The Shoulder Unit 9 Shoulder Anatomy Shoulder flashcards: Please get scissors and 1 color We will label 1 structure per card Scapula
Humerus Superior Angle
Greater Tubercle Spine of Scapula
Lesser Tubercle Acromion Process Head of Humerus Acromioclavicular Joint
Neck of Humerus Clavicle
Infraspinatus Fossa Coracoid Process
Lateral Border Sternoclavicular Joint
Inferior Angle Subscapularis Medial Fossa Border Bicipital groove Superior angle Spine of the Scapula
Medial border of the Scapula
Inferior angle
REFERENCE SLIDE Head of the Humerus
Greater tuberosity Infraspinatus Posterior view fossa
Lateral border of the Scapula Supraspinatus Neck of the fossa Humerus
Humerus Acromioclavicular Ligament Coracoclavicular Ligaments
Sternoclavicular Ligament FEEL FREE TO USE THIS EXTRA FLASHCARD TO LABEL BONY LANDMARKS FROM PREVIOUS SLIDES. JUST A REFERENCE Levator Scapulae Trapezius
Rhomboid Minor Rhomboid Major
Sternocleidomastoid
Pectoralis Minor
Serratus Anterior Middle Posterior Deltoid Deltoid
Teres Major Triceps Latissimus Brachii Dorsi
Anterior Deltoid
Pectoralis Major Biceps Brachii Middle Deltoid
Pectoralis Major
Biceps Brachii Anterior Deltoid
Triceps Brachii Supraspinatus Teres Minor
Infraspinatus S.I.T.S. (rotator
Subscapularis cuff) Triceps Brachii Shiny Desk PRACTICE Quiz: Movement & muscle.
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6 Practice Quiz: Movement & muscle. KEY Shoulder abduction Shoulder extension Scapular elevation Supraspinatus, Deltoids Latissimus dorsi, teres Trapezius, levator scapulae major, posterior deltoid
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Shoulder internal rotation Shoulder flexion Shoulder external rotation Pectoralis major, subscapularis, Pectoralis major, anterior Infraspinatus, supraspinatus, latissimus dorsi, teres major deltoid, biceps brachii teres minor • With a partner, run through the 6 MMT’s for the shoulder Manual • Start with a 3 score • Full ROM Muscle • Against gravity • No resistance Test (MMT) • If they can do a 3, move onto a 4 or 5 Practice • Stationary hand proximal to joint/side being tested • Resistance hand distal to joint being test (I would go to the distal joint) • Full ROM • Against gravity • Compare bilaterally • If they cannot do a 3, move onto a 2, 1 or 0 • 2 • Full ROM • With gravity • 1 • With gravity • Some ROM or muscle contraction • 0 • Nothing happening Shoulder Outline Shoulder Complex
• susceptible to injury = mobility compromising the stability • Repetitive movements place stress on the complex. • Throwing • Swimming • Serving in tennis or volleyball MOI: For many shoulder injuries
• FOOSHA: Falling On Out Stretched Hand / Arm Anatomy • Bones • Clavicle • S shaped 6 in. long • Supports the anterior shoulder • Prone to fx because of shape and not protected • Scapula • Flat, triangular • purpose is an articulating surface for the humerus • Humerus structures • Head, neck • Bicipital groove • Greater and Lesser tubercles • Glenohumeral joint Shoulder palpation video #1. Follow along with video click here for url: shoulder palps #1 Clavicular Fracture - Most frequent fx.
