Shoulder Complex Anatomy PDF

THE SHOULDER COMPLEX PTA 222  Dutton p.354 Bones of the Shoulder Complex OsteoKinematics Flexion Abduction Normal Ranges: Normal Ranges: ______________ ______________ Extension Adduction Normal Ran...

THE SHOULDER COMPLEX PTA 222  Dutton p.354 Bones of the Shoulder Complex OsteoKinematics Flexion Abduction Normal Ranges: Normal Ranges: ______________ ______________ Extension Adduction Normal Ranges: Normal Ranges: ______________ ______________ Internal Rotation Horizontal Abduction Normal Ranges: Normal Ranges: ______________ ______________ External Rotation Horizontal Adduction Normal Ranges: Normal Ranges: ______________ ______________ Shoulder Complex Dutton p.355 Composed of 4 articulations between the sternum, humerus, scapula, and clavicle. 3 synovial joints Glenohumeraljoint Acromioclavicularjoint (AC joint) Sternoclavicularjoint (SC joint) 2 functional articulations Suprahumeral/subacromial Scapulothoracic  Dutton p.354 Sternoclavicular Joint Articulation between the articular end of the clavicle, the clavicular notch of the manubrium of the sternum, and the cartilage of the first rib Motions include: Elevation and Depression Protraction and Retraction Axial rotation SC Joint Ligaments Sternoclavicular ligament: anterior and posterior reinforces connected between sternum and clavicle Interclavicular ligament: connects superior-medial sternal ends of each clavicle with the capsular ligaments and the upper sternum strengthen articular capsule and restricts downward forces Costoclavicular ligament: Dutton p.355 Strongest reinforces first rib and clavicle resists superior forces  Dutton 356 Acromioclavicular Joint Formed by the acromion and the lateral end of the clavicle Serves as the lever for the upper extremity against the torso Attachment site for many soft tissues Main articulation that suspends the UE from the trunk Joint about which the scapula moves AC Joint Ligaments Dutton p.355 Coracoclavicular Ligament: Conoid and Trapezoid ligaments reinforces connect between coracoid process and AC joint Acromioclavicular Ligament: between acromion process and clavicle reinforces connection between acromion and clavicle Coracoacromial ligament: runs from coracoid process to anterior-inferior aspect of acromion extending into AC joint reinforces connection between coracoid process and acromion for stabilization AC Joint Ligaments Glenohumeral Joint Dutton p.357 Ball and socket joint Relatively unstable requiring assistance from other structures Labrum Glenohumeral ligaments Superior, middle, and inferior Joint capsule Muscular dynamic stabilizers Rotator cuff, biceps tendon, muscles of scapular motion GH Joint Ligaments Inferior GH ligament: inferior glenoid to inferior humerus Dutton p.355 anterior stabilization during ABD Middle GH ligament: Strongest medial glenoid to lesser tubercle humerus limits ER at 45 deg of ABD Superior GH ligament: glenoid rim to humeral neck works with coracohumeral to prevent post/inf instability GH Joint Ligaments Coracohumeral ligament: reinforces upper capsule, lateral coracoid process to Dutton p.355 greater/lesser tubercle anterior support in flexion, passive stability in depend position Transverse Humeral ligament: across the bicipital groove stabilizes LH biceps in intertubercular groove Scapulothoracic Articulation Functionally acts as a joint, but lacks anatomic characteristics of a true Dutton p.356 synovial joint Lacks ligamentous support Relies solely on muscular support between the scapula and thorax Scapulothoracic Articulation Motions that occur Elevation, Depression, Protraction, Dutton p.356 Retraction Seen with clavicular motion at the SC joint, when the humerus moves, and shoulder shrugging Upward and Downward rotation Seen with clavicular motion at the AC joint and with humerus movement Winging and Tipping Seen with motions of the AC joint and humerus movement Scapulohumeral Rhythm Synchronized motion that occurs between the glenoid cavity and the humerus during arm Dutton p. 362 elevation Allows the glenoid to stay centered under the humeral head which resists downward (inferior) dislocation Ratio of ROM is 2:1 Every 2 degrees of abduction, there should be 1 degree of scapular upwards rotation Scapulohumeral Rhythm Motions of the GH joint Flexion 0-120 Extension 0-45 Internal Rotation 0-80 External Rotation 0-90 Dutton p. 362 Abduction 0-120 Muscles of the Shoulder Complex 3 main groups of muscles Thoracoscapular