The Shoulder Complex

Functions:
-The shoulder girdle must be capable of orientating the hand into any position in space, to allow our most useful tool, the hand, to operate successfully. -The girdle needs a large range of movement, - Good proprioception for fine control - The ability to transmit forces to and from the hand, for example when catching/throwing or opening a door . - Relies on the integration of intrinsic and extrinsic muscles - Dependant on scapula orientation, tsp and ribs - The support of accessory articulations to enable fulfillment of the functions

Anatomy
6 functional articulations of the shoulder (SC, AC, GH, Scapula-thoracic, Suprahumeral, Long head of biceps) S/C: an atypical synovial double-plane/saddle joint composed of two portions separated by an articular disc (fibrocartilage) . functionally ball and socket. The parts entering into its formation are the sternal end of the clavicle, the upper and lateral part of the manubrium sterni, and the cartilage of the first rib

Clavicle providing the only bony attachment for the arm to the axial skeleton. Quicker recovery due to its fibrous nature The clavicle provides one of the two pathways for force transmission. The anterior bony pathway allows forces to and from the upper extremity to travel via the gleno-humeral joint through the A/C and S/C joints to the sternum and thorax for absorption. The posterior myo-fascial pathway utilizes the gleno-humeral joint and scapula and trapezius and the posterior thorax for absorption. Ideally both pathways should be available with humeral position usually influencing the pathway utilized. Thoracic posture may also influence the pathway available.
3 which reinforce it interclavicular, sternoclavicular (anterior & posterior), costoclavicular ligs are v.strong, so it does not dislocate easily. In a fall you are more likely to # your clavicle (most common # bone in body) st also reinforced by subclavius (1 rib to clavicle). If tight cant functionally raise arm as st well because 1 rib holding it down. Movements movements are small when the arm is below 90 and are increased when the arm is used above this level it absorbs the final degrees of torque when the range in the GH, scapulo-thoracic and AC joints have been fully utilised A/C: less stable joint. Plane synovial joint Ligaments

Clavicle providing the only bony attachment for the arm to the axial skeleton. The acromio-clavicular joint follows gleno-humeral movement of flexion, extension, internal and

external rotation, also adduction and abduction to a lesser extent. Its effectiveness depends on the position of the scapula.
2 which reinforce it acromioclavicular - fibrouse band extending from the acromion to the clavicle that strengthens the AC superiorly coracoclavicular 2 bands: conoid (medial) & trapezoid (lateral). Does not X the joint but very important in stability if it ruptures your AC joint will dislocate. Good to work on these ligs with Pts with rounded shoulders. rd a 3 lig, the coracoacrominal does not stabilize the AC joint & is not part of the joint. But it forms the superior boundary for the GH joint stops superior subluxation of the humerus G/H: sacrificed stability for mobility. Vulnerable to dislocation, degeneration & muscle fatigue. Ball and socked joint. - is an incongruent joint consisting of a hemispherical head, articulating with the shallow smaller Ligaments

