Impingement SyndromeImpingement Syndrome

Impingement SyndromeImpingement Syndrome

If any condition decreases If any condition decreases the amount of space the amount of space between the acromion and between the acromion and the supraspinatus tendon,  the supraspinatus tendon,  the impingement process the impingement process may get worse.may get worse. SwellingSwelling Bone spursBone spurs Anatomical structure Anatomical structure 

Impingement SyndromeImpingement Syndrome

Rotator Cuff TearsRotator Cuff Tears

Rotator cuffRotator cuff

SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres minorTeres minor

Movement of RC MusclesMovement of RC Muscles Subscapularis is an Subscapularis is an

internal rotator of the arm. internal rotator of the arm. Supraspinatus assists the Supraspinatus assists the

deltoid in abducting the deltoid in abducting the arm, with its greatest arm, with its greatest contribution being the contribution being the initiation of abduction. initiation of abduction.

Infraspinatus and teres Infraspinatus and teres minor muscles both minor muscles both externally rotate the arm. externally rotate the arm.

Rotator Cuff InjuryRotator Cuff Injury

The throwing motion has been divided into The throwing motion has been divided into five phases: wind-up, cocking, acceleration, five phases: wind-up, cocking, acceleration, and follow-through. and follow-through.

Cocking phaseCocking phase Supraspinatus, infraspinatus, and teres minorSupraspinatus, infraspinatus, and teres minor

muscles begin to fire at the end of early cocking muscles begin to fire at the end of early cocking phase phase

SubscapularisSubscapularis subsequently fires in late cocking to subsequently fires in late cocking to decelerate the shoulder's external rotation. Also, it decelerate the shoulder's external rotation. Also, it is stretching during the cocking phase.is stretching during the cocking phase.

Rotator Cuff InjuryRotator Cuff Injury

Follow-throughFollow-through (muscles fire most intensely) (muscles fire most intensely) Subscapularis internally rotates the shoulder, Subscapularis internally rotates the shoulder, Remaining rotator cuff muscles are contracting Remaining rotator cuff muscles are contracting

eccentrically to decelerate the arm and are eccentrically to decelerate the arm and are stretched.stretched.

During this repetitive eccentric loading, the During this repetitive eccentric loading, the rotator cuff is prone to overload, fatigue, rotator cuff is prone to overload, fatigue, tendinitis, and even a partial undersurface tendinitis, and even a partial undersurface tear. tear.

Note: Surgery needs to be performed within 3 months or the supraspinatus muscle will atrophy and be too short to reattach

Shoulder SeparationShoulder Separation

Shoulder SeparationShoulder Separation

A shoulder separation is a fairly A shoulder separation is a fairly common injury, especially in an common injury, especially in an athletic population.  athletic population. 

A shoulder separation is actually A shoulder separation is actually a a dislocation of the dislocation of the acromioclavicular (AC) jointacromioclavicular (AC) joint.  . 

Some people mistake this for a Some people mistake this for a shoulder dislocationshoulder dislocation, and vice , and vice versa.  versa. 

This is a very different injury than This is a very different injury than a shoulder dislocation. a shoulder dislocation. 

Grades of Shoulder Grades of Shoulder SeparationSeparation

Shoulder SeparationShoulder Separation

The most common cause of an The most common cause of an acromicoclavicular (AC) joint separation is a fall acromicoclavicular (AC) joint separation is a fall on the shoulder.  on the shoulder. 

As the shoulder strikes the ground, the force As the shoulder strikes the ground, the force from the fall pushes the scapula down.  from the fall pushes the scapula down. 

The clavicle, because it is attached to the rib The clavicle, because it is attached to the rib cage, cannot move down enough to follow the cage, cannot move down enough to follow the motion of the scapula.  motion of the scapula. 

Something has to give, and the ligaments Something has to give, and the ligaments around the acromioclavicular (AC) joint begin to around the acromioclavicular (AC) joint begin to tear - separating, or dislocating, the joint.   tear - separating, or dislocating, the joint.   

Shoulder Dislocation & Shoulder Dislocation & InstabilityInstability

Shoulder DislocationShoulder Dislocation If the shoulder slips If the shoulder slips

completely out of the completely out of the socket, it has become socket, it has become dislocateddislocated.   .  

97 out of 100 dislocations 97 out of 100 dislocations are anterior.are anterior.

3 out of 100 dislocate 3 out of 100 dislocate posteriorly.posteriorly.

Repeated dislocations are Repeated dislocations are not only a nuisance, but not only a nuisance, but can cause further injury to can cause further injury to the shoulder and can lead the shoulder and can lead to arthritis of the shoulder if to arthritis of the shoulder if not treated. not treated.

Shoulder SubluxationShoulder Subluxation

The ligaments that make up the The ligaments that make up the joint capsulejoint capsule have a have a considerable amount of slack, or looseness, so that the considerable amount of slack, or looseness, so that the shoulder is unrestricted as it moves through its rather shoulder is unrestricted as it moves through its rather large range of motion.  large range of motion. 

Sometimes the Sometimes the shoulder does not shoulder does not come completely out come completely out of the socket but of the socket but slips partially out and slips partially out and then returns to its then returns to its normal position. This normal position. This is called is called subluxationsubluxation.  . 

