UNDERSTANDING ATHLETIC-RELATED INJURIES TO THE UPPER EXTREMITY

Shoulder Injuries

David Smith

ANATOMY OF THE SHOULDER

Ball and Socket JointGreat 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 structuresThrowers, swimmers, football, serving in

tennis or volleyball

MAJOR BONES OF SHOULDER JOINT

HumerusScapulaClavicleSternum

HUMERUSHead 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 CavitySituated laterally

on the scapula inferior to the acromion and is relatively shallow

The glenoid labrum increases the depth of the articulation

SCAPULAThree prominent projections

SpineDivides the posterior scapula unequallySupraspinatus fossa and Infraspinatus

fossa

AcromionSits 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 boneSupports 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 RegionSternoclavicular

joint (SC): Sternum articulates with the clavicle

Acromioclavicular joint (AC): Scapulas acromion process and clavicle articulate. Very weak joint

3.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

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)SupraspinatusInfraspinatusTeres MinorSubscapularis

All responsible for internally and externally rotating the arm, as well as abduction

B. Muscles: see handout for location of rotator cuff musclesFour 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 mindWeakness on posterior sideRotator Cuff (Decelerators)!!

Rounded shouldersTight pectorals and weak posterior

muscles Constant use of one muscle

Swim, baseball, volleyball…etcBalancing out the useProper 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 3rd 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

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

2nd degree: Partial tearing, cannot fully abduct arm

3rd 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, shooting, or repeating a swim stroke

MUSCLE AND TENDON INJURIES

Rotator Cuff Strain1°- pain with no loss of ROM or

stability2°- pain with some loss of ROM

and stability3°- pain with partial or complete

loss of ROM and stability

MUSCLE AND TENDON INJURIES CONT…

Rotator Cuff StrainOccur because of excessive

motion beyond the normal rangeMost often, Supraspinatus

Repetitive motions -> result in crepitus and impingement syndrome

Rehab- RICE and gentle strengthening and flexibility exercises

MUSCLE AND TENDON INJURIES CONT…

Impingement SyndromeRepetitive overhead types of

movementfreestyle 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 TendonitisVery commonRepetitive nature causes

irritation of tendon in bicipital groove

Rehab- stop repetitive action, immobilization, heat, anti-inflammatory medications

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

MUSCLE AND TENDON INJURIES CONT…

Biceps tendon ruptureDirect blow or severe

contractile forcesUnable to flex elbowLooks like a golf ball under skin

Rehab- ice and immobilization, refer to physician for surgical repair

BONE INJURIES

Clavicle FractureAt weakest pt- middle 1/3Immobilization 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 musculatureunable to move arm and experiencing pain, most likely felt or heard a pop

Splint, and check distal pulse

BONE INJURIES CONT…

Epiphysis InjuryGrowth plate in young athleteDirect or indirect blowMimic 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 FractureTearing bone off with ligamentMay accompany a AC or GH

sprainP! associated with fx Almost IMPOSSIBLE to detect

unless r/o by x-raySplint and ice, refer to MD

BONE INJURIES CONT…

GH Dislocations and SubluxationsDislocation: Head of humerus is

out of the socketComplete disruption of joint

Subluxation: Head of humerus went out of socket and then back inPartial disruption of joint

DISLOCATIONS AND SUBLUXATIONS

Excessive abduction and external rotation

Anterior is most common

Pain 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?