1. Bones Scapula & clavicle Move as a unit
Clavicle’s articulation with sternum is only bony link to axial skeleton

2. Bones Key bony landmarks Manubrium Clavicle Coracoid process
Acromion process
Glenoid fossa

3. Bones Key bony landmarks Lateral border Inferior angle Medial border
Superior angle
Spine of the scapula
From Seeley RR, Stephens TD, Tate P; anatomy and physiology, ed 7, New York, 2006, McGraw-Hill

4. 4 Main Articulations Glenohumeral Joint Acromioclavicular Joint
Sternoclavicular Joint
Scapulothoracic articulation
Not a true joint

5. Joints Shoulder girdle (scapulothoracic)
scapula moves on the rib cage
Sternoclavicular (SC)- average
Acromioclavicular (AC)- little

6. Acromioclavicular (AC) Joint
Gliding joint
Lat. End of clavicle
Acromion process of scapula
“separated shoulder”

7. Sternoclavicular (SC) Joint
Saddle “type” of joint
Only link of upper limb to axial skeleton

8. AC Ligaments AC T C AC ligament Coracoclavicular Lig.
Strengthens joint
Coracoclavicular Lig.
Trapezoid (Lat.)
Conoid (Med.)
If these ligaments are sprained it is a “separated shoulder” AC T C

9. SC Joint Stability Joint deepened by articular disc Ligaments
Ant./Post. SC ligament
Costoclavicular Ligament

10. Joints 25-degrees abduction-adduction
Scapulothoracic
not a true synovial joint
does not have regular synovial features
movement depends on SC & AC joints which allows the scapula to move
25-degrees abduction-adduction
60-degrees upward-downward rotation
55-degrees elevation-depression
supported dynamically by its muscles
no ligamentous support

11. Scapulothoracic Articulation
No direct bony attachment – not true jt
Scapula held to ribs by muscles
Provides base of support for movement of GH joint
Scapulohumeral Rhythm
Moves 1º for every 2º of abduction

12. Movements Focus on specific bony landmarks
inferior angle
glenoid fossa
acromion process
Shoulder girdle movements = scapula movements

13. Movements Abduction (protraction) Adduction (retraction)
scapula moves laterally away from spinal column
Adduction (retraction)
scapula moves medially toward spinal column

14. Movements Downward rotation Upward rotation
returning inferior angle inferomedially toward spinal column & glenoid fossa to normal position
Upward rotation
turning glenoid fossa upward & moving inferior angle superolaterally away from spinal column

15. Movements Depression Elevation
downward or inferior movement, as in returning to normal position
Elevation
upward or superior movement, as in shrugging shoulders

16. Movements
Shoulder joint & shoulder girdle work together in carrying out upper extremity activities
Shoulder girdle movement is not dependent upon the shoulder joint & its muscles

17. Movements Shoulder girdle muscles
Stabilize scapula so the shoulder joint muscles will have a stable base from which to exert force for moving the humerus
Contract to maintain scapula in a relatively static position during shoulder joint actions
Contract to move shoulder girdle & to enhance movement of upper extremity when shoulder goes through extreme ranges of motion

18. Movements Synergy with muscles of glenohumeral joint
As shoulder joint goes through more extreme ranges of motion, scapular muscles contract to move shoulder girdle so that its glenoid fossa will be in a more appropriate position from which the humerus can move
Without the accompanying scapula movement humerus can only be raised into approximately 90 degrees of total shoulder abduction & flexion

19. Movements Synergy with muscles of glenohumeral joint
This works through the appropriate muscles of both joints working in synergy to accomplish the desired action of the entire upper extremity
Ex. to raise our hand out to the side laterally as high as possible, the serratus anterior & trapezius (middle & lower fibers) muscles upwardly rotate scapula as supraspinatus & deltoid initiate glenohumeral abduction
This synergy between scapula & shoulder joint muscles enhances movement of entire upper extremity

20. Shoulder Girdle Movements
Elevation
Shoulder Girdle Movements
Abduction
Adduction
Upward
Rotation
Downward
Rotation
Depression

21. Muscles 5 muscles primarily involved in shoulder girdle movements
All originate on axial skeleton & insert on scapula and/or clavicle
Do not attach to humerus & do not cause shoulder joint actions
Essential in providing dynamic stability of the scapula so it can serve as a relative base of support for shoulder joint activities such as throwing, batting, & blocking

22. Shoulder Girdle Muscles
5 muscles primarily involved in shoulder girdle movements
Trapezius - upper, middle, lower
Rhomboid - deep
Levator scapula
Serratus anterior
Pectoralis minor - deep

