BIOMECHANICS,

MECHANISMS,
AND TREATMENTS ,
FOR SHOULDER INJURIES
IN ATHLETES
Functional anatomy-
static and dynamic
stablier of shoulder
 Functional anatomy- static and dynamic
 The Glenohumeral Joint is Synovial ball and socket articulation
Between the head of the humerus and the glenoid cavity of the
scapula. connecting the upper limb to the trunk.
 SHOULDER JOINT is component of SHOULDER GIRDLE which
comprises of five linkages.
1. Glenohumeral
2. Suprahumeral articulation:
Coracoacromial arch above with head of humerus below with
subdeltoid Acromioclavicular
Sternoclavicular
Scapulothoracic (muscular)
 Static Stabilizers

 Static stabilizers are the non-contractile tissue of the

glenohumeral joint.
 These static stabilizers set the base of support for the
shoulder joint.
 The main static stabilizers of the shoulder in the
functional position (abducted).
 The anterior / posterior band band of
the inferior glenohumeralligament .

 prevents anterior translation,/ posterior

translation of the humeral head.
The labrum has several functions, and 3 in
particular:
1. Increases the contact area between humeral head and scapula,
2. Contributes to the “Viscoelastic Piston” effect, maintaining -32
mmHg intra-articular negative pressure; this is especially effective
against traction stress and, to a lesser extent, against shear stress;
3. Provides insertion for stabilizing structures (Capsule and
Glenohumeral Ligaments), as a fibrous “crossroad”. Labrum and
ligaments are in synergy in a genuine complex, each structure's
contribution varying with the position of the limb: in abduction and
external rotation (ABER), the Inferior Glenohumeral Ligament (IGHL)
absorbs 51% of the stress, the Superior Glenohumeral Ligament
(SGHL) 22% and the Middle Glenohumeral Ligament (MGHL) 9%
 Glenoid Labrum
The labrum has several functions, and 3 in particular
1. Increases the contact area between humeral head and scapula,
2. Contributes to the “Viscoelastic Piston” effect, maintaining -32
mmHg intra-articular negative pressure; this is especially effective
against traction stress and, to a lesser extent, against shear stress;
3. Provides insertion for stabilizing structures (Capsule and
Glenohumeral Ligaments), as a fibrous “crossroad”. Labrum and
ligaments are in synergy in a genuine complex, each structure's
contribution varying with the position of the limb: in abduction and
external rotation (ABER), the Inferior Glenohumeral Ligament
(IGHL) absorbs 51% of the stress, the Superior Glenohumeral
Ligament (SGHL) 22% and the Middle Glenohumeral Ligament
(MGHL) 9%
 Dynamic Stabilizers

 Dynamic stabilizers include the rotator and

scapular stabilizers (ie, teres major, rhomboids, serratus
anterior, trapezius, levator scapula).
 The rotator cuff is composed of 4 muscles:
supraspinatus, infraspinatus, subscapularis, and teres minor.
Mechanisms and Treatments for
Shoulder Injuries in Overhead Throwing
Athletes
 Shoulder injuries in overhead throwing athletes are very common.
 Throwing volume and mechanical forces that are placed on the
glenohumeral joint and associated soft tissue structures are
contributors.
 Poor biomechanics and weak links in the kinetic chain place this
athletic population at increased risk for shoulder injuries.
 Common biomechanical deficiencies in overhead throwing athletes
typically involve poor sequential timing of muscle activity and
insufficient coordination also presented in shoulder elevation and
other functional tasks.
 Kinetic chain deficits will lead to injury due to poor transference of
energy from the lower extremities to the dominant upper extremity.
 Weak Links in the Kinetic Chain
 The kinetic chain connects body segments and transfers energy from
one body segment to the next during motion such as throwing .
 More than 50% of kinetic energy is transferred to the upper extremity
via the legs and core in overhead throwers .
 The typical sequence of events during a general throwing motion
includes the stride, pelvis rotation, upper torso rotation, elbow
extension, shoulder internal rotation, and wrist flexion.
 Deficits in the kinetic chain, otherwise known as deficiencies or “weak
links,” such as in the core, spine, hip, and glenohumeral range of
motion (ROM), and scapular kinetics, may lead to shoulder injury in
overhead throwers.
 professional pitchers who had less than 5° greater external rotation in the
throwing shoulder compared with the nondominant shoulder were four
times more likely to require shoulder surgery.
 the core, is important in providing stabilization to the spine and trunk of
the body, which allows transference of energy to the extremities .
 Proper glenohumeral ROM and scapular kinetics will lead to decrease
stress on shoulder during the cocking phase of throwing in baseball .
 For maximum efficiency of movement and injury prevention, coordinated
motions between the lower and upper body are required
 Biomechanical Deficiencies
 Proper sequential timing of muscle activity and coordination is required to safely transfer
energy from the lower extremities to the projectile release.
 An efficient kinetic chain involves all segments of the body that must work in unison.
 When specific aspects of the segmental coordination are compromised, loading stresses
develop at unaccustomed areas of the musculoskeletal tissues.
 Poor muscular flexibility, muscle endurance, low shoulder and hip ROM, poor spinal
mobility, and muscular weakness (particularly in the rotator cuff) are all factors that
increase shift mechanical loading to tissues along the kinetic chain. This increases the risk
of injury.
 A breakdown of the motion of the proximal segments (hips, core, legs, and spine) leads
to increased demands placed on the distal segments of the body (e.g., the shoulder,
elbow, and wrist).
Biomechanical Components of the Overhead Throwing
Motion

