kines 330 unit 4

shoulder complex,

shoulder anatomy

• ball and socket joint

• consists of 3 bones

• flat areas contain deeper muscles (scapula)

what helps to keep the ball in the shoulder socket?

• ligaments

• labrum

• capsule

increased ROM =

decreased stability

muscle contractions of the shoulder help to dynamically ____ the joint

control

Scapulohumeral Rhythm

• The movement of the scapula is relative to the humerus

• first 30 degrees of glenohummeral (GH) abduction is all on its own (no scapular motion)

• 30-appx 120 degrees, there is a 2:1 ratio of GH: scapula movement

• 120-180 degrees is a 1:1 ratio

brachial plexus

starts at cervical and runs under clavicle

Shoulder ROM: GH joint

• flexion

• extension

• abduction

• adduction

• internal

• external

• horizontal rotation

Shoulder ROM: scapular

• elevation

• depression

• adduction

• abduction

• upward rotation

prevention of shoulder injuries

• proper physical conditioning is key

• proper warm ups that include a full ROM

  • especially for overhead activities or those doing explosive arm movements

    • think tubing exercises, medicine balls, weighted water

    • helps with activation of rotator cuff muscles as well as scapula and humeral muscles

    • focus on follow through

• teach how to fall, proper throwing/throwing/dance/stunt/serving/spiking/how to hold instruments techniques

• protective equipment and braces

how do humeral fractures occur?

• tends to occur with a direct blow or foosh, and can fracture with an eccentric load

  • watch for growth plate fractures as well

symptoms of a humeral fracture

deformity, pain, swelling, decreased ROM

treatement of a humeral fracture

• splint and ship off for a cast or surgery

• tends to be 4-8 wk heal time

how does a clavicle fracture occur?

falling on outstretched hand or a direct hit

symptoms of clavicle fracture

pain, deformity, lack of ROM, swelling, and a snap

treatment of clavicle fracture

• Check for neurovascular injuries

• If in alignment, they get a figure 8 brace or sling and eventually PT

• If not in alignment, they get new hardware, sling, and PT

how does a SC sprain occur?

force on outside shoulder

SC sprain symptoms

• anterior is better, posterior will cause trachea to be compressed and loss of breathing

• grade 1: might be pain and discomfort

• grade 2: possible deformity and lack of ROM

• grade 3: deformity

treatment of SC sprain

sling and ship for imaging, might be 3-5 weeks in sling/brace with gradual PT

how does an AC sprain occur?

foosh or blow to outer shoulder

symptoms of AC sprain

• grade 1: ligament stretched

• grade 2: partial rupture A.C ligaments

• grade 3: complete rupture A.C and C.C ligaments

• grade 4: clavicle displaced posterior over acromion

• grade 5: clavicle displaced just under skin

• grade 6: clavicle underneath coracoid (very rare)

AC sprain treatment

• stabilize and ship for imaging to see how to best treat

  • grades 1-3 tends to be sling and gradual PT after apprx. 2 weeks

  • grades 4-6 are surgical

how does a GH Subluxations/Dislocations occur?

force on shoulder, can have anterior (most common), posterior, and inferior (rare) dislocations

GH Subluxations/Dislocations symptoms

A sublux will have pain, limited ROM, while a dislocation will have a deformity, pain, and no ROM

GH Subluxations/Dislocations treatment

• If trained, reduce it and ship; if not, splint and ship

  • first time dislocation = always suspect a fracture

  • chronic inj. = may brace to reduce the chance, as the labrum is torn

  • person needs to keep up with a rehab plan, as the dynamic muscles are the best thing to keep the GH head in

bankart lesion

anterior defect of labrum

hill sachs lesion

divot in humeral head

what are complications of GH dislocations?

Hills sachs and bankart lesion

how are Hills Sachs and Bankart lesions treated?

surgeon will try to fix these is the GH patient ops for surgery to fix their labrum

how does a SLAP lesion occur?

• can occur due to dislocation or on it’s own

• labral tear that has a specific location (superior labrum anterior to posterior)

SLAP lesion symptoms & treatment

• A defect in the superior labrum that begins posteriorly and extends anteriorly, which means it will affect the long head of the biceps

  • Bicep movements will tear the labrum more

• 4 types of tears, last 2 focus on the biceps tendon

• most are surgical cases

how does a GH labral tear occur & symptoms?

• may complain of grinding, catching, pain deep in the shoulder, and instability

• can have soreness post-eccentric contractions

• tends to be overhead athletes

GH labral tear treatment

might be surgically repaired esp. if patient begins to sublux or dislocate

how does a impingement occur?

• compression of the supraspinatus tendon, subacromial bursae, or long head of the biceps tendon as the space below the coracoacromial arch is limited (getting hit, an inflamed area)

• seen a lot in overhead athletes

symptoms of impingement

pain that comes over time, increased GH ER with decreased GH IR

treatment of impingement

• if we let it rest, it tends to calm down

  • use modalities, stretches, and work on mild strength

how does a rotator cuff tear occur?

