Human Pathophysiology for the

Exercise Sciences

Instructor: Paul A. Borsa, PhD, ATC

Upper Extremity: Shoulder, Elbow,
Forearm, Wrist, Hand & Fingers
 Learning Objectives
After completing this module, students will be able to:
1. Describe the structural & functional contributions to shoulder stability.
2. Identify and explain the mechanisms, pathophysiology and signs & symptoms of shoulder
injuries.
3. Identify the anatomical structures (bones, soft tissue) of the elbow, wrist, and hand.
4. Recognize the mechanisms, pathophysiology and signs & symptoms of elbow injuries.
5. Identify and explain injuries that affect the wrist and hand.
6. Differentiate between the types of injuries that affect the thumb and fingers.
4

Lower Extremity v. Upper Extremity

• Lower Extremity • Upper Extremity

• Weight bearing • Typical non-weight bearing
• Hip more stable, less mobile than • Shoulder is more mobile, less stable
shoulder • Arm is used for reaching
• Legs are used primarily for • Hand is used for grasping objects
locomotion
• Foot absorbs loads and propels
body during locomotion
Upper Extremity: Common Injuries to
the Shoulder Complex
 Shoulder (Pectoral) Girdle
• 2 bones – scapula (shoulder blade) and clavicle (collar bone)
• Connects the upper limb to the axial skeleton
 Anatomy: Shoulder
• Articulations:
3 1. Scapulo-Thoracic (ST)
2. Gleno-Humeral (GH)***most mobile
4 3. Acromio-Clavicular (AC)
4. Sterno-Clavicular (SC)
1
2 • Shoulder girdle and GH joint must move together
• Multi-planar motion
• Sagittal – flexion/extension
• Frontal – abduction/adduction
• Transverse – Internal/external rotation and horizontal
abduction/adduction
• Circumduction
• Major clinical issue: Mobility vs. Stability
 Anatomy: Shoulder
• Scapula
• Acromion process
• Coracoid process

• Clavicle
• Acromio-Clavicular (AC) joint
• AC ligament
• Coraco-clavicular ligament
• Coraco-acromial ligament

• GH joint below acromion process (scapula)

 Anatomy : Shoulder
• Static stabilizers (connective tissue)
• Acromioclavicular (AC) Jt.
• Superior AC lig.
• Coraco-acromial
• Coraco-clavicular (CC) ligs.
• Conoid (medial)
• Trapezoid (lateral)
• Glenohumeral (GH) Jt.
• Joint capsule
• GH ligs.
• Labrum (rim of glenoid) – fibrocartilage
 Anatomy: Shoulder
• AC joint and GH joint below acromion process
(scapula)
• Rotator ‘compressor’ cuff muscles originate on
scapula and insert on humeral head
• SITS
• Supraspinatus
• Infraspinatus
• Teres minor
• Subscapularis

• Stabilize GH joint (compressor) and initiate

movement (rotator)
 Functional Anatomy
• Bony configuration
• Ball-n-socket arrangement
• Glenoid (teardrop), labrum (fibrocartilage),
capsule/ligaments (connective tissue), and
muscle
• Capsulo-ligamentous/labrum
• Stabilize (passive)
• Guide movement
• Musculo-tendinous
• Stabilize (dynamic)
• Initiate movement
 Functional Anatomy
• Most mobile and least stable
• “golf ball (humeral head) on a tee (glenoid
fossa)”
• Glenoid has 1/4th the articular surface as the
humeral head
• Stability
• Concavity – glenoid & labrum
• Compression – ligament & RC pull
 Functional Anatomy

• Proper shoulder function is dependent upon

maintaining the humeral head centered
within the glenoid fossa
• Scapula must position & reposition to
maintain stability
• “seal balancing ball on its nose”
AC Joint/Clavicular Injuries
• Clavicle fracture (broken collarbone)
• Acromio-clavicular sprain/separation
 Fall on Outstretched Hand (FOOSH)
• Major MOI for upper extremity & shoulder-related injuries
• AC joint and clavicle
 Fractured Clavicle
• AKA broken collar bone
• MOI: direct blow or FOOSH
• Most common fracture in body
• Middle ⅓rd of bone
• Weak link
• Signs/symptoms
• Point tenderness
• Deformity (if displaced)
• Pain on movement
17
 Acromioclavicular Joint Injuries
• Sprain – ligament damage with no separation of joint
• Separation – ligament damage with separation of joint
• AC ligs & CC ligs
• MOI: FOOSH, Fall on elbow, point of shoulder – force
transmitted to AC joint
 Acromioclavicular Joint Injuries
• Severity of injury is determined by the specific
structures damaged
• 1st deg. - no significant damage
• No separation
• Minor disruption of AC lig.
• Mild symptoms
• 2nd deg - partial tearing of AC lig.
• Slight separation
• Tear of AC lig
• Minor disruption of CC ligs.
• Moderate symptoms
 Acromioclavicular Joint Injuries
• Severity of injury is determined by the specific structures damaged

• 3rd deg – complete tear/separation

• Full separation
• Tear of AC & CC ligs
• Snap or pop may be heard
• Severe pain and symptoms
 Signs & Symptoms
• Obvious deformity – separation
• Scapula droops downward exposing clavicle
• Point tender over AC joint
• Reaching across the body to touch the opposite
shoulder is painful
• Weakness during arm movements
 Management

