THE SHOULDER JOINT
MAJ VM PHILIP JUNIOR RESIDENT ORTHOPAEDICS
FUNCTIONS OF SHOULDER PRIMARY: hand placement in
various positions to accomplish the upper limb tasks
SECONDARY: 1) Suspension of the upper
limb
2)Sufficient fixation for upper limb movement
3)Fulcrum for arm elevation
SHOULDER COMPLEX
Three bones
Three joints
One pseudojoint
1/3 - 1/4
Diameter: 37- 55 mm
Diameter: ≈ 41 mm
Humeral head is half a sphere roughly articulating with one third to one fourth of the surface of glenoid fossa
ball and socket
Anatomy Glenohumeral joint
“Ball and socket” vs “Golf ball and tee”
Very mobile
Price: instability
45% of all dislocations
Joint stability depends on multiple factors
Glenohumeral Joint Humeral head faces medially,
posteriorly and superiorly
Glenoid :laterally,anteriorly and superiorly at rest and lateral, inferior and posterior in dependant position
Head shaft angle : 130 – 150 deg (long axis) and 30 – 40 deg retroverted in the frontal plane
Glenohumeral Joint GLENOID LABRUM
Dense fibro cartilage attached the glenoid fossa and joint capsule
Forms a part of articular surface
Long head of biceps: half of the fibres originate from the superior labrum
Increases joint stability (75% vertical and 56% transverse)
Glenohumeral Joint Joint capsule: - laterally attached to the neck
of humerus - medially to the periphery of
glenoid and labrum
Capsule is lax with multiple recesses
Axillary recess: inferiorly is lax and redundant permitting normal arm elevation
Joint Capsule - Posterior View
A. AcromionB. Scapular spineC. Coracohumeral ligamentD. Supraspinatus muscle
(cut away)E. Infraspinatus muscle (cut
away)F. Teres minor muscle (cut
away)G. Triceps muscle (cut away)H. Capsule
Glenohumeral Joint: capsule
Joint capsule: -Anteriorly reinforced by
the ‘Z’ ligaments
Rotator cuff : stregthens capsule anterior, superior and posteriorly
lined by synovial membrane
from glenoid labrum to neck of humerus
Anatomy
Scapula Glenoid Acromion Coracoid Subscapular fossa Scapular spine Supraspinatus
fossa Infraspinatus
fossa
GLENOHUMERAL JOINT Humerus
Anatomical neck
Greater and lesser tuberosities
IT groove: angle of wall(60° to 75°)
Tendon of long h ead of biceps makes an
abrupt right angle turn to lie in the IT groove
GLENOHUMERAL JOINT
Surgical neck of humerus
region below greater and lesser tuberosities where head meets the shaft
Axillary nerve
Posterior circumflex humeral artery
Glenohumeral Joint Joint capsule: -Anteriorly reinforced by the ‘Z’
ligaments
Rotator cuff : stregthens capsule anterior, superior and posteriorly
lined by synovial membrane from glenoid
labrum to neck of humerus
Glenohumeral Joint Ligaments : function in a load
sharing fashion by reciprocal tightening and loosening.
Lax in mid range of motion where rotator cuffs maintain stability
Anterior aspect of GH joint: Gleno humeral ligaments(sup,middle and inf) + coraco humeral ligaments:Z ligaments
Glenohumeral Joint : Ligaments
Superior GH ligament Origin - 12o’ clock of
glenoid rim Direction - inferior and
lateral Insertion - anatomical
neck Function - limits external
rotation and inferior translation of the humeral head with arm on the side
Glenohumeral Joint : Ligaments
Middle GH ligament: poorly developed
Origin :2 or 3 o’ clock of glenoid rim
Direction: inferior and lateral Insertion: anatomical neck limits external rotation and
anterior translation of the humeral head with arm in 0 to 45° of abduction
Glenohumeral Joint : Ligaments
Inferior GH ligament complex(IGHLC) Components:1. Anterior band2. Posterior band3. Axillary pouch Anterior band Origin : b/w 2 and 4 o’ clock of
glenoid rim Insertion : below lesser tuberosity Function : limits external rotation
and inferior translation of the humeral head with arm abducted to 90°
Glenohumeral Joint : Ligaments
Inferior GH ligament complex
- Posterior band - b/w 7 and 9 o’ clock of
glenoid rim - limits internal rotation in
abduction - Anteror + posterior : anterior
translation at 90° abduction
IGHLC
Glenohumeral Joint : Ligaments
Coracohumeral ligament: Functions
covers the Superior GH ligaments
fills the space b/w supraspinatus and subscapularis and complete the rotator cuff anteriorly