glenoid cavity of the scapula - Movement of an incongruous joint is not rotation about a fixed axis, but rather a gliding motion about a constantly changing axis of rotation. The muscles must not only move the joint, but must also afford it stability, providing a mobile axis of movement. -Instead relies on local intrinsic muscles, the rotator cuff, for maintaining approximation of the head of the humerus with the scapula and extrinsic muscles such as deltoid to provide power for the joint -Scapula should rest on the thoracic wall forming an angle of 30 - 50 with the frontal plane. This is the most mechanically efficient position for the humerus and enables efficient rotator cuff function. Effectively the scapula position determines gleno-humeral position.
Glenoid Labrum Capsule fibrocartilage rim which surrounds the glenoid fossa .Deepens the socket. . It may be considered as a redundant fold of the anterior capsule Very lax. Proximally all the way around glenoid labrum, except anteriorly extends to root of coracoid process. Distally around anatomical neck, except inferiorly where it extends a cm onto the shaft of the humerus st 2 openings. 1 anterior, just below coracoid process. There so an outpouching of synovial membrane pops out to form the subscapularis bursa (between subscapularis & capsule) = communication between bursa & synovial cavity: Foramen of Weitbrecht, may allow and be the site for dislocations of the humerus. nd 2 opening between lesser & gr.tubercles - a hole for tendon of biceps to pass into the joint. Inf. part of the capsule is the weakest part because it is the only part mo reinforced by the rotator cuff Not particularly strong Glenohumeral ligament has 3 bands (superior, middle, inferior, inf = most important) which reinforce anterior aspect of capsule Coracohumeral ligament reinforces superior aspect (quite strong). Limits external rotation of humerus. Any shortening of this lig is linked to adhesive capsulitus. From coracoids process to greater tubercle Transverse humeral a retinaculum which holds the long head of biceps in bicipital groove. Goes from greater to a lesser tubercle Coraco-acromial lig: Protective arch overlying the humeral head lots as big potential for friction at the shoulder. 2 most important: subscapularis between tendon of subscapularis & anterior aspect of capsule. Communicates with joint (inflammation from one can track to the other) Subacromial/supraspinatus between deltoid & capsule and also between supraspinatus tendon and coraco-acrominal lig. Does not communicate subcoracoid bursa-clos relation to the pec minor and neurovascular bundle Anterior & Posterior Circumflex Humeral arteries (from the Axillary artery) which anastomose around the humeral head Suprascapular artery to the scapula (from a branch of the Subclavian) Mainly posterior cord of brachial plexus Main nerves are: suprascapular; axillary; lateral pectoral a tight shoulder girdle can cause subtle neuropraxias of the arm (2ndary problem to a primary shoulder problem) Reinforces anterior, posterior & superior NOT inferior part of capsule (muscles attach

Ligaments

Bursae

Blood Supply

Nerves

Rotator Cuff:

Supraspinatus Infraspinatus Teres Minor Subscapularis (Fixing Muscles)

to capsule and therefore inferior part weak) Often referred to as the contractile ligs as they perform a ligamentous role They help govern the slide/roll of the humeral head in abduction and to stabilize it in the glenoid fossa To abduct the arm, the gr tuberosity has to pass under the acromion arch and avoid impingement on the coracoaromial lig. This can only be done by the coordinated action of the rotator cuff, deltoid and biceps. Deltoid elevates the humerus, this upward movement is countered by simultatneous depression & lateral rotation (teres minor & infraspinatus), subscapularis counters lateral rotation by rotating the humerous medially Scapula-Thoracic Articulation: Not a true joint scapular increases range of movement available @ G/H. G/H = 120 of abduction; scapula-thoracic 60. If not moving well the G/H will work harder and overstrain. rotation of scapula normally referred to as medial or lateral depending on the movement of the inferior angle of the scapula st superior angle @ 1 intercostals space; inferior angle @ T8; spine @ T3 Supra-Humeral Articulation (Space): Not a true joint Ligaments A protective articulation between the head of the humerus & an arch formed by the Coraco-acromial lig Prevents upward dislocation of the humerous Within the supra-humeral joint are found portions of the subacromial bursa, the subcoracoid bursa, the supraspinatus muscle and its tendon, the superior portion of the gleno-humeral capsule, a portion of the biceps tendon, and the interposed loose connective tissue. = many pain sensitive structures in an small area

As the arm abducts, the greater tuberosity must pass under the coraco-acromial ligament and not compress the enclosed tissues. The movement requires fine muscular co-ordination, laxity of soft tissues, and proper external rotation of the humerus. Impairment of any of these factors can result in limited movement, pain and disability.
if clavicle not working ok (bound down etc) often get pain in this area Long head of Biceps Articulation: Not a true joint Invaginates capsule but does not enter synovial cavity (intra-capsular/extra synovial) Pulls the head of the gh downwards

