The shoulder

Shallow G-H jt-glenoid labrum deepens capsule;also requires strong muscle force to stabilize the joint-

RTC (rotator cuff muscles) SITS ms.

Ligaments of shoulder joint:A-C ligament-sup and inf reinforce the joint

capsule and prevent post dislocation of the clavicle

G-H ligaments-originate from labrum and attach to lesser tubercle and anat neck (reinforce capsule) sup, mid and inf bands

Coracoclavicular lig.- lat(trapezoid) and med(conoid) Both prevent backward mvmt of the scapula and ind they limit scap rotation

Acromioclavicular Joint

A-C joint capsule

Coracoclavicular ligaments

Clavicular Ligaments

Conoid ligament

A-C Joint

Common Glenohumeral Problems

Rotator cuff tendinitisRotator cuff tearsBicipital tendinitis, ruptureGlenohumeral dislocation/subluxationLabral TearsFrozen shoulder syndromeArthritis

Rotator Cuff Problems

Rotator Cuff Impingement

Rotator Cuff Tear (RCT)

Phase 1 (0 to 6 weeks) • Passive range of motion exercises only for almost all tears.

• Active-assisted range of motion for very small tears or repairs with exceptionally good tissue

Phase 2 (6 to 12 weeks)

• Full passive motion • Begin active-assisted

motion • Strengthen intact cuff

muscles • Begin to strengthen the

muscles that stabilize the shoulder blade

Phase 3 (12 to 16 weeks)

•Passive stretching beyond the patient's own range of motion •Strengthening the repaired cuff muscles •More strengthening of the stabilizers of the shoulder blade

Phase 4 IV (> 16 weeks) •Functional strengthening •Rehabilitation for sports

Normal Cuff, Torn Supraspinatus on MRI

Bicipital Tendinitis

Long biceps tendon in intimate with joint capsule.

May be impinged beneath acromion, or sheared within bicipital groove.

Impingement

Shear in bicipital groove

Bony Structures

Avascular Necrosis of Humeral Head

May be seen with chronic corticosteroid use.

(GENTLY handle patients with history of steroid use.)

Can lead to total shoulder replacement.

Glenohumeral Arthritis

Glenohumeral Arthritis

Frozen Shoulder Syndrome

“Freezing” shoulder“Frozen” shoulder“Thawing” shoulder

Freezing Shoulder

“Freezing” shoulder Usually starts with inflammatory process,

such as impingement syndrome. Subscapularis trigger points limit

external rotation, abduction Shoulder becomes painful, then stiff Best opportunity for intervention is here!

Frozen Shoulder

Capsule undergoes fibrotic changes(“Adhesive capsulitis”)PT intervention alone is of

questionable help.May benefit from manipulation under

anesthesia, followed by PT care.

Thawing Shoulder

Shoulder spontaneously becomes less painful, less stiff.

If in rehab, take credit for result, but probably little effect from treatment.

Nearly all frozen shoulders spontaneously resolve in 6 to 18 months

May recur on opposite sideRare in African-Americans

Glenohumeral/Scapulothoracic Rhythm

Occur in 2:1 ratio GH/ST, but not in constant ratio.

GH joint moves first, with stabilized scapula

Then, move in 1:1 ratio.Then finish with mostly GH motionFINAL ratio is 2:1

Glenohumeral Dislocation

Usually caused by violent abduction/external rotation of humerus.

Humerus dislocates in anterior, inferior direction.

Causes disruption of anterior labrum (Bankart lesion)

If repeated, posterior aspect of humerus strikes labrum, producing indentation in humerus (Hill Sachs lesion.)

Superior Labral Tear Anterior and Posterior to Biceps Attachment (SLAP)

Biceps tendon

Anterior tearPosterior tear

Bicipital Tear (Longhead)

Scapulothoracic Problems

Winging scapula from poor posture, habit. Common in tall, early developing females,

swimmers Correlated with G-H problems

May be from long thoracic nerve palsy, taking out serratus anterior. Results in inability to raise arm above 120

degrees (ever.)

Serratus Anterior Loss

Winging 120 degrees abduction

Suprascapular Nerve Palsy

Suprascaular nerve innervates supra- and infraspinatus.

Injury results in selected weakness.

What’s the sensory pattern??

Coracoacromial lig- provides roof over the humeral head - acts as a protective arch

Scapular movements must be accompanied by shoulder joint movements therefore if you have impairment at G-H joint, must look at scapula

Kinematics of shoulder joint-scapulohumeral rythymexternal rotation with abductionscapular plane

Muscles-RTC(rotator cuff muscles) SITSsupraspinatus-imp to keep head of humerus in

glenoid fossa along with other ms.Infra, teres minor, subscap-act to depress

head during flexion and abduction-counteract strong deltoid

long head of biceps becomes very active in shld flex and abd past 90

Ms. named from areas they originate and insert-grouping as follows:

Scapulohumeral:deltoid, supraspinatus, infraspinatus, teres minor, subscapularis, teres major, coracobrachialis

Axioscapular:pect minor, trapezius, rhomboids, lev scap, serr ant

Axiohumeral: pect major, lat dorsiDeltoid-ant, mid and post portionOrigin: ant portion-lateral 1/3rd of claviclemid-acromion, post-spine of scapulaInsertion-deltoid tuberosity of humerusaction-all portions abduct, ant fibers flex

and med rotate, post fibers extend and laterally rotate

innervation-axillary (C5,6)supraspinatus:origin-supraspinatus fossa of scapulainsertion-greater tubercle of humerusaction- stabilizes head of humerus in capsule,

assists in abduction-acts as force couple with deltoid to assist with abd

innervation-suprascapular (C4,5,6)