INJURY MOI: FOOSHA, direct impact, occurs in middle 3rd S/S: athlete supports arm, swelling, deformity, point tenderness. tilts head to the injured side w/ chin toward opposite side. Clavicle Fracture TX: sling and swathe,
refer for x-ray. INJURY
Special tests: piano key Fracture of the Humerus •Humeral Shaft:
INJURY comminuted or transverse. MOI: direct blow or fall on arm Fracture of the Humerus
• Proximal Humerus: great INJURY danger to nerve and vessels MOI: direct blow, dislocation • Most likely at the neck • Can be mistaken for dislocation Fracture of the Humerus
INJURY • Epiphyseal fx: young athlete 10 years and younger MOI: direct blow, or indirect force applied to the length of the axis. Fractures to the Humerus
INJURY S/S: x –ray, pain, inability to move arm, swelling, point tenderness, discoloration TX: splint, treat for shock, refer Shoulder sling elastic wrap Click here for url: shoulder sling video Acute Subluxation/Dislocation
• Account for 50% of all dislocations • Shoulder instability increases chances • 85-90% re-occurrence Subluxations
INJURY MOI: brief translation of the humeral head without separation of the joint surfaces. Can occur: anteriorly, posteriorly, or inferiorly. Anterior Glenohumeral Dislocation
INJURY MOI: Forced abduction, external rotation and extension. direct impact to the posterior or posterorlateral aspect Arm is held in abduction & ER Acute Anterior Subluxations/Dislocations
INJURY S/S: Anterior TX: - flat deltoid - immediate immobilization - Feel humeral head - PRICE - Athlete carries the affected arm - Refer in slight abduction and ER - Unable to touch opposite shoulder Shoulder Spica elastic wrap click here for url: shoulder spica Posterior Glenohumeral Dislocation
INJURY MOI: - forced adduction and IR, - or fall on an extended and internally rotated arm - Labrum damage Acute Posterior Subluxations/Dislocations
INJURY S/S: posterior TX: - severe pain and disablitity - immediate immobilization - Held in adduction and IR - PRICE - Flat anterior deltoid - Refer - Acromion and coracoid processes - Limited ER & elevation Bone Palpations: Get up and review • Anterior • Clavicle • Sternoclavicular joint • Acromioclavicular joint • Coracoid process • Sternum • Humeral head • Bicipital groove • Posterior • Scapula • Spine of scapula • Medial and lateral borders • Inferior angle Articulations
• Sternoclavicular Joint (SC) • Clavicle + Manubrium of sternum • Only direct connection between the upper extremity and trunk • articulation disk = shock absorption, allows movement • Acromioclavicular Joint (AC) • Lateral end of clavicle + acromion process • Weak junction Articulations • Glenohumeral joint (shoulder joint) • Ball and socket joint • Head of humerus + glenoid cavity of scapula • Held by the glenoid labrum, capsular ligamentous structures, rotator cuff • cushioned by labrum • Scapulothoracic Joint • Not a true joint • Scapula + thoracic cage Ligaments • Sternoclavicular joint ligaments • Pull clavicle downward and toward the sternum • Acromioclavicular joint ligaments • Coracoclavicular ligament • Glenohumeral joint ligaments • Superior, middles, and inferior Shoulder Palpation #2 click here: shoulder palpation #2 Grade 1 AC Joint Sprain
INJURY • Grade 1: - point tenderness - Discomfort during movement - No deformity - Mild stretching of AC lig. Grade 2 AC joint Sprain
INJURY • Grade 2: - tearing or rupture of AC lig - Stretching or tearing of coracoclavicular lig - Displacement of distal end of clavicle - Moderate pain - Unable to abduct arm through full ROM Grade 3 AC joint Sprain
INJURY • Grade 3: - rupture of the AC &coracoclavicular lig - Dislx of the clavicle - Gross deformity - LOF - instability AC joint Sprain