23. Shoulder Girdle Muscles
Location & action
Anterior
Pectoralis minor – abduction, downward rotation, & depression
Subclavius – depression
Posterior & laterally
Serratus anterior – abduction & upward rotation

24. Shoulder Girdle Muscles
Location & action
Posterior
Trapezius
Upper fibers – elevation & extension of the head
Middle fibers – elevation, adduction, & upper rotation
Lower fibers – adduction, depression, & upper rotation
Rhomboid – adduction, downward rotation, & elevation
Levator scapulae – elevation

25. Shoulder and Shoulder Girdle

26. 4 Bones of the Shoulder
Humerus
Scapula
Clavicle
Sternum (Manubrium)

27. Humerus Upper arm Humeral head attaches with glenoid fossa of scapula
Greater and lesser tubercles = muscle attachment
Bicipital groove is between tubercles

28. Scapula “shoulder blade” Irregular; triangular shaped
Articulates with humerus but not the rib cage
3 projections
Spine
Acromion process
Coracoid process
Posterior
Anterior
Medial

29. Clavicle “collarbone” “S” shaped – 6 “ long
Med 2/3 is round and lateral 1/3 is flattened
Weakest where is changes shape
Supports anterior shoulder & keeps it off the thoracic cage

30. Sternum (manubrium) “breastbone” Divided into 3 parts
Body
Xiphoid process
Only place the appendicular skeleton attaches to the axial skeleton

31. Glenohumeral Joint Ball & socket joint Wide range of motion
Head of Humerus
Glenoid fossa
Wide range of motion

32. Brachial Plexus Nerve bundle that goes to shoulder and arm C5-T1
When overstretched or compressed it is often called a “stinger”
Numbness and tingling down arm and into fingers
“Dead Arm” and/or weakness
Typically takes 15 minutes to resolve
Residual soreness in the traps

33. The Shoulder Joint
Wide range of motion of the shoulder joint in many different planes requires a significant amount of laxity
Common to have instability problems
Rotator cuff impingement
Subluxations & dislocations
The price of mobility is reduced stability
The more mobile a joint is, the less stable it is & the more stable it is, the less mobile

34. Glenohumeral Joint
multiaxial ball-&-socket

35. Glenohumeral Joint
Glenoid labrum slightly enhances stability

36. Glenohumeral Joint Glenohumeral ligaments provide stability
especially anteriorly & inferiorly
inferior glenohumeral ligament
Ligaments are quite lax until extreme ranges of motion is reached due to wide range of motion involved
Stability is sacrificed to gain mobility

37. Glenohumeral Joint
Determining exact range of each movement is difficult due to accompanying shoulder girdle movement

38. Glenohumeral Joint 90 to 95 degrees abduction
0 degrees adduction, 75 degrees anterior to trunk

39. Glenohumeral Joint 40 to 60 degrees of extension
90 to 100 degrees of flexion

40. Glenohumeral Joint
70 to 90 degrees of internal & external rotation

41. Glenohumeral Joint 45 degrees of horizontal abduction
135 degrees of horizontal adduction

42. Glenohumeral Joint Frequently injured due to anatomical design
shallowness of glenoid fossa
laxity of ligamentous structures
lack of strength & endurance in muscles
anterior or anteroinferior glenohumeral subluxations & dislocations – common
posterior dislocations – rare
posterior instability problems somewhat common

43. Glenohumeral Joint Rotator cuff is frequently injured
Subscapularis, supraspinatus, infraspinatus, & teres minor muscles
attach to the front, top, & rear of humeral head
point of insertion enables humeral rotation
vital in maintaining humeral head in correct approximation within glenoid fossa while more powerful muscles move humerus through its wide range of motion

44. Pairing of shoulder girdle & shoulder joint movements
Abduction
Upward rotation
Adduction
Downward rotation
Flexion
Elevation/upward rotation
Extension
Depression/downward rotation
Internal rotation
Abduction (protraction)
External rotation
Adduction (retraction)
Horizontal abduction
Horizontal adduction

45. Movements Abduction Adduction
upward lateral movement of humerus out to the side, away from body
Adduction
downward movement of humerus medially toward body from abduction

46. Movements Flexion Extension movement of humerus straight anteriorly
movement of humerus straight posteriorly

47. Movements Horizontal adduction (transverse flexion)
movement of humerus in a horizontal or transverse plane toward & across chest
Horizontal abduction (transverse extension)
movement of humerus in a horizontal or transverse plane away from chest

48. Movements External rotation Internal rotation
movement of humerus laterally around its long axis away from midline
Internal rotation
movement of humerus medially around its long axis toward midline

49. Movements Diagonal abduction Diagonal adduction
movement of humerus in a diagonal plane away from midline of body
Diagonal adduction
movement of humerus in a diagonal plane toward midline of body

50. Muscles Intrinsic glenohumeral muscles Extrinsic glenohumeral muscles
Originate on scapula & clavicle
Deltoid, Coracobrachialis, Teres major
Rotator cuff group
subscapularis, supraspinatus, infraspinatus, & teres minor
Extrinsic glenohumeral muscles
latissimus dorsi & pectoralis major

51. Muscles Anterior Superior Pectoralis major Coracobrachialis
Subscapularis
Superior
Deltoid
Supraspinatus
From Shier D, Butler J, Lewis R: Hole’s essentials of human anatomy and physiology, ed 9, New York, 2006, McGraw-Hill.