Vindicator
CVS Oncological MSK Infective Neuro GU GIT Resp AI/ Rheumato Congenital Endocrine
Haematoma; Heart/ spleen referral (left), Axillary vein thrombosis. Pancoast tumour Wear/tear: Subacromial Bursitis, Tendinopathy, O/A Trauma, dislocation, #, Subluxation, SLAP lesion, Supraspinatus tear, C5 lesion; C8 lesion; Ulnar nerve lesion; Long Thoracic Nerve of Bell, TOS Gallbladder referral via diaphragm (right);perforated duodenal ulcer, pleurisy PMR, Polymyositis, Cervical Rib; Klippelfe Frozen Shoulder

Common Problems
GH Dislocation Anterior Def:Humeral head slips off the anterior aspect of the glenoid fossa Mechanism: abducted and externally rotated. Sign:shoulder appears flatter and elbow points outwards;humeral head can be palpated in infraclavicular fossa. In young people, the anterior part of the labrum may be torn this is a Bankart Lesion, and makes recurrent dislocation more likely Test: Provisional diagnosis is made on clinical findings, X-Ray rules out # Asses nerve function before reduction There are four methods of reducing a GH dislocation

1. MUA: manipulation under anaesthetic 2. Hanging Arm Method: patient prone. Arm hanging, sometimes muscle relaxants used 3. Hippocratic Method 4. Kocher Method: txx+Ext rot+add Recurrent dislocations: capsule reattached to glenoid rim+ subscapular tendon shortened Possible Complications: Vascular damage Nerve damage Joint stiffness, including frozen shoulder syndrome Recurrent dislocation Glenoid labrum ripped from glenoid rim GH Dislocation Posterior Much less common often a subluxation rather than a dislocation (5%of the cases) Often occur as a result of a direct blow to the shoulder in internal rotation &adduction or with epileptic seizures. Arm internally rotated & adducted (no ext rot possible) Posterior prominence palpable. Anterior shoulder contour lost. Coracoid process is more prominent Can be recurrent, especially if the patient has ligamentous laxity. Surgical ttt involves reattachment of the capsule and shortening of the infraspinatus tendon to limit internal rotation Complications: can be recurrent inferior (1%) arm abducted 110-160 and held with forearm resting on or behind patients head. humeral head is against the acromion. Inferior dislocations have a high complication rate due to proximity of neurovascular bundle Ant/post/inf Pt with ligamentous laxity Pt may du voluntary dislocation Complication: rotator cuff damage, vascular compression Definition: Tear of superior labrum in an anterior-posterior direction. Mechanism: Due to the long head of biceps tendon anchor pulling on labrum or fall on the outstretched arm Onset: traction (e.g. pull of heavy object, dislocation,etc.), or compression (e.g. fall onto outstretched arm) or repetitive overhead throwing Symptoms: pain at top of shoulder (dd AC joint); clicking/pain with overhead activities. Treatment: Anti-inflammatories, painkillers, surgery Surgery indicated if poor improvement. (depends on patients age, activity level, etc) Diagnosis: Often TTP over ant. aspect of G/H, on AR biceps contration MRI or commonly found during surgery Differential diagnosis: often confused with A/C problems SLAP lesion, eccentric biceps loading results in pain A/C joint, pain usually felt when pressing out (e.g. at end of bench press). Degenerative/ flap/ vertical labral tears and Bankart lesions A tear to the labrum of the GH joint/ small avulsion # of glenoid rim (Iledezak lesion) Ant-inf labral lesion Occurs specifically to the inferior GH ligament with dislocation of the shoulder (especially in younger patients) Symptoms: catching; Aching; cannot trust their shoulder Complications: recurrent dislocations Ttt:Repair of the ligamentous damage, tightens of the capsule, reattach the labrum Definition: Condition affecting the gh capsule where active and passive movements are affected. Inflammation and adhesion of the capsule and ST Pathophysiology: This is most commonly the sequelae of protective rest for the shoulder due to trauma elsewhere, or due to long term wear and tear of the