Ant band limits extension of GH Post band limits flexion of GHJ Both limit the inferior and posterior
translation of humeral head
Glenohumeral Joint : Ligaments
Coraco acromial ligament: roof of the shoulder
From coracoid to antero inferior acromion ext into AC joints
Two bands near acromion
Prevent separation of AC jt
Glenohumeral Joint : Ligaments Coraco acromial arch: Ant inf
acromion + coracoacromial ligament +inf ascpect of AC jt
Scaption: supraspinatus tendon passes under the arch
Scaption + int rotation : SS tendon passes under coraco acromial ligament
Scaption + ext rotation: SS tendon passes under acromion
Glenohumeral Joint : Suprahumeral space
Boundaries:Inf : tuberosity of humerus
ant med : coracoid process sup : coraco acromial arch Structures (inf to sup)- Head of humerus- Long head of biceps tendon- Superior aspect of joint capsule- Supraspinatus,upper margins of
subscapularis and infraspinatus- Subacromial-subdeltoid bursae
Glenohumeral Joint : Suprahumeral space
Arm adducted by the side : 11 mm
Arm at 90° abduction : 5.7mm
Space is narrowest b/w 60° and 120°
Anatomy
Rotator Cuff Muscles
S – Supraspinatus
I – Infraspinatus
T - Teres minor
S- Supscapularis
Glenohumeral Joint : Bursae
Approx eight in shoulder complex
Subacromial Bursa: one of the largest
Two smooth serosal layers to deltoid and rotator cuff
Also connected to acromion,GT,coraco acromial ligament
Allows rotator cuff to slide easily beneath deltoid
Glenohumeral Joint Nerve supply
Derived from C5 to C8 nerve roots embryologically
Anterior shoulder joint : axillary(C5-C6) subscapular(C5-C6) lateral pectoral(C5-C6)
Posterior shoulder joint : suprascapular(C5-C6) axillary(C5-C6)
Glenohumeral Joint : Blood supply Branches of Axillary artery
- ant circumflex humeral
- post circumflex humeral
- suprascapular
- circumflex scapular
Glenohumeral Joint : Blood supply
Labrum: post cx humeral and subscapular ( capsule)
Rotator cuff: - supraspinatus : thoracoacromial
- subscapularis : ant cx humeral - infraspinatus post cx humeral - teres minor suprascapular
Glenohumeral Joint : Blood supply Biceps :Branches of Brachial artery Critical zones : supraspinatus and biceps
relatively avascular
Supraspinatus vulnerable: compressed by subacromial sructures Blood supply parallel to tendon fibres, susceptible to
stretch Critical zone proximal to insertion
Acromioclavicular Joint
Connects acromion process with lateral clavicle
Plane- synovial joint Gliding motion
occurs in all planes Suspends upper limb
from the trunk
Acromioclavicular Joint hyaline cartilage initially,
fibrous in adolescence
10 to 50 deg inclination
Acromion faces ant, med and sup
Thin capsule ,capsular lig
AC ligament prevents posterior translation and posterior axial rotation
Acromioclavicular Joint: ligaments
CORACOCLAVICULAR from coracoid to inferior
surface of clavicle Two parts: Conoid ligament Trapezoid ligament Vertical stability to AC
jt, superior & ant translation , ant axial rotation
Acromioclavicular Joint: ligaments Conoid ligament Fan shaped
Apex inferior
Medial of the two
Frontal pane
prevent coracoid movt away from clavicle
Acromioclavicular Joint: ligaments Trapezoid ligament Quadrilateral sheet From medial border of
upper surface of coracoid Runs supero laterally to
the inferior surface of clavicle
Larger,longer and stronger
Plane perpendicular to conoid
Blocks medial coracoid movt
Sternoclavicular Joint
Formed by- medial end of clavicle- claviclar notch of manubrium- first rib cartilage
Saddle/plane joint Fibrocartilagenous articular
disc Angulated 20° posterolaterally Lateral aspect of the joint acts
as an ovoid
Sternoclavicular Joint In vertical: proximal
end of clavicle is convex and manubrium concave
In AP view: proximal clavicle is concave and the manubrium convex
Sternoclavicular Joint (cont’d)
Articular disk - attached to the upper and
posterior end of clavicle and cartilage of first rib
- thick in perphery - divides the joint into two unequal
parts - more movt occurs b/w clavicle and
disk - prevents medial displacement of
clavicle -