52. Muscles Superior Posterior Deltoid Supraspinatus Latissimus dorsi
Teres major
Infraspinatus
Teres minor
From Shier D, Butler J, Lewis R: Hole’s essentials of human anatomy and physiology, ed 9, New York, 2006, McGraw-Hill.

53. Deltoid Muscle
Anterior fibers: abduction, flexion, horizontal adduction, & internal rotation
Posterior fibers: abduction, extension, horizontal abduction, & external rotation
Middle fibers: abduction

54. Teres Major Muscle
Extension, particularly from the flexed position to the posteriorly extended position
Internal rotation
Adduction, particularly from the abducted position down to the side & toward midline of body

55. Pectoralis Major Muscle
Upper fibers (clavicular head): internal rotation, horizontal adduction, flexion, abduction (once arm is abducted 90 degrees, upper fibers assist in further abduction), & adduction (with arm below 90 degrees of abduction)
Lower fibers (sternal head): internal rotation, horizontal adduction, extension, & adduction

56. Latissimus Dorsi Muscle
Adduction
Extension
Internal rotation
Horizontal abduction

57. Coracobrachialis Muscle
Flexion
Adduction
Horizontal adduction

58. Rotator cuff muscles Teres Minor Subscapularis Supraspinatus
attach to greater tubercle from above (Abduct)
Infraspinatus
attach to greater tubercle posteriorly (Ext. Rot.)
Teres Minor
attach to greater tubercle posteriorly (Ext. Rot.)
Subscapularis
attach to lesser tubercle anterior (Int. Rot.)

59. Rotator cuff muscles not very large
must possess strength & muscular endurance
conducting repetitious overhead activities (throwing, swimming, & pitching) with poor technique, muscle fatigue, or inadequate warm-up & conditioning leads to failure of rotator cuff muscle group in dynamically stabilizing humeral head in glenoid cavity
leads to further rotator cuff problems such as tendinitis & rotator cuff impingement within subacromial space

60. Subscapularis Muscle Internal rotation Adduction Extension
Stabilization of the humeral head in glenoid fossa

61. Supraspinatus Muscle
Abduction
Stabilization of the humeral head in glenoid fossa

62. Infraspinatus Muscle External rotation Horizontal abduction Extension
Stabilization of humeral head in the glenoid fossa

63. Teres Minor Muscle External rotation Horizontal abduction Extension
Stabilization of humeral head in the glenoid fossa

64. Shoulder Evaluation
H-I-P-S

65. History: MAPPSS Mechanism of Injury Acute or Chronic? Previous Injury
How the injury happened
Position of the arm
Direction of blow or force
Where impact occurred
Was the arm forced beyond normal limits
Acute or Chronic?
Previous Injury
Previous injury to this or opposite shoulder
What type & how was it treated?
Was shoulder fully functional after treatment?

66. History Cont. Pain Sounds Signs/Symptoms
What type of pain is the athlete feeling?
Sharp, dull, localized, diffuse, radiating, burning
Location of pain
Activities that increase or decrease pain
Does it wake athlete at night?
Sounds
Did athlete hear any sounds at time of injury?
Pop, snap, crepitus
Signs/Symptoms
Numbness
Instability
Locking or catching
Grinding or crepitus

67. Inspection
If possible, observe athlete in seated and standing position
Compare Bilaterally
Check overall posture and position
Is the athlete moving or using injured shoulder
Holding, supporting or favoring part of shoulder or arm
Abnormal positioning of shoulder or arm
Watch face for signs of discomfort and pain
Look for signs of trauma
Deformity- “Piano Key”
Flattened deltoid
Abnormal position of the humerus
Discoloration or contusion
Deformity of clavicle
Swelling

68. Palpation 6 Different findings from palpation:
Point Tenderness: localizes source of pain
Crepitus: presence of grinding or grating; may indicate fracture, tendinitis, bursitis
Swelling: localized or diffuse
Temperature:
Increased Temp= Inflammation
Decreased Temp= Compromised Circulation
Cutaneous Sensation:
Change in sensation can indicate neurological injury or lack of circulation
Vascular Pulses

