The shoulder
Download
Report
Transcript The shoulder
The shoulder
Shallow G-H jtglenoid labrum
deepens capsule;also
requires strong
muscle force to
stabilize the jointRTC (rotator cuff
muscles) SITS ms.
Ligaments of shoulder joint:
A-C ligament-sup and inf reinforce the
joint capsule and prevent post
dislocation of the clavicle
G-H ligaments-originate from labrum
and attach to lesser tubercle and anat
neck (reinforce capsule) sup, mid and
inf bands
Coracoclavicular lig.- lat(trapezoid) and
med(conoid) Both prevent backward
mvmt of the scapula and ind they limit
scap rotation
Acromioclavicular Joint
A-C joint capsule
Coracoclavicular
ligaments
Clavicular Ligaments
A-C Joint
Conoid ligament
Common Glenohumeral
Problems
Rotator cuff tendinitis
Rotator cuff tears
Bicipital tendinitis, rupture
Glenohumeral dislocation/subluxation
Labral Tears
Frozen shoulder syndrome
Arthritis
Rotator Cuff Problems
Rotator Cuff Impingement
Rotator Cuff Tear (RCT)
Phase 1 (0 to 6 weeks)
Phase 2 (6 to 12 weeks)
• Passive range of motion
exercises only for almost
all tears.
• Active-assisted range of
motion for very small
tears or repairs with
exceptionally good tissue
• Full passive motion
• Begin active-assisted
motion
• Strengthen intact cuff
muscles
• Begin to strengthen the
muscles that stabilize the
shoulder blade
Phase 3 (12 to 16 weeks)
Phase 4 IV (> 16 weeks)
•Passive stretching beyond
the patient's own range of
motion
•Strengthening the repaired
cuff muscles
•More strengthening of the
stabilizers of the shoulder
blade
•Functional strengthening
•Rehabilitation for sports
Normal Cuff, Torn
Supraspinatus on MRI
Bicipital Tendinitis
Impingement
Shear in bicipital groove
Long biceps tendon in
intimate with joint
capsule.
May be impinged
beneath acromion, or
sheared within
bicipital groove.
Bony Structures
Avascular Necrosis of
Humeral Head
May be seen with
chronic corticosteroid
use.
(GENTLY handle
patients with history
of steroid use.)
Can lead to total
shoulder
replacement.
Glenohumeral Arthritis
Glenohumeral Arthritis
Frozen Shoulder Syndrome
“Freezing” shoulder
“Frozen” shoulder
“Thawing” shoulder
Freezing Shoulder
“Freezing” shoulder
Usually starts with inflammatory process,
such as impingement syndrome.
Subscapularis trigger points limit external
rotation, abduction
Shoulder becomes painful, then stiff
Best opportunity for intervention is here!
Frozen Shoulder
Capsule undergoes fibrotic changes
(“Adhesive capsulitis”)
PT intervention alone is of questionable
help.
May benefit from manipulation under
anesthesia, followed by PT care.
Thawing Shoulder
Shoulder spontaneously becomes less painful,
less stiff.
If in rehab, take credit for result, but probably
little effect from treatment.
Nearly all frozen shoulders spontaneously
resolve in 6 to 18 months
May recur on opposite side
Rare in African-Americans
Glenohumeral/Scapulothor
acic Rhythm
Occur in 2:1 ratio GH/ST, but not in
constant ratio.
GH joint moves first, with stabilized
scapula
Then, move in 1:1 ratio.
Then finish with mostly GH motion
FINAL ratio is 2:1
Glenohumeral Dislocation
Usually caused by violent abduction/external
rotation of humerus.
Humerus dislocates in anterior, inferior direction.
Causes disruption of anterior labrum (Bankart
lesion)
If repeated, posterior aspect of humerus strikes
labrum, producing indentation in humerus (Hill
Sachs lesion.)
