Shoulder Anatomy

Great ROM Little stability Inconsistent ligamentous support Increased reliance on muscular support Many structures in a small area

Bony Anatomy
Shoulder Complex:
Sternum(manubrium) Clavicle Scapula Humerus

Manubrium
Portion of the sternum
Jugular notch

Attachment site of the clavicle

Clavicular notch

Clavicle
Convex proximal 2/3 Concave distal 1/3 to meet scapula Superior surface not protected by muscle mass Elevates and rotates to maintain alignment of scapula

Scapula
Subscapular fossa Vertebral borders Spine of scapula Coracoid process Glenoid fossa Plane of the scapula

Humerus
Humeral head
projects medially off the anatomical neck

Bicipital groove
greater tuberosity lesser tuberosity surgical neck

Joints of the shoulder girdle

Sternoclavicular Acromioclavicular Scapulothoracic articulation Glenohumeral

Sternoclavicular Joint (SC)

Shoulders only bony attachment to axial skeleton 3 degrees of motion
protraction/retraction elevation/depression internal/external rotation

Acromioclavicular Joint (AC)

Distal end of clavicle meets scapulas acromion 3 degrees of freedom and movement
scapular rotation scapular winging scapular tipping

Scapulothoracic Articulation
Articulation between scapula and posterior rib cage 3 degrees of movement
elevation/depression protraction/retraction upward/downward rotation

Glenohumeral joint (GH)

Formed by the head of the humerus and glenoid fossa 3 degrees of movement
internal/external rotation abduction/adduction flexion/extension

Muscles of the shoulder girdle

Two groups of muscles:
Muscles acting on the scapula Muscles acting on the humerus

Muscles acting on the scapula

Move the scapula to allow increased ROM Fixate scapula to thorax Muscles include:
Rhomboid major and minor Levator scapulae Serratus Anterior Pectoralis Major and Minor Trapezius Latissimus Dorsi

Rhomboid major and minor

Retract scapula Elevate scapula Downwardly rotate scapula

Levator scapulae
Elevate scapula Downwardly rotate scapula

Serratus anterior
Upwardly rotate and protract scapula Weakness may lead to scapular winging
winging is where the scapulas vertebral border lifts away from the thorax

Pectoralis Minor
Upward rotation and forward tilt of scapula

Trapezius
Upper
elevate and upwardly rotate scapula

Middle
retract scapula

Lower
retract and depress scapula

Latissimus Dorsi
Upper fibers assist in retraction and downward rotation of scapula

Pectoralis Major
Clavicular portion aids with scapular depression

Muscles acting on the humerus

Rotator Cuff Teres Major Deltoid Pectoralis Major Latissimus Dorsi Long Head of triceps Coracobrachialis Biceps

Rotator Cuff Muscles

Supraspinatus
abduction/external rotation

Infraspinatus
external rotation/horizontal abduction

Teres Minor
external rotation/horizontal abduction

Subscapularis
internal rotation

Teres Major
Internal Rotation Adduction External Rotation

Deltoid
Abduction
Anterior 1/3: flexion/internal rotation Middle: abduction Posterior: extension/external rotation

Force Couple
Two muscles work together to create movement

Pectoralis Major
Adduction Internal Rotation
Clavicular portion: flexion/IR/horizontal add Sternal portion: depresses shoulder girdle

Latissimus Dorsi
Origin: lumbarspine/illiac crest Insertion: Intertubercular groove Adduction Internal rotation Extension

Long Head of triceps

Infraglenoid tubercle extension

Coracobrachialis
Flexion Adduction

Biceps
Flexion Abduction
Long head attaches on the supraglenoid tubersosity of the scapula Short head attaches on the coracoid process of scapula Stability is provided by the transverse humeral ligament

Scapulothoracic Rhythm
To obtain maximal arc of motion GH and scapulothoracic articulations must combine ROM

Bursa
Two in GH joint
Subacromial Subdeltoid

Buffers supraspinatus tendon when humerus is elevated Inflammation can lead to RC tendinitis

Shoulder Evaluation

Clinical Evaluation History

Location Onset
Insidious vs. sudden

Activity and injury mechanism

Repetitive-overuse to soft tissue Direct blow Fall on outstretched hand

Symptoms Prior Injury

Alteration of GH mechanics due to previous injury

Inspection
Position of head of humerus Position of arm Willingness to move arm (carry angle) Anterior structures Lateral Structures Posterior

Inspection
Anterior:
Level of shoulders Contour of clavicles Symmetry of deltoid (C5-C6) Anterior humerus Bicep brachii

Inspection
Lateral structures:
Deltoid Acromion process Step deformity Position of humerus

