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Overview
• Importance of pectoral girdle • Ligaments, ligaments…tensegrity • Bones, joints, muscles • Neurovasculature • Innervation…dermatomal and peripheral • Myofascial Pain Syndromes • It’s all connected!
• Deltoid • Trapezius • Infraspinatus • Supraspinatus • Teres minor • Subscapularis • Levator scapulae • Omohyoid
• Rhomboid minor • Rhomboid major • Serratus Anterior • Latissimus • Teres Major • Triceps – long head • Biceps –long, short • Coracobrachialis • Pectoralis Minor
Labrum
http://3doptimalperformance.blogspot.com/2009/12/3-d-shoulder-rotator-cuff-impingement.html
To The Extremity and Beyond….
• Supraspinatus Syndrome • Deltoid Syndrome • Teres Major Syndrome • Scapulocostal Syndrome • Thoracic Outlet Syndrome • Adhesive Capsulitis
Supraspinatus Syndrome (M79.7) • Symptom Presentation:
exquisite tenderness superior border of the scapula. Pain on ROM and pain referred to the shoulder in a non dermatomal pattern.
• Mechanics: repetitive overhead trauma, a single injury, or chronic deconditioning of the agonist and antagonist muscle unit.
Supraspinatus Syndrome
• Predisposing factors: weekend warrior, poor posture while typing or watching television, prior injuries that result in abnormal muscle function
• Treatment: Trigger point
injection (TPI) with local anesthetic or saline. Use of pregabalin if no response to TPI.
• Adjunt therapies: PT, therapeutic heat and cold, transcutaneous nerve stimulation, and electrical stimulation
Deltoid Syndrome (M79.7) • Symptom Presentation:
trigger points in both the anterior and posterior deltoid fibers.
• Mechanics: Flexion-extension and lateral motion stretch injuries, repetitive lifting or impact injuries.
Deltoid Syndrome
• Predisposing factors: weekend warrior, poor posture while typing or watching television, prior injuries that result in abnormal muscle function
• Treatment: Trigger point
injection (TPI) with local anesthetic or saline. Use of pregabalin if no response to TPI.
• Adjunt therapies: PT, therapeutic heat and cold, transcutaneous nerve stimulation, and electrical stimulation
Teres Major Syndrome (M79.7)
• Symptom Presentation: trigger points lateral to scapula. • Mechanics: Stretch or impact injuries sustained while
playing sports or MVAs in addition to falls onto the lateral scapula. Repetitive reaching up and behind
Teres Major Syndrome
• Predisposing factors: weekend warrior, poor posture while typing or watching television, prior injuries that result in abnormal muscle function
• Treatment: Trigger point
injection (TPI) with local anesthetic or saline. Use of pregabalin if no response to TPI.
• Adjunt therapies: PT, therapeutic heat and cold, transcutaneous nerve stimulation, and electrical stimulation
Scapulocostal Syndrome (G56.80) • Symptom Presentation:
Unilateral pain and paresthesias at medial scapula. Referred pain from deltoid to dorsal hand. Decreased scapula ROM.
• Mechanics: repetitive reaching backward to retrieve items causing overuse of scapular stabilization muscles.
Scapulocostal Syndrome
• Predisposing factors: weekend warrior, poor posture while typing or watching television, prior injuries that result in abnormal muscle function
• Treatment: Trigger point
injection (TPI) with local anesthetic or saline. Use of pregabalin if no response to TPI.
• Adjunt therapies: PT, therapeutic heat and cold, transcutaneous nerve stimulation, and electrical stimulation
Travelling Salesman’s Shoulder
What If no improvement after TPI?
• …tight muscles • …overstretched muscles • …weakness of other surrounding muscles • …cross pattern imbalance • …primary hypermobility of joint • …additional injury
Thoracic Outlet Syndrome (G54.0)
• Symptom Presentation: ache or paresthesias at neck with radiation into the shoulder
• Mechanics: compression of the neurovascular bundle due to cervical rib, hypertonicity of anterior and middle scalenes, somatic dysfunction of the clavicle or upper ribs, abnormal insertion of the pectoralis minor
Thoracic Outlet Syndrome
• Special tests – Adson’s (compression between the scalenes), Wright’s (compression under the pectoralis minor), Military posture (compression between clavicle and 1st rib).
• Treatment – OMT, PT, OT, gabapentin, carbamazepine (SE: aplastic anemia), pregabalin, baclofen, nerve block
Adhesive Capsulitis (M75.00)
• Symptom Presentation: aching anterior shoulder, grating/ popping and decreased PROM/ AROM typically after prolonged immobility and age over 40 years. Pain affects sleep.
• Worse with abduction, internal and external rotation. Extension is typically preserved.
• Mechanics: formation of fibrous adhesions.
Two Categories
Within Shoulder • Rotator Cuff
Tendinopathy • Subdeltoid Bursitis • Biceps Tendinopathy
Other Diseases • Stroke • Diabetes • Myocardial Infarction • Reflex Sympathetic
Dystrophy
Adhesive Capsulitis
• Prevention is the best treatment option; early mobilization after shoulder injury. Treatment – NSAIDs, COX-2 inhibitors, PT, rest, heat, corticosteroid injection, NSAIDs, rest, heat; OMT – Spencer technique, GH joint, upper thoracic
Resources • Abbasi, D. & Keener, J. Biceps Tendonitis. Retrieved from https://www.orthobullets.com/shoulder-and-
elbow/3045/biceps-tendonitis
• Armstrong, A. D. & Hubbard, M. C. (2016) Essentials of Musculoskeletal Care – 5th Ed. Rosemont, IL: American Academy of Orthopedic Surgeons
• Chung, K. W. & Chung, H. M. (2008) BRS Gross Anatomy – 6th Ed. Baltimore, MD: Lippincott Williams & Wilkins.
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• Waldman, S. D. (2012) Atlas of Common Pain Syndromes – 3rd Ed. Philadelphia, PA: Elsevier.