 Throwing motions from different sports have common phases

and events
 Each throwing motion involves an initiation of the throw, a
transfer of linear energy from the lower body to rotational
energy in the upper body, and projectile release.
 Sequential timing of muscle activity in the lower extremities,
trunk, and the dominant upper extremity is required for
optimal energy transfer.
THE BIOMECHANICS OF THROWING
THE BIOMECHANICS OF THROWING
 Throwing is a whole body activity that commences
with drive from the large leg muscles and rotation of
the hips, and progresses through segmental rotation
of the trunk and shoulder girdle with a "whip_like"
transfer of momentum through elbow extension and
through the small muscles of the forearm and hand,
transferring propulsive force to the ball.
Throwing-wind-up
Throwing- cocking
Acceleration phase
Throwing- deceleration/follow-through
NORMAL BIOMECHANICS OF
THE SCAPULA IN THROWING
Scapular function in normal shoulder mechanics

1. provides a stable socket for the humerus

2. retracts and protracts along the thoracic wall
3. rotates to elevate the acromion
4. provides a base for muscle attachment
5. provides a key link in the kinetic chain
Abnormal scapular biomechanics and
physiology
Biomechanics of Swimming
 Swimming biomechanics and shoulder pain
 Shoulder pain is extremely common among swimmers
and is usually due to impingement and rotator cuff
tendinopathy.
 anatomical factors were thought to cause impingement
but it now appears that it is largely due to.
 Muscle weakness,
 Dynamic muscle imbalance,
 Biomechanical faults.
How to prevent shoulder injury in a swimmer.

1. swimmer has adequate strength and control of the

scapular stabilizing muscles
2. ensure that the internal to external rotator strength
ratio is normal (3:1)
3. ensure the swimmer stretches the scapulohumeral
muscles, including the infraspinatus, teres minor, and
subscapularis muscles
4. correct cervical and thoracic hypomobillty.
Common technical
errors
in specific
swimming strokes
that predispose
to injury
Biomechanics of tennis
 The shoulder receives maximal loads during the serve and
overhead strokes, and rotator cuff impingement may arise
from a mechanism parallel to that in throwers and swimmers.
 The tennis service begins with 90° abduction and external
rotation in the cocking phase.
 The shoulder then moves rapidly from external to internal
rotation and from abduction into forward flexion.
 The deceleration or follow through phase is controlled by the
external rotators.
 Impingement is exacerbated by increased internal rotation of
the shoulder in forward flexion. Over 50% of the total kinetic
energy and total force generated in the tennis serve is created
by the lower legs, hips, and trunk.
Volleyball

 The overhead spike in volleyball is associated with a high incidence of shoulder

injury.
 The technique is similar to the throwing action.
 There is limitation in the amount of follow-through available with a spike due to the
proximity of the net.
 Another potential hazard for the "spiker" is that the spike may be blocked by an
opponent. Internal and external rotator muscle balance must be maintained to
prevent injury, and the practitioner should also ensure that sportspeople have
adequate scapular contro.
Biomechanics of other overhead
sports
Any sport involving overhead
activity may lead to the
development of shoulder and
elbow problems.
Shoulder Pain DD
Clinical perspective
of
Shoulder Pain
 Rotator cuff
 Instability
 Labral injury
 Stiffness
 Acromioclavicular (AC) joint pathology
 Referred pain.
1)Rotator cuff muscles and tendons
 May be acute, chronic, or acute on chronic. Acute
injuries include muscle strains, and partial or complete
tendon tears. Overuse injuries include tendinopathy.
Sports people with rotator cuff tendon injuries present
with shoulder pain and difficulty with overhead activities.