Sternoclavicular Joint : ligaments Anterior Sternoclavicular Posterior Sternoclavicular Interclavicular Costoclavicular
Ant sternoclavicular Covers ant aspect Runs obliquely from clavicle to
sternum
Sternoclavicular Joint (cont’d)
Post SC ligaments Posterior aspect of jt Runs down and medially
Interclavicular ligaments Connects the
superomedial sternal ends of both clavicles with the capsular ligaments and upper sternum
Scapulothoracic Articulation
Not a joint anatomically Scapula moves over the rib cage of the
thorax Not directly attached
Connected indirectly via the clavicle and several muscles
Provides motion and flexibility to the body
15-18 cms of translation at ST jt normally
Anterior Shoulder Muscles
Coracobrachialis Pectoralis Major Subscapularis Biceps Brachii
Biceps Brachii Origin Short head:
coracoid process of scapulaLong head: supraglenoid tubercle of scapula
Insertion Tuberosity of radius
Action Flexion of the elbow and shoulder, Supinates forearm
***the long head is the “5th rotator cuff”
Coracobrachialis O: Coracoid process I: Anteromedial
surface of midshaft of humerus
Actions: (WEAK!) Flexion Adduction of the
shoulder
Pectoralis Major Origin:
Medial two-thirds of clavicle Sternum
Insertion: intertubercular groove
Actions Upper fibers (Clavicular)
• Flexion• Horizontal Adduction
Lower fibers (Sternal)• Internal/medial Rotation• Horizontal adduction
Subscapularis O: Subscapular fossa
I: Lesser tubercle and crest of humerus
Actions: Internal Rotation
Stabilization
Anterior Rotator Cuff Muscle.
Superior Shoulder Muscles Deltoid Supraspinatus
Deltoid Origin
Lateral 1/3 of clavicle (Anterior fibers)
Acromion process (Middle fibers)
Spine of scapula (Posterior fibers)
Insertion – deltoid tuberosity
ActionsAnterior –FlexionMiddle – AbductionPosterior –Extension
Inferior Shoulder Muscles Latissimus Dorsi Teres Major
Latissimus Dorsi O: Spinous process of
lower 6 thoracic and all lumbar and sacral vertebrae; iliac crest
I: Intertubercular groove
Actions:
Adduction Internal Rotation Extension
Teres Major O: Inferior angle of
scapula
I: Intertubercular groove
Actions: Adduction Internal rotation
“Lats little helper”
Posterior Shoulder Muscles Infraspinatus Teres Minor Triceps
Brachii
Triceps Brachii Origin
Long head: infraglenoid tubercle of scapula
Lateral head: posterior surface of humerus,
Medial head: posterior surface of humerus
Insertion Olecranon process of ulna
Action Chief extensor of elbow (long head extends the shoulder)
Infraspinatus O: Infraspinous fossa I: Greater tubercle Actions:
External rotation Stabilization Posterior Rotator Cuff
Muscle Second most commonly
injured rotator cuff muscle
Teres Minor O: lateral border of
scapula I: Greater tubercle Actions:
External rotation Stabilization Posterior Rotator
Cuff Muscle
Trapezius Origin occipital
bone, nuchal ligament, and spinous processes of C7 - T12 vertebrae
Insertion Lateral third of clavicle, acromion, and spine of scapula
Action superior fibers
elevate, middle fibers retract, inferior fibers
depress scapula;
Levator Scapula Origin C1 - C4
vertebrae Insertion
Superior angle Action Elevates
scapula
Rhomboid major and minor Origin Minor: spinous
processes of C7 and T1 vertebraeMajor: spinous processes of T2 - T5 vertebrae
Insertion Medial border of scapula
Action Retract scapula
Serratus Anterior Origin the eight
upper frontal ribs
Insertion lateral border of scapula
Action protracts scapula
Glenohumeral Joint: Biomechanics
Complex interaction amongst the joints in a smooth harmonious movt
G-H :: ball on a seal’s nose
Greatest ROM
2:1 at gh:st joints
Glenohumeral Joint: Biomechanics
Three DOF:- flexion/extension
- abduction/adduction
- internal/ext rotation
Glenohumeral Joint:biomechanics
Scapula: stable base Attaches indirectly to the rib
cage• Anteriorly concave and glides over
the convex rib• Located between the second and
seventh ribs
• Position : 30 degrees (frontal) 3 degree superior
FRONTAL PLANE
SAGITTAL PLANESCAPULAR PLANE
30 degrees
Glenohumeral Joint
Scaption : arm elevation occuring at 30 to 45 degrees anterior to the frontal plane
Glenohumeral Joint: Biomechanics
