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The Shoulder Complex

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Rotator Cuff Muscles: subscapularis, supraspinatus, infraspinatus, and teres minor Region between the anterior scapula and thoracic wall. ... – PowerPoint PPT presentation

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Title: The Shoulder Complex


1
The Shoulder Complex
2
The Shoulder Complex
  1. General Structure Function
  2. Structure Function of Specific Joints
  3. Muscular Considerations
  4. Specific Functional Considerations
  5. Common Injuries

3
The Shoulder Complex
  • General Structure Function
  • Structure Function of Specific Joints
  • Muscular Considerations
  • Specific Functional Considerations
  • Common Injuries

4
General Structure
5
General Function
  • Provides very mobile, yet strong base for hand to
    perform its intricate gross and skilled functions
  • Transmits loads from upper extremity to axial
    skeleton

6
Shoulder Girdle
7
Shoulder Complex Movements
  • Shoulder Girdle
  • Elevation depression
  • Protraction retraction
  • Upward downward rotation
  • Upward tilt
  • Shoulder (glenohumeral)
  • FL, EXT, HyperEXT
  • ABD, ADD, HyperADD, HyperABD
  • MR, LR, HorizontalABD, HorizontalADD

8
Abduction/Lateral Tilt (Protraction)
Linear Movement Frontal Plane Angular
movement Transverse Plane
Adduction/Reduced Lateral Tilt (Retraction)
9
Depression
Elevation
Linear Movement Frontal Plane
10
Downward rotation
Upward rotation
11
Shoulder Complex Movements
Upward tilt Reduction of Upward Tilt Angular
movement Sagittal plane
12
Limited by capsular torsion
Limited by bony impingement of greater tubercle
on acromion
13
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14
Large ROM Due To
  • Poor bony structure
  • Poor ligamentous restraint
  • Scapulohumeral cooperative action

15
The Shoulder Complex
  1. General Structure Function
  2. Structure Function of Specific Joints
  3. Muscular Considerations
  4. Specific Functional Considerations
  5. Common Injuries

16
Structure Function of Specific Joints
  1. Sternoclavicular Joint
  2. Acromioclavicular Joint
  3. Scapulothoracic Joint
  4. Glenolhumeral Joint
  5. Coracoacromial Arch

17
Sternoclavicular Joint Bony Structure
Poor Diarthrodial Biaxial
18
Sternoclavicular Joint Capsule
Very strong
19
Sternoclavicular Joint Interclavicular Ligament
Resists superior anterior (posterior portion)
motion
20
Sternoclavicular Joint Sternoclavicular Ligament
Resists anterior (PSL), posterior (ASL),
superior motion
21
Sternoclavicular Joint Costoclavicular Ligament
Resists upward and posterior motion
22
Sternoclavicular Joint Accessory Structures
Resists medial inferior displacement via
articular contact
23
Sternoclavicular Joint Articular Surfaces
  • Medial end of clavice
  • is convex
  • Clavicular facet is
  • reciprocally shaped

24
Sternoclavicular Joint Motions
Axial Rotation 50 EL/DEP 35 PROT/RET 35
25
Sternoclavicular Joint Motions
  • Frontal plane
  • Elev/Dep
  • Sagittal plane
  • Post Rot
  • Horizontal plane
  • ProT/ReT
  • Ant/Post axis
  • Vertical axis

26
Acromioclavicular JointBony Structure
Poor Diarthrodial Nonaxial
27
Acromioclavicular JointJoint Capsule
Very weak
28
Acromioclavicular JointAcromioclavicular Ligament
Resists axial rotation posterior motion
29
Acromioclavicular JointCoracoclavicular Ligament
Resists superior motion
30
Acromioclavicular JointAccessory Structures
Articular disc
31
Acromioclavicular Joint Motion
Little relative motion at AC joint
UR/DR 60 EL/DEP 30 PROT/RET 30-50
32
Acromioclavicular Joint Osteokinematics
  • Horizontal plane
  • adjustments
  • during scapulothoracic
  • protraction
  • Sagittal plane adjustment
  • during scapulothoracic
  • elevation

33
Clavicle
  • Acts a strut connecting upper extremity to thorax
  • Protects brachial plexus vascular structures
  • Serves as attachment site for many shoulder
    muscles