2)Shoulder instability
May arise from the anterior, posterior, or superior shoulder
capsule and labrum, and from the periscapular muscles.
Instability may result from changes to passive structures
such as ligament, capsule or labrum (Le. hypermobility), or
it can be caused by poor motor control (i.e. dyuamic
instability).
3)Labral injury
Glenoid lahrallesions may occur either as an acute injury
or from overuse. Instability may be obvious clinically in
patients with recurrent episodes of dislocation or
subluxation. In many cases, however, instability may
initially cause relatively minor symptoms, such as
impingement or joint pain.

4)Shoulder stiffness
Hypomobility may be secondary to trauma, including
surgery, or from injury to the cervical nerve roots or
brachial plexus. It may occur spontaneously in middle
age-a condition termed "idiopathic adhesive capsulitis" or
"frozen shoulder."
5)Acromioclavicular joint pathology
Pain is usually localized over the acromioclavicular joint.

6)Referred pain
Pain can refer to the shoulder from the cervical spine, the
upper thoracic spine, and associated soft tissues .Similarly,
shoulder dysfunction can lead to trapezial fatigue or may
radiate into the neck. behind the scapula, the upper ann,
forearm, or, less commonly. the wrist and hand. Diagnosis of
shoulder pain in the sportsperson requires taking a thorough
history, performing a thorough examination, and organizing
appropriate investigations
 Shoulder injures
and management.
1. Impingement
2. Gird
3. Rotator cuff injuries/tear
rotator cuff tendinopathy
4. 3.Glenoid labrum injuries
slap lesion
5. Dislocation of the glenohumeral joint.
6. Shoulder instability
7. Fracture of the clavicle
Impingement
 Subacromial impingement syndrome (SIS)
 Subacromial pain syndrome (SAPS)
 Rotator cuff related disorders
 Biomechanical impingement of the shoulder
 overuse iniury' with tendinopathy of supraspinatus,
especially on its undersurface near biceps (this is the
location of highest stress).
 Pain causes secondary rotator cuff muscle dysfunction,
leading to proximal humeral head migration, and
subsequent subacromial bursitis.
 The additional pain caused by the bursitis leads to
increased dysfunction and impingement, which leads to
ossification of the coracoacromial ligament (i.e. bone
spur).
 SUMMARIZE.
 younger sports people will present with undersurface
tendinopathies and tears, bursal side changes with more
chronic overuse, and intra substance tears with more
severe tendinopathy.
 Shoulder impingement may be:
 External
a)primary
b)secondary
 Internal .

 Subacromial impingement: Bursal side

 Internal impingement: Articular side
 Intrinsic mechanisms: Within the tendons
 Extrinsic mechanisms: Eternal to the tendons.
 Primary external impingement

 Abnormalities of the superior structures may lead to

encroachment into the subacromial space from
above.
 The undersurface of the acromion may be
abnormally beaked, curved, or hooked .
 These abnormalities result from either a
congenital abnormality (os acromiale) or
osteophyte formation.
 Other abnormalities that tend to occur in older age
groups include thickening of the coracoacromial
arch or osteophyte formation on the inferior
surface of the acromioclavicular joint.
 Secondary external impingement
 Impingement into the subacromial space from above in younger
sportspeople may also occur as a result of excessive angulation of
the acromion due to inadequate muscular stabilization of the scapula.
 The muscles responsible for stabilization and motion of the scapula
can become deficient, either because their activation in force couples
is altered, or because their strength balance is altered.
 These deficiencies result in failure to control scapulohumeral rhythm,
which results in abnormal scapular movement.
 The anterior tilt and excessive internal rotation create more
narrowing of the subacromial space via anteroinferior movement of the
acromion, and may result in impingement symptoms .
 excessive tightness of the pectoralis minor, which pulls the
scapula into a protracted position.
 The rotator cuff tendons are also liable to be weakened
following large volumes of load (e.g. through resistance in
swimming or throwing).
 Imbalance between the elevators of the humeral head
(deltoid) and the humeral head stabilizers (rotator cuff
muscles) may lead to the humeral head moving superiorly
with deltoid contraction.
 To effectively treat shoulder pain associated with
impingement, it is essential to recognize the specific
factor(s) contributing to the impingement.
 lack of scapular stabilization results
in excessive rotation and protraction
of the scapula with glenohumeral
movement,This causes inferior
movement of the acromion .
 In any sportsperson presenting with
impingement, it is important to
consider superior labral injury or
instability.
 Expert clinical opinion suggests that
these may lead to the development
of impingement via several
mechanisms.
Internal impingement