Inferior dislocation

Multidirectional dislocation

Superior Labrum Anterior-Posterior lesions (SLAP lesions)

Non-SLAP lesions Bankart Lesion

Frozen Shoulder

shoulder joint causing irritation or stasis of the capsule resulting in a capsular reaction. Any such insult to the capsule normally results in a capsular pattern being observed as those parts of the capsule most prone to irritation become inflamed and reduce those ranges of movement that would stretch those inflamed areas. When this inflammation is resolved, the range is often still reduced due to shortening of those close-by structures from protective mechanisms or disuse. Onset: after injury,surgery or immobilisation P.F: 50-55 years, women, diabetics, thyroid disease, previous degenerative shoulder Symptoms: Global deep joint pain of acute or chronic onset Either shoulder can be affected but most commonly it is the non-dominant side. In about 1 in 5 cases it develops in the other shoulder at some stage Restriction of all shoulder movements, both active and passive. Unable to sleep on affected side Impaired external rotation, e.g. driving, dressing Typically, flexion, abduction and external rotation become restricted first (e.g. combing hair, reaching into back pocket,etc.), but other movements also become restricted to varying degrees Tends to be 3 phases: painful freezing (can last 6months):pain on pm/am, ache. Spasm, night pain, rest pain, little response to NSAIDS stiffness frozen phase (6 months): less pain, decrease night pain, rest pain, EOR discomfort, increases restriction recovery thaw phase (6 months):decrease pain and restriction, gradual inc of ROM Only about 15% of frozen shoulders are true frozen shoulders A frozen shoulder occasionally follows a shoulder injury, but this is not usual and most cases occur for no apparent reason Coracohumeral lig a big player in frozen shoulder blends with capsule & layers of rotator cuff Symptoms can persist for 18 months to 3 years or more Ttt: steroid injection (better outcome if administered early) manipulation under anaesthetic: MUA arthroscopic release of capsule Complication: Bilateral Nerve irritation Long term NSAIDs can irritate stomach A/C Injuries # of the clavicle (lateral 1/3 : fairly common; fall on outstretched hand / fall onto tip of shoulder AC dislocation: 1. Forces directed down (e.g. heavy carrying, rugby, fall of cycle, etc.) onto the acromion, the coracoid and, if the force is great, the first rib, act as a fulcrum for subluxation of the A-C joint surfaces and if tearing of the trap/con ligs occurs then dislocation.
rd

2.Forces directed upwards (e.g. fall on hand) through the humerus are absorbed by the coraco-acromial arch, the acromion is forced up and back with tearing of the joint capsule and ligaments. Clinical findings: Local pain and tenderness over the joint All except grade 1 observable or palpable step Step can be temporarily eliminated by lifting the arm and elbow whilst holding down the clavicle (piano key clavicle) Injury graded according to the damage; 1 Ac ligamentous sprain, 2 disruption +subcoracoid dislocation Complications: OA, instability, dislocation Painful Arc = sign NOT diagnosis