INJURY TX: tape down, sling, refer for x-rays Special tests: Piano Key, Compression Piano Positive/Procedure Diagnosis Key -Push down on clavicle with -AC sprain fingers to find pain & Test movement of lateral clavicle Compression/ Positive/Procedure Diagnosis Squeeze -Squeeze clavicle & spine of -AC sprain scapula with heels of both Test hands to find pain & movement of lateral clavicle Glenohumeral Joint Sprain
MOI: forced abduction, external
INJURY rotation, direct blow S/S: pain w/ movement and palpation, decreased ROM TX: ROM, PREs Special tests: load and shift, Sulcus, Apprehension Crank GH Glide/ Positive/Procedure Diagnosis Load and Shift -Stabilize as you move the -GH joint sprain humeral head inferiorly, Test anteriorly, and posteriorly to find laxity compared bilaterally Sulcus Sign Positive/Procedure Diagnosis -Stabilize as you pull -GH joint sprain Test humerus inferiorly, eyes on the deltoid to see an observable gap Apprehension/Crank Test Positive/Procedure Diagnosis -passive put athlete into ER -GH joint sprain and look for athlete to be apprehensive or try to resistant movement Review Shoulder Muscle PRACTICE quiz
Shiny desk review 1 6
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12 Posterior deltoid Pectoralis minor Middle Pectoralis deltoid major Triceps Serratus brachii anterior Latissimus dorsi KEY Pectoralis major
Trapezius
Biceps Sternocleidomastoid brachii
Rhomboid major Movements Review PRACTICE quiz
• Shiny desk or scrap paper 1 6
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12 Abduction, extension Stabilize, breathing Abduction Flex., Add., IR, H. add. Extension Protraction
Ext., Add., IR, H. abd. KEY Flex., Add., IR, H. add.
Ele., Ret., Dep.
Flexion Flexion, rotation
Retraction Musculature write the muscles for each • Glenohumeral joint • Scapulothoracic joint movements movements • Flexion • Protraction • Extension • Retraction • Abduction • Depression • Adduction • elevation • External rotation • Internal rotation • Horizontal abduction • Horizontal adduction Shoulder Palpation: Click here: shoulder palpation #3 Bicipital Tenosynovitis
• MOI
INJURY • Overuse in overhead activity • S/S • Pain in the anterior upper arm over bicipital groove while performing overhead activity • Some swelling, crepitus • TX • Complete rest for a few days, NSAIDS, gradual PRE program • Special Tests: Yergasons, Speeds Yergason’s Test Positive/Procedure Diagnosis -resist supination from full -Biceps pronation to see if pain in tendinitis/Tenosynovitis distal biceps tendon Speed’s Test Positive/Procedure Diagnosis -resist shoulder flexion to -Biceps see if pain in proximal tendinitis/Tenosynovitis biceps tendon or bicipital groove Rotator Cuff Muscles
• Supraspinatus • Infraspinatus • Teres minor • Subscapularis Drop arm Test Positive/Procedure Diagnosis -actively go into full -Supraspinatus weakness abduction, then lower to 90 and hold to see if athlete has to drop the arm and cannot hold abduction Empty can Test Positive/Procedure Diagnosis -Athlete in IR and 30 -Supraspinatus weakness degrees of H. abd., ATC pushes arms down to see if pain or inability to hold position Shoulder Impingement
INJURY MOI: - acute: direct blow - Chronic: - Impingement - Tendonitis - Degeneration
* Mostly supraspinatus Shoulder Impingement
INJURY S/S: - complains of diffuse pain - Overhead activities increase pain - Painful arc - Pain on insertion of supraspinatus TX: PRICE, Strength, ROM, NSAIDS Special tests: Neer, Hawkins Kennedy empty can test, drop arm Neer’s Test Positive/Procedure Diagnosis -Passively put into IR and -Shoulder impingement or shoulder flexion to see if bursitis pain or pinching Hawkin’s-Kennedy Test Positive/Procedure Diagnosis -Passively put into shoulder -Shoulder impingement or and elbow 90 degree bursitis flexion, apply overpressure in IR to see if pain or pinching Shoulder ROM/MMTs
• Practice MMT’s on your partner
• Don’t forget to say the muscle you are testing! Bursa • Subacromial (subdeltoid) bursa • Most important • Subjected to trauma with overhead positions compressing the bursa under the coracoacromial arch Shoulder Bursitis