Static shoulder stabilisation- requires very little muscle support- provided by trapezius and supraspinatus- vertical stability:glenoid facing up by trapezius- inferior stability: intra articular pressure and adhesion/cohesion of articular surfaces- anatomic curvature of humerus- glenoid labrum- negative intraarticular pressure
Glenohumeral Joint: Biomechanics
Dynamic shoulder stabilisation - requires complex factors
Major dynamic stabilisers- long head of triceps and biceps - humeral head max stabilisation: subscapularis
Posterior restraints- <90° abduction : post capsule- 90° abduction : IGHLC
Scapulohumeral Rhythm
Describes the movement relationship between the scapula and humerus to maintain angle b/w scapula and humerus <30°
First 30° of shoulder joint motion pure GH motion
After that, for every 2° of shoulder flexion or abduction, the scapula rotates 1°
2:1 ratio → scapulohumeral rhythm
Full abduction: glenoid completely support humerus
0-80° →more humeral motion 80-140° → more scapular motion 140-170° →neighbouring joints
Scapulothoracic Articulation:Biomechanics 0-90°=60°+30° at GH and ST
- St movt = 20-25°of clavicular elevation at SC jt 05-10° of upward rotation at AC jt
90 to 180° = 60° of GH movt + 30° ST movt
- St movt = 05-10°of clavicular elevation at SC jt 20-25° of upward rotation at AC jt
Glenohumeral Joint:Biomechanics
Close Pack position : 90° abduction and full external rotation
Open Pack position : 55°abduction with 30° horizontal adduction
Zero position : 0 degree abduction,12° flexion,10° external rotn
Capsular pattern-Ext rotn:abduction: internal rotation = 3:2:1
Acromioclavicular Joint:Biomechanics Three types: rotation,spin,glide Rotation: - AP rotatation
- superoinferior
AP rotation: longitudinal Through SC and AC jts
30 to 50 deg -mostly SC
Acromioclavicular Joint:Biomechanics Protraction:ant movt of
acromial end of clavicle
Retraction: post movt of acromial end
Acromioclavicular Joint: Biomechanics Close Packed position 90° GH joint abduction
Open Packed position Arm is on the side Clavicle is 15° retracted
and 2° elevated Capsular pattern pain in extremes of
horizontal adduction and full elevation
Sternoclavicular Joint: Biomechanics Two types of translations A-P & sup-inf (2:1) allowing1. Elevation/depression2. Protraction/retraction3. Backward /forward rotation
Elevation and depression - 35 to 40 deg of elevation
- 15 deg depression
Sternoclavicular Joint: Biomechanics
Protraction/retraction - 15 to 20 deg both
- on protraction the concave surface of clavicle moves on convex sternum producing an anterior glide of clavicle and anterior rotation of lateral clavicle
- on retraction medial clavicle articulates with flat surface and posterior rotation of lateral end
Sternoclavicular Joint: Biomechanics
Rotationspin of the clavicle on manubrium
40° anterior and 5° posterior rotation Close Packed position
maximum arm elevation and protraction Open Packed position
arm by the side (postulated) Capsular pattern
full elevation and horizontal adduction
Scapulothoracic Articulation:Biomechanics scapula has five degrees of
freedom for movement on the thorax:
two translations and rotate in three planes around three different axes.
translations: - Elevation /Depression
- retraction &Protraction
Rotations: - scapular winging . - scapular tipping - up & down rotation
Rotational Movement of the Scapula
All three parts work together (synergists) to retract the scapula
Rotational Movement of the Scapula (cont’d)
Middle trapezius - prime mover Upper and lower trapezius are antagonistic in
elevation/ depression Upper and lower trapezius are agonistic in upward
rotation
Clinical Examination History Inspection Palpation Range of Motion Measurements Special Tests
History - PainHistory - Pain
Type and location of pain or symptoms Onset of pain (traumatic, insidious) Onset of pain (traumatic, insidious) Location of pain Location of pain Alleviating/Aggravating factors Alleviating/Aggravating factors Night pain Night pain Pain/weakness overhead activitiesPain/weakness overhead activities
Pain
Typically pain of gleno-humeral origin is felt in the upper arm, often at the insertion of the deltoid.