34
Scapula
35
Scapular Plane
36
Scapulothoracic Joint
  • No osseous connection
  • SUBSCAP SA

37
Glenohumeral Joint Humerus
Retroversion angle 30
38
Glenohumeral Joint Humerus
Inclination angle 45
39
Glenohumeral Joint Glenoid Fossa
  • Inclination angle 5
  • Retroversion angle 7

40
Glenohumeral Joint Glenoid Fossa
  • Articular cartilage thicker on periphery
  • Shallow fossa 1/3 diameter of humeral head

41
Glenohumeral Joint Bony Structure
  • Pure rotation
  • Bony restraint poor
  • Head 4-5X larger than fossa
  • Close-packed position
  • ABD with LR

42
Glenohumeral Joint Joint Capsule
  • Inherently lax
  • Surface area 2X head
  • Provides restraint for ABD, ADD, LR, MR

43
Glenohumeral JointSuperior GH Ligament
  • Resists inferior translation in rest or adducted
    arm
  • Well-developed in 50

44
Glenohumeral Joint Coracohumeral Ligament
  • Resists inferior translation in shoulders with
    less-developed SGH

45
Glenohumeral JointMiddle GH Ligament
  • Great variability in proximal attachment
    morphology
  • Absent in 30
  • Resists inferior translation in ABD ER
  • Restrains anterior translation (45 ABD)

46
Glenohumeral JointInferior GH Ligament
  • 3 components (A,P,Ax)
  • Resists inferior, anterior, posterior
    translation

47
Glenohumeral Joint Bursae
  • Subcoracoid
  • Subacromial
  • Subscapular

48
Glenohumeral Joint Accessory Structures
Labrum
  • 50 of depth
  • Increases tangential stability 20

49
Glenohumeral Joint Intra-articular Pressure
  • Synovial fluid causes adhesion
  • Provides 50 restraint

50
Coracoacromial Arch
51
Glenohumeral Joint ROM
  • Flexion (167 W 171 M)
  • 30 in max LR
  • Extension (60)
  • Abduction (180)
  • 60 in max IR
  • Hyperadduction (75)

52
Glenohumeral Joint ROM
  • Total rotation 180
  • Total ROT 90 in 90 ABD
  • Medial rotation (90)
  • Lateral rotation (90)
  • Horizontal abduction (45)
  • Horizontal adduction (135)

Role of multiarticular muscles???
53
Glenohumeral Joint ROM
  • Medial rotation (90)
  • Lateral rotation (90)
  • Horizontal abduction (45)
  • Horizontal adduction (135)

54
Soft Tissue Restraint Summary
  • Anterior
  • Capsule
  • Labrum
  • Glenohumeral lig
  • Coracohumeral lig
  • Subscapularis
  • Pectoralis major
  • Inferior
  • Capsule
  • Triceps brachii (L)
  • Posterior
  • Capsule
  • Labrum
  • Teres minor
  • Infraspinatus
  • Superior
  • Labrum
  • Coracohumeral lig
  • Suprapinatus
  • Biceps brachii (L)
  • Coracoacromial arch
  • Subacromial bursa

55
The Shoulder Complex
  1. General Structure Function
  2. Structure Function of Specific Joints
  3. Muscular Considerations
  4. Specific Functional Considerations
  5. Common Injuries

56
Shoulder girdle has its own set of muscles.
57
Retraction of the Scapulothoracic Joint
Levator scapula
58
Protraction of the Scapulothoracic Joint
Pectoralis minor
59
Pathomechanics of a weak serratus anterior muscle
  • Deltoid force causes scapula to downwardly
    rotate.

Unstable and cannot resist deltoid force
60
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61
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62
GH Flexion
  • Prime flexors
  • Anterior deltoid
  • Pectoralis major clavicular portion
  • Assistant flexors
  • Coracobrachialis
  • Biceps brachii short head

63
GH Flexion
  • Anterior deltoid
  • Coracobrachialis
  • Biceps brachii

64
GH Extension
  • Gravitational force
  • Posterior deltoid
  • Latissimus dorsi
  • Pectoralis major (sternal)
  • Teres major (with resistance)

65
Abduction at Glenohumeral Joint
  • Major abductors of humerus
  • Supraspinatus
  • Initiates abduction
  • Active for first 110 degrees of abduction
  • Middle deltoid
  • Active 90-180 degrees of abduction
  • Superior dislocating component neutralized by
    infraspinatus, subscapularis, and teres minor