 Internal or glenoid impingement occurs mainly in

overhead sports people during the late cocking stage of
throwing (extension, abduction, and external rotation),
when impingement of the undersurface of the rotator cuff
occurs against the posterosuperior surface of the glenoid .
 This is normally a physiological occurrence; however, it
may become pathologic in the overhead sportsperson due
to repetitive trauma/ overuse, and injury to the superior
labrum.
  Contributing Factors
 There are both intrinsic and extrinsic factors which could predispose a
person from experiencing a reduction in subacromial space during arm
elevation.
 Intrinsic factors: (generally non-modifiable)
 Tendon histology (quality of the tendons)
 Age
 Genetics
 Extrinsic factors: (potentially modifiable)
 Muscle extensibility / performance
 Anatomical/osseous
 GH joint kinematics
 Posture/ergonomics
 Different types of impingement
 Subacromial extra-articular impingement:
Bursal. Compression caused as a result of a decreased in
subacromial (AHD) space. Pain is generally located over the
anterior aspect of the shoulder with elevation.
 Internal impingement:
 Articular. Caused by contact between the articular side of the
supra/infraspinatus and the posterosuperior rim of the glenoid.
Pain is located posteriorly "inside" the joint when in a ABER
(throwing) position.
 Subcoracoid impingement: A history of dull pain in the
anterior aspect of the shoulder. Exacerbated by the shoulder in
forward flexion, ADDuction and internal (medial) rotation (such
as the motion of hitting the ball with a racket).
 Impingement Mechanisms

 There are 3 main mechanisms that can affect the

distance/space of the subacromial space (acromio-
humeral distance).
 Loss of control of the humeral head (GH instabilities).
 Loss of scapular control (scapular instabilities).
 Change to the actual size of structures within the space
(tendons of the RC muscles, subacromial bursae,
 Clinical Presentation
 Patients report pain on elevating the arm
between 70 ° and 120 °, the “Painful Arc”
 The symptoms may be acute or chronic.
 Most often it is a gradual, degenerative
condition that causes "impingement",
rather than due to a strong external force.
 Therefore, patients often have difficulties
with determining the exact onset of
symptoms.
 GIRD

 GIRD (Glenohumeral Internal Rotation Deficit), which can

be understood as a loss of internal (medial) rotation range of
motion, in the presence of a loss of total rotational motion
(evaluation of the total range of motion, of both shoulders).
 GIRD = (side-to-side difference in ER) + (side-to-side
difference in IR)
 A contributing factor to GIRD has been theorized to be the
thickening of the posterior GH capsule, limiting the overall
range of internal rotation of the GH joint .
 Signs and Symptoms
 pain in the front and top of the shoulder
 pain that is worse with reaching overhead
 tenderness or swelling over the shoulder
 loss of strength
 limited motion of the shoulder
 aching when not using the arm
 a crackling sound when moving the arm
 Increased Risk
 overhead sports (baseball, tennis, swimming or volleyball)
 weightlifting and bodybuilding
 previous injury to the rotator cuff or shoulder
 poor physical conditioning (strength and flexibility)
 poor warm-up before practice or competition
 bone spurs in the shoulder
Physical Examination
 Hawkins-Kennedy Test
 Painful Arc Test
 Infraspinatus (External Rotation)
Resistance Tests
 Diagnostic Procedures
 There are anatomical factors which may influence the
narrowing of the subacromial space, such as:

 The presence of a subacromial bone spur (potential

thickening or calcification of the coracoacromial ligament)
 The shape of the acromion (type I (flat) / type II (curved)/
type III (hook)/ type IV (upward oriented acromion))
 AC joint arthrosis (degeneration of surrounding tissues)
 Instability of the humeral head (of the GH joint)
 Antero-posterior View with the arm at 30 degrees external
rotation which is useful for assessing the glenohumeral joint,
subacromial osteophytes and sclerosis of the greater
tuberosity.
 Outlet Y View is useful because it shows the subacromial
space and can differentiate the acromial processes.
 Axillary View is helpful in visualizing the acromion and the
process coracoid, as well as coracoacromial ligament
calcifications. The size of the subacromial space can also be
measured
Physical Therapy Management
 RICE therapy in the acute phase to reduce pain and swelling
 Stability and postural correction exercises (forward head
posture/kyphosis)
 Mobility Exercises (cervical spine / thoracic spine / upper extremity in
general / GH joint and scapular)
 Manual therapy of the cervical and / or thoracic spine (also thoracic cage)
 Strengthening and Neuromuscular control exercises
 Stretching exercises, including capsular stretching
 Manual therapy techniques of the shoulder
 Taping techniques (kinesiology taping)
 Electrical stimulation
 Ultrasound therapy
 Low-level laser therapy has positive effects on all symptoms except on
muscle strength
 Corticosteroid injections, in the first 8 weeks
Treatment/Management
How to Prevent

 Do correct warm-up and stretching before practice or

competition.
 Allow time for ample rest and recovery between
practices and competitions.
 Maintain suitable conditioning, shoulder flexibility,
muscle strength and endurance.
 Use proper technique with training and activity.