1. Anatomy of the Shoulder
ATHT 205
Chad Dufrene
Spring 2016

2. Objectives Knowledge of Anatomy Knowledge of Pathology
Knowledge of HOPS associated with pathology
Rehabilitation

3. Bony Anatomy
Shoulder complex
Sternum
Clavicle
Scapula
Humerus

4. Sternum Manubrium Attachment site for clavicle Jugular notch
Clavicular notch

5. Clavicle Short bone between the sternum and scapula
Elevates and rotates for kinematic efficiency
Anterior convex bend at proximal 2/3.
Flattened concave bend at distal 1/3.
The distal 1/3 is the most common site for fractures.

6. Scapula Glenoid fossa Subscapular fossa Vertebral border
Inferior angle
Superior angle
Scapular spine
Infraspinous fossa
Supraspinous fossa
Acromion process
Coracoid process

7. Humerus Humeral head Anatomical neck Bicipital groove
Greater tuberosity
Lesser tuberosity
Surgical neck
Deltoid tuberosity

8. Shoulder Joints Sternoclavicular (SC) Acromioclavicular (AC)
Scapulothoracic
Glenohumeral

9. Sternoclavicular (SC)
Articulation of the proximal clavicle, manubrium, and first costal cartilage
Gliding synovial joint
Allows 3 degrees of motion.
Aids in elevation, depression, protraction, retraction, internal rotation, and external rotation
Poor bony stability
Sternoclavicular disk
-shock absorber

10. Sternoclavicular (SC) cont.
Strong ligamentous support
Difficult to dislocate.
Ligaments
Posterior sternoclavicular
Anterior sternoclavicular
Interclavicular
costoclavicular

11. Acromioclavicular (AC)
Articulation of the distal clavicle and the acromion process.
Plane synovial joint
Allows 3 degrees of motion
Aids in internal rotation, external rotation, upward rotation, downward rotation, anterior scapular tipping, and posterior scapular tipping
Synovial disk present in approximately first 20 years of life

12. Acromioclavicular (AC) cont.
Coracoacromial ligament
Acromioclavicular ligament
Restricts superior clavicular movement
Coracoclavicular ligament
Trapezoid ligament
Conoid ligament
Restricts horizontal movement of clavicle
Restricts rotation of the scapula

14. Scapulothoracic Not a true anatomical joint
No fibrous, cartilaginous, or synovial articulation
Movement only in response to AC and SC joint movement
Limited mobility in AC or SC affect mobility of scapulothoracic joint

16. Glenohumeral (GH)
Articulation of the humeral head and the glenoid fossa
Ball and socket joint
3 degress of motion
Aids in flexion, extension, abduction, adduction, internal rotation, and external rotation
Horizontal adduction, horizonal abduction, and circumduction

17. Glenohumeral (GH) cont.
Glenoid labrum
Thick fibrous tissue
Deepens the GH articulation
Joint capsule
Glenohumeral ligaments
Superior, middle, and inferior
Inferior pouch
Foramen of Weitbrecht (weak spot)

18. Glenohumeral Ligaments
External Rotation
Ligament Stressed
External Rotation in 0 degrees of abduction
Superior GH Ligament
Coracohumeral Ligament
External Rotation in 45 degrees of abduction
Middle GH Ligament
Anterior Band of Inferior GH Ligament
External Rotation in 90 degrees abduction
Posterior Band of Inferior GH Ligament

19. Glenohumeral Ligaments
Movement
Ligament Stressed
Internal rotation at 90 degrees abduction
Posterior Band of Inferior GH Ligament
Inferior Displacement in 0 degrees abduction
Superior GH Ligament
Coracohumeral Ligament
Inferior displacement in 90 degrees abduction
Inferior GH Ligament

20. Glenohumeral (GH) cont.
Coracohumeral ligament
Joins superior capsule and supraspinatus tendon to the greater tuberosity
Limits inferior translation of humeral head
Limits flexion and extension
Limits external rotation

21. Glenohumeral (GH) cont.
Coracoacromial ligament
Stretches from the inferior acromion process to the posterior portion of the coracoid process.
Forms the coracoacromial arch
Protects the superior humeral head, rotator cuff tendons, and bursae.
Prevents superior and anterior GH dislocations.