Severe shoulder problems can cause pain to radiate as far as the radial side of the wrist.
Impingement/rotator cuff pathology:anterior/lateral shoulder pain aggrevated with overhead activities
Pain The shoulder is derived from the fifth
cervical segment and therefore refers pain into the C5 dermatome.
The acromio-clavicular joint is a C4 structure and refers pain into the C4 dermatome.
Pain The shoulder is deep and proximal in the
C5 dermatome, hence it can potentially refer pain a great distance.
Conversely the acromio-clavicular joint is a superficial structure at the distal end of the dermatome causing it to give rise to accurate, local pain
Physical Exam – Inspection
Front & Back Height of shoulder
& scapulae Asymmetry Obvious deformity Ecchymosis Muscle atrophy
Supraspinatus Infraspinatus Deltoid
Physical Exam –Inspection
Front & Back Height of shoulder
& scapulae Asymmetry Obvious deformity Ecchymosis Muscle atrophy
Supraspinatus Infraspinatus Deltoid
Physical Exam – Inspection
Front & Back Height of shoulder
& scapulae Asymmetry Obvious deformity Ecchymosis Muscle atrophy
Supraspinatus Infraspinatus Deltoid
Palpation
At rest & with movement
Bony structures Joints Soft tissues
Palpation Surface Anatomy
(Anterior)
Clavicle SC Joint Acromion process AC Joint GH joint Coracoid process LT GT Subacromial bursa Pectoralis major Trapezius Biceps (long head)
AC joint
SC joint
biceps
Palpation Surface Anatomy
(Posterior)
Scapular spine Acromion process Supraspinatus Infraspinatus Teres Minor Trapezius Latissumus dorsi Scapula
• Inferior angle• Medial border
Supraspinatus
Infraspinatus
Inferior angle of scapula
Range of Motion
Forward flexion:160 - 180°
Extension: 40 - 60° Abduction: 180◦ Adduction: 45 ° External rotation:
80 - 90 ° Internal rotation:
60 - 90 °
Range of Motion
Scapular dyskinesis (Scapulothoracic dysfuntion)
Compare scapular motion through ROM on both sides
Wall push-ups
Symmetrical Smooth No or minimal winging
Strength Testing External rotation
Tests RTC muscles that ER the shoulder
• Infraspinatus• Teres minor
Arms at the sides
Elbows flexed to 90 degrees
Externally rotates arms against resistance
Strength Testing Internal rotation
Tests RTC muscle that IR the shoulder
• Subscapularis
Arms at the sides Elbows flexed to 90
degrees Internally rotates arms
against resistance
Subscapularis Lift-Off Test
Other techniques
Strength Testing Supraspinatus
“Empty can" testJobe’s Test
Tests Supraspinatus
Attempt to isolate from deltoid
Special Tests
Impingement
Rotator Cuff Integrity
Labrum and Biceps
AC (SC) Joints
Instability
:TESTS FOR ROTATOR CUFF/IMPINGMENT
TESTS FOR ACROMIOCLAVICULAR JOINT
TESTS FOR BICEP TENDON
TESTS FOR INSTABILITY
Neer impingment test
Hawkins kennedy test
Empty can test
Drop arm test
Lift off.Test
Infraspinatus test
Spring back test
Teres minor test
Teres major test
Apley scratch test
Painful arc
Forced adduction test
Forced adduction test in hanging arm
Duga’s test
1. Speed test
2. Yergason test
3. Bicep tendon with transverse humeral ligament test
1. Anterior apprehension test
2. Posterior apprehension test
3. Anterior posterior drawer test
4. Inferior instability test
5. Sulcus test
Impingement
TESTS FOR ROTATOR CUFF AND IMPINGMENT SYNDROME
IMPINGEMENT:Primary impingment Secondary impingment
Occur because of degenerative changes to the rotator cuff,the acromian process,the coracoid process and anterior tissues from stress overload.
Occurs due to problem with muscle dynamics with an upset in the normal force couple action leading to muscle imbalance and abnormal movement patterns at both the glenohumeral joint and the scapulothoracic articulation.
Impingement is primary cause of pain.
It is secondary to altered muscle dynamics.
Occurs mostly in 40+ age group people.
Occurs in young patients.(15-35years old)
It is said to be intrinsic when rotator cuff degeneration occurs and extrinsic when the shape of the acromian and degeneration of the coracoacromial ligament occurs.