66
Abduction at Glenohumeral Joint
Initiates abduction Active for first 110 degrees
of abduction
Active 90-180 degrees of abduction Superior
dislocating componentneutralized by
infraspinatus, subscapularis, and teres minor
67
Abduction at Glenohumeral Joint The Kinetic Arc
68
Adduction of Glenohumeral Joint
  • Primary adductors
  • Latissimus dorsi
  • Teres major
  • Sternocostal pectoralis
  • Minor assistance
  • Biceps brachii short head
  • Triceps brachii long head
  • Above 90 degrees- coracobrachialis and
    subscapularis

69
GH Medial Rotation
  • Subscapularis
  • Latissimus dorsi
  • Pectoralis major
  • Teres major (with resistance)

Decreased activity with ABD
70
GH Lateral Rotation
  • Primary
  • Infraspinatus
  • Assistant
  • Teres minor
  • Posterior deltoid

71
Horizontal Adduction and Abduction
  • Anterior to joint
  • Pectoralis major (both heads), anterior deltoid,
    coracobrachialis
  • Assisted by short head of biceps brachi
  • Posterior to joint
  • Middle and posterior deltoid, infraspinatus,
    teres minor
  • Assisted by teres major, latissimus dorsi

72
Muscle Strength
  • Adduction (2X ABD)
  • Extension
  • Flexion
  • Abduction
  • Internal rotation (max in neutral)
  • External rotation (max at 90 FL)

Role of multiarticular muscles???
73
The Shoulder Complex
  1. General Structure Function
  2. Structure Function of Specific Joints
  3. Muscular Considerations
  4. Specific Functional Considerations
  5. Common Injuries

74
Specific Functional Considerations
  • Stability Functions of Shoulder Girdle
  • Mobility Functions of Shoulder Girdle
  • Rotator Cuff Function

75
Stability Functions of Shoulder Girdle
  • Provides stable base from which shoulder muscles
    can generate force
  • Shoulder girdle muscles as stabilizers
  • Maintain appropriate force-length relationship
  • Maintain maximum congruence of shoulder joint

76
Specific Functional Considerations
  • Stability Functions of Shoulder Girdle
  • Mobility Functions of Shoulder Girdle
  • Rotator Cuff Function

77
Mobility Functions of Shoulder Girdle
  • Permits largest ROM of any complex in the body
  • Shoulder girdle increases ROM with less
    compromise of stability (scapulohumeral rhythm)
    (4 joints vs. 1 joint)
  • Facilitate movements of the upper extremity by
    positioning GH favorably

78
Dynamic Stabilization Mechanisms
  • Passive muscle tension
  • Compressive forces from muscle contraction
  • Joint motion that results in tightening of
    passive structures
  • Redirection of joint force toward center of GH
    joint

79
Muscular Considerations
  • Force-length relationships quite variable due to
    multiple joints
  • Tension development in agonist frequently
    requires tension development in antagonist to
    prevent dislocation of the humeral head
  • Force couple 2 forces equal in magnitude but
    opposite in direction

80
Movements in the Frontal PlaneGH Joint -
Abduction
ABD - 60 UR - 20
  • Shoulder Girdle UR
  • Totals
  • Upward rotation - 60
  • GH Abduction - 120
  • 21 (.66) ratio
  • 1.251 after 30
  • 0.5-0.75 across individuals

ABD - 30 UR - 40
ABD 30
81
Movements in the Frontal PlaneGH Joint -
Adduction
  • Shoulder Girdle DR

Fig 5.17
82
Movements in the Sagittal PlaneGH Joint
Flexion Extension
  • Shoulder Girdle
  • UR
  • ELEV (gt90)
  • PROT ( to 90)
  • RET (gt90)

Fig 5.18
83
Movements in the Sagittal PlaneGH Joint -
Hyperextension
  • Shoulder Girdle Upward tilt of scapula

Fig 5.20
84
Movements in the Transverse PlaneGH Joint MR
LR
Fig 5.22a
85
Spinal Contribution to GH Motion
86
Movements in the Transverse PlaneGH HAdd HAbd
87
Influences on GH ROM
  • Humeral position in other planes
  • FL limited by ER (30? FL in max ER)
  • ABD limited by IR (60?-90? ABD in max IR)
  • ABD with ER 90-120?
  • Rotation limited by ABD (total ROT only 90? in
    90? ABD)
  • Scapular position
  • Elbow position

