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by: Jerrell Klein


Jerrell Klein
GPA 3.93


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Class Notes
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This 14 page Class Notes was uploaded by Jerrell Klein on Saturday September 12, 2015. The Class Notes belongs to KINS 3200 at University of Georgia taught by Cooper in Fall. Since its upload, it has received 59 views. For similar materials see /class/202065/kins-3200-university-of-georgia in Kinesiology at University of Georgia.

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Date Created: 09/12/15
Ch 17 Shoulder Pathologies 212012 52200 PM Shoulder Anatomy o Bony Anatomy 0 O O O O O O O O Formed by the sternum clavicle scapula and humerus Shallow articular surfaces inconsistent ligamentous support and increased reliance on dynamic support through muscle activity Bones are not designed for weight bearing Much smaller than the lower extremity Precise degree of ROM strength and coordination must be maintained between these bones to ensure efficient biomechanics Manubrium Serves as site of attachment for each clavicle Clavicle Elevates and rotates to maintain alignment of the scapula Allows for additional motion when the arm is raised Prevents excessive anterior motion of scapula Scapula Attached to the torso by the clavicle Held to the torso by muscles AngleofInclination Relationship between the shaft of the humerus and the humeral head in the frontal plane AngleofTorsion Relationship between the shaft of the humerus and the humeral head in the transverse plane 0 Joints of the Shoulder Complex 0 Sternoclavicular SC Joint Least mobile joint in shoulder motion Poorest bony stability of any of the major joints Surrounded by a synovial membrane Dislocates posteriorly a May puncture lungs or jugular Usually occurs with fracture due to large force Ligaments n Anterior and posterior sternoclavicular n Interclavicular n Costoclavicular o Acromioclavicular Joint AC Least mobile joint in shoulder motion Gliding articulation with a synovial membrane Ligaments n Acromioclavicular ligament o Anterior and posterior bands n Coracoclavicular ligament o Provides most of the joint s intrinsic stability o Trapezoid 0 Lateral 0 Limits lateral movement of clavicle over acromion o Conoid o Restricts superior movement of the clavicle o Scapulothoracic Articulation Changes in mobility at either the AC or SC joints influence the movement of the scapulothoracic articulation o Glenohumeral Joint Formed by the head of the humerus and the scapula s glenoid fossa Ball and socket joint Motions occur in multidirections and multi planes Large ball small socket loose joint capsule and weak ligamentout support Glenoid Labrum n Increases articular surface and deepens the socket n Acts as a suction cup to keep humeral head in socket Joint Capsule n Arises from labrum and glenoid fossa and blends with rotator cuff muscles Ligaments n Glenohumeral Ligament o Reinforces the capsule o Superior middle and inferior o Thickenings in the joint capsule o Motion limited by the position of the humerus o Foramen of Weitbrecht 0 Area between the superior and middle GH ligaments 0 Weak site in the capsule often torn in anterior dislocations n Coracohumeral Ligament o Merges with superior capsule and supraspinatus tendon 0 Coracoacromial Arch n Protects superior portion of the acromion process to the posterior portion of the coracoid process a Protects bursa tendons etc from direct trauma n Provides restraint against superior and anterior dislocations n Involved with impingement syndrome 0 Muscles of the Shoulder Muscle imbalance leads to injury People are usually more muscular anteriorly n Posterior muscles are important in deceleration Scapular Musculature a Two main functions o Control position of glenoid fossa o Keep scapula fixated so that it is in contact with the thoracic cage n Rhomboid Minor o Retraction and medial border elevation o Assists in controlling hypermobility during the deceleration phase of throwing motion o Controls winging n Serratus Anterior o Scapular protraction and fixation of scapula o Weakness causes winging n Muscles and Function Lats depression Levator Elevation Scapulae Rhomboids Retraction updown rot Serratus Protraction elevation Anterior up rot Upper Trap Elevation up rot Mid Trap Retraction Low Trap Depression down rot Pec Major Depression Pec Minor Anterior tilt Rotator Cuff Musculature n Supraspinatus o Increases contact area between humeral head and glenoid fossa o Test it in the scaption plane a Infraspinatus o Tight one may be a reason for winging n TeresMinor o Keeps head in the fossa n Pull medially n Whenever we abduct o Supraspinatus pulls humeral head into glenoid fossa while deltoid elevates the humerus I Supraspinatus