Commonly seen with joint instability.
NEER IMPINGMENT TEST: PATIENT’S AFFECTED ARM IS PASSIVELY AND FORCIBLY FULLY ELEVATED IN THE SCAPULAR PLANE WITH THE ARM MEDIALLY ROTATED BY THE EXAMINER.
•This passive stress causes “jamming of
the greater tuberosity against the
anteroinferior border of the acromian.
•The patient’s face shows pain reflecting
a +ve test.
HAWKIN’S KENNEDY IMPINGMENT TEST: PATIENT STANDS / SITS WHILE THE EXAMINER FORWARD FLEXS THE ARM TO 90º AND FORCIBLY MEDIALLY ROTATES THE SHOULDER.
•This movement pushes the
supraspinatus tendon against the anterior surface of the coracoacromial
ligament and coracoid process.
•Pain indicates +ve test.
SUPRASPINATUS TEST/EMPTY CAN TEST: THIS TEST MAY BE PERFORMED WITH THE PATIENT STANDING OR SEATED.WITH THE ELBOW EXTENDED, THE PATIENT’S ARM IS HELD AT 90° OF ABDUCTION,30° OF HORIZONTAL FLEXION, AND IN INTERNAL ROTATION (WITH THUMB FACING DOWN). THE EXAMINER EXERTS PRESSURE ON THE UPPER ARM DURING THE ABDUCTION AND HORIZONTAL FLEXION MOTION.
•When this test elicits severe pain and the patient isunable to hold his or her arm abducted 90° against gravity, this is called a positive empty can test/supraspinatus tendinitis.
•The superior portions of the rotator cuff (supraspinatus) are particularly assessed in internal rotation (with the thumb down), and the•anterior portions in external rotation.
DROP ARM(CODMAN’S)TEST:THE PATIENT IS SEATED, AND THE EXAMINER PASSIVELY ABDUCTS THE PATIENT’S EXTENDED ARM APPROXIMATELY 120°. THE PATIENT IS ASKED TO HOLD THE ARM IN THIS POSITION WITHOUT SUPPORT AND THEN SLOWLY ALLOW IT TO DROP.
Weakness in maintaining the position of the arm, with orwithout pain, or sudden dropping of the arm suggests a rotator cufflesion. Most often this is due to a defect in the supraspinatus.
APLEY’S SCRTCH TEST: THE SEATED PATIENT IS ASKED TO TOUCH THE CONTRALATERAL SUPERIOR MEDIAL CORNER OF THE
SCAPULA WITH THE INDEX FINGER.
Pain elicited in the rotator cuff and failure to reach the scapula because of restricted
mobility in external rotation and abduction indicate rotator cuff pathology (most
probably involving the supraspinatus).
YOCUM TEST
LIFT PATIENT’S ELBOW TO SHOULDER HEIGHT WITH ARM RESTING ON THE NORMAL SHOULDER
HORNBLOWER’S SIGN (PATTE TEST)
determines the strength of the teres minor.
The examiner elevates the patient’s arm to 90 degrees in the scapular plane. The therapist then flexes the elbow to 90 degrees, and the patient is asked to laterally rotate the shoulder. A positive test occurs with weakness and/or pain.
SUBSCAPULARIS TEST/LIFT OFF TEST: PATIENT IN STANDING POSITION PLACES THE DORSUM OF THE HAND ON THE BACK. THE PATIENT THEN LIFTS THE HAND AWAY FROM THE BACK. IF PATIENT IS ABLE TO DO THEN LOAD PUSHING ON HAND IS DONE BY THE EXAMINER TO CHECK THE STRENGH.
•A patient with a subscapularis tear will be unable to dothis.
•Abnormal motion in the scapula during the test may indicate scapular instability.
INFRASPINATUS TEST: COMPARATIVE TESTING OF BOTH SIDES IS BEST. THE PATIENT’S ARMS SHOULD HANG RELAXED WITH THE ELBOWS FLEXED 90° BUT NOT QUITE TOUCHING THE TRUNK. THE EXAMINER PLACES HIS OR HER PALMS ON THE DORSUM OF EACH OF THE PATIENT’S HANDS AND THEN ASKS THE PATIENT TO EXTERNALLY ROTATE BOTH FOREARMS AGAINST THE RESISTANCE OF THE EXAMINER’S HANDS.
Pain or weakness in external rotation indicates a disorder of the infraspinatus (external rotator).