88
Large ROM Due To
  • Poor bony structure
  • Poor ligamentous restraint
  • Scapulohumeral coordination
  • Normal movement dependent on interrelationships
    of 4 joints
  • Restriction in any of these four can impair
    normal function

89
Specific Functional Considerations
  • Stability Functions of Shoulder Girdle
  • Mobility Functions of Shoulder Girdle
  • Rotator Cuff Function

90
Teres minor
Supraspinatus
Subscapularis
Infraspinatus
91
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92
Function of Rotator Cuff
  • Large external muscles (e.g., lats, delts) create
    shear forces
  • Rotator cuff provides
  • Joint compression
  • Tangential restraint (Ant, Post, Sup)

93
Destabilizing Action of Deltoid
94
Deltoid produces superior shear force at GH joint.
95
Subscapularis
  • Resists superior shear
  • Produces simultaneous internal rotation

96
Infraspinatus Teres Minor
  • Resists superior shear
  • Neutralizes SUBSCAP internal rotation

97
Supraspinatus
98
Summary of Active Arthrokinematics Resisting Shear
99
Destabilizing Action of Latissimus Dorsi
  • LD pulls humerus INF
  • SSP resists INF force
  • INF SUBSCAP create compressive force

100
The Shoulder Complex
  1. General Structure Function
  2. Structure Function of Specific Joints
  3. Muscular Considerations
  4. Specific Functional Considerations
  5. Common Injuries

101
Common Shoulder Injuries
  • Joint dislocations
  • Clavicular fracture
  • Rotator cuff injuries
  • Other rotational injuries
  • Subscapular neuropathy

102
Evaluation of Injuries
  • Mechanism of Injury (MOI)
  • How did the injury occur?
  • Pathology (PATH)
  • What tissues are damaged?
  • Sign Symptoms (SS)
  • What does the patient tell you?
  • What can be determined from an evaluation of the
    injury?

103
Joint Dislocations Acromioclavicular Sprain
  • AKA Shoulder Separation
  • MOI Downward blow to outer end of shoulder
  • Fall on outstretched hand, Punching
  • PATH Sprain of AC ligaments
  • SS Pain over AC joint
  • Laxity of AC joint???

104
Joint DislocationsShoulder Dislocation
  • MOI Arm forcefully ABD LR
  • May occur by a blow to top of shoulder
  • PATH Head of humerus is forced out of the
    glenoid fossa
  • SS Arm held out from side in slight ABD LR
  • Loss of normal rounded contour of deltoid muscle

105
Chronic Dislocation of the Shoulder
  • MOI Congenital abnormality
  • Repeated acute dislocations
  • PATH Head of humerus relatively easily come out
    of the glenoid fossa
  • Tissue damage due to repeated dislocations
  • SS Usually not very painful

106
Clavicular Fracture
  • MOI Downward blow to outer end of shoulder
  • Fall on outstretched hand
  • PATH Fracture to middle 1/3
  • SS Patient supports injured arm
  • Head may be tilted toward injured side with face
    turned to opposite side

107
Rotator Cuff Injuries
  • MOI Overuse
  • Falling on an outstretched hand
  • PATH Strains or tearing of rotator cuff muscles
  • Supraspinatus most often injured
  • SS Pain, Inflammation, Weakness

108
Impingement
  • Possible mechanisms
  • Weak or inflexible rotator cuff
  • Small anatomical space
  • Hyperabduction of GH joint
  • GH ABD ROT

109
Impingement Roll-Slide Kinematics
Roll created by abduction not countered with
Slide action
110
Rotator Cuff Injury
  • Anatomical cause of rotator cuff injury
  • Kinesiological cause of injury

111
Impingement
  • Narrow space
  • Inextensibility of capsule, ligaments, muscles
    esp. rotator cuff
  • Abduction and internal/external rotations

112
  • During ABD
  • SSP tendon pushed into acromion process CA
    ligament
  • During ROT
  • SSP tendon dragged along the inferior surface of
    the acromion process

113
Rotator Cuff Injury
  • Anatomical cause of rotator cuff injury
  • Kinesiological cause of injury

114
Kinesiological breakdown of overhand throwing
Wind-Up Phase
No excessive movements
(safe)
First Motion
Maximum knee lift of leg
115
Kinesiological breakdown of overhand throwing
  • Shoulder ABD (DELT SSP)
  • RC maintain proper humeral head position