INJURY MOI: build up of fluid - chronic inflammation - Overuse - Direct impact - Fall on tip of shoulder * Subacromial bursa is most inflamed. Shoulder Bursitis
INJURY S/S: - pain with movement ( ab, add, IR) - Pain, tenderness TX: - RICE - NSAIDS - Strengthening, ROM Special tests: Neer, Hawkins-Kennedy • Nerve Supply • Brachial Plexus • C5-T1 • Blood Supply • Subclavian artery • Axillary artery • Brachial artery Thoracic Outlet Compression Syndrome (TOC) “stinger”
INJURY • MOI: compression of brachial plexus, and/or subclavian artery and vein. • S/S: paresthesia and pain Scapulohumeral Rhythm • Describes the movement of the scapula relative to the movement of the humerus through a full ROM of abduction • As humerus elevates 30° scapula doesn’t move (setting phase) • 30-90° ratio become 1:2 • Scapula rotates 1° for every 2° of humeral elevation • From 90° to full abduction (180) the scapula moves 1° for each 1° of humeral elevation • 1:1 ratio • www.chiroandosteo.com/content/15/1/17
Preventing Shoulder Injuries
• Proper total physical training through full ROM • Proper warm up • Instruction on how to properly fall • Not with out stretched hand/arm • Shoulder roll • Shoulder pads • Appropriate techniques must be taught Shoulder Assessment History A“Type of pain” pins and needles = radiating pain from cervical pathology sharp pain = acute inflammation dull, aching, sense of heaviness = chronic rotator cuff deep, aching pain in the neck/shoulder region = TOCS night pain = rotator cuff tear burning pain = acute tendinitis weakness, numbness = nerve pathology History
B“specific movements that cause pain” • neck = cervical spine injury • shoulder ER = dislocation/subluxation • above 90 degrees = ACJ History
• Normal activities • Ability to talk/swallow = SCJ • Which hand is dominant • Crepitus • Distortion in temperature • What movements hurt most Observation
From all sides • symmetry • level of shoulders • muscle wasting v. hypertrophy • deformities • discoloration • swelling • how the shoulder is carried Observation
Anteriorly • Step deformity at the ACJ = dislocation • Flat deltoid = anterior dislocation Observation
Laterally • kyphosis: shoulders slumped forwards • Forward or backward arm hang = scoliosis Observation
Posteriorly • muscle definition • scapulohumeral rhythm • scapular winging during flexion and abduction Posture assessment: Plumb line activity: Shoulder ONLY Static postural Assessments
• When you are properly aligned if facilitates proper joint mechanics, allowing the body to generate and accept forces throughout the kinetic chain and promotes joint stability and mobility.
• “Straighten the body BEFORE strengthening it” • Start by looking at clients posture • Observe client in all three planes • Body is in good posture when balanced around the body’s line of gravity • Represented by plumb line Plumb Line a.Objective: observe the client’s symmetry against the plumb line b.Make sure client is nice and relaxed in natural position Anterior PL placement overview • • • • • • • • • • Alignment: point) malleolimedialas reference equidistantfromline(use FacingfeetPL with the Clientbetween wall PLand Between feet Frontal bone Manubrium/mandible/maxilla Sternum Umbilicus Pubis Ankles Posterior PL placement Overview • • • • • Alignment: from suspended line w/insides ofthe heels equidistant Facing away from thePL Client between awallPL and Spinous process of spine reference Intersect sacrum (PSIS as Sagittal PL placement Overview • • • • • Alignment: malleolus immediately anterior to thelateral Facing sideways with the PLaligned Client between wallPL and • • Greater trochanter Anterior 3 line withorjust behindtheear lobe) Anterior to mastoid the process (in Acromioclavicular rd of the knee joint Plumb Line check list: • Frontal: • Overall body symmetry • Ankle: observe for