Shoulder InstabilityShoulder Instability InstabilityInstability means that the shoulder is too loose and has a tendency to means that the shoulder is too loose and has a tendency to

slip out of the socket, (or glenoid fossa). slip out of the socket, (or glenoid fossa).  This initial injury is usually fairly significant and the shoulder must be This initial injury is usually fairly significant and the shoulder must be

reduced, or put back into the socket, by a physician.  reduced, or put back into the socket, by a physician.  After that first violent injury that causes the shoulder to dislocate, the After that first violent injury that causes the shoulder to dislocate, the

joint may remain unstable.   joint may remain unstable.   The ligaments that are supposed to hold the shoulder in the socket The ligaments that are supposed to hold the shoulder in the socket may may

not heal back properlynot heal back properly, or they may remain stretched and , or they may remain stretched and too loosetoo loose to to keep the shoulder in the socket in certain positions.  keep the shoulder in the socket in certain positions. 

Glenoid LabrumGlenoid Labrum

Labral TearLabral Tear

A part of the scapula, called the A part of the scapula, called the glenoid cavity, makes up the glenoid cavity, makes up the socket of the shoulder.  socket of the shoulder. 

This socket is very shallow and This socket is very shallow and flat.  flat. 

To make the socket more like a To make the socket more like a cup, there is a rim of soft tissue cup, there is a rim of soft tissue called the called the labrumlabrum.   .  

Labral TearLabral Tear

The labrum acts sort of like The labrum acts sort of like a gasket, turning the flat a gasket, turning the flat surface of the glenoid into a surface of the glenoid into a deeper socket that molds to deeper socket that molds to the head of the humerus for the head of the humerus for a better fit.a better fit.

A tear of labrum can cause A tear of labrum can cause a very difficult to diagnose a very difficult to diagnose problem of pain and aproblem of pain and a catchingcatching sensation with sensation with movement of the shoulder. movement of the shoulder. 

Labral TearLabral Tear

This tissue can be caught between the This tissue can be caught between the socket and the humerus and be torn. socket and the humerus and be torn.

This flap of tissue can move in and out This flap of tissue can move in and out of the joint, getting caught between the of the joint, getting caught between the humeral head and glenoid socket, and humeral head and glenoid socket, and cause pain and catching.  cause pain and catching. 

The labrum is also the area for The labrum is also the area for attachment of several of the tendons attachment of several of the tendons and ligaments of the shoulder.  and ligaments of the shoulder. 

The ligaments that attach to the The ligaments that attach to the labrum help with maintaining the labrum help with maintaining the stability of the shoulder. stability of the shoulder. 

Labral TearLabral Tear

Most labral tears are probably the Most labral tears are probably the result of an injury to the shoulder, result of an injury to the shoulder, such as falling on an outstretched such as falling on an outstretched hand.  hand. 

There is reason to believe that the There is reason to believe that the excess motion of the humerus excess motion of the humerus moving around on the glenoid may moving around on the glenoid may cause damage to the labrum over cause damage to the labrum over time.   time.  

An unstable shoulder may also An unstable shoulder may also cause injury to the labrum, if it cause injury to the labrum, if it repeatedly dislocates out of the repeatedly dislocates out of the glenoid. glenoid.

Exercises Exercises

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Shoulder action = ?Shoulder muscle(s) = ?

Scapula action = ?Scapula muscle(s) = ?

Abduction

Deltoid

Upward Rotation

Ser. Ant.,Trap (lower)

Shoulder action = ?Shoulder muscle(s) = ?

Flexion

Ant DeltoidUpper Pect MajorCoracobrach

Shoulder action = ?Shoulder muscle(s) = ?

Scapula action = ?Scapula muscle(s) = ?

Horz. Add.

Ant. DeltoidPect. MajorCoracobrach.

Abduction

Pect. MinorSer. Ant.

Scapula action = ?Scapula muscle(s) = ?

Elevation

Lev. Scap.RhomboidsUp. & Mid. Trap

Shoulder action = ?Shoulder muscle(s) = ?

Scapula action = ?Scapula muscle(s) = ?

Hor. Abd

Lat.Post. DeltoidTeres MinorInfraspinatus

Adduction

RhomboidUpper and Mid. Trap.

Shoulder action = ?Shoulder muscle(s) = ?

Scapula action = ?Scapula muscle(s) = ?

Adduction

Pect. MajorCoracobrach.Lat.Teres Major

Downward Rotation

Pect. MinorRhomboid

Shoulder action = ?Shoulder muscle(s) = ?

Scapula action = ?Scapula muscle(s) = ?

Horizontal Add

Ant. DeltoidPect. MajorCoracobrach.

Adduction

RhomboidUpper and Mid. Trap.

Shoulder action = ?Shoulder muscle(s) = ?

Scapula action = ?Scapula muscle(s) = ?

Extension

LatsTeres MinorPost. Deltoid

Adduction

RhomboidUpper and Mid. Trap.

Shoulder action = ?Shoulder muscle(s) = ?

External Rotation

InfrspinatusTeres Minor

Rotator Cuff ExercisesRotator Cuff Exercises

Internal Rotation

External Rotation

Internal Rotation

Rotator Cuff ExercisesRotator Cuff ExercisesExternal Rotation

External Rotation

Internal Rotation

Abduction (to work the supraspinatus)

What position are her shoulders in?

Flexion

What rotation action is his shoulder performing as he continues to through the ball?

Internal Rotation

What position is his right shoulder in?

Horizontal Abduction andExternal Rotation

What position are her shoulders in?

Flexion

What position are his shoulders in?

Horizontal abduction or Extension

1.2.

FlexionExtension

Position of their shoulders?

Position of his scapula?

Upward Rotation

Position of his shoulder?

Abduction

What is the position of scapula?

Adduction

What is the position of shoulder?

Extension