1. Shoulder Problem Evaluation

2. Shoulder assessment Second most common musculoskeletal complaint
Difficult joint to examine
Multidirectional range of motion- UNIQUE!
Shoulder injury can affect nearly every sport and many daily activities

3. Bony Anatomy Anterior

4. Bony Anatomy Anterior and Posterior4

6. Bones Scapula & clavicle Move as a unit
Clavicle’s articulation with sternum is only bony link to axial skeleton
The Shoulder Girdle
Manual of Structural Kinesiology

7. Bones Key bony landmarks Manubrium Clavicle Coracoid process
Acromion process
Glenoid fossa
Lateral border
Inferior angle
Medial border
The Shoulder Girdle
Manual of Structural Kinesiology

8. Bones Key bony landmarks Acromion process Glenoid fossa Lateral border
Inferior angle
Medial border
Superior angle
Spine of the scapula
The Shoulder Girdle
Manual of Structural Kinesiology

9. Radiographic Anatomy 9

10. 6 Articulations or Joints
Coraco Clavicular
Sterno Clavicular
Acromio Clavicular
Gleno Humeral
Scapulo Thoracic
Sub Acromial Space

11. Coraco Clavicular

12. Sterno Clavicular

13. Acromio Clavicular

14. A/C Joint
Grade 1+ A/C Separation

15. Gleno Humeral

16. Scapulo Thoracic

17. Sub Acromial

18. Where do things go wrong?? Fractures

19. Where do things go wrong?? Dislocations and Separations
Dislocations and separations are protected by both “static” and “dynamic” stabilizers…

20. Where do things go wrong?? Dislocations and Separations
Oh, yeah…Arthritis can happen at these joints, too…

21. Voluntary Posterior Subluxation

22. Glenohumeral Joint Shallow (“golf ball sitting on a tee”)
Inherently unstable (maximizes ROM)
Static stabilizers
glenohumeral ligaments, glenoid labrum and capsule
Dynamic stabilizers
Predominantly rotator cuff muscles
Also scapular stabilizers
Trapezius, leavator scapulae, serratus anterior, rhomboids

23. Bony Anatomy “Static Stabilizers”

24. What goes wrong… Besides separations and dislocations??
Instability!!! 24

25. LABRUM

26. What goes wrong? Tears and tendonopathies

27. The Rotator Cuff Muscles
Supraspinatus Infraspinatus Teres minor Supscapularis

28. The Rotator Cuff Muscles: SITS
Teres minor ER
Supscapularis IR
Supraspinatus ABD
Infraspinatus ER
Depress humeral head against glenoid to allow full abduction

29. Finally…the subacromial space

30. What can go wrong???
Impingement!!!!!!!

31. Impingement 31

32. Picture 6: Rotator Cuff MRI

33. Shoulder Complex Muscles
Scapular Muscles

34. Levator Scapulae O – Transverse processes of C1-C4
I – Medial border of scapula between superior angle and root of spine of scapula
N – Nerve root C3-5 F
scapular elevation
retraction

35. Rhomboid Major O – I – N – Dorsal Scapular
Major – T2-T5 spinous processes
Minor – Ligamentum nuchae, C7-T1 spinour processes
I –
Major – Medial borde of scapula between spine and inferior angle
Minor – medial border at root of spine of scapula
N – Dorsal Scapular

36. Upper Trapezius O – I – N – spinal accessory F – Occiptal protuberance
Medial 1/3 of nuchal line
Upper part of ligamentum nuchae
C7 spinous process
I –
Posterior border of lateral 1/3 of clavicle
Acromion process
N – spinal accessory
F –
Scapular elevation, retraction
Rotation of head to opp. Side
Lateral flexion of head to opp. side

37. Middle Trapezius O – I – N – Spinal accessory F –
Inferior part of ligamentum nuchea
T1-T5 spinous processes
I –
Medial margin of acromion process
Superior lip of spine of scapula
N – Spinal accessory
F –
Scapular retraction

38. Lower Trapezius O – I – N – spinal accessory F –
T6-T12 spinous processes
I –
Tubercle at apex of root of spine of scapula
N – spinal accessory
F –
Scapular depression, retraction and upward rotation

39. Serratus Anterior O – I – N – F –
Outer surfaces and superior border of ribs 1-8
I –
Ventral scapular surface on medial border from superior angle to inferior angle
N –
Long Thoracic
F –
Scapular protraction, upward rotation
Scapular depression (lower fibers)
Scapular elevation (upper fibers