.
SPRING BACK TEST:Infraspinatus
Patient either in sitting or standing hold the elbow in flexion at 90º by the side. Examiner passively bring the shoulder to 90º abduction and laterally rotate to the end range and ask the patient to hold the arm to this position. For +ve test of infraspinatus weakness/lesion patient cannot hold the position and hand spring back anteriorly.
TERES MAJOR TEST:THE PATIENT IS STANDING AND RELAXED. THE EXAMINER ASSESSES THE POSITION OF THE PATIENT’S HANDS FROM BEHIND. THE TERES MAJOR IS AN INTERNAL ROTATOR. WHERE A CONTRACTURE IS PRESENT, THE PALM OF THE AFFECTED HAND WILL FACE BACKWARD COMPARED WITH THE
CONTRALATERAL HAND.
LABRAL TEARS
Clunk test
Crank Test
O Brien’s Test
Compression-rotation test akin to Apley’s grinding
Biceps load test
CLUNK TEST Patient supine, examiner
puts hand on the posterior aspect of the shoulder, other hand hold the humerus above the elbow and abducts the arm over the head. Then pushing anteriorly with the hand under the shoulder and rotating the humerus laterally with the other hand, feel for a grind or clunk which may indicate a tear of the labrum.
O’BRIEN’S TEST Labral, AC, or biceps
pathology
Arm flexed to 90° Arm cross-arm
adducted 10-15° Elbow extended Max pronation Resist downward force
Positive test if painful Beware location of
pain AC Biceps
LABRAL TEAR: CRANK TEST
Abduct arm to 90-120° Stabilize shoulder Elbow secured with
one hand Axially load with ER /
IR at shoulder
Positive test: audible or painful click / catch / grind
ACROMIOCLAVICULAR JOINT TESTS
PAINFUL ARC:THE PATIENT’S ARM IS PASSIVELY AND ACTIVELY ABDUCTED FROM THE REST POSITION ALONGSIDE THE TRUNK. PAIN IN THE ACROMIOCLAVICULAR JOINT OCCURS BETWEEN 140°AND 180° OF ABDUCTION. IN AN IMPINGEMENT SYNDROME OR A ROTATOR CUFF TEAR, BY COMPARISON, PAIN SYMPTOMS WILL OCCUR BETWEEN 70°AND 120°.
In the evaluation of the active and passive ranges of motion, the patient can often avoid the painful arc by externally rotating the arm while abducting it. This increases the clearance between the acromion and the diseased tendinous portion of the rotator cuff, avoiding impingement in the range between 70° and 120°.
FORCED ADDUCTION TEST:THE 90°-ABDUCTED ARM ON THE AFFECTED SIDE IS FORCIBLY ADDUCTED ACROSS THE CHEST TOWARD THE NORMAL SIDE.
FORCED ADDUCTION TEST ON HANGING ARM:THE EXAMINER GRASPS THE UPPER ARM OF THE AFFECTED SIDEWITH ONE HAND WHILE THE OTHER HAND RESTS ON THE CONTRALATERAL SHOULDER AND IMMOBILIZES THE SHOULDER GIRDLE. THEN THE EXAMINER FORCIBLY ADDUCTS THE HANGING AFFECTED ARM BEHIND THE PATIENT’S BACK AGAINST THE PATIENT’S RESISTANCE.
Pain across the anterior aspect of the shoulder suggestsacromioclavicular joint disease or subacromial impingement.
DUGA’S TEST: THE PATIENT IS SEATED OR STANDING AND TOUCHES THE CONTRALATERAL SHOULDER WITH THE HAND OF THE 90°-FLEXED ARM OF THE AFFECTED SIDE THEN ATTEMPT TO LOWER THE ELBOW TO THE CHEST IS MADE.
Acromioclavicular joint pain suggests joint disease (osteoarthritis,instability, disk injury, or infection).
A differential diagnosismust exclude anterior subacromial impingement
BICEP TENDON TEST
THE CLOSE ANATOMIC PROXIMITY OF THE INTRAARTICULAR PORTION OF THE TENDON TO THE CORACOACROMIAL ARCH PREDISPOSES IT TO INVOLVEMENT IN DEGENERATIVE PROCESSES IN THE SUBACROMIAL SPACE. A ROTATOR CUFF TEAR IS OFTEN ACCOMPANIED BY A RUPTURE OR INJURIES OF THE BICEPS TENDON.