22. Muscles of the Shoulder Complex
Chad Dufrene
ATHT 469

33. Supraspinatus
Origin- Supraspinous fossa
Insertion- Medial aspect of the greater tuberosity and GH joint capsule
Action- Abduction, External rotation, and Humeral head stabilization.
Innervation- Suprascapular (C4,C5,C6)

34. Infraspinatus Origin- Infraspinous fossa of the scapula
Insertion- Lateral portion of greater tuberosity of the humerus, GH capsule
Action- External rotation, Horizontal abduction, Humeral head stabilization
Innervation- Suprascapular (C5,C6)

40. Clinical Examination of Shoulder Injuries
ATHT 469
Dufrene

41. Disclaimer
A thorough evaluation is key due to the interrelationship between the shoulder complex and the cervical spine, thoracic spine, torso, abdomen, and elbow.
The shoulder complex is a common site for visceral organ referred pain and orthopedic radiating pain.

42. History (Past Conditions)
“Have you injured your shoulder before?”
Past medical history
Pre-participation physicals are important.
There may be a relationship between the current condition and a past condition.

43. History (Present Conditions)
Location
“Where does it hurt?”
“Point with one finger where it hurts the most.”
“What type of pain?”
“Is the pain traveling or radiating?”
“Is there numbness or tingling?”

44. History Onset “When did the pain start?”
“Did the pain worsen over time?”
“Is the pain constant?”
“What activities worsen pain?”
“Did you hear or feel a pop or snap?”
Acute? Chronic?
Insidious onset?

45. History Mechanism of Injury
This is the investigation of “how” the injury happened.
What inside or outside forces caused this injury?
Was there an impact?
Was it a non-contact injury?
Was it a chronic injury caused by repetitive force?

46. History Symptoms Pain? Performance Deficiency? Loss of ROM?
Joint Instability?
Radiating Pain?
Numbness? Tingling?

47. History Conclusion
The history of an acute traumatic injury should focus on the mechanism of injury.
The history-taking process expands for cases involving an insidious onset.

48. Observation Functional Assessment Apprehension to movement?
Bracing to alleviate or reduce symptoms?
Example (flexing the trunk while abducting for supraspinatus pathology)
Observe the scapula during movement

49. Observation Shoulder level Thoracic Outlet Syndrome
AC joints, clavicles, and SC joints should align bilaterally
Dominant shoulder may appear slightly lower than nondominant one.
Resting position?
Decreased muscular tone?
Depressed shoulder complexes can lead to thoracic outlet syndrome
Rounded shoulders indicate tight pectoralis musculature.
Scoliosis?

50. Observation Head Position Normally assumes an upright position
A head that is rotated or bent to the side may indicate muscle spasm, cervical nerve root compression, or stretching of the cervical nerves.

51. Observation Arm Position Is arm locked in a fixed position?
GH dislocation
Is arm splinted?
Traumatic injury
Is arm hanging?
Brachial plexus injury

52. Observation Clavicles Clavicular Fx Compare clavicles bilaterally
Look for gross deformities
SC or AC joint sprains usually present gross deformity at the articulation
Past trauma?
Clavicular fx present a clear deformity of the shaft
Usually the distal 1/3
Patient holds arm next to body and rotates head to opposite side

53. Observation Deltoid Symmetry
Dominant arm is usually more hypertrophied compared to nondominant arm.
Severe atrophy may reflect C5 and C6 pathology.
Flattening of deltoid area is an indication of a dislocated GH joint.

54. Observation Biceps Brachii Biceps Tendon Rupture
A long head of the biceps tendon rupture will present a unilateral bulge within the muscle.
Distal tendon can rupture also.

55. Observation Acromion Process AC Sprain Step Deformity? AC sprain
The clavicle rides above the acromion process.

56. Observation Scapular Position Scapular Winging
Vertebral borders should be equidistant from the spinous processes
In anatomical position, the scapula is in full contact with the thorax
Unilateral protraction?
Unilateral retraction?
Unilateral tilting?
Scapular winging?
Sprengel’s deformity
Congenital undescended scapula

57. Observation Muscle Development Ecchymosis Look for symmetry Spasm?
Deformity?
Discoloration?
Ecchymosis
Muscle wasting?

58. Clinical Evaluation of the Shoulder
Part 2
Chad Dufrene

59. Palpation
The bony structures are palpated prior to soft tissue structures to rule out fractures, dislocations, and gross joint injury.
If gross deformity is found, the limb should be examined for neurologic and vascular compromise.
Immobilize the shoulder and refer to a physician.

