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The Shoulder Complex . The Shoulder Complex. General Structure & Function Structure & Function of Specific Joints Muscular Considerations Specific Functional Considerations Common Injuries. The Shoulder Complex. General Structure & Function Structure & Function of Specific Joints

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the shoulder complex1
The Shoulder Complex
  • General Structure & Function
  • Structure & Function of Specific Joints
  • Muscular Considerations
  • Specific Functional Considerations
  • Common Injuries
the shoulder complex2
The Shoulder Complex
  • General Structure & Function
  • Structure & Function of Specific Joints
  • Muscular Considerations
  • Specific Functional Considerations
  • Common Injuries
general function
General Function
  • Provides very mobile, yet strong base forhand to perform its intricate gross and skilled functions
  • Transmits loads from upper extremity to axial skeleton
shoulder complex movements
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
slide8

Abduction/Lateral Tilt (Protraction)

Linear Movement

Frontal Plane

Angular movement

Transverse Plane

Adduction/Reduced Lateral Tilt

(Retraction)

slide9

Depression

Elevation

Linear Movement

Frontal Plane

slide10

Downward rotation

Upwardrotation

shoulder complex movements1
Shoulder Complex Movements

Upward tilt

Reduction of Upward Tilt

Angular movement

Sagittal plane

slide12

Limited by capsular torsion

Limited by bony impingement of greater tubercle on acromion

large rom due to
Large ROM Due To:
  • Poor bony structure
  • Poor ligamentous restraint
  • Scapulohumeral cooperative action
the shoulder complex3
The Shoulder Complex
  • General Structure & Function
  • Structure & Function of Specific Joints
  • Muscular Considerations
  • Specific Functional Considerations
  • Common Injuries
structure function of specific joints
Structure & Function of Specific Joints
  • Sternoclavicular Joint
  • Acromioclavicular Joint
  • Scapulothoracic Joint
  • Glenolhumeral Joint
  • Coracoacromial Arch
sternoclavicular joint interclavicular ligament
Sternoclavicular Joint: Interclavicular Ligament

Resists superior & anterior (posterior portion) motion

sternoclavicular joint sternoclavicular ligament
Sternoclavicular Joint: Sternoclavicular Ligament

Resists anterior (PSL), posterior (ASL), & superior motion

sternoclavicular joint costoclavicular ligament
Sternoclavicular Joint: Costoclavicular Ligament

Resists upward and posterior motion

sternoclavicular joint accessory structures
Sternoclavicular Joint: Accessory Structures

Resists medial & inferior displacement via articular contact

sternoclavicular joint articular surfaces
Sternoclavicular Joint: Articular Surfaces

Medial end of clavice

is convex

Clavicular facet is

reciprocally shaped

sternoclavicular joint motions
Sternoclavicular Joint: Motions

Axial Rotation: 50°

EL/DEP: 35°

PROT/RET: 35°

sternoclavicular joint motions1
Sternoclavicular Joint: Motions

Frontal plane

Elev/Dep

Sagittal plane

Post Rot

Horizontal plane

ProT/ReT

Ant/Post axis

Vertical axis

acromioclavicular joint bony structure
Acromioclavicular JointBony Structure

Poor

Diarthrodial Nonaxial

acromioclavicular joint acromioclavicular ligament
Acromioclavicular JointAcromioclavicular Ligament

Resists axial rotation & posterior motion

acromioclavicular joint motion
Acromioclavicular Joint: Motion

Little relative motion at AC joint

UR/DR: 60°

EL/DEP: 30°

PROT/RET: 30-50°

acromioclavicular joint osteokinematics
Acromioclavicular Joint: Osteokinematics

Horizontal plane

adjustments

during scapulothoracic

protraction

Sagittal plane adjustment

during scapulothoracic

elevation

clavicle
Clavicle
  • Acts a strut connecting upper extremity to thorax
  • Protects brachial plexus & vascular structures
  • Serves as attachment site for many shoulder muscles
scapulothoracic joint
Scapulothoracic Joint
  • No osseous connection
  • SUBSCAP & SA
glenohumeral joint humerus
Glenohumeral Joint: Humerus