Inspection
Posterior:
Alignment of spinal vertebrae (scoliosis) Position of scapula Sprengels deformity Atrophy Position of humerus

Palpation
Anterior
Jugular notch SC joint Clavicular shaft Acromion Process Pectoralis major/minor Coracobrachialis-coracoid process

Palpation
Humerus:
Head of humerus Greater tuberosity (passively extend) Bicipital groove/lesser tuberosity
ER to make more palpable

Humeral shaft Deltoid Bicep Tricep

Palpation
Scapula:
Rotator Cuff Teres major/latissimus dorsi Spine of scapula Superior/inferior angle Axial border Trapezius Levator Scapulae Rhomboids

Functional Tests
AROM PROM RROM Ligamentous/capsular testing Neurologic testing Special Tests

Shoulder ROM
Deficit at 1 joint will affect motion of other joints Do not perform ROM if suspect fracture/dislocation/complete tear Strength may differ with athletes in throwing sports

Shoulder Goniometry
Flexion Extension Abduction/Adduction Internal/External Rotation

AROM
Always compare bilaterally

Flexion 180/Extension 50-60

Apleys scratch test

Abduction170-180 Adduction IR 70-80/ ER 80-90(at 0 and 90 degrees)

90 abduction (ER 40-50 at neutral/IR blocked by torso)

Horizontal adduction 120/ abduction 45

Active ROM Tests

*Performed Bilaterally

Apleys Stretch Test

Touch opposite acromion with hand of affected shoulder (add/IR) Reach behind the head and touch opposite shoulder from behind(abd/ER) Reach behind back and touch opposite scapula(add/IR)

PROM
Flexion/Extension (firm end feel) Abduction/Adduction (firm)
Adduction not usually measured
Humerus strikes the body

Internal Rotation/External Rotation(firm)

Apprehension test position (90 abd/90 elbow)

Horizontal Flexion (soft) Horizontal Extension (firm)

RROM
Internal rotation/ External rotation
Gerber Lift Off Test

RROM
Scapulothoracic Rhythm:
Observe motion of scapula during active humeral movements Compare bilaterally

Test for RROM

*Perform Bilaterally

Flexion/Extension Abduction/Adduction IR/ER (shoulder abducted at 90 degrees) Scapular elevation/retraction/protraction Elbow extension Elbow flexion

MMT of Scapular muscles

Rhomboids
Seated position
Elbow flexed/Humerus adducted

Examiner attempts to horizontally abduct humerus

Note Scapular protraction indicating weakness

 Middle Trapezius
Prone Position
Elbow is extended and humerus is abducted to 90 deg and ER so thumb points upward

Downward pressure applied to humerus

Ligamentous/capsular testing
SC laxity
Up/down/ant/post

AC laxity
Anterior/Posterior/superior/inferior

GH laxity
Anterior/Posterior/inferior

Neurologic testing
Neurological symptoms may be produced by:
Cervical nerve root trauma Brachial Plexus Injury Thoracic Outlet syndrome

Special Tests AC
Traction test
Patient
Sitting or standing with arm hanging naturally

Examiner
Grasps patients humerus proximal to elbow Opposite hand gently palpates the AC joint

Procedure
Applies downward position

Positive Test
Humerus and scapula move inferior to clavicle causing step deformity

Implications
AC sprain

Special Tests for AC

AC compression/ Spring test
Patient
Sitting or standing with arm hanging at side

Examiner
Hands cupped over anterior and posterior joint structures

Procedure
Squeeze hands together, compress AC joint

Positive Tests
Pain at AC joint or excursion of clavicle over acromion process

Implications
Damage to AC ligament

Special Tests
Glenohumeral Glide Test
Patient
Lying supine with GH joint over edge of table

Examiner
One hand grasp scapula/ other grasp humerus

Procedure
Applies gentle, firm force on head of humerus Repeat posterior/inferior

Positive Tests
Pain or increased motion

Implications
Labral tear

Special Tests for Glenohumeral Laxity

Apprehension(Crank test)
Patient
Supine, standing, or sitting GH joint abducted to 90deg/elbow flexed to 90 degree

Examiner
Support humerus midshaft/forearm grasped to wrist

Procedure
Support humerus and passively ER while placing pressure to anterior forearm

Positive Test
apprehensive resistance to further dislocation feels like previous dislocation

 Relocation test
Patient
Supine, GH 90 abduction/elbow 90 flexion

Examiner
Forearm grasped proximal to wrist to provide leverage to ER of humerus Opposite hand over humeral head

