UNDERSTANDING ATHLETICRELATED INJURIES TO THE UPPER EXTREMITY Shoulder

UNDERSTANDING ATHLETICRELATED INJURIES TO THE UPPER EXTREMITY Shoulder Injuries David Smith

ANATOMY OF THE SHOULDER Ball and Socket Joint Great degree of mobility, therefore it is highly susceptible to injury Many sports activities, in particular those that involve repetitive overhead movements place a great deal of stress on the supporting structures Throwers, volleyball swimmers, football, serving in tennis or

MAJOR BONES OF SHOULDER JOINT Humerus Scapula Clavicle Sternum

HUMERUS Head of the humerus articulates with the scapula’s shallow glenoid fossa Bicipital groove for biceps tendon. It fits between the greater and lesser tuberosity

SCAPULA Glenoid Cavity Situated laterally on the scapula inferior to the acromion and is relatively shallow The glenoid labrum increases the depth of the articulation

SCAPULA Three prominent projections Spine Divides the posterior scapula unequally Supraspinatus fossa and Infraspinatus fossa Acromion Sits at the lateral tip of the spine of the scapula. Tip of the shoulder Coracoid Process “Hooklike Projection” arises anteriorly from the scapula. Curves upward, forward, and outward in front of the glenoid fossa

CLAVICLE S- shaped bone Supports the anterior portion of the shoulder Articulates at tip of shoulder with the acromion and at the sternum near throat

CLAVICLE Medial 2/3 bends convexly forward, and the lateral 1/3 is concave The point at which the clavicle changes shape and contour presents a structural weakness Fractures occur at this point (The Middle 1/3)

ANATOMY OF THE SHOULDER CONT… Scapula Serves mainly as an articulating surface for the head of the humerus Glenoid Cavity Situated laterally on the scapula inferior to the acromion and is relatively shallow The glenoid labrum increases the depth of the articulation Serves as the site for many muscle attachements

A. Bony Components 1. Clavicle: Collarbone 2. Scapula: Shoulder blade 3. Humerus: Upper arm

ANATOMY OF THE SHOULDER CONT… Articulations Sternum and Clavicle Acromion and Clavicle Glenoid cavity and Humerus Scapula and Thoracic cage

ANATOMY OF THE SHOULDER CONT… Joints Acromioclavicular Joint (AC) Acromion Process of Scapula and distal end of Clavicle Weak junction

ANATOMY OF THE SHOULDER CONT… Glenohumeral Joint (GH Joint) Head of humerus and glenoid fossa Ball and socket, very mobile Very shallow, very susceptible to injury Deepend by the glenoid labrum

ANATOMY OF THE SHOULDER CONT… Sternoclavicular Joint (SC Joint) Clavicle articulates with the manubrium of the sterum Allows the clavicle to move up and down, forward and backward, in combination, and in rotation

ANATOMY OF THE SHOULDER CONT… Scapulothoracic Joint Not a true joint- movement of the scapula on the wall of thoracic cage is critical to shoulder joint motion Scapular muscles attach the scapula to the axial skeleton is critical to stabilizing the scaupla

F. Major Joints of the Shoulder Region Sternoclavicular joint (SC): Sternum articulates with the clavicle Acromioclavicular joint (AC): Scapulas acromion process and clavicle articulate. Very weak joint

Coracoclavicular Joint (CC): Clavicle and the scapulas coracoid process articulate 4. Glenohumeral joint: ball and socket joint, humerus articulates with the scapulas glenoid cavity. Glenoid labrum deepens the joint so the humerus can move. The joint is surrounded by synovial capsule 3.

Other Anatomy

ANATOMY OF THE SHOULDER CONT… Muscles Acting on the Glenohumeral Joint Originating on the scapula and attaching to the humerus Rotator Cuff (Decelerator Muscles) Supraspinatus Infraspinatus Teres Minor Subscapularis All responsible for internally and externally rotating the arm, as well as abduction

B. Muscles: see handout for location of rotator cuff muscles Four muscles of the rotator cuff: SITS Supraspinatus: abduction of the arm Infraspinatus: external rotation of the arm Teres Minor: external rotation of the arm Subscapularis: internal rotation of the arm

ANATOMY OF THE SHOULDER CONT… Deltoid Abducts, flexes, and extends the shoulder Pectoralis Major and Minor Biceps and Triceps

MAJOR MOVEMENTS OF THE SHOULDER Flexion Extension IR ER Abduction Adduction

PREVENTING SHOULDER INJURIES Most often caused by: Weakness Postural problems Nature of game (overhead movements)

MUSCULAR WEAKNESS AND POSTURAL PROBLEMS CAN CAUSE INJURIES Out of sight, out of mind Weakness on posterior side Rotator Cuff (Decelerators)!! Rounded shoulders Tight pectorals and weak posterior muscles Constant use of one muscle Swim, baseball, volleyball…etc Balancing out the use Proper techniques

LIGAMENT INJURIES Sternoclavicular Ligament Sprain (SC) Separation of SC Joint Injured by falling on lateral side of shoulder Hit in sternum with violent force Acromioclavicular Ligament Sprain (AC) Shoulder separation, 1 -3° sprain Injured by impact to the top of shoulder or by falling on an outstretched arm Glenohumeral Ligament Sprain (GH) Vulnerable when in abduction and external rotation Dislocation and subluxation

