1. Lecture 7
The Shoulder

2. Anatomy Review
The shoulder is difficult to assess because of the many structure located in a small area
There are a number of different joints and the shoulder may be a site of referred pain

3. Glenohumeral Joint
Mulit-axial ball and socket synovial joint
Depends on muscle rather than ligaments for support
Has a labrum – or a ring of fibrocartilage that surrounds and deepens the glenoid cavity

4. Resting position
55 degrees of abduction
30 degrees of cross extension
The humerus sits in the upper part of the glenoid cavity with contraction of the rotator cuff muscles it is pulled down into the lower wider part – allowing for full abduction

5. Ligaments of the GH
Superior, middle and inferior glenohumeral ligaments
Z – shaped band across the front of the GH joint
Weak and easily stretched

6. AC Joint
Irregular diarthrodial joint
limited motion in all three planes
Augments the ROM of the humerus
Resting position
arm by side

7. Ligaments of the AC
Acromioclavicular
Coracoclavicular
Both function to hold clavicle down

8. Sternoclavicular Joint
Along with the AC joint the SC joint enables the humerus to move through a full 180 degrees of abduction
Saddle shaped – synovial joint
Medial end of clavicle and manubrium of the sternum and cartilage of the first rib
Disc between the two ends of joint
ROM include elevation, depression, protraction and retraction (rotation)

10. Scapulothoracic joint
Not a true joint
Functions as an integral part of the shoulder complex - important in stabilization of shoulder and facilitates movement
Body of scapula and muscles covering the posterior wall of the chest form this pseudo joint

11. Scapulohumeral rhythm
the coordination of the scapular and humeral movements
this enables much greater ROM of the shoulder
If arm elevated past 30 abduction or of flexion the scapula rotates , contributing 1/3 of total rotational movement of the humerus

12. Roughly 2-1 rotation of humerus to scapula
Hiking of the shoulder
reverse scapulohumeral rhythm – scapula moves more than the humerous

13. winging of the medial border of the scapula
Winging of the scapula
winging of the medial border of the scapula
indicative of injury or weakness of the serratus anterior muscle or the long thoracic nerve
have athlete stand at wall and do a push up to see winging of scapula
ROM end feels

14. ROM of shoulder
LR/MR (ER/IR) Ext/Flex, Abd/add, cross flex/cross ext, ( hor-abd/hor-add) circumduction
Muscles ?

15. Special Tests

16. AC Distraction / Compression Test
AC joint
apply downward traction (distraction) on the upper extremity , this will lead to downward movement of acromion away from clavicle if AC is unstable
positive test - will produce pain and joint movement
AC Compression
Horizontal adduction of humerus across the chest compresses the AC joint and will lead to pain if injured
positive test - will produce pain

17. Load and shift GH joint instability
Athlete sitting or supine
Press humerus into the glenoid cavity (the load)
Move humeral head Ant/post noting the amount of translation (shift)
Positive test – more movement( instability)
Normal is about 25% of humeral head diameter

18. Apprehension / Crank test ( anterior instability) GH joint
Examiner passively abducts the arm to 90 degrees and LR athletes shoulder slowly
positive test - is indicated by the feeling or look of apprehension of the athlete
Athlete will likely resist further movement
Do this test very slowly as this is the position of most dislocations

19. Sulcus Sign (Inferior instability) GH joint
Examiner grasps athletes forearm below elbow and pulls down (distally)
The arm is in a neutral position with no rotation and slight abduction (10 – 20 degrees)
Positive test- Presence of a sulcus at the top of the shoulder is a positive sign of inferior instability
If athlete has an inferior instability – usually multidirectional instability as well

20. Speed’s Test Biceps tendon
Athletes arm is straight out in a flexed position with the palm up (supinated)
Examiner then pushed down on the forearm (pushing into extension)
Positive test - is pain and weakness in the anterior part of the shoulder (bicepital groove)
Indicative of biceps tendon injury (long head)

21. Empty can Supraspinatus
Athlete stands with arm out to side (approx 45 degrees cross extension)
Thumb is pointed down (arm internally rotated)
Examiner pushes down on the forearm
Positive test -is pain and weakness
Indicative of a supraspinatus tendinitis or strain

22. Drop Arm
Rotator cuff
Examiner passively abducts the athletes arm to 90 degrees
Athlete tries to hold it there and then slowly lower arm to side
Positive test -occurs when athlete can not lower arm slowly and with out pain
Indicative of a tear in the Rotator cuff complex

23. Hawkin’s Test
Impinges supraspinatus muscle, Teres Minor muscle, and Infraspinatus muscle
Hawk trainers hold their arm in the starting position of this test
Shoulder forward flexed to 90 degrees
Elbow flexed to 90 degrees
Examiner grasps patients elbow with one hand and their wrist with the other
Examiner passively internally rotates the shoulder
Positive sign – pain – shoulder impingement

24. Costoclavicular syndrome test
Test for thoracic outlet syndrome
Examiner palpates the radial pulse then draws athletes shoulder down and back while athlete hyperextends their neck
Positive test - is a diminishing or absence of radial pulse
Subclavian artery is being blocked by costolclavicular structures of the shoulder

25. Adson Maneuver
Test for thoracic outlet syndrome
Examiner palpates radial pulse
Athlete rotates head toward affected shoulder ( keeps head extended) , while examiner LR and extends shoulder
Athlete takes a deep breath and holds
Positive test - if radial pulse diminishes or is absent, then subclavian artery is being blocked by anterior and middle scalene muscles

27. Sport Specific Functional Tests
All functional patterns should be fluid and painfree
throwing
swimming strokes
overhead serves...