I Abduction ER I I Infraspinatus I ER horizontal abd I Teres Minor I ER horizontal abd I I Subscapularis I IR Other Humeral Musculature Biceps Brachii Forward flexion Coracobrach Adduction flexion Anterior Deltoid Flexion h add IR abd Middle Deltoid Abduction flexion Posterior Deltoid Extension h abd ER Lats Extension IR adduction Pec Major Add h add flex IR dep Teres Major ER h abd Triceps Extension adduction Bursa of the Shoulder Complex n Buffer supraspinatus tendon against its contact with the acromion process and coracoacromial ligament n Subacromial Bursa o Inferior to supraspinatus as it goes through subacromial arch n Subdeltoid Bursa o Above the supraspinatus below the deloid Scapulothoracic Rhythm 1 Clinical Examination of Shoulder Injuries o History 0 Determine onset and duration of condition and location of pain 0 Past Medical History Previous injuries can alter biomechanics of the GH or AC History of cervical spine injury can cause problems 0 History of Present Condition Location of the pain a Helps us rule out certain conditions and localize our examination o Onset of symptoms Indicates the underlying pathology Chronic vs acute issues Provides many clues 0 Activity and injury mechanism Repeated overhead throwing Direct blow Ask sport specific questions a Find out where their arm slot is if they are a thrower n Find out what kind of serve they have etc a See at what point in their activity the pain begins 0 Symptoms How the patient describes their discomfort 0 Observation 0 Functional Assessment Observe their willingness to move affected limb Observe their functional activities Carry ADLs sport specific activities Scapular winging Pain Location a Follow Through RC pathology n Cocked position instability or impingement n Deceleration SLAP bicep pathology a Loss of ControlVelocity int impingement o Anterior Structures Observe differences in shoulder levels a Overmusculature on one side Position of the Head u If the head is side bent or rotated muscle spasm cervical spine injury or nerve compression may be indicated Position of the arm n Arm splinted to the side dislocation or subluxation n Arm hanging limp possible brachial plexus Contour of Clavicles n Inspect for deformity indicating fracture or AC sprains Anterior humerus and biceps brachii n Check for deformities or ruptures 0 Lateral Structures Deltoids n Atrophy associated with C5 or C6 nerve root involvement Acromion Process a Look for presence of step off deformity o Piano key sign Position of the Humerus n Adhesions muscle spasms or pain may keep arm splinted to the body 0 Posterior Structures Position of Scapulae n Vertebral borders should be equidistant to spinous processes a Look for any resting winging protraction retraction or tilting n Sprengel s Deformity o Congenital defect o Undescended scapula Muscle Development a Check for symmetry on each side a Observe prominence of scapular spine 0 Joint Stability Testing SC AC 39oint la a Good tests for grade one u Be careful when performing on SC Glenohumeral Joint Play Involves sliding of the humeral head relative to the genoid fossa n Anterior posterior and inferior movement a Performed in neutral with scapula stabilized o Neurological Testing Upper quarter screen necessary for some injuries Brachial plexus and cervical spine issues 0 Palpation Should be able to palpate the necessary structures blindfolded Must be able to see with your hands AROM O O O O O 0 Plays largest role in dynamic function for the athlete Drop Arm Test a Used to determine patient s ability to control humerus motion via an eccentric contraction n Slowly lower arm from full abduction a Positive tests usually indicates RC pathology AQlex s Scratch Test a Quick evaluation of the motion available to the shoulder complex a Touch opposite shoulder a Reach behind head and touch opposite shoulder a Reach behind back and touch opposite scapula RROM Manual muscle tests Asses force production in a joint Determines where in the ROM pain is felt AROM measurements Flexion 180 Extension 60 Abduction 180 Internal Rotation 90 External Rotation 100 Horizontal Abd 90 Horizontal Add 50 Manual Muscle Testing Gerber Lift Off Test a Subscapularis sensitive test Flexion and extension a Primary in flexion anterior deltoid a Primary in extension lats and teres major Abduction n Deltoids and supraspinatus Adduction n Pectoralis major lats teres major Internal Rotation n Subscapularis External Rotation n Infraspinatus teres minor Horizontal Adduction n Pectoralis major Horizontal Abduction n Posterior deltoid Shoulder Pathologies o Sternoclavicular Joint Pathologies O O O O Occur from longitudinal force being placed on the clavicle MOI FOOSH distraction anterolateralposeriolateral forces Acute injury Take special care of posterior dislocations Can damage underlying