Rhomboids, levator scapulae, serratus anterior, and trapezius muscles Thoracohumeral Latissimus dorsi and pectoralis major Dutton p. 357 Scapulohumeral Supraspinatus, infraspinatus, teres minor, subscapularis, and deltoid Muscle of the GH joint FLEXORS: coracobrachilas, LH/SH biceps, pec major, anterior delt EXTENSORS: Dutton p. 357 LH triceps, posterior delt, pec major, teres major, latissimus dorsi ABDUCTORS: supraspinatus, anterior/mid delt ADDUCTORS: pec major, latissimus dorsi, teres major, coracobrachilas IR: pec major, subscap, latissimus dorsi, teres major ER: infraspinatus, posterior delt, teres minor  S I The RTC is made up of 4 muscles Supraspinatus T S Infraspinatus Teres minor Subscapularis Muscles of the Scapula Protractors: pec minor, SA Retractors: levator scapulae, rhomboids, mid trap Elevators: Dutton p. 357 upper trap, levator scapulae, rhomboids Depressors: lower trap, latissimus dorsi, pec minor, subclavius Upward rotators: SA, Upper/Lower trap Downward rotators: rhomboids, pec minor, levator scapula Nerves of the Shoulder Complex 1. Pectoral N. 1. Pec Major 1. Medial Pectoral N. 1. Pec Minor Dutton p.359 2. Thoracodorsal 2. Latissimus Dorsi 3. Subscapular 3. Teres Major 4. Axillary 4. Teres Minor, Deltoid 5. Suprascapular 5. Supraspinatus, 6. Upper & Lower Infraspinatus Subscapular 6. Subscapularis 7. Long Thoracic 7. Serratus Anterior 8. Dorsal Scapular 8. Levator Scapula, 9. Musculocutaneous Rhomoids 9. Coracobrachilas, Biceps 10. Spinal Accessory (CN XI) Brachii 10.Trapezius 11. Radial 11.Triceps Spinal Nerve Roots C5 C6 Dutton p.359 C7 C8 T1  Please download and install the Slido app on all computers you use Join at slido.com #3440842 ⓘ Start presenting to display the joining instructions on this slide.  Please download and install the Slido app on all computers you use What is the importance of the brachial plexus? ⓘ Start presenting to display the poll results on this slide.  Suprahumeral/Subacromial Space Boundaries are formed by: Greater tuberosity of the humeral head, inferiorly Coracoid process, Dutton p.363 anteromedially Coracoacromial arch, superiorly  Structures located in Subacromial Space: Head of Humerus LH of biceps tendon Superior Joint Capsule Dutton p.363 Supraspinatus & upper Subscapularis and Infraspinatus Subacromial Bursa Inferior Coracoacromial Arch The Labrum The Labrum Fibrocartilagenous tissue that deepens the glenoid cavity of the scapula Injury occurs with Dutton p. 380 trauma or with repetitive movement Force Couples Dutton p.364 Function of the Shoulder  COMMON CONDITIONS OF THE SHOULDER COMPLEX Scapular Dyskinesia and the Sick Scapula Dyskinesia alteration in normal motion SICK Scapula S-scapular malposition I-inferior medial border prominence Dutton p. 377 C-coracoid pain and malposition K-dyskinesis of scapular movement The Sick Scapula Signs & Symptoms Scapula appears lower; protracted Inferior medial border prominent Tight pec minor Pain Anterior shoulder Posterosuperior scapula Superior shoulder Proximal lateral arm Treatment for Sick Scapula Stretching Pectoralis minor Posteroinferior capsule Strengthening Open-chain and closed-chain exercises for scapular musculature and posterior rotator cuff. Tendonitis Inflammation of the tendon Most common forms: Bicep’s Tendonitis Supraspinatus Tendonitis Rotator Cuff Tendonitis Clinical Treatment for Tendonitis Decrease pain and inflammation Modalities as needed Increase flexibility Manual intervention Increase joint stability Initiate therapeutic exercise as tolerated Joint stabilization activity  Surgical Interventions Biceps Tenodesis Repositions the biceps tendon to relieve pain or weakness Can involve releasing the tendon from the labrum Can involve relocating the tendon attachment Arthroscopic or Open Dutton p. 487 Often performed with another surgical procedure of the shoulder Subacromial Impingement Increased superior translation with shoulder elevation resulting in encroachment of the coracoacromial arch producing compression of the suprahumeral structures Dutton p.377  Common Factors of Impingement Shape and Form of Acromion Blood Flow to the RTC Dynamic Stabilizers Dutton p.377 Condition of AC Joint Positon of Arm during Activity Scapular Musculature Endurance Capsular Tightness Age Surgical Interventions Subacromial decompression (S.A.D.) Arthroscopic Goal is to remove the cause of impingement to allow for more free movement Dutton p.487 Can include: Removal of the bursa Coracoacromial ligament