60. Palpation (pgs.634-636) Anterior Bony Structures
Posterior Bony Structures
Jugular notch
SC joint
Clavicular shaft
Acromion process
AC joint
Coracoid process
Humeral head
Greater tuberosity
Lesser tuberosity
Bicipital groove
Humeral shaft
Scapular spine
Superior angle
Inferior angle
Spinous processes from C1-T12

61. Palpation (pgs. 634-636) Anterior Muscular Structures
Posterior Muscular Structures
Pectoralis major
Pectoralis minor
Coracobrachialis
Deltoids
Biceps brachii
Rotator cuff muscles
Teres major
Rhomboids
Levator scapulae
Trapezius
Latissimus dorsi
Posterior deltoid
Triceps brachii

62. Goniometry Glenohumeral Flexion GH isolaged: 0-120 degrees
Shoulder complex: degrees.
Patient Supine
Fulcrum: lateral to the acromion process
Stationary arm: parallel to the thorax
Movement arm: midline of lateral humerus
Isolate GH flexion by stabilizing the axillary border of the scapula
Note measurement when scapula begins to move

63. Goniometry Glenohumeral Extension 0-60 degrees Patient prone
Fulcrum: Aligned lateral to the acromion process
Stationary arm: parallel to the thorax
Movement arm: over midline of lateral humerus
Stabilize scapula on its posterior surface to isolate GH extension

64. Goniometry Abduction GH isolated: 0-120 degrees
Shoulder complex: degrees
Patient Supine
Fulcrum: Anterior to acromion process
Stationary arm: parallel to midline of torso
Movement arm: midline of anterior humerus
To isolate GH, stabilize the scapula at its axillary border.
Note the measurement when scapula begins to move.

65. Goniometry Internal Rotation 0-90 degrees
Patient supine with shoulder and elbow 90/90
Fulcrum: lateral to olecranon process
Stationary arm: perpendicular to floor or parallel to tabletop
Movement arm: long axis of ulna
Stabilize scapula to isolate GH joint. When scapula moves, notate the measurement.

66. Goniometry External Rotation 0-100 degrees
Patient Prone with shoulders 90/90
Fulcrum: lateral to olecranon process
Stationary arm: perpendicular to floor or parallel to tabletop
Movement arm: over long axis of ulna
Stabilize the scapula until it starts to move. That’s when you notate the measurement.

67. Goniometry Horizontal Abduction 0-90 degrees
Patient seated with arm abducted to 90 degrees, elbow flexed, and forearm pronated.
Fulcrum: Superior acromioclavicular joint
Stationary arm: perpendicular to trunk
Movement arm: parallel to longitudinal axis of humerus
Isolate GH motion during horizontal adduction, stabilize scapula at axillary border.

68. Goniometry Horizonatl Adduction 0-50 degrees
Patient seated with arm abducted to 90 degrees, elbow flexed, and forearm pronated.
Fulcrum: Superior AC
Stationary arm: perpendicular to trunk
Movement arm: parallel to longitudinal axis of the humerus
Isolate GH motion during horizontal adduction. Stabilize scapula at axillary border.

69. Muscle Review (minor movements in italics)
Scapular Elevation
Scapular Depression
Levator scapulae
Trapezius (upper portion)
Rhomboid major
Rhomboid minor
Serratus anterior (upper portion)
Trapezius (lower portion)
Pectoralis major (clavicular portion)
Serratus anterior (lower portion)

70. Muscle Review Scapular Protraction Scapular Retraction
Serratus anterior
Rhomboid major
Rhomboid minor
Trapezius (middle)
Trapezius (lower)

71. Muscle Review Scapular Upward Rotation Scapular Downward Rotation
Serratus anterior
Trapezius (upper)
Rhomboid major
Rhomboid minor
Levator scapulae
Trapezius (lower)

72. Muscle Review Shoulder Flexion Shoulder Extension Biceps brachii
Coracobrachialis
Deltoid (anterior)
Pectoralis major (clavicular head)
Deltoid (posterior)
Latissimus dorsi
Teres major
Triceps brachii (long head)

73. Muscle Review Adduction Abduction Coracobrachialis Latissimus dorsi
Pectoralis major
Teres major
Triceps brachii
Supraspinatus (1st 30 degrees)
Deltoid (middle)
Biceps brachii
Deltoid (anterior)
Deltoid (posterior)