69. Palpation Cont.
Bony Palpation: Note tenderness, deformity, crepitation
Sternoclavicular Joint
Clavicle
Coracoid Process
Acromioclavicular Joint
Acromion Process
Greater Tuberosity of Humerus
Spine of Scapula
Medial Border of Scapula
Lateral Border of Scapula

70. Palpation Cont.
Soft Tissue: Note tone, size & shape, hypertrophy & atrophy, point tenderness, deformities
Rotator Cuff Muscles:
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
Pectoralis Major
Sternocleidomastoid
Deltoid
Biceps
Triceps
Trapezius
Rhomboids
Latissimus Dorsi
Serratus Anterior

71. Special Tests Range of Motion Check Active, Passive, & Resistive
Active & Passive= Used to determine if athlete’s ROM is limited
Resisted= Used to determine strength of involved muscles
Motions:
Flexion
Extension
Abduction
Adduction
Horizontal Abduction
Horizontal Adduction
Internal Rotation
External Rotation
Circumduction

72. Special Tests Stress Tests: Used to evaluate anatomical structures
Speed’s Test
Position of Athlete: Standing or sitting, arm extended, forearm supinated
Position of Trainer: Standing next to athlete, stabilizing shoulder with one hand, applying resistance to anterior forearm with other hand
Procedure: Trainer applies resistance to forearm as the athlete tries to flex the shoulder through full range of motion
Positive Test Result: Pain, tenderness, weakness
What does it mean? Possible biceps tendinitis, or stretching/tearing of biceps

74. Special Tests Stress Tests Cont. Drop Arm Test
Position of Athlete: Standing or sitting, athlete abducts shoulder just above 90 degrees
Position of Trainer: Standing in front of athlete
Procedure: Trainer applies resistance to forearm while athlete tries to maintain 90 degrees of abduction
Positive Results: Pain, and inability to hold abduction
What does it mean? Tear of rotator cuff

76. Special Tests Stress Tests Cont. Empty Can Test
Position of Athlete: Standing, arms in 90 degrees of abduction and 45 degrees horizontal adduction, forearm in pronated position
Position of Trainer: Standing in front of athlete, hands on both forearms
Procedure: Trainer applies resistance to forearms while athlete tries to maintain position
Positive Results: Pain, weakness, inability to maintain position
What does it mean? Tear of Supraspinatus

78. Special Tests Stress Tests Cont. Anterior Apprehension Test
Position of Athlete: Lying supine
Position of Trainer: Standing next to athlete
Procedure: Trainer passively abducts & externally rotates athletes shoulder
Positive Results: Look of alarm or apprehension on athlete’s face as the athlete may feel that the shoulder is going to dislocate again
What does it mean? Athlete suffered an anterior dislocation or subluxation

80. Special Tests Stress Tests Cont. Posterior Apprehension Test
Position of Athlete: Sitting or lying supine
Position of Trainer: Standing next to athlete
Procedure: Trainer passively flexes shoulder to 90 degrees & internally rotates shoulder
Positive Results: Look of alarm or apprehension on athlete’s face as the athlete may feel that the shoulder is going to dislocate again
What does it mean? Athlete suffered a posterior dislocation or subluxation

82. Special Tests Stress Tests Cont. Acromioclavicular Traction Test
Position of Athlete: Sitting, arm at side
Position of Trainer: Standing on side of injured shoulder
Procedure: Trainer palpates AC joint with one hand and pulls down on the arm with other hand
Positive Results: Pain and increased movement at AC joint
What does it mean? Athlete has separation of AC joint

84. Special Test Stress Tests Cont. Acromioclavicular Compression Test
Position of Athlete: Sitting
Position of Trainer: Standing next to injured injured shoulder
Procedure: Trainer passively horizontally adducts shoulder
Positive Results: Pain, inability to horizontally adduct
What does it mean? Athlete has an AC separation

86. Special Tests Stress Tests Cont. Shoulder Impingement Test
Position of Athlete: Standing or sitting, anatomical position
Position of Trainer: Standing on side of athlete
Procedure: Trainer passively flexes athlete’s shoulder
Positive Results: Pain with motion, especially near end range
What does it mean? Long head of Biceps, Supraspinatus tendons are impinged

88. Special Tests Stress Tests Cont. Modified Impingement Test
Position of Athlete: Standing or sitting, anatomical position
Position of Trainer: Standing on side of athlete
Procedure: Trainer passively flexes elbow and shoulder to 90 degrees, horizontally adducts, and internally rotates shoulder
Positive Results: Pain
What does it mean? Long head of Biceps, Supraspinatus tendons are impinged