Retroversion angle: 30°

glenohumeral joint humerus1
Glenohumeral Joint: Humerus

Inclination angle: 45°

glenohumeral joint glenoid fossa
Glenohumeral Joint: Glenoid Fossa
  • Inclination angle: 5°
  • Retroversion angle: 7°
glenohumeral joint glenoid fossa1
Glenohumeral Joint: Glenoid Fossa
  • Articular cartilage thicker on periphery
  • Shallow fossa 1/3 diameter of humeral head
glenohumeral joint bony structure
Pure rotation

Bony restraint poor

Head 4-5X larger than fossa

Close-packed position

ABD with LR

Glenohumeral Joint: Bony Structure
glenohumeral joint joint capsule
Glenohumeral Joint: Joint Capsule
  • Inherently lax
  • Surface area 2X head
  • Provides restraint for ABD, ADD, LR, MR
glenohumeral joint superior gh ligament
Glenohumeral Joint:Superior GH Ligament
  • Resists inferior translation in rest or adducted arm
  • Well-developed in 50%
glenohumeral joint coracohumeral ligament
Glenohumeral Joint: Coracohumeral Ligament
  • Resists inferior translation in shoulders with less-developed SGH
glenohumeral joint middle gh ligament
Glenohumeral Joint:Middle GH Ligament
  • Great variability in proximal attachment & morphology
  • Absent in 30%
  • Resists inferior translation in ABD & ER
  • Restrains anterior translation (45° ABD)
glenohumeral joint inferior gh ligament
Glenohumeral Joint:Inferior GH Ligament
  • 3 components (A,P,Ax)
  • Resists inferior, anterior, & posterior translation
glenohumeral joint bursae
Glenohumeral Joint: Bursae
  • Subcoracoid
  • Subacromial
  • Subscapular
glenohumeral joint accessory structures
Glenohumeral Joint: Accessory Structures

Labrum

  • 50% of depth
  • Increases tangential stability 20%
glenohumeral joint intra articular pressure
Glenohumeral Joint: Intra-articular Pressure
  • Synovial fluid causes adhesion
  • Provides ~50% restraint
glenohumeral joint rom
Glenohumeral Joint: ROM
  • Flexion (167° W; 171° M)
    • 30° in max LR
  • Extension (60°)
  • Abduction (180°)
    • 60° in max IR
  • Hyperadduction (75°)
glenohumeral joint rom1
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???

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

Soft Tissue Restraint Summary
the shoulder complex4
The Shoulder Complex
  • General Structure & Function
  • Structure & Function of Specific Joints
  • Muscular Considerations
  • Specific Functional Considerations
  • Common Injuries
pathomechanics of a weak serratus anterior muscle
Pathomechanics of a weak serratus anterior muscle

Deltoid force causes scapula to downwardly rotate.

Unstable and cannot resist deltoid force

gh flexion
GH Flexion
  • Prime flexors:
    • Anterior deltoid
    • Pectoralis major: clavicular portion
  • Assistant flexors:
    • Coracobrachialis
    • Biceps brachii: short head
gh extension
GH Extension
  • Gravitational force
  • Posterior deltoid
  • Latissimus dorsi
  • Pectoralis major (sternal)
  • Teres major (with resistance)
abduction at glenohumeral joint
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
adduction of glenohumeral joint
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
gh medial rotation
GH Medial Rotation
  • Subscapularis
  • Latissimus dorsi
  • Pectoralis major
  • Teres major (with resistance)

Decreased activity with ABD

gh lateral rotation
GH Lateral Rotation
  • Primary
    • Infraspinatus
  • Assistant:
    • Teres minor
    • Posterior deltoid
horizontal adduction and abduction
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
muscle strength
Muscle Strength
  • Adduction (2X ABD)
  • Extension
  • Flexion
  • Abduction
  • Internal rotation (max in neutral)
  • External rotation (max at 90° FL)

Role of multiarticular muscles???

the shoulder complex5
The Shoulder Complex
  • General Structure & Function
  • Structure & Function of Specific Joints
  • Muscular Considerations
  • Specific Functional Considerations
  • Common Injuries
specific functional considerations
Specific Functional Considerations
  • Stability Functions of Shoulder Girdle
  • Mobility Functions of Shoulder Girdle
  • Rotator Cuff Function
stability functions of shoulder girdle
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
specific functional considerations1
Specific Functional Considerations
  • Stability Functions of Shoulder Girdle
  • Mobility Functions of Shoulder Girdle
  • Rotator Cuff Function
mobility functions of shoulder girdle
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
dynamic stabilization mechanisms
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
muscular considerations
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
movements in the frontal plane gh joint abduction
Shoulder Girdle: UR