• tends to come at the insertion of the muscles

• can be partial or full thickness tear

• full thickness tends to be overhead athletes over 40 y/o with history of RC injuries

rotator cuff tear symptoms

pain and lack of IR/ER ROM

rotator cuff treatment

• management depends on tear

  • Partial is conservative with PT

  • Full is surgical and immobilization

rotator cuff is how many muscles?

4

biceps tendon rupture occurance & symptoms

• tends to be a powerful contraction where the bicep avulses off of insertion or origin

  • if it’s insertion area, you have little ROM and a popeye muscle

  • it it’s origin, you may still have ROM (as it has two heads)

  • both have pain, bruising, swelling and will feel a pop

biceps tendon rupture treatment

• ice, splint and ship

  • tend to have surgery, but only exception is elderly at origin

Frozen Shoulder/Adhesive Capsulitis symptoms & occurrence

• joint capsule becomes thickened, contracts and becomes inelastic

• pain with all motions no matter if active or passive

Frozen Shoulder/Adhesive Capsulitis treatment

• might have to hurt the patient

  • aggressive joint mobs will be the best thing

  • use modalities to help with pain

  • have to stretch post-mob or else we lose what we gained

elbow and forearm anatomy & pathology

• The radius and ulna have an interosseous membrane to help hold it together

• 3 bones have 3 joints: humeroulnar, humeroradial, and radioulnar

• MCL/Ulnar ligament has 3 bands

• LCL/Radial has 1 part

the elbow bones have what joint?

humeroulnar

forearm flexor muscle

medial side

forearm extensor muscle

lateral side

vascular aspects of the elbow/forearm

vessels and nerves can’t go over the olecranon process so it wraps around

elbow & forearm ROM

• 145 degrees flexion

• 90 degrees supination or pronation

• 0 degrees extension (hyperextension can happen)

carrying angle of eblow

• normal, it just tells us the distal projection of the humerus (hands cant slam into hips)

• can see when we put someone in anatomical position

• “normal” is 5-15 degrees, cubital varus is less than 5 degrees (closer to body), while cubital valgus is over 15 degrees

• males are typically 5-10 degrees while women are 10-15 degrees

prevention of elbow/forearm injuries

• braces help prevent injuries typically for a secondary injury

• how to fall

  • FOOSH causes a mess for UE, try to teach how to brace without putting arm down

• decrease overuse by cross training

  • if we cross train children, they have less injuries

  • also helps them to decrease their chances at burnout

• proper biomechanics

• adequate recovery

• adolescent and post-injury— number of throws/hits & types

  • theres charts on this dependent on age, league, position, etc. we need these protocols so that kids don’t get overuse injuries

olecranon bursitis

as the bursae is superficial, we tend to injure it a lot with direct blows

symptoms of olecranon bursitis

mild pain, pressure, swelling, tenderness

treatment of olecranon bursitis

• compress and ice it

• if swelling doesn’t resolve, we can drain it

• if athlete, we tend to pad the area so it doesn’t keep happening

muscle strains & avulsions

tends to occur with resistive motion or repeated microtears due to overuse

symptoms of muscle strains & avulsions

pain during motion as well as tenderness, reduced strength

treatment of muscle strains & avulsions

depends on the severity of strain, usually ice and rest works wonders

UCL sprain

• UCL’s tend to rupture with valgus forces on the elbow

  • the more repetitive they are, the more microtears you get

symptoms of UCL sprain

• can hear or feel a pop, pain and tenderness on medial elbow, possible tingling, and laxity at joint line

treatment of UCL sprain

• in depth, if grade 1 or 2, we hope conservative treatment will scar the area and stabilize it

• grade 3= 12-18 month rehab after surgery

• throwing athletes can return to activity 22-26 weeks post-surgery with full recovery at 18-24 months

• grade 3 rehabs are slow for a reason for overhead athletes

lateral & medial epicondylitis

• lateral epicondylitis: tennis elbow

• medial epicondylitis: golfers elbow

• both are where muscle groups insert and are inflamed due to overuse

symptoms of lateral & medial epicondylitis

aching pain, possible tenderness, weakness in muscle group, pain worsening as muscle group is used, decreased ROM

treatment of lateral & medial epicondylitis

rest, NSAID’s, ice, and seeing if we can slightly change biomechanics

• eventually slight stretches, slow strengthening exercises, massage and use counterforce brace

elbow dislocation

• tends to occur due to a FOOSH

• we usually see a posterior dislocation, but weird things can happen

  • can also fracture with dislocation

symptoms of elbow dislocation

deformity, pain, and swelling

treatment of elbow dislocation

• check neurovascular stat

• sling and ship so they can be reduced and imaged

• usually will need to be in that sling for at least 3 weeks

  • rehab will consist of a lot of hand things until we feel they are stabilized

  • stay away from stretching for those weeks

elbow fracture

• FOOSH mechanism or direct hit

  • possible even incorrect reduction with elbow

symptoms of elbow fracture

• swelling, muscle spasm, pain, possible deformity, reduced ROM, compromised neurovascular

treatment of elbow fracture

• stabilize and ship

  • may need a sling or cast or surgery

  • depends on cast vs. surgery

forearm fractures

• FOOSH or direct blows

• super common in youth due to the MOI, but rare to see it as ulanr and radial fractures simultaneously

