Introduction

1. Introduction • The function of the shoulder allows the greatest range of motion of any joint in the body. • This great range of motion can also lead to several common problems affecting the shoulder joint. • In other words, the shoulder is built for motion, not stability

2. Considerations • What happens to the ROM during flexion if the arm is externally and internally rotated? Why? • Which arm can you reach furthest up your back with? • Why?

3. Bones • The bones of the shoulder include the humerus, the scapula, and the clavicle. • A “roof” of the shoulder is formed by a part of the scapula called the acromion.

4. Joints • There are actually two joints around the shoulder • The glenohumeral joint or the shoulder joint • The acromioclavicular (AC) joint where the clavicle meets the acromion.

5. Joint Capsule • The joint capsule is made by a group of ligaments that connect the humerus to the socket of the shoulder joint on the scapula. • Three ligaments are the main source of stability for the shoulder, and help to keep the shoulder from dislocating. • Coracohumeral ligament • Middle glenohumeral ligament • Inferior glenohumeral ligament

6. Bursa • Sandwiched between the rotator cuff muscle layer and the outer layer of large bulky muscles is a structure known as a bursa. • A bursa is simply a closed space between two moving surfaces that has a small amount of lubricating fluid inside

8. Ligaments • Ligaments are soft tissue structures that connect bones to bones. • The acromioclavicular ligaments that attach the clavicle to the acromion • The coracoclavicular (2)ligaments connects the clavicle to the coracoid process. • The coracoacromial ligament connects the coracoid process and the acromion process Coracoacromial ligament

9. coracoclavicular coracoacromial

12. A Guide to Shoulder Problems http://www.castleortho.com/group/shoulder/default.htm

13. Shoulder Injuries • Impingement/Bursitis • Rotator Cuff Tear • Acromioclavicular(AC) Joint Separation • Shoulder Instability • Labral Tear

14. Impingement Syndrome

15. Impingement Syndrome • The supraspinatus tendon connects the humerus with the scapula (shoulder blade) and helps raise and rotate the arm. • As the arm is raised, the supraspinatus tendon also keeps the humerus tightly in the socket (glenoid) of the scapula. 

16. Impingement Syndrome • The part of the scapula that makes up the roof of the shoulder is called the acromion process.  • Between the acromion process and the supraspinatus tendon there is a bursa.  • The bursa is a lubricated sac of tissue that protects the muscles and tendons as they move against one another.  • The bursa simply allows the moving parts to slide against one another without too much friction.

17. Impingement Syndrome

18. Impingement Syndrome • If any condition decreases the amount of space between the acromion and the supraspinatus tendon,  the impingement process may get worse. • Swelling • Bone spurs • Anatomical structure 

19. Impingement Syndrome

20. Rotator Cuff Tears

21. Rotator cuff • Subscapularis • Supraspinatus • Infraspinatus • Teres minor

22. Movement of RC Muscles • Subscapularis is an internal rotator of the arm. • Supraspinatus assists the deltoid in abducting the arm, with its greatest contribution being the initiation of abduction. • Infraspinatus and teres minor muscles both externally rotate the arm.

23. Rotator Cuff Injury • The throwing motion has been divided into five phases: wind-up, cocking, acceleration, and follow-through. • Cocking phase • Supraspinatus, infraspinatus, and teres minor muscles begin to fire at the end of early cocking phase • Subscapularis subsequently fires in late cocking to decelerate the shoulder's external rotation. Also, it is stretching during the cocking phase.

24. Rotator Cuff Injury • Follow-through (muscles fire most intensely) • Subscapularis internally rotates the shoulder, • Remaining rotator cuff muscles are contracting eccentrically to decelerate the arm and are stretched. • During this repetitive eccentric loading, the rotator cuff is prone to overload, fatigue, tendinitis, and even a partial undersurface tear.

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

27. Shoulder Separation

28. Shoulder Separation • A shoulder separation is a fairly common injury, especially in an athletic population.  • A shoulder separation is actually a dislocation of the acromioclavicular (AC) joint.  • Some people mistake this for a shoulder dislocation, and vice versa.  • This is a very different injury than a shoulder dislocation. 

29. Grades of Shoulder Separation

30. Shoulder Separation • The most common cause of an acromicoclavicular (AC) joint separation is a fall on the shoulder.  • As the shoulder strikes the ground, the force from the fall pushes the scapula down.  • The clavicle, because it is attached to the rib cage, cannot move down enough to follow the motion of the scapula.  • Something has to give, and the ligaments around the acromioclavicular (AC) joint begin to tear - separating, or dislocating, the joint.   