MM Rotator cuff strain/ tendinopathy/ calcific tendinopathy Rotator cuff Total tear may => night (d.d. malignancy) tear/rupture Partial: supraspinatus tendonitis and hypovascularisation of the supraspinatus Complete: associated with trauma. Signs: Traumatic:Immediate pain, pain active abd, no pain passive abduction, above 90 abd pt maintans position, lowering arm:dropping arm Partial: gradual decrease pain and increase ROM. May repair Complete: pain decrease, but ROM doesnt increase. Little repair Complications:Rupture tends to adhere to locat ST Cause: -1- Degeneration plays a big part in supraspinatus problems somebody who has used their arms a lot (especially overhead or at acromion level e.g. swimmers/ throwers/ raquet sports) -2- It is the most active/vulnerable rotator cuff muscle. The function of holding the head in glenoid cavity is always on even whilst arm is at side at rest means it is almost always under traction tension which reduces the blood supply -3- flexion and abduction compression of the tendon in the subacromial space Pathophysiology: Therefore affects blood supply (receives supply from both ends) which means it is quite a slow healer.Critical zone ischaemic 18 h at day Signs: thinning of the tendon, pulling away of the fibres from the area of attachment, osteophyte formation, torn of the tuberosity, compression of the bicipital tendon, bursitis often worthy to x-ray to see if osteophytes there. Doesnt respond well to osteopathic TTT. Best to refer to shoulder specialist (who may scrape the osteophytes off) differential diagnosis: minor tear active pain but power almost normal; major tear- on activity, inable to sleep on affected shoulder, +ve impingement signs, weakness tendinopathy active pain with reduced power/ tenderness over insertion, painful arc in abduction (70-120o) Empty can test, impingement tests EOR passive flexion Treatment Ice and avoidance of agg. Factors GTN patches (3-6onths) and corticosteroid injection Address cause e.g. scapula mechanics/ activities Strengthen ext. rotators and int. rotation (may need to stretch post. Capsule) Calcific tendinopathy- may be severe at rest, with movement and @ night. Damage may have occurred as the upper extremity moved forcibly into external rotation, causing tearing, swelling, pain, etc. If the damage is near its insertion on the humerus then shortening may occur and the arm may be held in a protective, internally rotated position. Thus the external rotators will be held on stretch, especially teres minor and infraspinatus. If the arm attempts to externally rotate pain will be felt over subscapularis, movement will be limited, and the humeral head held in relative internal rotation. Biceps tendinopathy/rupture Long head rupture at the shoulder Cause: degeneration Incidence: >50 Signs and symptoms: minimal trauma, may hear a snap, musc belly forms a ball in the lower part of the arm, ache in the area, slight bruising Ttt: Normally surgery not needed since short head of biceps can compensate. Surgery in youn actives This is a local periostitis causing pain and tenderness around its insertion on the angle of the scapula. The intense aching in this small area may be increased by pressure on its lower fibres, the muscle is contracted and tender, but not normally associated with pain in the neck. It occasionally does refer via the lig.nuchae to the sub-occipital area and through its muscular pull it is often associated with limitation,

Supraspinatus tendonitis and degeneration

Subscapular tear/shortening

Levator scapulae

side bending and rotation of C1 & C2. Nerve entrapment Long Thoracic Nerve of Bell Lesion supplies serratus anterior Due to its long, relatively superficial course, it is susceptible to injury either through direct trauma or stretch can be compressed in the neck (scalenes), Breast surgery, blow to the ribs = asymmetrical scapula winging due to nerve weakness (bilateral winging is often normal) C5-C6 Innervates supraspinatus and infraspinatus Passes through the suprascapular notch Atrophy, decreased abd and ext rotation Cause: txx and osteophyte formation
Erbs palsy total or partial paralysis of structures supplied by the C5, C6 and (C7) nerve roots. Most common during birth but can occur at any age due to trauma. Caused by an excessive shoulder to head interval that can physical tears the nerve roots out. Suprascapular nerve is most commonly affected due to its fixed attachment on the suprascapular notch; the next most affected nerves are the musculocutaneous and axillary nerves. This leads to the loss or reduction in abduction and lateral rotation of the GH, flexion at the elbow, supination. Also sensory changes to the lateral forearm arm and shoulder. Can show as waiter tip Klumpkes Palsy Rare condition that effect the C8 T1, most common at birth when arm and head come out first, but can occur during a high fall a person was to grab onto something with one outstretch arm. Affects the ulnar nerve distribution and all intrinsic hand muscles. If T1 nerve root is completely torn from the spinal cord then this will cause Horners syndrome.

Suprascapular

Brachial plexus

# Clavicle/ coracoid Scapula Neck of humerus