Sprains to Joint-can occur in 3 major joints Sternoclavicular Sprain: Uncommon injury, occurs when the Medial end of clavicle is displaced. A 3 rd degree is life threatening due to pressure placed on blood vessels, esophagus, or trachea

GRADES OF AN SC SPRAIN

2. Acromioclavicular Sprain (separated shoulder): AC joint is extremely vulnerable to sprains. Caused by a direct blow to tip of the shoulder or landing on an outstretched arm or elbow, may also occur with a blow from behind the shoulder

Ø 1 st degree: Minor stretching and tearing, AC has point tenderness

Ø 2 nd degree: Partial tearing, cannot fully abduct arm

Ø 3 rd degree: complete rupture of ligament, dislocation.

ACROMIOCLAVICULAR SEPERATION

AC JOINT SEPARATION

CLINICAL APPEARANCE OF AC SEPARATION

MUSCLE AND TENDON INJURIES Most caused by overuse Throwing, stroke shooting, or repeating a swim

MUSCLE AND TENDON INJURIES Rotator 1°- Cuff Strain pain with no loss of ROM or stability 2°- pain with some loss of ROM and stability 3°- pain with partial or complete loss of ROM and stability

MUSCLE AND TENDON INJURIES CONT… Rotator Cuff Strain Occur because of excessive motion beyond the normal range Most often, Supraspinatus Repetitive motions -> result in crepitus and impingement syndrome Rehab- RICE and gentle strengthening and flexibility exercises

MUSCLE AND TENDON INJURIES CONT… Impingement Repetitive Syndrome overhead types of movement freestyle swimmers, throwers, and tennis players Supraspinatus and biceps run through space beneath acromion process Rehab- strengthening posterior muscles, modifying activity, and improving flexibility of pectorals

IMPINGEMENT SYNDROME

Rotator Cuff Impingement Syndrome: Impression of supraspinatus tendon between head of the humerus and the acromion process. Symptoms: Aching and pain when abducting the arm above 90 degrees.

MUSCLE AND TENDON INJURIES CONT… Bicipital Tendonitis Very common Repetitive nature causes irritation of tendon in bicipital groove Rehab- stop repetitive action, immobilization, heat, antiinflammatory medications

7. Bicipital Tendonitis: Irritation of the long head of the biceps tendon in the bicipital groove

MUSCLE AND TENDON INJURIES CONT… Biceps tendon rupture Direct forces blow or severe contractile Unable to flex elbow Looks like a golf ball under skin Rehab- ice and immobilization, refer to physician for surgical repair

BONE INJURIES Clavicle At Fracture weakest pt- middle 1/3 Immobilization and Ice, physician will set clavicle in place using a harness May need surgery if displaced

Clavicle Fracture: Nearly 80% of all clavicle fractures occur in the middle 1/3 of clavicle. Caused by direct blow or fall on outstretched arm. Athlete will hold arm and tilt head toward clavicle and chin is turned the opposite side.

CLAVICLE FRACTURE

CLAVICLE FRACTURE

CLAVICLE SURGERY REPAIR

Humeral Fractures- May be hard to detect because of musculature unable to move arm and experiencing pain, most likely felt or heard a pop Splint, and check distal pulse

BONE INJURIES CONT… Epiphysis Growth Injury plate in young athlete Direct or indirect blow Mimic humeral fx- pain, inability to use arm, guarding, feeling/hearing pop Can cause permanent growth impairment Rehab- ice, splint, and refer to physician

BONE INJURIES CONT… Avulsion Tearing Fracture bone off with ligament May accompany a AC or GH sprain P! associated with fx Almost IMPOSSIBLE to detect unless r/o by x-ray Splint and ice, refer to MD

BONE INJURIES CONT… GH Dislocations and Subluxations Dislocation: socket Head of humerus is out of the Complete disruption of joint Subluxation: Head of humerus went out of socket and then back in Partial disruption of joint

DISLOCATIONS AND SUBLUXATIONS Excessive Anterior Pain abduction and external rotation is most common and inability to use shoulder, deformity at deltoid muscle

GH Dislocations and Subluxations X-ray is necessary to determine extent of injury Permanent changes to the nerves, cartilage, and blood vessels Rehab: strengthen muscles of adduction and internal rotation, restrict abduction and external rotation, Harness and Surgery is likely

4. Dislocation to the Glenohumeral Joint: Anterior displacement of the humerus is caused by forced abduction and external rotation. Dislocation can tear the capsule, ligaments and labrum. Displays a flattened deltoid and severe pain and disability. Injury is beyond the scope of an athletic trainer’s duties, athlete needs a referral for x-rays and reduction.

SHOULDER DISLOCATION

QUESTIONS What are the bones of the shoulder joint? (4 Bones) What are the 4 joints of the shoulder girdle? (4) What are the 4 muscles of the rotator cuff? What is the rotator cuff known as? (Think function) What are the differences in rotator cuff strains? What is the difference b/n dislocation and subluxation?

END OF SHOULDER ANATOMY

HANDS ON…. Point to each bones in the shoulder girdle Locate each joint in the shoulder girdle Demonstrate special tests?