40. Pectoralis Minor O – I – N – F –
Superior margins and outer surface ribs 3-5 near cartilages
Fascia overlying corresponding intercostal muscles
I –
Medial border, superior surface of coracoid process
N –
Medial Pectoral
F –
Scapular depression, downward rotation, protraction

41. Glenohumeral Muscles

42. Biceps Brachii O I – N – Musculocutaneous F –
Short head – coracoid process
Long head – supraglenoid tubercle of scapula
I –
Radial tuberosity
Biceps brachii aponeurosis
N – Musculocutaneous
F –
Shoulder – flexion
Elbow – flexion, forearm supination

43. Coracobrachialis O – I – N –Musculocutaneous F – Coracoid process
Medial surface of mid-humerus, opposite to deltoid tuberosity
N –Musculocutaneous
F –
GH flexion, adduction, Hor. Adduction

44. Pectoralis Major O – I – N – F –
Sternal – anterior surface of sternum, cartilages of ribs 1-6 or7
Clavicular – anterior surface of sternal ½ clavicle
I –
crest of humerus’s greater tuberosity
N –
Sternal – medial pectoral
Clavicular – lateral pectora
F –
GH ADD, H. ADD and IR

45. Anterior Deltoid O – I – N – Axillary F –
Anterior border, superior surface of lateral third of clavicle
I –
Deltoid tuberosity
N – Axillary
F –
GH H. ADD, flexion
IR when in supine position

46. Middle Deltoid O – I – N – F –
Lateral margin and superior surface of acromion
I –
Deltoid Tuberosity
N –
Axillary
F –
GH ABD

47. Posterior Deltoid O – I – N – Axillary F –
Inferior lip of posterior border of spine of scapula
I –
Deltoid tuberosity
N – Axillary
F –
GH extension, H. ABD,
ER when in prone position

48. Triceps Brachii O – I – N – Radial F –
Long Head – infraglenoid tubercle
Lateral Head – lateral and posterior surface of proximal ½ of body of humerus
Medial Head – distal 2/3 of medial and posterior surfaces of humerus below radial groove
I –
Posterior surface of olecranon proess
N – Radial
F –
Shoulder – long head – Ext and ADD
Elbow -- extension

49. Latissimus Dorsi O – I – N – Thoracodorsal F –
Posterior layer of lumbodorsal fascia, then attaching to the T6-T12, lumbar and sacral vertabrae
External lip of iliace creast lateral to erector spinae
Ribs 9-12
Slip from inferior angle of scapula
I –
Intertubercular groove (distal aspect)
N – Thoracodorsal
F –
GH IR, ADD, Ext,

50. Teres Major (Lat’s Little Helper)
Dorsal surface of inferior angle
Lower 1/3 of scapula lateral border
I –
Crest of lesser tuberosity
N – Lower Subscapular
F –
GH IR, ADD, Ext

51. Rotator Cuff

52. Suprspinatus O – I – N – Suprascapular F –
Medial 2/3 supraspinatus fossa
I –
Superior portion of greater tuberosity
N – Suprascapular
F –
Intiates shoulder ABD
Humeral head stabilization

53. Infraspinatus O – I – N – Suprascapular F –
Medial 2/3 infraspinatus fossa
I –
Middle portion of greater tuberosity
N – Suprascapular
F –
GH ER
Humeral head stabilization

54. Teres Minor
O –
Upper 2/3 dorsal surface of lateral border of scapula
I --
Lowest portion of greater tuberosity
N –
Axillary
F –
GH ER
Humeral head stabilization

55. Subscapularis O – I – N – F – Subscapular Fossa Lesser tuberosity
Anterior capsule of GH joint
N –
Upper and lower subscapular
F –
GH IR
Humeral head stabilization

56. Basic Shoulder Complex Mechanics

57. Performing Abduction Initiation Scapulohumeral Ryhthm Clavicle
First 30 degrees
> 30 degrees
Clavicle

58. So…what causes shoulder pain?
Impingement
Labrum and biceps pathology
A-C joint pathology
Rotator Cuff Injury
Instability
Among other things…

