Anatomy of sports related shoulder problems

Prof P Bala National University of Singapore

Common sports related problems of shoulder

Rotator cuff tendinitis Impingement Rotator cuff tears mechanical Frozen shoulder non-mechanical Instability, dislocation Nerve injuries Non-sports related problems

Shoulder Problems: clinical complaint

Pain: local or referred Stiffness , painful arc Instability Weakness Drop arm syndrome

Shoulder : clinical presentation

To understand the pathology, clinical features, diagnostic imaging and treatment A knowledge of shoulder anatomy is necessary.

Otherwise we will be treating images

The shoulder
A region that connects neck, trunk and upper limb to place hand in space Enjoys greater freedom of motion Relies on muscles and ligaments for stability To achieve its function, shoulder built up on 3 bones and 4 joints

Use of shoulder in sports

Power ,speed and drive for Throwing, pitching, tennis stroke, spiking, gymnastics , weight lifting, swimming etc. Shoulder acceleration and deceleration are demanding actions in overhead throw Overuse and excessive loadrotator cuff failure, proximal head migration and instability

Shoulder anatomy
Is a 5 jointed system consisting of Scapulothoracic joint Acromiothoracic joint Sternoclavicular joint Coracoclavicular joint syndesmosis Glenohumeral joint

Shoulder muscles
Motorised by 3 groups of muscles Axio-scapulartrapezius, lev scapulae, rhomboids, serratus anterior Axio-humeral---pec major&minor,lat dorsi

Glenohumeralsubscapularis, supraspinatus, infraspinatus, teres minor

Scapular muscles and movement

2 functionsprovide stability of scapula when shoulder complex is loaded. -movement of scapula pointing itself under the humeral head to maintain proper lever length and functional length of musls. Provides the fulcrum to elevate the arm in all planes Scapular motion by a force couple on a moving platformthe glenoid

Scapulo-humeral rhythm
During the first 30 deg of abd scapular movement is only 1/5 of GH movement Beyond 30 deg: 1 deg for every 2 deg of movement of humerus. The synchrony of GH and SC-Th motion produces mobility without loss of stability

Scapulo-humeral muscles
In 2 sleeves Outer sleeve: deltoid & teres major Inner sleeve : subscapularis supraspinatus rotator cuff infraspinatus teres minor The 2 sleeves glide on each other Subacromial bursa gliding mechanism

Role of rotator cuff and capsular ligaments

GH joint lacks bony stability as in hip Flat glenoid, no stability for a large head
Only little contact, yet great stability Due to 2 factors-ability of scapula to rotate and support humeral head

Efficiency of soft tissues enveloping head. Contraction of this group maintains the H head in constant contact with glenoid.

Stability of GH joint
Atmospheric pressure Glenoid fossa and labrumchock effect Glenohumeral ligaments and long head of biceps attached to labrum Inferior GH ligament complex like a hammock supporting head in abd and ext. rotation Middle GH ligament acts like a check rein to prevent posterior translation

Stability of GH joint ctd

Superior GH ligament restricts inferior translation Collectively the capsular ligaments and labrum are static stabilizers Dynamic stability by rotator cuff and long head of biceps A thrower relies on dynamic effect of rotator cuff for joint compression to avoid capsule stretching

Glenoid labrum and tears

Common in throwers Large compression and shearing forces drive the head anteriorly and posteriorly Creating traumatic cartilage injury and labral tear Three types of surface motion at GH joint Rotation, rolling and translation (gliding)

Subacromial space and bursa

Subacromial space is inferior to acromion, A-C joint, and coracoacromial ligament Subacromial bursa lies in the sub acrom. space, between the acromion process and the coracoacromial ligament above and the GH joint below The bursa cushions the rotator cuff from the overlying acromion

Subacromial space
Acromion type- 3 has downward pointing spur Basis for anterior acromioplasty Sourcil sign: sclerosis on the undersurface of acromion( eyebrow) due to chronic rotator disease GH joint and sub acromial space may communicate in ch rotator cuff disease

Long tendon of biceps

Attached to the supraglenoid tubercle Intrasynovial Biciptal tendinitis SLAP tear type 2,3 & 4 involve the biceps tendon

Nerves , shoulder and sports

Thoracic outlet syndrome Scapular neuropathy in volleyball players Denervation of infraspinatus, repeated stretching during serving Referred pain from neck ,heart, gallbaldder

Coracoclavicular ligament/ joint

Is a syndesmosis Strong conoid and trapezoid ligaments This joint permits little movement Ligament torn in grade 3 dislocation of acromioclavicular joint

Summary
Shoulder is a complex joint system. In the pursuit of speed and power Its soft tissues mainly are injured Precise location of the source difficult. A thorough knowledge of its anatomy necessary to diagnose and treat them