Procedure
ER until pain, discomfort,apprehension or normal ROM

Positive Test
Decreased pain or increased ROM

 Posterior Apprehension Test

Patient
Sitting or supine shoulder flex 90 deg/elbow flex 90

Examiner
One hand grasping forearm Opposite hand stabilizing posterior scapula

Procedure
Apply longitudinal force to humeral shaft

Positive Test
Patient displays apprehension

Implication
Torn labrum

 Clunk Test
Patient
Supine

Examiner
AT moves arm from 90 deg of abduction to full abduction with arm ER at 90 One hand at elbow with pressure on humerus, other over GH jt

Procedure
Humerus is IR/ER as arm moves into full abduction

Positive Test
Clunk or popping sensation

Implication
Instability of GH joint

 Sulcus sign
Patient
Sitting arm hanging at side

Examiner
Grip arm distal to elbow

Procedure
Downward traction force

Positive Test
Indentation (sulcus) appears

Implications
Inferior instability

 OBrien Test
Patient
Standing, GH joint flexed to 90/adducted to 15 Forearm pronated/humerus IR

Examiner
Front of patient with hand over distal forearm

Procedure
Apply downward force and repeat in supination

Positive Test
Pain or clicking

Special Tests for Impingement

Neer shoulder Impingement
Patient
Standing/sitting (in anatomical position)

Examiner
Stabilize posterior aspect Grip patients arm distal to elbow joint

Procedure
Elbow extended, humerus is IR and forearm is pronated

Positive Test
Pain with motion

 Hawkins Shoulder Impingement

Patient
Sitting or standing in anatomical position

Examiner
Gripping patients arm at elbow joint

Procedure
With elbow flexed, GH joint elevated to 90deg in scapular plane

Positive test
Pain with motion (esp. near end of ROM)

Implications
Pathology present in RC groups Motion of tests impinges structures

Special Tests Supraspinatus

Empty Can
Patient
Sitting or standing

Examiner
Place hand on superior portion of mid forearm to resist abduction in scapular plane

Procedure
Resists abduction (applies downward pressure)

Positive Tests
Weakness or pain

Implications

Posterior Instability Tests

Posterior Apprehension Posterior-instability in plane of scapula

Tests for RC Injuries

Forward Flexion Impingement Empty Can Drop Arm(also known as Codmans)

Special Tests for Biceps Tendon Subluxation

Yergasons
Patient
Sitting or standing Elbow flexed at 90 degrees

Examiner
Stabilize olecranon inferiorly and maintained to thorax Forearm stabilize proximal to wrist

Procedure
Patient provides resistance while examiner moves GH joint in ER and supination

Tests for Bicep tendon stability

Speeds
Patient
Sitting or standing Elbow extended/ GH jt in neutral or slightly extended to stretch biceps brachii

Examiner
One hand over bicipital groove (stabilizing shoulder) Forearm stabilized proximal to wrist

Procedure
Examiner resists flexion of GH joint and elbow while palpating for tenderness over bicipital groove

Bicep Tendon Rupture

Ludingtons
Patient
Standing or sitting Hands on top of head with fingers interlocked

Examiner
Standing behind patient palpating long head of biceps brachii

Procedure
Pt. Contracts bicep brachii by applying force to top of head Examiner palpates long head of biceps tendon

Special Tests for Thoracic Outlet Syndrome

Adson Costoclavicular Hyperabduction

 Adsons Test
Patient
Sitting, shoulder abducted to 30 deg, elbow extended with thumb pointed upward, humerus ER

Examiner
Standing behind patient, one hand palpating radial pulse

Procedure
Examiner ER and extends patients shoulder while face is rotated toward involved side and extends neck

 Allen Test
Patient
Sitting, head facing forward

Examiner
Stand behind patient/ feel radial pulse

Procedure
Elbow is flexed at 90 deg while clinician abducts shoulder to 90 Shoulder is passively horizontally abducted and placed into ER Patient rotates head towards opposite shoulder

 Military Brace Position

Patient
Standing, shoulders in relaxed position, head looking forward

Examiner
Standing behind patient, one hand positioned to locate radial pulse on involved extremity

Procedure
Patient retracts and depresses shoulder(coming to attention) Humerus is extended and abducted to 30 deg. Neck and head are hyperextended

On field evaluation
R/o Fx/dislocation
Distal pulse Upper quarter screen
Rule out C-spine injury

Palpation under shoulder pads

Remove shoulder pads

On the field
History
Location of pain Mx of injury

Inspection
Arm posture Gross deformity

Palpation
AC/clavicle/SC/Humerus

Functional Tests Neurologic Tests

Initial management
Fracture of clavicle
Sling/swathe ACE

AC joint
Spica wrap

Dislocation Fractures
Keep fingers expose Check circulation