59. Clinical Exam History
Pain
Acute
Chronic
Weakness
Deformity

60. Clinical Exam History Single event Repetitive overload Instability
Does it feel like it’s going to come out?
Catching/Locking

61. Clinical Exam History Sport / Occupation Previous injury
Previous treatment
Other joints involved
Disability

62. Physical Exam: Big 6 Inspection Palpation Range of Motion Strength
Neurovascular
Special Tests

63. Special Tests Impingement Rotator Cuff Integrity Labrum and Biceps
AC (SC) Joints
Instability 63

64. Throwing Mechanics
Arm Cocking Phase
Begins
Ends

65. Throwing Mechanics
Arm Acceleration
Begins
Ends

66. Throwing Mechanics
Follow-through
Begins
Ends

67. Pathomechanics of Throwing
Shoulder
Rotator Cuff
Labrum
Impingement
SLAP Lesion

68. Common problems of the Shoulder
Arthritis, tendinitis,
Dislocation- joint slips out of place ie, the bones move from their normal position. D/T: blow, fall, trauma
Subluxation- incomplete or partial dislocation. D/T: same as above
The Shoulder Girdle

69. Case #1
22-year-old male rugby player falls onto his right shoulder while being tackled
Severe pain on top of his right shoulder

70. Case #1 Notable deformity over superior shoulder
Painful range of motion
Unable to lift right arm above waist
Special Tests??
Diagnosis???

71. Acromioclavicular (A-C) Sprain
Special Tests
Shear Test
Cross Arm Test
A-C Palpation
Resisted Extension
Active compression test

72. Acromioclavicular (A-C) Sprain
Damage to A-C joint ligaments
Pain and/or deformity over A-C joint
Graded I-VI
I-III usually treated non-operatively
IV-VI referred to orthopedic surgery

73. AC Joint Sprain Treatment
Analgesics, ice prn
Sling for as long as needed
Physical Therapy
ROM restoration
Gradual strength exercise
Return to sport activity as tolerated

74. Case #2 24-year-old male handball player
Fell onto his shoulder after being pushed
Intense pain
Hand is tingling and arm feels like it’s hanging
X-rays

75. X RAYS

76. Shoulder Dislocation/Anterior Instability
Humeral head dislocates from glenoid fossa
Almost always anterior (95%)
Usually traumatic with injury to capsule-labrum complex

77. Shoulder Dislocation/Anterior Instability
Treatment
Reduction of dislocation
Protection & rehab, rehab, rehab
Most will have future dislocations and/or instability
At least 70%!!! (young)
May require surgical tightening/repair of the capsule/labrum complex

78. Special Tests Glenoid Labrum and Instability
Biceps Load I and II
Kim Test
Jerk Test
Active-Compression Test (O’Brien)
Crank Test
Apprehension Test
Relocation Test
Load and Shift
Sulcas Sign

79. Which of the following structures can be “impinged”?
Biceps tendon
Subacromial Bursa
Rotator Cuff Tendons
All of the above 30 10

80. Case #3 35-year-old male tennis player
Shoulder pain exacerbated by practicing serves
Develops dull, aching pain in right shoulder

81. SHOULDER PAIN Physical Exam
Tenderness to palpation anterior shoulder
Pain with abduction starting around 90 degrees
Unable to lift arm past 120 degrees
Pain with forward flexion at degrees
Special Tests??? Diagnosis???

82. Shoulder Pain Physical Exam
Hawkin’s positive
Neer’s positive
IMPINGEMENT??? 82

83. Impingement as a Clinical Sign
Repetitive overhead activities
Subacromial bursa and/or rotator cuff impinged between acromion & humerus
Physical therapy, activity modification +/- medications

84. Diagnoses associated with clinical sign of Rotator Cuff Impingement:
Subacromial bone spurs and / or bursal hypertrophy
AC joint arthrosis and /or bone spurs
Rotator cuff disease
Superior labral injury
Glenohumeral instability
Scapular dyskinesis
Biceps tendinopathy
A diagnostic injection sometimes helps to clarify the diagnosis

85. Case #4 45-year-old weight lifter
Caught bar as it was falling off his shoulder
Sudden pain
Severe weakness left shoulder
Worse with overhead activities; while sleeping at night
Pain in anterior lateral shoulder
Special tests?