structures Pain felt in flexion abduction and horizontal abduction Do not test ROM if dislocation is suspected o Acromioclavicular Joint Pathologies O Anterior and posterior stability of AC joint maintained by the AC ligament Superior stability is maintained by the conoid and trapezoid ligaments MOI Landing on forwardflexed outstretched arm or the point of the elbow which drives the scapula posterior to the clavicle Blow to superior acromion process which drives scapula inferiorly Force that drives clavicle away from scapula when scapula is fixated Overuse repetitive stress mechanisms 0 Pain located over distal clavicle AC joint anterolateral neck superior scapula and lateral deltoid 0 Notable displacement creates a step off deformity Piano key sign a Indicates trauma to coracoclavicular ligament 0 Special Tests Apley s Scratch Test a Pain on movements above 90 degrees Acromioclavicular Traction Test a Reveals trauma to coracoclavicular ligament AC Compression Test a Reproduces horizontal instability Chronic AC pain may be the result of a degenerative process within the articulation previous injury or aging 0 AC Sprain Classifications O Grade Damage Observation 1 Partial damage to AC and Point tender over AC capsule No laxity or deformity 2 Rupture of AC lig and partial Slight laxity and to CC lig deformity Step off 3 Complete tear of AC and CC Dislocation of clavicle from acromion 4 Complete tear of AC and CC Posterior clavicle tearing of deltoid and trap displacement into trap Fascia 5 Same as 4 Displacement of clavicle superiorly and posterior 6 Same as 4 Displacement of clavicle inferiorly under coracoid 0 Usually treated conservatively Sometimes surgically repaired if causing significant loss of function o Glenohumeral Instability o Severity of instability graded based on joint play movements 0 Glenohumeral ligaments provide primary passive stability o Anterior Instability Result of laxity of the anterior stabilizing structures a Laxity of GH ligaments tears or weakness in RC dysfunction of LHBT Bankart Lesion n Inferior GH ligament may be avulsed from the labrum or may be avulsed with part of the labrum n Difficult to identify clinically HillSachs Lesion n Defect in posterior humeral head s articular cartilage caused by the impact of the humeral head on the glenoid fossa as the humerus attempts to relocate n Diagnositc tool in determining severity of dislocation Primary Mechanism n Excessive external rotation and abduction of the humerus Special Tests for Anterior Instability n Apprehension Crank Test o Passive external rotation at 90 n Relocation Test o Posterior pressure added to anterior humeral head to add artificial stability a Surprise Test o Follows relocation test Sudden release of the posterior pressure 0 Posterior Instability Relatively rare Occurs when the humerus is flexed and internally rotated while a longitudinal posterior force is placed on the humerus a Secondary to repeated forced blows on a forward flexed arm Can result from having a weak subscapularis a Primary dynamic restraint from posterior humeral displacement n LHBT weakness also Pain reported when doing horizontal adduction movements Special Tests for Posterior Instability n Posterior Apprehension Test a Jerk Test o Used to detect posteroinferior instability by applying axial load to humerus as it horizontally adducts o Painless clunk associated with instability o Painful clunk associated with labral tear o Inferior Instability Primary restraint against inferior translation depends on the position of the humerus In neutral the GH ligament is primary restraint Rotator cuff pathology and weakness can lead to inferior instability Trauma usually comes from above in acute situations Sulcus Sign a Pull down on humerus and look for divot a Positive in neutral assume lax in all positions a Positive at 90 flexion inferior instability o Multidirectional Instability Combination of two or more unidirectional instabilities Important to determine mechanism Will not have a history of trauma Must treat all affected areas and directions Patients will likely benefit from surgical reconstruction o Rotator Cuff Pathology 0 Impingement Occurs when there is decreased space through which the rotator cuff tendons pass under the coracoacromial arch Usually begins with inflammation of RC tendons Source is either tensile or compressive then classified into primary or secondary Occurs at 90 degrees of ER and associated with GIRD u If untreated continued internal impingement forces will lead to SLAP lesions 0 Impingement Syndrome LHBT supraspinatus infraspinatus subacromial bursa GH joint capsule and humeral head can all become compressed Fatigue from overuse restricted GH motion decreased RC strength 212012 52200 PM


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