Infraspinatus-origin-infra fossainsertion-greater tubercle and shld capsuleinnervaton-suprascap nerveaction-ext rotation of shoulder and depression of

humeral head and stabilizes head during movementTeres minor-origin-upper lateral border of scapulainsertion-greater tub and shoulder capsuleaction-lat rotation and add of humerus along with

infrainnervation-axillary nerve

Subscapularis-origin-subscapular fossainsertion-lesser tubercle of humerus and capsuleaction-int rotation of humerus and works with

other ms.Innervation-subscapular (C5-7)Teres major-origin-acillary border of inf angle of

scapinsertion-med tip of inter grooveaction-med rotation, adduction and shouler extInnervation-lower subscapular(C5-7)

Axioscapular-pect minor:origin-ribs 3,4,5 and fascia of intercostal msinsert-coracoid processaction-elevation and downward rot of scapinnervation-medial pect (C8-T1)trapezius-origin-upper from occ protuberance, nuchal

line and spinous porcess of C7, middle from spinous process T1-5 and lower from T6-12

insertion- upper from lat clav and acromionmiddle from acromion and spine of scaplower from apex of spine of scap

Rhomboid major-origin-spinous process T2-5insertion-vertebral borderaction-down rotation, elevation and adduction

of scapinnervation-dorsal scapular (C4-5)rhomboid minor-origin-spinous processes C7-T1insert-root of spine of scapaction-same as majorinn-same as major

Levator scapula-origin-transverse processes C1-4insertion-sup med border of scapaction- elevation, down rotation and add of scapinnervation-dorsal scapularSerratus anterior-origin-upper 8-9 ribs ant

surfaceinsertion -medial, inf surf of scapaction-up rot, elevation and abductioninn-long thoracic (C5-7)

Axiohumeral-Pectoralis major-origin:clavicle, sternum and

cartilage of first 6-7 ribsinsert-lat inter. Grooveaction: med rotation, flexion and horizontal

adductionLatissimus dorsi-origin-sp processes of T6-12, last 3

ribs, thoracolumbar fascia and iliac crestinsert-inter grooveaction-med rotation, adduction and ext of shld, ext

of L spine, flex of T spine

Disorders of PNS-neuropraxia-local blockage interfering with

conduction , it’s OK above and below-commonly caused by compression-Saturday night palsy-radial nerve or Bell’s palsy, no disruption of axon

Axonotmesis-nerve injury characterized by disruption of the axon and myelin sheath but with preservation of supporting CT resulting in axonal degeneration distal to the injury site-the deficit depends on the # of axons affected

neurotmesis- partial or complete severance of a nerve with disruption of axons, myelin sheaths and supporting connective tissue resulting in degeneration of axons distal to the injury site (worst of the 3)

Disorders of PNS

Erb’s palsy-compression or stretching of upper BP nerve roots (C5,6)-results in “waiter’s tip” sign

Klumpke’s paralysis-compression or stretching of lower BP (C8,T1)-results in functionless hand

Bursae-fluid filled sac which can be inflammed-bursitis-most common in shoulder-subdeltoid and subacromial-least likely subscapular bursitis

Signs-warm, edematous with tenderness over area

Pain quality-intense, dull, throbbing all movements painful

Tendonitis-inflammation of the tendonRTC tendonitis-supraspinatus most involved-results

from overuse, tennis, baseball, carpenters, plumbers-can also be poor blood supply causing scarring or Ca deposits-can bring about tears, bursitis or impingements; local steroids can relieve symptoms but may cause structural wknss of tendon

Pain quality-sharp twinges ie. Donning jacket, reaching OH, abd or IR arm

Onset-gradual. May sometimes refer to C5-6 dermatome

RTC tears-acute, chronic, full, partial thickness tears;<1cm. Small, >5cm. Massive-usually traumatic but may be degenerative

pain-not always severe but pt con’t raise arm and has severs atrophy lat and ant deltoid region-may require surgery

Adhesive capsulitis-frozen shld.-trauma, disuse, immobilization, RTC lesions

pain-dull-severe with activity, pain at night

Onset-gradual, will see increase activity of upper trapsImpingement syndrome-supra, long head biceps,

subacro bursa most affected-pt. will exhibit painful arc of motion b/w 70-120 degrees

3 stages:I-edema-athlete or poor posture, young person with no

recollection of injuryII-fiborsis and tendinitis (20-40 yo)recurrent pain with

activityIII-bone spurs and tendon ruptures-long history (50-

60yo)

G-H instability-hum head dislocates through ant capsule, RTC ms. Can be weak

Brachial plexus lesions-numbness and burning entire arm, hand, fingers, sensory loss over 2 or more dermatomes, paralysis of arm, may be transcient -tenderness over BP with increased symptoms with movement of head to opposite side

Thoracic outlet syndrome-often called neurovascular compression-symptoms resulting from injury at upper border of thorax where BP and subclavian a are located-can be caused from a C-rib

treatment-postural correction ex to bring back shoulders

Brach plex lesions-numbness and burning entire arm, hand, fingers-sensory los over 2 or more derm-paralysis of arm-may be transcient-tenderness over BP with increase symptoms when turning head opp. side

Diagnostic tests-X-ray-for bony defects, alignment, exostosis

(bone spurs), osteophytes and diseasesC-T scans-specific for boneMRI-magnetic resonance imaging-soft tissue-no

radiation as in X-rayangiography-contrast mat injected into vascular

systemmyelograpy-inject dye into SA spaceEEG-records brain electrical activity

EMG and NVC-see if diseases are neuromuscular in origin

arthrogram-injects dye and air-views jt space, cartilage, ligs