74. Muscle Review Horizontal Adduction Horizontal Abduction
Deltoid (anterior)
Pectoralis major
Infraspinatus
Teres Minor
Deltoid (posterior)

75. Muscle Review Internal Rotation External Rotation Subscapularis
Teres major
Pectoralis major
Latissimus dorsi
Deltoid (anterior)
Infraspinatus
Teres Minor
Supraspinatus
Deltoid (posterior)

76. Clinical Examination of the Shoulder
Dufrene
Part 3

77. Manual Muscle Testing
Following active range of motion (AROM), manual muscle testing is used to detect pain or weakness associated with more specific muscle involvement.
Remember to be aware of the athlete’s reaction to your manual muscle testing (MMT).
The content in the textbook between pg is a helpful tool in understanding manual muscle testing.

78. Dermatome/Myotome C4 Dermatome: Superior shoulder, clavicle area.
Myotome: Shoulder shrug (trapezius, levator scapulae)
Reflex: N/A

79. Dermatome/Myotome C5 Dermatome: Deltoid, lateral upper arm
Myotome: Shoulder abduction (deltoid), elbow flexion (biceps)
Reflex: Biceps

80. Dermatome/Myotome C6
Dermatome: Lateral forearm, radial side of hand, thumb, and index finger
Myotome: Elbow flexion (biceps, supinator), wrist extension
Reflex: Brachioradialis

81. Dermatome/Myotome C7
Dermatome: Posterior lateral arm and forearm, middle finger
Myotome: Elbow extension (triceps), wrist flexion
Reflex: Triceps

82. Dermatome/Myotome C8
Dermatome: Medial forearm, ulnar border of hand, ring and little finger.
Myotome: Ulnar deviation, thumb extension, finger flexion and abduction.
Reflex: N/A

83. Dermatome/Myotome T1 Dermatome: Medial elbow, arm
Myotome: Finger abduction
Reflex: N/A

84. Nerve Branches Musculocutaneous (C5-C7) Dermatome: Lateral forearm
Myotome: Elbow flexion
Reflex: N/A

85. Nerve Branches Median (C5-C7, C8-T1)
Dermatome: Distal radial aspect, index finger
Myotome: Thumb pinch, opposition, and abduction
Reflex: N/A

86. Nerve Branches Ulnar (C8,T1, some C7)
Dermatome: Distal ulnar side of 5th finger
Myotome: Abduction, 5th finger
Reflex: N/A

87. Nerve Branches Axillary (C5,C6) Dermatome: Lateral arm, deltoid
Myotome: Shoulder abduction
Reflex: N/A

88. Nerve Branches Radial (C5-C8, T1)
Dermatome: Dorsal web space, between thumb and index fingers
Myotome: Wrist extension, thumb extension
Reflex: N/A

89. Shoulder Pathology and Injury

90. Sternoclavicular Injury
Most commonly caused by falling on an outstreched arm (FOOSH) which causes a longitudinal force.
Anterior dislocations are more common than posterior dislocations.
Posterior dislocations are a medical emergency due to threat to subclavian artery, subclavian vein, trachea, and esophagus.

91. Sternoclavicular Joint Injury
HOPS
Be aware of ligamentous and/or SC disk damage.
Pseudo-dislocation: The clavicle’s medial epiphysis does not completely fuse until approximately age 25. A fracture at this area can mimic an SC dislocation.
H: FOOSH
O: Displacement
P: Pain, crepitus
S: Joint play testing.
-Grade 1: pain
-Grade 2: hypermobility
-Grade 3: hypermobility

92. Sternoclavicular Injury
Treatment
A closed reduction is usually performed to fix a dislocation.
Unstable dislocations are usually repaired surgically.
Immobilization
Control of inflammation
Initiate ROM exercises
Strengthen surrounding musculature.

93. Shoulder Lecture
Part 4
Dufrene

94. Acromioclavicular Joint
Anterior and posterior stability of the AC joint is maintained by the AC ligament.
Superior stability is maintained by the conoid and trapezoid segments of the coracoclavicular ligament.

95. AC Joint Pathology Mechanism of Injury
Landing on a forward-flexed outstreched arm or the point of the elbow, which drives the scapula posterior to the clavicle.
A blow to the superior acromion process, which drives the scapula inferior to the clavicle.
A force that drives the clavicle away from the scapula when the scapula is fixated.
Acute overuse with repetitive stress.