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Shoulder: Anatomy, Related Injuries, Assessments, and Treatments


Biceps. Coracobrachialis. Triceps. Brachial Plexus (Figure 17-13) ... Biceps strain: common in skiing, throwing overhand, and tennis. ... – PowerPoint PPT presentation

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Title: Shoulder: Anatomy, Related Injuries, Assessments, and Treatments

Shoulder Anatomy, Related Injuries, Assessments,
and Treatments
  • Anatomy of the shoulder bones, muscles, and
  • Related injuries Contusions, strains, sprains,
    dislocation, and fractures.
  • Assessment History, observation, and physical
  • Evaluation of findings.

Anatomy of the Shoulder
  • Sternoclavicular Joint
  • Acromioclavicular Joint
  • Glenohumeral Joint
  • Shoulder Muscles
  • Brachial plexus
  • Composed of the sternal end of the clavicle, the
    cartilage of the first rib, and the manbrium.
  • Articulation between the lateral end of the
    clavicle and the medial margin of the acromion
    process of the scapula.
  • Shoulder joint is a synovial joint--ball and
  • Many muscles--refer to Table 17-1.
  • Shoulder nerves are part of the brachial plexus.

Sternoclavicular Joint
  • This joint is surrounded by a loose articular
    capsule which is reinforced by the anterior and
    posterior sternoclavicular ligaments.
  • The interclavicular ligament strengthens the
    superior aspect of the joint capsule--this is the
    stablizing factor for the right and left
    sternoclavicular joints.
  • Although injuries occur to this joint
    infrequently, this synovial joint is very
    important because it is the only bony attachment
    between the upper limb and the axial skeleton.
  • The articulation between the clavicle and the
    sternum is the pivot point which movements of the
    shoulder as a whole occur.

Acromioclavcular Joint
  • This synovial joint permits a limited amount of
    rotation and numerous gliding movements.
  • This is surrounded by a loose-fitting articular
    capsule, which is strengthened by the
    acromioclavicular ligament.
  • Together the joint and the acromioclavicular
    ligament play a small role in holding the
    clavicle and the scapula together--which is a
    sight for injury because of the high amount of
    sensory nerves contained here.
  • The coracoclavicular ligament plays a role in
    preventing separation of the clavicle from the
  • The coracoclavicular ligament is divided into two
    sections the trapezoid and conoid ligaments.
  • The concoid ligament restrains backward movement
    of the scapula where the trapezoid ligament
    prevents excessive forward displacement.
  • If the coracoclavicular ligament tears, it can
    cause the acromion to be forced down and away
    from the clavicle.

Glenohumeral Joint
  • Our most moveable joint--has three axes which
    allows transverse (flexion and extension),
    anteriorpostior (abduction and adduction), and
    vertical (medial and lateral rotation) to occur.
  • Components head of the humerus, adjacent
    glenoidal surface of the scapula, the glenoid
    labrum, the articular capsule, and the
    coracohumeral, glenohumeral, transverse, and
    coracoacromial ligament.
  • Static stabilizers ligaments, joint capsule, and
    glenoid labrum
  • Disruption of the glenoid labrum is commonly
    associated with recurrently dislocating
  • Dynamic stabilizers rotator cuff and adjacent
  • The SITS muscles (supraspinatus, infraspinatus,
    teres minor, and subscapularis) blend with and
    strengthen the articular capsule to form the
    rotator cuff.

Glenohumeral Joint cont
  • The supraspinatus is the primary abductor of the
  • The infraspinatus and the teres minor are
    external rotators which are attached to the
    greater tuberosity.
  • The subscapularis is the internal rotator which
    is attached to the lesser tuberosity.
  • The rotator cuff provides strength to help
    prevent anterior, superior, and posterior
    displacement of the humeral head during activity.

Muscles of the shoulder(Table 17-1)
  • Trapezius
  • Levator scapulae
  • Rhomboids
  • Serratus anterior
  • Supraspinatus
  • Infraspinatus
  • Teres minor
  • Subscapularis
  • Teres major
  • Deltoid
  • Pectoralis major (upper fibers)
  • Pectoralis major (lower fibers)
  • Pectoralis minor
  • Latissimus dorsi
  • Biceps
  • Coracobrachialis
  • Triceps

Brachial Plexus(Figure 17-13)
  • Complex network consisting of nerves, trunks,
    divisions, and main branches that ultimately
    provide motor and sensory innervation to the
    entire upper extremity.
  • When pressure is put on this nerve plexus or the
    blood vessels that are along this area, serious
    injury can occur.

Injuries to the shoulder
  • Injuries to the shoulder occur because there is
    an extensive range of motion that can occur, but
    there is a lack of stability of the shoulder
  • Mechanisms causing most of the trauma direct
    trauma, indirect trauma, and throwing movements.
  • Direct trauma tackling in football or checking
    in ice hockey.
  • Indirect trauma athlete lands on an
    outstretched hand and an athlete landing on the
    point of a flexed elbow.
  • These injuries can be acute, and chronic.

  • Most common contusion is to the acromion process
    (fig 17-16) called a shoulder pointer, which does
    not involve ligaments.
  • Trainer must be aware of contusions to the
    acromioclavicular joint, the deltoid muscle, the
    shaft of the clavicle
  • Complications with repeated blows to the point of
    attachment of the deltoid muscle and on the
    lateral humerus is a painful periostitis, which
    can develop into an irritative exostosis referred
    to as a blockers spur.