Superior Labral Tear Anterior and
Posterior to Biceps Attachment
(SLAP)
Biceps tendon
Posterior tear
Anterior tear
Bicipital Tear (Longhead)
Scapulothoracic Problems
Winging scapula from poor posture, habit.
Common in tall, early developing females, swimmers
Correlated with G-H problems
May be from long thoracic nerve palsy, taking
out serratus anterior.
Results in inability to raise arm above 120 degrees
(ever.)
Serratus Anterior Loss
Winging
120 degrees abduction
Suprascapular Nerve Palsy
Suprascaular nerve
innervates supra- and
infraspinatus.
Injury results in
selected weakness.
What’s the sensory
pattern??
Coracoacromial lig- provides roof over
the humeral head - acts as a protective
arch
Scapular movements must be
accompanied by shoulder joint
movements therefore if you have
impairment at G-H joint, must look at
scapula
Kinematics of shoulder jointscapulohumeral rythym
external rotation with abduction
scapular plane
Muscles-RTC(rotator cuff muscles) SITS
supraspinatus-imp to keep head of
humerus in glenoid fossa along with
other ms.
Infra, teres minor, subscap-act to
depress head during flexion and
abduction-counteract strong deltoid
long head of biceps becomes very
active in shld flex and abd past 90
Ms. named from areas they originate
and insert-grouping as follows:
Scapulohumeral:deltoid, supraspinatus,
infraspinatus, teres minor,
subscapularis, teres major,
coracobrachialis
Axioscapular:pect minor, trapezius,
rhomboids, lev scap, serr ant
Axiohumeral: pect major, lat dorsi
Deltoid-ant, mid and post portion
Origin: ant portion-lateral 1/3rd of
clavicle
mid-acromion, post-spine of scapula
Insertion-deltoid tuberosity of humerus
and med rotate, post fibers extend and
laterally rotate
innervation-axillary (C5,6)
supraspinatus:
origin-supraspinatus fossa of scapula
insertion-greater tubercle of humerus
action- stabilizes head of humerus in
capsule, assists in abduction-acts as
force couple with deltoid to assist with
abd
innervation-suprascapular (C4,5,6)
Infraspinatus-origin-infra fossa
insertion-greater tubercle and shld
capsule
innervaton-suprascap nerve
action-ext rotation of shoulder and
depression of humeral head and
stabilizes head during movement
Teres minor-origin-upper lateral border
of scapula
insertion-greater tub and shoulder
capsule
action-lat rotation and add of humerus
Subscapularis-origin-subscapular fossa
insertion-lesser tubercle of humerus
and capsule
action-int rotation of humerus and
works with other ms.
Innervation-subscapular (C5-7)
Teres major-origin-acillary border of inf
angle of scap
insertion-med tip of inter groove
action-med rotation, adduction and
shouler ext
Innervation-lower subscapular(C5-7)
Axioscapular-pect minor:
origin-ribs 3,4,5 and fascia of intercostal
ms
insert-coracoid process
action-elevation and downward rot of
scap
innervation-medial pect (C8-T1)
trapezius-origin-upper from occ
protuberance, nuchal line and spinous
porcess of C7, middle from spinous
process T1-5 and lower from T6-12
insertion- upper from lat clav and
Rhomboid major-origin-spinous process
T2-5
insertion-vertebral border
action-down rotation, elevation and
adduction of scap
innervation-dorsal scapular (C4-5)
rhomboid minor-origin-spinous
processes C7-T1
insert-root of spine of scap
action-same as major
inn-same as major
Levator scapula-origin-transverse
processes C1-4
insertion-sup med border of scap
action- elevation, down rotation and
add of scap
innervation-dorsal scapular
Serratus anterior-origin-upper 8-9 ribs
ant surface
insertion -medial, inf surf of scap
action-up rot, elevation and abduction
inn-long thoracic (C5-7)
AxiohumeralPectoralis major-origin:clavicle, sternum
and cartilage of first 6-7 ribs
insert-lat inter. Groove