Stride
Abduction and no rotation
(Safe)
Lead leg begins to move Arms separate
Lead foot contacts the ground
116
Kinesiological breakdown of overhand throwing
  • ER in ABD position ER 150-180
  • ECC action of SUBSCAP (decelerates ER humerus)
  • RC stabilization

Arm Cocking
External rotation in abducted position
Possible cuff damage
Lead foot contact
Maximum shoulder external rotation
117
Kinesiological breakdown of overhand throwing
Arm Acceleration
  • Concentric IR (PMJR LD )
  • IR velocity (gt 1000 /s)
  • RC stabilization

Internal rotation in abducted position
Possible cuff damage
Maximum shoulder ER
Ball release
118
Kinesiological breakdown of overhand throwing
Arm Deceleration
  • Decelerating IR ADD
  • ECC action of TMin
  • RC stabilization

Internal rotation Abduction reduced
Safer
Ball release
Maximum shoulder IR
119
Kinesiological breakdown of overhand throwing
Follow Through
  • Decelerating IR
  • ECC action of TMin
  • RC stabilization

Reduced internal rotation
Safe
Maximum shoulder IR
Ends in balanced position
120
Rotator Cuff Injuries Solution
  • Alter technique during problem phases to avoid
    impingement
  • Arm cocking
  • Arm acceleration
  • Strengthen rotator cuff
  • Surgical repair

Video techniques
121
Risk Factors
  • Risk factor a characteristic that influences
    the loading on the musculoskeletal system
  • Movement risk factors characteristics of a
    movement
  • Intrinsic risk factors the personal, physical,
    and psychological characteristics of an
    individual
  • Extrinsic risk factors the environmental and
    administrative procedures

122
Intrinsic Risk Factors
  • Age and gender
  • Physical fitness
  • Overtraining
  • Skeletal abnormalities
  • Technique
  • Warm-up
  • Psychological factors

123
Technique
  • Technique refers to the movement pattern of an
    individual during a particular movement or
    sequence of movements. Good technique is a
    movement pattern not only effective in
    performance, but also one that minimizes risk of
    injury by appropriately distributing the overall
    load throughout the kinetic chain. Poor technique
    is characterized by inappropriate utilization and
    summation of muscular effort and abnormal joint
    movements, both of which result in localized
    overload and, therefore, increased risk of injury.

124
Swimming
  • Solutions
  • Lead with hand to ? IR
  • Increase body roll to ? ABD

Mechanism ABD IR
125
Supraspinatus Tear
126
Other Rotational Injuries
  • Tears of labrum
  • Mostly in anterior-superior region
  • Tears of biceps brachii tendon
  • Due to forceful rotational movements
  • Also calcification of soft tissues, degenerative
    changes in articular surfaces, bursitis

127
Biceps Tendon Tear
128
Subscapular Neuropathy
  • Denervation of INF with ? strength GH ER
  • Mechanism Repeated stretching of nerve

129
Loads on the Shoulder
  • Arm segment moment arm
  • Perpendicular distance between weight vector and
    shoulder.
  • With elbow flexion, upper arm and forearm/hand
    segments must be analyzed separately.
  • Large torques from extended moment arms countered
    by shoulder muscles.
  • Load reduced by half with maximal elbow flexion

130
Injury Potential in the Shoulder Complex -
Impacts
  • Sternoclavicular Joint
  • not commonly injured
  • may sprain anteriorly if fall on top of shoulder
    or middle delt - pain in horizontal abd
  • children may dislocate anteriorly during throwing
    because of increased joint mobility as compared
    to adults
  • posterior dislocation may occur when force is
    applied to sternal end of clavicle serious
    because of trachea, esophagus, and blood vessels
    located posteriorly
  • Clavicular Injuries
  • fx to any part due to direct trauma
  • fx to middle 1/3 can occur by falling on
    shoulder, outstretched arm, or direct trauma to
    shoulder that transmits force down shaft of
    clavicle
  • AC Injuries
  • dislocation from fall on shoulder, fall on elbow
    or outstretched arm
  • overuse injuries from overhand pattern (throwing,
    tennis, swimming) or sports that repeatedly load
    in the overhead position (wrestling, wt lifting)

131
Glenohumeral Injuries
  • Most common dislocation in anterior
    (anterior-inferior 95)
  • most commonly dislocated when abducted and ER
    overhead
  • recurrence rate 33-50 (66-90 lt20 yrs)
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