  • Mechanisms for a strain injury overstretching,
    violent contractions, and repetitive use.
  • Strains are common in sports that require the
    athlete to propel an object pitching and
  • Nature of the strain depends on several factors
    that the athletic trainer must take into
    consideration age and maturity of the athlete,
    the type and weight of the object being
    propelled, the type of delivery, the presence of
    weakness, fatigue, incoordination, fibrous
    scarring or degenerative changes from previous
    injuries, and microtrauma from repetitive

Strains cont
  • Rotator cuff strains difficult to detect
    because the muscles lie deep in the shoulder.
  • Biceps strain common in skiing, throwing
    overhand, and tennis.
  • Repetitive motion of the shoulder causes the
    biceps tendon to slide up and down causing an
    inflammatory reaction called bicipital
  • Impingement syndrome occurs when there is
    injury to the soft tissues of the shoulder that
    make up the subacromial space swimmers

  • Acromioclavicular sprain the most common
  • Occur as a result of a blow to the tip of the
    shoulder or falling on an outstretched arm which
    can cause a sprain to the supporting ligaments
    shoulder separation.
  • Glenohumeral sprain seldom occur
  • Sternoclavicular sprain result when force is
    directed along the long axis of the clavicle
    toward the sternal end and stress is applied to
    the sternoclavicular and costoclavicular

  • Glenohumeral dislocation athlete usually has
    the shoulder in an abducted, externally rotated
    position and receives a blow somewhere along the
  • Complication of an anterior shoulder dislocation
    is the axillary nerve injury. The athlete may
    have loss of sensation over the lateral aspect of
    the shoulder and decreased function of the
    deltoid muscle.

  • Clavicle fracture the medial fragment is
    normally pulled upward by the contractions of the
    sternocleidomastoid and trapezius muscles,
    whereas the lateral portion is displaced downward
    by the contraction of the pectoralis major muscle
    and the weight of the arm.
  • Humerus Fracture resembles a glenohumeral
    dislocation and most often is the result from
    falling on an outstretched arm.
  • Proximal humerus epiphyseal fracture uncommon,
    but a dislocated shoulder can lead to this in a
    young athlete.

Assessment Process
  • The shoulder girdle is the most frequently
    injured area of the upper extremity.
  • The glenohumeral joint has an extensive ROM, it
    is relatively unstable compared to other major
    joints of the body.
  • The trainer must take the following factors into
    consideration when assessing the shoulder
    unique anatomic features, intricate functional
    characteristics, various mechanisms of injury,
    and associated signs and symptoms.

Secondary Survey, History, and Observation
  • Secondary survey depend on the position and
    status of the athlete at time of injury. The
    athlete will more than likely be moving around.
  • History question the athlete.
  • Are the symptoms of the current injury similar to
    those of any previous injuries?
  • When did the onset of symptoms occur?
  • Observation Look before you touch
  • Is the athlete favoring one side of his shoulder?
  • Do not remove articles of clothing covering the
    shoulder right away--instead, palpate underneath.

Physical Examination
  • Easy to palpate due to the fact that most of the
    structures are subcutaneous.
  • Conduct palpation of the shoulder girdle with the
    area as relaxed as possible.
  • Normally have the athlete sit on a table or
  • The clavicle is a good reference point to begin
    because it is subcutaneous along its entire
  • Next palpate distally to the lateral end of the
    clavicle where it articulates with the acromion
    to form the cromioclavicular joint. Expressed
    tenderness means injury.

  • To check for a injury referred to as the
    shoulder pointer palpate the acromion process
    at the tip of the shoulder.
  • The vertebral border is the point of reference
    for the muscles attached along its
    length--palpate the spine of the vertebral or
    medial borders of scapula.
  • For greater and lesser tuberosities, palpation
    should be as follows with the humerus
    externally rotated, the bicipital groove and
    lesser tuberosity are exposed--to expose the
    greater tuberosity, internal rotation causes the
    structure to be more prominent.
  • Deltoid muscle must be carefully palpated
    tenderness related to touch may indicate
    tenosynovitis of the biceps tendon or an injury
    to the deltoid muscle--tenderness deep in the
    deltoid, is associated with subdeltoid bursitis
    or rotator cuff problems.

Movement procedures
  • Painful arc pain is absent at beginning of ROM
    but develops near midrange of movement and then
    stops as this point is passed.
  • Apleys scratch test instruct athlete to place
    each hand in two different places to determine
    the active ROM of the shoulder while you compare
  • Drop arm test instruct athlete to abduct the
    arm past 90 and then slowly lower it to the
    side. A positive test is indicated if the
    athlete is unable to return the arm to the side
    slowly or has pain when attempting the movement.

  • Empty can position the arm is horizontally
    abducted 30 with the arm internally rotated and
    the thumb pointing downward. Ask athlete to hold
    this position and if there is a tear in the
    supraspinatus muscle, the arm will again drop
    because of weakness or pain.
  • Yergason test test determines if the tendon of
    the long head of the biceps is stable in the
    bicipital grove or if a tenosynovitis exists.
    Have athlete flex the elbow on the involved side
    90, then ask them to hold this position while
    outwardly rotating the arm. If no discomfort in
    the bicipital groove, then there is no related
  • Apprehension tests have athlete in supine
    position and passively move the arm to 90 of
    abduction and then gently outwardly rotate. If
    the athlete has had prior complications with the
    glenohumeral joint, then they will express
    apprehension and resist further movement.

  • Shoulder injuries require frequent reevaluations
    so you can monitor and determine when the athlete
    can return to activity.
  • When to refer the athlete
  • Suspected fracture, separation, or dislocation
  • Gross deformity
  • Significant loss of motion
  • Significant or continued pain
  • Joint instability
  • Abnormal sensations that do not quickly go away,
    such as weakness or numbness
  • Absent or weak pulse distal to the point of
  • Any doubt regarding the severity or nature of the