Shoulder Anatomy

1
Shoulder Anatomy

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

2
Bony Anatomy

• Shoulder Complex
• Sternum(manubrium)
• Clavicle
• Scapula
• Humerus

3
Manubrium

• Portion of the sternum
• Jugular notch
• Attachment site of the clavicle
• Clavicular notch

4
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

5
Scapula

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

6
Humerus

• Humeral head
• projects medially off the anatomical neck
• Bicipital groove
• greater tuberosity
• lesser tuberosity
• surgical neck

7
Joints of the shoulder girdle

• Sternoclavicular
• Acromioclavicular
• Scapulothoracic articulation
• Glenohumeral

8
Sternoclavicular Joint (SC)

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

9
Acromioclavicular Joint (AC)

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

10
Scapulothoracic Articulation

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

11
Glenohumeral joint (GH)

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

12
Muscles of the shoulder girdle

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

13
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

14
Rhomboid major and minor

• Retract scapula
• Elevate scapula
• Downwardly rotate scapula

15
Levator scapulae

• Elevate scapula
• Downwardly rotate scapula

16
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

17
Pectoralis Minor

• Upward rotation and forward tilt of scapula

18
Trapezius

• Upper
• elevate and upwardly rotate scapula
• Middle
• retract scapula
• Lower
• retract and depress scapula

19
Latissimus Dorsi

• Upper fibers assist in retraction and downward
  rotation of scapula

20
Pectoralis Major

• Clavicular portion aids with scapular depression

21
Muscles acting on the humerus

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

22
Rotator Cuff Muscles

• Supraspinatus
• abduction/external rotation
• Infraspinatus
• external rotation/horizontal abduction
• Teres Minor
• external rotation/horizontal abduction
• Subscapularis
• internal rotation

23
Teres Major

• Internal Rotation
• Adduction
• External Rotation

24
Deltoid

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

25
Force Couple

• Two muscles work together to create movement

26
Pectoralis Major

• Adduction
• Internal Rotation
• Clavicular portion flexion/IR/horizontal add
• Sternal portion depresses shoulder girdle

27
Latissimus Dorsi

• Origin lumbarspine/illiac crest
• Insertion Intertubercular groove
• Adduction
• Internal rotation
• Extension

28
Long Head of triceps

• Infraglenoid tubercle
• extension

29
Coracobrachialis

• Flexion
• Adduction

30
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

31
Scapulothoracic Rhythm

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

32
Bursa

• Two in GH joint
• Subacromial
• Subdeltoid
• Buffers supraspinatus tendon when humerus is
  elevated
• Inflammation can lead to RC tendinitis

33

• Shoulder
• Evaluation

34
Clinical EvaluationHistory

• 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

35
Inspection

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

36
Inspection

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

37
Inspection

• Lateral structures
• Deltoid
• Acromion process
• Step deformity
• Position of humerus

38
Inspection

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

39
Palpation

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

40
Palpation

• Humerus
• Head of humerus
• Greater tuberosity (passively extend)
• Bicipital groove/lesser tuberosity
• ER to make more palpable
• Humeral shaft
• Deltoid
• Bicep
• Tricep

41
Palpation

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

42
Functional Tests

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

43
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

44
Shoulder Goniometry

• Flexion
• Extension
• Abduction/Adduction
• Internal/External Rotation

45
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

46
Active ROM TestsPerformed 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)

47
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)

48
RROM

• Internal rotation/ External rotation
• Gerber Lift Off Test

49
RROM

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

50
Test for RROMPerform Bilaterally

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

51
MMT of Scapular muscles

• Rhomboids
• Seated position
• Elbow flexed/Humerus adducted
• Examiner attempts to horizontally abduct humerus
• Note Scapular protraction indicating weakness

52

• 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

53
Ligamentous/capsular testing

• SC laxity
• Up/down/ant/post
• AC laxity
• Anterior/Posterior/superior/inferior
• GH laxity
• Anterior/Posterior/inferior

54
Neurologic testing

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

55
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

56
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

57
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

58
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

59

• 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

60

• 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

61

• 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

62

• 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

63

• 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

64
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

65

• 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

66
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

67
Posterior Instability Tests

• Posterior Apprehension
• Posterior-instability in plane of scapula

68
Tests for RC Injuries

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

69
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

70
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

71
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

72
Special Tests forThoracic Outlet Syndrome

• Adson
• Costoclavicular
• Hyperabduction

73

• 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

74

• 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

75

• 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

76
On field evaluation

• R/o Fx/dislocation
• Distal pulse
• Upper quarter screen
• Rule out C-spine injury
• Palpation under shoulder pads
• Remove shoulder pads

77
On the field

• History
• Location of pain
• Mx of injury
• Inspection
• Arm posture
• Gross deformity
• Palpation
• AC/clavicle/SC/Humerus
• Functional Tests
• Neurologic Tests

78
Initial management

• Fracture of clavicle
• Sling/swathe
• ACE
• AC joint
• Spica wrap
• Dislocation
• Fractures
• Keep fingers expose
• Check circulation