action: med rotation, flexion and
horizontal adduction
Latissimus dorsi-origin-sp processes of
T6-12, last 3 ribs, thoracolumbar fascia
and iliac crest
insert-inter groove
action-med rotation, adduction and ext
of shld, ext of L spine, flex of T spine
Disorders of PNSneuropraxia-local blockage interfering
with conduction , it’s OK above and
below-commonly caused by
compression-Saturday night palsy-radial
nerve or Bell’s palsy, no disruption of
axon
Axonotmesis-nerve injury characterized
by disruption of the axon and myelin
sheath but with preservation of
supporting CT resulting in axonal
degeneration distal to the injury site-the
deficit depends on the # of axons
neurotmesis- partial or complete
severance of a nerve with disruption of
axons, myelin sheaths and supporting
connective tissue resulting in
degeneration of axons distal to the injury
site (worst of the 3)
Disorders of PNS
Erb’s palsy-compression or stretching of
upper BP nerve roots (C5,6)-results in
“waiter’s tip” sign
Klumpke’s paralysis-compression or
stretching of lower BP (C8,T1)-results in
functionless hand
Bursae-fluid filled sac which can be
inflammed-bursitis-most common in
shoulder-subdeltoid and subacromialleast likely subscapular bursitis
Signs-warm, edematous with
tenderness over area
Pain quality-intense, dull, throbbing all
movements painful
Tendonitis-inflammation of the tendon
RTC tendonitis-supraspinatus most
involved-results from overuse, tennis,
baseball, carpenters, plumbers-can also
be poor blood supply causing scarring
or Ca deposits-can bring about tears,
bursitis or impingements; local steroids
can relieve symptoms but may cause
structural wknss of tendon
Pain quality-sharp twinges ie. Donning
jacket, reaching OH, abd or IR arm
Onset-gradual. May sometimes refer to
C5-6 dermatome
RTC tears-acute, chronic, full, partial
thickness tears;<1cm. Small, >5cm.
Massive-usually traumatic but may be
degenerative
pain-not always severe but pt con’t
raise arm and has severs atrophy lat
and ant deltoid region-may require
surgery
Adhesive capsulitis-frozen shld.-trauma,
disuse, immobilization, RTC lesions
pain-dull-severe with activity, pain at
Onset-gradual, will see increase activity
of upper traps
Impingement syndrome-supra, long
head biceps, subacro bursa most
affected-pt. will exhibit painful arc of
motion b/w 70-120 degrees
3 stages:
I-edema-athlete or poor posture, young
person with no recollection of injury
II-fiborsis and tendinitis (20-40
yo)recurrent pain with activity
III-bone spurs and tendon ruptureslong history (50-60yo)
G-H instability-hum head dislocates
through ant capsule, RTC ms. Can be
weak
Brachial plexus lesions-numbness
and burning entire arm, hand,
fingers, sensory loss over 2 or
more dermatomes, paralysis of
arm, may be transcient tenderness over BP with increased
symptoms with movement of head
to opposite side
Thoracic outlet syndrome-often called
neurovascular compression-symptoms
resulting from injury at upper border of
thorax where BP and subclavian a are
located-can be caused from a C-rib
treatment-postural correction ex to bring
back shoulders
Brach plex lesions-numbness and burning
entire arm, hand, fingers-sensory los over
2 or more derm-paralysis of arm-may be
transcient-tenderness over BP with
increase symptoms when turning head
opp. side
Diagnostic testsX-ray-for bony defects, alignment,
exostosis (bone spurs), osteophytes and
diseases
C-T scans-specific for bone
MRI-magnetic resonance imaging-soft
tissue-no radiation as in X-ray
angiography-contrast mat injected into
vascular system
myelograpy-inject dye into SA space
EEG-records brain electrical activity
EMG and NVC-see if diseases are
neuromuscular in origin
arthrogram-injects dye and air-views jt
space, cartilage, ligs