The shoulder by R4ESKfSG

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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


              A-C Joint




      Conoid ligament
Common Glenohumeral
Problems

Rotator cuff tendinitis
Rotator cuff tears
Bicipital tendinitis, rupture
Glenohumeral dislocation/subluxation
Labral Tears
Frozen shoulder syndrome
Arthritis
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

                          • Full passive motion
                          • Begin active-assisted
                            motion
Phase 2 (6 to 12 weeks)   • Strengthen intact cuff
                            muscles
                          • Begin to strengthen the
                            muscles that stabilize the
                            shoulder blade
                           •Passive stretching beyond
                           the patient's own range of
                           motion
Phase 3 (12 to 16 weeks)   •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
    Impingement                   intimate with joint
                                  capsule.
                                 May be impinged
                                  beneath acromion, or
                                  sheared within
     Shear in bicipital groove    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 side
Rare in African-Americans
Glenohumeral/Scapulothor
acic 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 motion
FINAL 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




          Posterior tear     Anterior 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 rythym
external rotation with abduction
scapular plane
Muscles-RTC(rotator cuff muscles) SITS
supraspinatus-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 dorsi
Deltoid-ant, mid and post portion
Origin: ant portion-lateral 1/3rd of
 clavicle
mid-acromion, post-spine of scapula
Insertion-deltoid tuberosity of humerus
and med rotate, post fibers extend and
 laterally rotate
innervation-axillary (C5,6)
supraspinatus:
origin-supraspinatus fossa of scapula
insertion-greater tubercle of humerus
action- 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 fossa
insertion-greater tubercle and shld
 capsule
innervaton-suprascap nerve
action-ext rotation of shoulder and
 depression of humeral head and
 stabilizes head during movement
Teres minor-origin-upper lateral border
 of scapula
insertion-greater tub and shoulder
 capsule
action-lat rotation and add of humerus
Subscapularis-origin-subscapular fossa
insertion-lesser tubercle of humerus
 and capsule
action-int rotation of humerus and
 works with other ms.
Innervation-subscapular (C5-7)
Teres major-origin-acillary border of inf
 angle of scap
insertion-med tip of inter groove
action-med rotation, adduction and
 shouler ext
Innervation-lower subscapular(C5-7)
Axioscapular-pect minor:
origin-ribs 3,4,5 and fascia of
 intercostal ms
insert-coracoid process
action-elevation and downward rot of
 scap
innervation-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
Rhomboid major-origin-spinous process
 T2-5
insertion-vertebral border
action-down rotation, elevation and
 adduction of scap
innervation-dorsal scapular (C4-5)
rhomboid minor-origin-spinous
 processes C7-T1
insert-root of spine of scap
action-same as major
inn-same as major
Levator scapula-origin-transverse
 processes C1-4
insertion-sup med border of scap
action- elevation, down rotation and
 add of scap
innervation-dorsal scapular
Serratus anterior-origin-upper 8-9 ribs
 ant surface
insertion -medial, inf surf of scap
action-up rot, elevation and abduction
inn-long thoracic (C5-7)
Axiohumeral-
Pectoralis major-origin:clavicle, sternum
 and cartilage of first 6-7 ribs
insert-lat inter. Groove
action: med rotation, flexion and
 horizontal adduction
Latissimus dorsi-origin-sp processes of
 T6-12, last 3 ribs, thoracolumbar fascia
 and iliac crest
insert-inter groove
action-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
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 tendon
RTC 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
Onset-gradual, will see increase activity
 of upper traps
Impingement 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 injury
II-fiborsis and tendinitis (20-40
 yo)recurrent pain with activity
III-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
 diseases
C-T scans-specific for bone
MRI-magnetic resonance imaging-soft
 tissue-no radiation as in X-ray
angiography-contrast mat injected into
 vascular system
myelograpy-inject dye into SA space
EEG-records brain electrical activity
EMG and NVC-see if diseases are
 neuromuscular in origin
arthrogram-injects dye and air-views jt
 space, cartilage, ligs

								
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