resection Anterior acromioplasty Excision of outer clavicle Osteotomy of the glenoid or acromion Surgical Intervention for Shoulder Pathology Acromioplasty Surgical removal of a piece of bone to allow for increased space within the joint space Distal clavicle resection: Removal of the end of the clavicle closest to the acromion to alleviate pain and loss of motion Bursitis Inflammation of the bursa Synovial fluid can become infected or get irritated by movement Symptoms: Localized tenderness Warmth Edema Erythema Loss of function PSGI Posterior-Superior Glenoid Impingement Common in throwing athletes Compression of the supraspinatus and infraspinatus against the glenoid and labrum MOI Shoulder extension/abduction/external rotation Dutton p.377 3 Stages of Impingement Stage I: (under 25 years of age) Edema and hemorrhage History of trauma or repetitive microtrauma Pain with shoulder ABDuction over 90 degrees Dutton p.379 Considered reversible at this stage Typically responds to PT intervention 3 Stages of Impingement Stage II (between 25 and 40 years of age) Progressive detoriation Fibrosis and tendonitis Pain with daily activities and at night Considered irreversible* Dutton p.379 Supraspinatus and bicep tendon as well as subacromial bursa are fibrotic Pain with daily activities involving OH motions, at end of day 3 Stages of Impingement Stage III (over 40 years of age) Long history of shoulder pain Significant muscle weakness Osteophytes develop at acromion/ AC joint Macrotrauma Dutton p.379 Tendon degeneration Rotator cuff tears Rotator cuff ruptures Rotator Cuff Repairs Two Categories Partial Thickness Tear Full Thickness Tear Indications Persistent pain that interferes with ADL’s Unresponsive to conservative care Dutton p.379 Active patients 2% of dislocations Forward flexed, adducted Inferior Instability Hyperabduction or inferior force (carrying heavy object) Dutton p. 381 Multidirectional Instability GH instability in more than one direction AMBRI A M B R I Shoulder Dislocations Shoulder is the most commonly dislocated joint in the body Men more often than women* Anterior: shoulder ABDuction, extension, and external rotation Posterior: shoulder ABDuction, flexion, and internal rotation GH Joint Instability Treatment Conservative treatment Dynamic strengthening Stability activities Surgical intervention “Capsulorrhaphy” Dutton p382 Tightens the inferior capsule Tightens the rotator interval LABRAL TEARS  Dutton p.382 SLAP Lesions Superior Labrum Anterior to Posterior Causes: Repetitive overhead movements FOOSH injury Sudden deceleration/traction forces MVA Chronic ant/post instability SLAP Lesions Type 1: Fraying and degeneration of superior labrum Can not horizontally ABD or ER with forearm pronation without pain Type 2: Pathologic detachment of the labrum and biceps tendon anchor Dutton p.382 Loss of stabilizing effect of labrum and biceps Type 3: Vertical tear of the labrum Remaining portions of labrum and biceps are intact Type 4: Extension of tear into the biceps tendon Portion of labrum and biceps tendon displaced into GH joint Bankart Lesion Avulsion of the anterior inferior labrum from the glenoid rim Requires surgical stabilization “TUBS” Traumatic Dutton p.380 Unidirectional instability Bankart lesion requiring Surgery Hill-Sachs Lesion Compression fracture on the posterior humeral head at the site where the humeral head impacted the inferior glenoid rim Dutton p.381 Labral Tears - Treatment Conservative treatment is attempted first: 1. Avoidance of provocative position 2. Gentle ROM/ submaximal isometric exercises 3. Scapular stability exercises Dutton p.382-3 4. Closed chain exercises 5. Improve scapulohumeral rhythm 6. Open chain activities  Surgical Intervention for Labral Tears For persons who remain symptomatic following conservative Rx For persons whose instability is so gross that conservative Rx is not appropriate Dutton p.383-385 Bankart Repair Capsulorrhaphy SLAP Repair Adhesive Capsulitis “FROZEN SHOULDER” Most common in Symptoms include: women between 40 Decreased shoulder and 60 years old ROM Often insidious onset Pain Possible trauma Dutton p.385-388 Capsular immobilization Inflammation Diabetes Fibrous synovial thyroid disease adhesions Reduction of joint cavity Adhesive Capsulitis Primary Dutton p.385-388 Progressive and painful loss of ROM Shankman p.358 Secondary* Trauma or immobilization  Stages of Progression Adhesive Capsulitis Freezing: Intense pain at rest Capsular