• Sling-and-swathe
• Immediate care
• Clavicle & AC jt. injuries
• Figure of 8 strapping
• Worn during healing of clavicle fractures and AC tears
• Postural brace
• Aligns and positions bones and joint
• Referral for X-ray
23

Glenohumeral Joint (GHJ) Injuries

• Formed by humeral head and glenoid fossa
• Extremely mobile but inherently unstable
• Teardrop or upside-down comma shape
• Capsule/ligaments/labrum
• Superior, middle, inferior and posterior GH ligs.
• Labrum
24

Capsulo-ligamentous Disruption

• Sprain – ligament damage with no displacement

• Dislocation/subluxation – ligament & labral damage causing
displacement of humeral head (instability)
• Directions
• Anterior – abduction/ER with extension
• Most common
• Posterior – fall on outstretched arm
 Anterior Dislocation
• Position of arm
• Abduction/External Rotation
• Hyper-abduction
• With a force into
• Horizontal extension and ER
• Humeral head is forced anterior against capsule
• Bankart lesion – labrum detached from glenoid
• Occurs with dislocation
• 12 to 3-6 o’clock position
• Hill-Sachs lesion
• Humeral head ‘chip’ fracture
26

Pathophysiology

• Chronic (on acute)

• Joint becomes unstable
• Sensation of “Giving-out”
• 85-90% of injuries tend to recur
• Repeated dislocations/subluxations
• Additional microtrauma to joint
• Axillary nerve contusion
27

Management

• Immediate: PRICE (as always in acute joint trauma)

• Sling & swathe bandage
• Check for sensation and blood flow to hand and fingers
• Do not try to relocate (put back in place – why?)
 Special Tests

• Stress tests
• Tests for joint stability
• Subjective – based on “feel”
• Apprehension/Relocation test
• Manual laxity test
• Anterior-Posterior drawer
 Tendon-related Injuries
• Rotator cuff tendon
• Strain
• Impingement
• Bicep’s tendon (long head)
 Rotator Cuff Strains
• Most strains affect the supraspinatus tendon
• MOI: acute v. chronic
• Acute – sudden tensile force on tendon
• Eccentric loading causing macrotrauma
• Chronic –overuse as with throwing
• Eccentric loading causing microtrauma
• Tensile forces during deceleration of arm after throwing (follow
through)
• ‘braking’ force on arm
• Middle third of tendon
• Hypo-vascular zone
• Delayed healing
 Impingement

• Tendon is ‘squeezed’ between coraco-acromial arch and

humeral head
• Overhead activity decreases sub-acromial space
• Fatigue of RC muscles during activity limits dynamic
stability
• Compression and shear forces cause microtrauma to
tendon and labrum
32

Signs/Symptoms

• Point tenderness over tendon (supraspinatus)

• Limited ROM & stiffness
• “Painful arc” or pain during arm abduction 1
• Between 80° and 120° of abduction
• Neer test – pain with arm elevation
• Strength loss (weakness)
• Drop arm test
• Empty can 3 2

• Persistent, dull-aching pain

• Nocturnal pain
• Wakes you up during sleep
33

Overhead & Throwing Injuries

Sports:
• Baseball pitchers, javelin throwers, swimmers, volleyball
• Repetitive stress and overuse cause microtrauma to joint
structures (chronic conditions that can lead to acute
episodes)
34

Overhead & Throwing Injuries

Pathophysiology:
• Cocking phase – stress on joint (ligament and labrum); leads
to capsular laxity and SLAP lesions
• “Peel back” maneuver
• Follow-through – eccentric loading causes stress on the RC,
posterior capsule, bicep’s tendon and elbow (discuss in
more detail later)
• SLAP lesion
• Superior Labrum Anterior to Posterior
• MOI: pull of biceps tendon or peel back
• Throwing related or overhead activity
• 10 to 2 o’clock position
 Treatment
• Stretching
• Shoulder girdle
• Strengthening
• Light weight with high repetitions
 Thoracic Outlet Syndrome
• Compression of nerves (brachial plexus) and blood
vessels (subclavian artery) at neck/shoulder region
• “crowded house” – fixed or positional compression

• Overhead activity
• Overuse
• Lifting weights, occupational lifting
• Overdeveloped or tight neck or shoulder muscles
• Typing
 Thoracic Outlet Syndrome
• 3 levels of compression
1. Scalene muscle – between ant. & middle
2. 1st rib and clavicle (costoclavicular syndrome)
3. Pectoralis minor muscle

2 1
3
38

Assessment
• S/S:
• Numbness and tingling into hand during repetitive overhead activity (hand and fingers
falling asleep)
• Weakness of grip and uncoordinated arm movements
• Special tests
• Adson’s maneuver
• Check radial pulse for changes in quality, rhythm, rate as arm is moved into extension and
head/neck is rotated and flexed
• Roos – arm in abduction and external rotation; open and close hand
 Management

Management:
• Extreme – removal of 1st rib
• Postural retraining – retract shoulders
• Stretching and flexibility training
• Vigorous stretching of neck and shoulder girdle muscles

• Strengthening muscles that aid in good posture

• Upper back muscles
Please contact the Instructor with any questions.
pborsa@ufl.edu