31. Shoulder Dislocation & Instability

32. Shoulder Dislocation • If the shoulder slips completely out of the socket, it has become dislocated.   • 97 out of 100 dislocations are anterior. • 3 out of 100 dislocate posteriorly. • Repeated dislocations are not only a nuisance, but can cause further injury to the shoulder and can lead to arthritis of the shoulder if not treated.

33. The ligaments that make up the joint capsule have a considerable amount of slack, or looseness, so that the shoulder is unrestricted as it moves through its rather large range of motion.  Sometimes the shoulder does not come completely out of the socket but slips partially out and then returns to its normal position. This is called subluxation.  Shoulder Subluxation

34. Shoulder Instability • Instability means that the shoulder is too loose and has a tendency to slip out of the socket, (or glenoid fossa).  • This initial injury is usually fairly significant and the shoulder must be reduced, or put back into the socket, by a physician.  • After that first violent injury that causes the shoulder to dislocate, the joint may remain unstable.   • The ligaments that are supposed to hold the shoulder in the socket may not heal back properly, or they may remain stretched and too loose to keep the shoulder in the socket in certain positions. 

35. Glenoid Labrum

36. Labral Tear • A part of the scapula, called the glenoid cavity, makes up the socket of the shoulder.  • This socket is very shallow and flat.  • To make the socket more like a cup, there is a rim of soft tissue called the labrum.  

37. Labral Tear • The labrum acts sort of like a gasket, turning the flat surface of the glenoid into a deeper socket that molds to the head of the humerus for a better fit. • A tear of labrum can cause a very difficult to diagnose problem of pain and a catching sensation with movement of the shoulder. 

38. Labral Tear • This tissue can be caught between the socket and the humerus and be torn. • This flap of tissue can move in and out of the joint, getting caught between the humeral head and glenoid socket, and cause pain and catching.  • The labrum is also the area for attachment of several of the tendons and ligaments of the shoulder.  • The ligaments that attach to the labrum help with maintaining the stability of the shoulder. 

39. Labral Tear • Most labral tears are probably the result of an injury to the shoulder, such as falling on an outstretched hand.  • There is reason to believe that the excess motion of the humerus moving around on the glenoid may cause damage to the labrum over time.   • An unstable shoulder may also cause injury to the labrum, if it repeatedly dislocates out of the glenoid.

40. Exercises • www.bodybuilding.com/fun/shoulders • www.bestpersonaltraining.com/aze.htm

41. Shoulder action = ? Shoulder muscle(s) = ? Scapula action = ? Scapula muscle(s) = ? Upward Rotation Abduction Deltoid Ser. Ant., Trap (lower)

42. Shoulder action = ? Shoulder muscle(s) = ? Flexion Ant Deltoid Upper Pect Major Coracobrach

43. Shoulder action = ? Shoulder muscle(s) = ? Scapula action = ? Scapula muscle(s) = ? Horz. Add. Ant. Deltoid Pect. Major Coracobrach. Abduction Pect. Minor Ser. Ant.

44. Scapula action = ? Scapula muscle(s) = ? Elevation Lev. Scap. Rhomboids Up. & Mid. Trap

45. Shoulder action = ? Shoulder muscle(s) = ? Scapula action = ? Scapula muscle(s) = ? Hor. Abd Adduction Rhomboid Upper and Mid. Trap. Lat. Post. Deltoid Teres Minor Infraspinatus

46. Shoulder action = ? Shoulder muscle(s) = ? Scapula action = ? Scapula muscle(s) = ? Downward Rotation Adduction Pect. Major Coracobrach. Lat. Teres Major Pect. Minor Rhomboid

47. Shoulder action = ? Shoulder muscle(s) = ? Scapula action = ? Scapula muscle(s) = ? Adduction Horizontal Add Ant. Deltoid Pect. Major Coracobrach. Rhomboid Upper and Mid. Trap.

48. Shoulder action = ? Shoulder muscle(s) = ? Scapula action = ? Scapula muscle(s) = ? Adduction Extension Rhomboid Upper and Mid. Trap. Lats Teres Minor Post. Deltoid

49. Shoulder action = ? Shoulder muscle(s) = ? External Rotation Infrspinatus Teres Minor

50. Rotator Cuff Exercises External Rotation Internal Rotation Internal Rotation