pattern loss of motion Painful inflammation Dutton p.386 10-36 weeks Frozen: Pain with movement Loss of ROM in all planes Weakness 4-12 months Thawing: Slow, steady recovery of ROM Surgical Manipulation AC/ SC Joint Sprain AC Joint Sprain SC Joint Sprain Acute Traumatic FOOSH Fall on shoulder in Flex/ADD ADDucted position Ext/ADD Chronic Type I Dutton p.388-89 OA, inflammation Sprain of SC ligament Grade I, II Type II Incomplete Subluxation Grade III Type III Complete dislocation AC joint ‘separation’ FRACTURES Clavicle Humerus Clavicle Fracture FOOSH OR blow to shoulder Difficulty elevating above 60 degrees, painful horizontal ADD Clavicular deformity TTP over fracture site Dutton p.391 Proximal Humerus Fracture Most common fracture of the humerus Results from direct blow to anterior, lateral, or posterolateral humerus or FOOSH Represent a major morbidity in the elderly Dutton p.391-2 population Involve the proximal third of the humerus Proximal Humerus Fracture Non-displaced fractures: Dutton p.391-2 Immobilization x 2-3 weeks Gentle ROM Therapeutic exercise as indicated by physician Displaced fractures: Classified into categories Greater tuberosity, lesser tuberosity, surgical neck, and anatomic neck ORIF Allows progression of ROM and strengthening quicker due to stabilization of fracture Proximal Humerus Fracture Primary goals to achieve with rehab Functional motion of the glenohumeral joint Purposeful, functional strength Regain scapular mobility Dutton p.391-2 Osteoarthritis Also known as degenerative joint disease Development of fissures, cracks, thinning of joint cartilage, synovial inflammation Dutton p. 123 Total Shoulder Arthroplasty Removal of the humeral head and glenoid and replaced with metal or plastic TSR requires intact Dutton p.392-4 rotator cuff in order to provide return to functional activity Reverse Total Shoulder Arthroplasty Switching of the glenoid and humeral head positioning in order to provide functional Dutton p.392-4 movement without intact rotator cuff Rehabilitation Following Total Shoulder Arthroplasty Immobilization Dutton p.392-4 Early range of motion Progressive exercises Functional return of the affected arm can be expected around 6 months post-operatively EXAMINATION SPECIAL TESTS FOR THE SHOULDER COMPLEX  RTC BICEPS INVOLVEMENT* Drop Arm Speed’s Empty/Full Can Yergason’s Lift Off IMPINGEMENT LABRAL* Neer O’Brien’s Hawkins Kennedy Bicep’s Load II Dutton p.365-371 Painful Arc Compression/Rotation INSTABILITY Anterior Apprehension RED: LAB Posterior BLACK: LECTURE Apprehension Sulcus Sign Drop Arm Test The patient sits on a table while the tester passively ABDucts the arm to 90 degrees The patient is asked to slowly Cook p.170; Konin p.30-31 lower their arm to the side If the patient is unable to slowly lower the arm to their side or experiences significant pain with task, this is a positive result indicating supraspinatus pathology  Empty Can (Supraspinatus Test) The patient stands with both shoulders ABDucted to 90 degrees first with their thumbs up The tester provides a downward force on the arms and notes the patient’s strength Cook p.166, 171 Next, the patient elevates the arms to 90 degrees of ABDuction and 30 degrees of horizontal ADDuction with thumbs down The tester provides downward pressure on the arms and notes the patient’s strength. Empty Can (Supraspinatus Test) Empty Can (Supraspinatus Test) Increased weakness in the empty can position vs the full can position with or without complaints of pain is indicative of a positive result. Lift Off Test Testing for subscapularis involvement Patient is seated with affected arm behind back Patient is asked to lift their arm Cook p.163 away from the back + test: inability to lift arm away Speed’s Test The patient sits on a table with the involved shoulder flexed to 90 degrees, the elbow in full extension, and the forearm in supination. The tester places one hand on the volar Cook p. 193; Konin p.26-27 aspect of the patient’s forearm and the other on the proximal aspect of the patient’s humerus and resists the patient’s attempt to flex the humerus Speed’s Test A positive test is indicated by pain in the bicipital groove that may suggest bicipital tendon pathology or SLAP tear  Yergason Test Subject seated with elbow flexed to 90 degress and stabilized against thorax Cook p. 182, Konnin p. 25- 26 Forearm pronated Examiner places on hand on subject’s forearm and other on proximal humerus near biceptal groove Resists