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Shoulder

 The region of upper-limb attachment to the trunk\

Bone framework of the shoulder


 Clavicle and scapula
 Proximal end of humerus

Superficial muscles of the shoulder


 Trapezius
 Deltoid
These muscles connect the scapula and clavicle to the trunk

Bones
Clavicle

 The only boney attachment between the upper limb and the trunk
 Palpable along its entire length and has gentle S-shaped contour with forward-facing convex
part medial and forward-facing concave part lateral
 The acromial end of the clavicle is flat
 The sternal end is quadrangular shape
Scapula

 A large, flat triangular bone with:


 3 angles
 3 borders
 2 surfaces
 3 processes
 Lateral angle
 Marked by a shallow comma-shaped glenoid cavity
 Infraglenod tubercle
 A large triangular shaped roughening inferior to the glenoid cavity
 Supraglenoid tubercle
 Less distinct
 Located superior to the glenoid cavity
 Spine
 Subdivides the posterior surface of the scapula into supraspinous fossa and infra
spinous fossa
 Acromion
 Anterolateral projection of the spine
 Arches over the GH joint
Types of acromion
1. at inferiorly (12%) 6
2. curved (56%)
o parallel to the humeral head with a concave undersurface
o considered most common type 3
3. hooked (29%)
o the most anterior portion of the acromion has a hooked shape
o associated with increased incidence of shoulder impingement
4. convex (upturned) (3%)
o most recent classification of acromion process shape
o the undersurface of the acromion is convex near the distal end 4

o no convincing correlation between a type 4 acromion and impingement syndrome exists

 Greater scapular notch


 Region between lateral angle of the scapula
 Attachment of the spine to the posterior surface of the scapula
 Subscapular fossa
 Shallow concave surface at the costal surface of the scapula
 Coracoid Process
 Hook-like structure
 Projects anterolaterally

Proximal Humerus
 Head
 Half spherical in shape
 Projects medially
 Anatomical neck
 Very short
 Formed by a narrow constriction
 Surgical neck\
 Greater and lesser tubercle
 Attachment to 4 rotator cuff muscles
 Bicipital Groove
Muscles

 The rotator cuff control 3 basic motions:


 abduction,
 internal rotation
 external rotation,
 Consists of .
 The supraspinatus muscle is responsible for initiating abduction
 the infraspinatus and teres minor muscles control external rotation, and
 the subscapularis muscle controls internal rotation.

The rotator cuff muscles provide dynamic stabilization to the humeral head on the glenoid fossa,
forming a force couple with the deltoid to allow elevation of the arm.

Description of the disease


 Shoulder impingement syndrome
 is a condition where your shoulders rotator cuff tendons are intermittently trapped and
compressed during shoulder movements This causes injury to the shoulder tendons and
bursa resulting in painful shoulder movements.

Neer 3 stages of Rotator cuff impingement

Stage 1, commonly affecting patients younger than 25 years, is depicted by acute inflammation, edema,
and hemorrhage in the rotator cuff. This stage usually is reversible with nonoperative treatment.

Stage 2 usually affects patients aged 25-40 years, resulting as a continuum of stage 1. The rotator cuff
tendon progresses to fibrosis and tendonitis, which commonly does not respond to conservative
treatment and requires operative intervention.
Stage 3 commonly affects patients older than 40 years. As this condition progresses, it may lead to
mechanical disruption of the rotator cuff tendon and to changes in the coracoacromial arch with
osteophytosis along the anterior acromion. Surgical l anterior acromioplasty and rotator cuff repair is
commonly required.

The Painful arc

Etiology

Primary impingement
 Increased subacromial loading
 Acromial morphology (A hooked acromion, presence of an os acromiale or osteophyte, and/or
calcific deposits in the subacromial space make patients more predisposed for primary
impingement.)
 Acromioclavicular arthrosis (inferior osteophytes)
 Coracoacromial ligament hypertrophy
 Coracoid impingement
 Subacromial bursal thickening and fibrosis
 Prominent humeral greater tuberosity
 Trauma (direct macrotrauma or repetitive microtrauma)
 Overhead activity (athletic and nonathletic)

Secondary impingement
 Rotator cuff overload/soft tissue imbalance
 Eccentric muscle overload
 Glenohumeral laxity/instability
 Long head of the biceps tendon laxity/weakness
 Glenoid labral lesions
 Muscle imbalance
 Scapular dyskinesia
 Posterior capsular tightness
 Trapezius paralysis

Epidemiology
 Rotator cuff tears are more common in the older population
 impingement and rotator cuff disease are frequently seen in the repetitive overhead athlete.
 Impingement syndrome and rotator cuff disease affect athletes at a younger age compared with
the general population

Still, No documented information on the occurrence of shoulder impingement syndrome exists

Associated S/Sx
 Onset: Sudden onset of sharp pain in the shoulder with tearing sensation is suggestive of a
rotator cuff tear. Gradual increase in shoulder pain with overhead activities is suggestive of an
impingement problem.
 Chronicity of symptoms
 Location: Pain usually is reported over the lateral, superior, anterior shoulder; occasionally
refers to the deltoid region. Posterior shoulder capsule pain usually is consistent with anterior
instability, causing posterior tightness.
 Setting during which symptoms arise (eg, pain during sleep, in various sleeping positions, at
night, with activity, types of activities, while resting)
 Quality of pain (eg, sharp, dull, radiating, throbbing, burning, constant, intermittent, occasional)
 Quantity of pain (on a scale of 0-10, 10 being the worst)
 Alleviating factors (eg, change of position, medication, rest)
 Aggravating factors (eg, change of position, medication, increase in practice, increase in play,
change in athletic gear/foot wear, change in position played)
 Functional symptoms - Patient changed mechanics (eg, throwing motion, swim stroke) to
compensate for pain
 Associated manifestations (eg, possibly chest pain, dizziness, abdominal pain, shortness of
breath)
 Provocative position: Pain with humerus in forward-flexed and internally rotated position
suggests rotator cuff impingement. Pain with humerus in abducted and externally rotated
position suggests anterior glenohumeral instability and laxity.

DDx