86. Case #4 Drop Arm Test Positive External Rotation Lag Sign positive
Weakness with Empty Can Sign
Normal bear hug and belly press tests…
Diagnosis????? 86

87. Rotator Cuff Tear Supraspinatus tendon most common
Acute trauma or chronic tendinopathy
Treatment dependent upon age/activity
Young, active usually require operative treatment
Older, low-activity usually respond to non-operative treatment

88. Case #5 42-year-old female with dull pain right shoulder
Pain is diffuse in nature
Sometimes spreads to between shoulder blades
Seems worse at night

89. Physical Exam Obese, pleasant female Diffuse pain Normal shoulder exam
Not able to reproduce pain during exam
What else do you want to do???

90. Shoulder pain isn’t always the shoulder!! Get more history…
Gall bladder disease
Peptic Ulcer Disease
Cervical radiculopathy
Cardiac ischemia
Pulmonary conditions
ie Pancoast’s tumor, Pneumonia

91. In the human body, which is the most incredible joint?
PIP
Knee
Ankle
Shoulder
None of the above

92. Case #6 40-year-old male Recently shoveled 16” of snow
Can hardly lift left arm due to pain
Special Tests? Diagnosis?

93. Biceps Tendonopathy
Speed Test
Yergason Test
Direct palpation

94. Biceps Tendonopathies
Repetitive overhead activity
Repetitive forearm flexion/supination
Difficult to discern from rotator cuff tendinopathy or impingement 94

95. Conclusion Shoulder injuries are common.
Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis.
Impingement is a clinical sign, not a diagnosis.
Don’t forget about medical causes.

96. QUESTIONS?

97. Physical Exam Inspection
Front & back
Height of shoulder and scapulae
Muscle atrophy, asymmetry 97

98. Physical Exam Range of Motion
Abduction 0-180o 98

99. Physical Exam Range of Motion
Forward flexion:
0o – 180o 99

100. Physical Exam Range of Motion
Extension
0o – 40 to 60o
100

101. Physical Exam Range of Motion
Internal rotation
T5 segment
External rotation
80-90o
101

102. Physical Exam Strength
Empty can test
30o angle
Steady downward pressure
Tests supraspinatus strength and pain
102

103. Physical Exam Strength
Resisted external rotation
Tests infraspinatus, teres minor strength
103

104. Physical Exam Strength of Subscapularis
Liftoff test Belly press test
104

105. Cross-Arm Adduction Test
AC joint pathology
Arm flexed to 90°
Hyperadduct arm across body as far as possible
Pain in AC = (+) test
105

106. A-C Shear Test
Interlock fingers with hand on distal clavicle and spine of scapula
Pain in A-C joint when hands squeezed together = (+) test
106

107. Sulcus Sign Inferior instability
Arm relaxed in neutral position, pull downward at elbow
(+) test = sulcus at infra-acromial area
compare to unaffected side
107

108. Apprehension Test Anterior instability
Shoulder at 90° abducted, slight anterior pressure & External rotation
(+) test = dislocation apprehension
some false (+)
108

109. Relocation Test Perform after positive apprehension test
Apply post force over humeral head during external rotation (ER)
(+) test = increased ER tolerance
109

110. Load & Shift Test Test for multidirectional instability
Grasp humeral head, slide anteriorly and posteriorly while securing rest of shoulder
(+) if greater than 50% displacement (graded 1-3)
110

111. Impingement Signs
Hawkins
Neer
111

112. Drop Arm Test Suggestive of Rotator Cuff Tear
Passive abduction to 90°
Instruct patient to slowly lower arm
At 90° abducted arm will suddenly drop, may need to add slight pressure
(+) drop = (+) test
112

113. Speed’s Test Biceps Tendinopathy
Long head of biceps tendonitis
Fwd flex to 90°, abd 10°, full supination
Apply downward force to distal arm
Pain = (+) test
weakness w/o pain = muscle weakness or rupture
113

114. O’Brien’s Active Compression SLAP lesion (Superior Labrum Antero-Posterior)
Labral/AC pathology
Arm flexed to 90°, elbow extended, adduct 10-15°, resist downward force
+ if AC pain or internal pain/click
114

115. O’Brien’s Active Compression SLAP lesion
Supination should be pain free (decreased pain)
115

116. Crank Test Labral injury
Glenoid labrum tear
Abduct arm to 160°, pt is supine or upright, elbow secured with one hand axial load at shoulder with other
(+) if audible/painful catch/grind is noted
116