subject’s attempt to actively supinate and ER the humerus (+) : pain at bicipital groove Neer Impingement Test The patient sits with both upper extremities relaxed The tester stands with one hand on the scapula (posteriorly) and the other hand on Cook p. 177, Konin p.42-43 the patient’s elbow (anteriorly) The tester passively flexes the test shoulder through end range Neer Impingement Test Pain and/or apprehension with forward flexion are indicative of shoulder impingement, specifically the supraspinatus and biceps long head tendons Hawkins-Kennedy Test The patient sits or stands with both UE’s relaxed. The tester stands and raises the arm into approximately 90 degrees of flexion and/or abduction Cook p.178; Konin p.44-45 with one hand and stabilizes the scapula with the other hand The tester then internally rotates the UE Hawkins-Kennedy Test Shoulder pain and apprehension are indicative of supraspinatus tendon impingement This test is considered the most sensitive for assessing Subacromial impingement Painful Arc Patient is in standing with examiner facing the patient to watch motions The patient is instructed to actively abduct the involved Cook p.179 shoulder (+): patient report of pain in the 60-120 deg range Pain at 180 deg is typically indicative of AC joint disorder Anterior Apprehension Test The patient lies supine on the table The tester places the patient’s arm in 90 degrees of abduction and 90 degrees of elbow flexion Cook p. 189, Konin p.52-53 and then slowly externally rotates the shoulder The patient demonstrating apprehension is indicative of a positive test. This position mimics the positioning of an anterior dislocation, recreating instability Posterior Apprehension Subject lies in supine, elbow is flexed to 90 deg with shoulder flexed to 90 with IR Examiner grasps subject’s elbow with one hand and Cook p. 205, Konoin p. 54- 55 stabilizes ipsilateral shoulder with the other Applies a posterior force through long axis of humerus (+) : subject looks or verbalizes apprehensive, guards or examiner feels instability Sulcus Sign The patient sits with hands resting in their lap. The tester uses the proximal hand to grasp the scapula and the distal hand to grasp the patient’s elbow The tester then applies an inferior force Konin p.56-57 (distraction) with the distal hand Sulcus Sign Excessive inferior humeral head translation with a visible or palpable “step-off” is indicative of inferior and/or multi-directional instability O’Brien Test The patient stands with the arm in 90 degrees of flexion, 30-45 degrees of horizontal ADDuction and maximal internal rotation while the tester grasps Cook p. 201, Konin p.74-75 their wrist The patient tries to flex and horizontally ADDuct the arm against the tester’s resistance The test is then repeated with the arm in external rotation O’Brien Test Pain and/or clicking in an internally rotated position but absent in the externally rotated position is indicative of a SLAP lesion Bicep’s Load II Patient in supine, Examiner on involved side Examiner places shoulder in 90 deg ABD, then flexes elbow to 90 deg with forearm supination Cook p. 201 Examiner moves the shoulder to end range ER Asks patient to flex elbow while examiner resists (+): no change with apprehension or worsened with resisted elbow flexion Compression Rotation Patient is in supine, examiner on involved side Examiner passively places shoulder in 90 deg ABD and elbow 90 deg Cook p.199 flexion Applies compression force to the humerus Rotates humerus back and forth from IR to ER (+): production of “catch” “snap” SLAP tear  SHOULDER COMPLEX INTERVENTIONS  Stretching and ROM Exercises Strengthening Exercises Manual PROM Soft Tissue Cross friction: Supraspinatus Biceps Mobilizations Inf/ant/sup/lat glide SC mob Distraction Scapular Mobs/ PROM ACUTE Codman’s Pendulum PROM AAROM Cane Pulley’s Dutton p. 372-3 Protocols Bibliography Shankman, Manske, Fundamental Orthopedic Management for the Physical Therapist Assistant, 4th edition. Elsevier. 2016 Brody, Hall. Therapeutic Exercise. Konin, Lebsack, Valier, Isear, Special Tests for Orthopedic Examination, 4th edition. Slack. 2016 Dutton, Orthopaedics for the Physical Therapist Assistant. Jones&Bartlett, 2nd edition, 2019 Burkart, Morgan, Kibler. (2003). The disabled throwing shoulder: spectrum of pathology part III: the SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. The Journal of Arthroscopic and Related Surgery. Volume 19, Issue 6, Pages 641–661