Totals

Upward rotation - 60°

GH Abduction - 120°

2:1 (.66) ratio

1.25:1 after 30°

0.5-0.75 across individuals

Movements in the Frontal PlaneGH Joint - Abduction

ABD - 60°

UR - 20°

ABD - 30°

UR - 40°

ABD

30°

movements in the sagittal plane gh joint flexion extension
Movements in the Sagittal PlaneGH Joint – Flexion & Extension
  • Shoulder Girdle:
    • UR
    • ELEV (>90°)
    • PROT ( to 90°)
    • RET (>90°)

Fig 5.18

large rom due to1
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
specific functional considerations2
Specific Functional Considerations
  • Stability Functions of Shoulder Girdle
  • Mobility Functions of Shoulder Girdle
  • Rotator Cuff Function
slide85

Teres minor

Supraspinatus

Subscapularis

Infraspinatus

function of rotator cuff
Large external muscles (e.g., lats, delts) create shear forces

Rotator cuff provides

Joint compression

Tangential restraint (Ant, Post, Sup)

Function of Rotator Cuff
subscapularis
Resists superior shear

Produces simultaneous internal rotation

Subscapularis
infraspinatus teres minor
Resists superior shear

Neutralizes SUBSCAP internal rotation

Infraspinatus & Teres Minor
destabilizing action of latissimus dorsi
LD pulls humerus INF

SSP resists INF force

INF & SUBSCAP create compressive force

Destabilizing Action of Latissimus Dorsi
the shoulder complex6
The Shoulder Complex
  • General Structure & Function
  • Structure & Function of Specific Joints
  • Muscular Considerations
  • Specific Functional Considerations
  • Common Injuries
common shoulder injuries
Common Shoulder Injuries
  • Joint dislocations
  • Clavicular fracture
  • Rotator cuff injuries
  • Other rotational injuries
  • Subscapular neuropathy
impingement
Impingement

Possible mechanisms

  • Weak or inflexible rotator cuff
  • Small anatomical space
  • Hyperabduction of GH joint
  • GH ABD + ROT
impingement roll slide kinematics
Impingement: Roll-Slide Kinematics

“Roll” created by abduction not countered with “Slide” action

slide99
During ABD

SSP tendon pushed into acromion process & CA ligament

During ROT

SSP tendon dragged along the inferior surface of the acromion process

slide100

Kinesiological breakdown of overhand throwing

Wind-Up Phase

No excessive movements

(safe)

First Motion

Maximum knee lift of leg

slide101

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

slide102

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

slide103

Kinesiological breakdown of overhand throwing

Arm Acceleration

  • Concentric IR (PMJR & LD )
  • IR velocity (> 1000 °/s)
  • RC stabilization

Internal rotation in abducted position

Possible cuff damage

Maximum shoulder ER

Ball release

slide104

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

slide105

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

rotator cuff injuries solution
Rotator Cuff Injuries: Solution
  • Alter technique during problem phases to avoid impingement
    • Arm cocking
    • Arm acceleration
  • Strengthen rotator cuff
  • Surgical repair

Video techniques

intrinsic risk factors
Intrinsic Risk Factors
  • Age and gender
  • Physical fitness
  • Overtraining
  • Skeletal abnormalities
  • Technique
  • Warm-up
  • Psychological factors
technique
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.

swimming
Swimming

Solutions:

  • Lead with hand to ↓IR
  • Increase body roll to ↓ ABD

Mechanism: ABD + IR

other rotational injuries
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
subscapular neuropathy
Subscapular Neuropathy
  • Denervation of INF with ↓ strength GH ER
  • Mechanism: Repeated stretching of nerve
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)

Injury Potential in the Shoulder Complex - Impacts
glenohumeral injuries
Most common dislocation in anterior (anterior-inferior 95%)

most commonly dislocated when abducted and ER overhead

recurrence rate 33-50% (66-90% <20 yrs)

Glenohumeral Injuries