• Colles fx: radius & ulna fracture where they hyperextend (go dorsally)

• smith fx: radius & ulna fracture and hyperflex (go volarly)

forearm fractures symptoms

pop, pain, swelling, possible deformity, lack of ROM

forearm fractures treatment

splint and ship, will need cast or surgery (4-8 weeks then therapy)

volkmann’s contracture

• associated with forearm fractures which causes muscle spams, swelling, and reduced brachial artery flow

• can be permament or temporary. If we can fix blood flow, should be temporary. Can still have muscle damage within hours

volkmann’s contracture symptoms

pain in forearm, passive extension of fingers, coldness in arm (no blood flow), decreased ROM

volkmann’s contracture treatment

if caused by a cast or wrap, take it off

bones in the hand

• 8 carpals, 5 metacarpals, 2 sesamoids, 14 phalanges

• MCP, MP, DIP, PIP joints

muscles of the hand

• thenar: 4 thumb muscles

• hypothenar: 3 pinky muscles

• anatomical snuffbox: ext pollicus brevis and longus and adductor pollicus

• retinaculum hold down tendons at joint areas

• palmaris longus is sometimes not needed

neurovascular aspects of the hand

• carpal tunnel: straight down wrist (dorsal side) and has median nerve

• tunnel of guyon (hook or hamate is “roof”): is on ulnar side with the ulnar nerve

wrist and hand ROM

• thumb is the only saddle joint in body, remember its motions are “abnormal” from all other joints

• MCP, DIP, and PIP joints flex and extend

• pinky does opposition, and fingers flex, extend, abd, adduct

wrist sprain

• most common wrist injury

• occurs with an abnormal, forced movement (falling on hyperext. wrist or violent flexion)

wrist sprain symptoms

pain, swelling, tenderness, difficulties with ROM

wrist sprain treatment

• can send for images to rule out a fracture

  • can splint in brace if bad enough

  • treatment for pain management (meds, modalities)

  • can prevent or treat with wrist tape

TFCC injury

• Triangular fibrocartilage complex (TFCC) is a combination of ligaments and “meniscus” cartilage on ulnar side

• Gets injured when patient has a violent twist of the wrist, typically with a hyperextension

TFCC injury symptoms

pain on ulnar side, possible clicking, lack of wrist extension, swelling

TFCC injury treatment

• if suspected, should send to dr for images

  • may need splint for about 4 weeks (rest), then start with strengthening and ROM exercises (bad case may need surgery)

nerve compression

• Bishop’s hand = median or ulnar nerve

• Ape hand = median nerve

• Claw hand = ulnar nerve

• Drop wrist = radial nerve

• direct trauma to area

nerve compression symptoms

sharp or burning pain, skin sensitivity, muscle atrophy, paralysis

nerve compression treatment

• if chronic, may have irreversible damage

• may need surgical decompression

carpal tunnel syndrome

• Compression of median nerve due to inflamed tendons running in this tunnel

• Occurs with repeated wrist flexion or direct trauma to dorsal side of wrist

carpal tunnel syndrome symptoms

• Pts tend to have sensory and motor deficits, weakness in muscles

carpal tunnel syndrome treatment

• Start with conservative tx (rest, splint, meds). If it doesn’t work, try a corticosteroid injection or a surgical decompression

carpal fractures

• Scaphoid fx caused by FOOSH and scaphoid gets compressed. Tends to fail due to poor blood supply

• Hamate fx is FOOSH or contact where pt is holding something (think a bat)

carpal fractures symptoms + treatment

• Sxs include pain, weakness, tenderness

• Imaging needed. Cast or surgery. Possible padding needed

wrist ganglion cyst

• tends to grow after a wrist sprain

wrist ganglion cyst symptoms + treatment

• lump is present, also complains of pressure

• can feel soft, hard or even rubbery

• the more the pt uses the wrist, the more pain increases

• Three things we can do: break down swelling then hold down with a pad, aspiration, or surgically remove. First 2 may come back. Last one, we need to get the root out or it will come back. 

metacarpal fractures

due to direct axial or compressive force

metacarpal fractures symptoms + treatments

• Sxs include pain, swelling, deformity, rotation of nail, loss of ROM

• Can send in for imaging to see if they need to splint/buddy tape or possible cast. If rotational, will possibly need surgical repair

• Bennett’s = 1^st metacarpal

• Boxer’s = 5^th metacarpal

gamekeeper’s thumb

• sprain of UCL of MCP jt

• occurs from forceful abduction of proximal phalanx with slight hyperextension

gamekeeper’s thumb symptoms + treatment

• pain in area and weak with thumb motions

• imaging tells us treatment, may be able to splint 4-8 weeks in neutral position

boutonniere finger deformity

rupture of extensor expansion dorsal to middle phalanx. Tendon slides below PIP and forces PIP into flexion & DIP into extension. Manage with splinting