pronation/supination • Knees: rotation and height discrepancies • Hip adduction: observe for shifting to a side as witnessed by the position of the pubis in relation to PL • Alignment of iliac crests • Alignment of torso: umbilicus and sternum in relation to the PL • Alignment of the shoulders • Arm spacing: space to the sides of the torso • Hand position: position relative to the torso (IR/ER) • Head position: alignment of the ears, nose, eyes, and chin Plumb Line check list: • Posterior View • Overall body symmetry: symmetric alignment of the left and right hemispheres • Alignment of the spine: vertical alignment • Alignment of the scapulae: inferior angle of scapula look for presence of winged scapula • Alignment of the shoulders • Head: alignment of the ears Plumb Line check list: • Sagittal view • Overall body symmetry: symmetrical alignment of load bearing joint landmarks with PL • Knees; flexion or extension • Pelvic tilting: relationship of ASIS to PSIS • Spinal curves: thoracic, kyphosis, lumbar lordosis, flat back • Shoulder position: forward rounding (protraction) of the scapula • Head position: neutral cervical curvature PRACTICE R L 1
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5 Time to practice • Using your Sagittal and frontal deviation charts write out the deviations that you observe • With your LAB partner you will work through the Ant/sagittal plane slides (the instructor will progress slides for reference) • We are focusing on the Thoracic/head neck region only Anterior Bony Palpation
clavicle sternoclavicular joint acromioclavicular joint Humeral head coracoid process Bicipital groove Posterior Bony Palpation
• spine of scapula • medial border of the scapula • inferior angle • lateral border Anterior soft tissue palpations
• SC, AC joint ligaments • Deltoid • Rotator cuff tendons • with thumb on subscapularis, second, third and fourth fingers will be over the insertion of other three rotator cuff muscles: supraspinatus, infraspinatus, teres minor • Sternocleidomastoid • Biceps muscle and tendon Posterior Soft tissue palpations
• Rhomboids • Levator scapulae • Trapezius • Supraspinatus • Infraspinatus • Teres major and minor • Lattisimus dorsi Special test review:
• KAHOOT Shoulder Rehab
Sports Med 2 Teach new posture:
• Most athletes have a “rounded” shoulder. • Must teach them to activate lower trapezius and rhomboids.
• “scaps” in back pocket and squeeze together Phase 1
Wall Walks Regains ROM in flexion and abduction (p. 582 Tubing ER, IR, Flexion, Extension, Abd., Add. Helps strengthen scapular stabilizers Strengthening (p. 586) I’s, Y’s and T’s Rhomboids: lying prone, Rowing Wall pushups Ceiling punches: lying supine punch towards ceiling Pendulum Regains ROM (p. 581) Phase 2 Stabilization Fist: lying supine, arm at 30,90, and 120 degrees of flexion, push fist in all directions Balancing Vibe plate Dot drill Pushups Regular Tubing Phase 2 • Stretching • Corner (pec. Major) • Sleeper (posterior capsule) • Posterior/anterior deltoid (capsule) • Triceps (inferior capsule) • Strengthening • I’s, Y’s and T’s with weight • Ceiling Punch with weight • Rhomboid row with weight Phase 3 • Plyometrics • Push up • Trampoline • Forward • side • Catch and throw med ball Phase 3 • Strengthening • I’s, Y’s and T’s on ball w/weight • Pushups • theraball • Tubing • D2 pattern • Balancing • theraball • PNF patterns Shoulder PNF • Ceiling Punch • Resist protraction and retraction • Pitching • Extend fingers, wrist, elbow, arm • Flex fingers, wrist, elbow and horizontal adduction (punch) across the chest. • Shrugs • Athlete does a shoulder shrug up and down with arm in 90 degrees of elbow flexion, examiner resists • Shiver • Athlete is supine with elbow in 90 degrees of flexion and moves their arm in flexion and extension • Examiner resists SLEEPER STRETCH for external rotators
PEC MINOR STRETCH for pectoralis minor