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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