SPEED TEST: IN SITTING THE EXAMINER RESISTS SHOULDER FORWARD FLEXION BY THE PATIENT WHILE THE PATIENT’S FOREARM IS IN SUPINATION. PAIN IN THE REGION OF THE BICIPITAL GROOVE SUGGESTS A DISORDER OF THE LONG HEAD OF THE BICEPS TENDON.
YERGASON TEST:WITH THE PATIENT’S ELBOW FLEXED TO 90º AND STABILIZED AGAINST THORAX AND WITH FOREARM PRONATED, THE EXAMINER RESISTS SUPINATION WHILE THE PATIENT ALSO LATERALLY ROTATES THE ARM AGAINST RESISTANCE. DURING THIS MOVEMENT WHEN THE TENDON IS FELT IN GROOVE
AS “POP OUT” .
•Pain in the bicipital groove is a sign of a lesion of the biceps tendon, its tendon sheath, or its ligamentous connection via the•transverse ligament.
•The typical provoked pain can be increased by pressing on the tendon in the bicipital groove.
BICEP TENDINITIS WITH TRANSVERSE HUMERAL LIGAMENT TEST:THE PATIENT IS SEATED WITH THE ARM ABDUCTED 90°, INTERNALLY ROTATED, AND EXTENDED AT THE ELBOW. FROM THIS POSITION, THE EXAMINER EXTERNALLY ROTATES THE ARM WHILE PALPATING THE BICIPITAL GROOVE TO VERIFY WHETHER THE TENDON SNAPS.
•In the presence of ligamentous insufficiency, this motion will cause the biceps tendon to spontaneously displace out of the bicipital groove.
•Pain reported without displacement suggests biceps•tendinitis.
INSTABILITY TESTS
SHOULDER PAIN MAY BE ATTRIBUTABLE TO AN UNSTABLE SHOULDER. USUALLY HISTORY OF A PERIOD OF INTENSIVE SHOULDER USE (SUCH AS COMPETITIVE SPORTS), AN EPISODE OF REPEATED MINOR TRAUMA (OVERHEAD USE), OR GENERALIZED LIGAMENT LAXITY. BOTH YOUNG ATHLETES AND INACTIVE PERSONS ARE AFFECTED, MEN AND WOMEN ALIKE.
ANTERIOR APPREHENSION TEST: PATIENT LIE SUPINE OR IN SITTING . ARM IS ABDUCTED TO 90º WITH OTHER HAND ON THE HUMERAL HEAD AND LATERALLY ROTATED SLOWLY BY THE EXAMINER. WHILE PERFORMING PATIENT’S EXPRESSIONS ARE NOTED FOR APPREHENSION/FURTHER RESISTENCE TO ROTATION. . WITH THE GUIDING HAND, THE EXAMINER PRESSES THE HUMERAL HEAD IN AN ANTERIOR AND INFERIOR DIRECTION
Shoulder pain with reflexive muscle tensing is a sign of an anterior instability syndrome. This muscle tension is an attempt by the patient to prevent imminent subluxation or dislocation of the humeralhead.
SURPRISE TEST
Similar to apprehension test
But at max ext rotation the posterior force on the humerus is removed and we look for apprehension
Most accurate single test for anterior instability
ROCKWOOD TEST
It is important to know that at 45° of abduction,
the test primarily evaluates the medial glenohumeral ligament and the subscapularis tendon. At or above 90° of abduction, the stabilizing effect of the subscapularis is neutralized and the test primarily evaluates the inferior glenohumeral ligament.
POSTERIOR APPREHENSION TEST: PATIENT LIES SUPINE OR IN SITTING POSITION AND EXAMINER ABDUCTS ARM IN SCAPULAR PLNE TO 90º WHILE STABILIZING THE SCAPULA WITH OTHER HAND. EXAMINER THEN APPLIES A POSTERIOR FORCE ON THE ELBOW AND MOVES THE ARM IN ADDUCTION AND MEDIALLY ROTATION.
ANTERIOR AND POSTERIOR DRAWER TEST:THE PATIENT IS SEATED. THE EXAMINER STANDS BEHIND THE PATIENT. TO EVALUATE THE RIGHT SHOULDER, THE EXAMINER GRASPS THE PATIENT’S SHOULDER WITH THE LEFT HAND TO STABILIZE THE CLAVICLE AND SUPERIOR MARGIN OF THE SCAPULA WHILE USING THE RIGHT HAND TO MOVE THE HUMERAL HEAD ANTERIORLY AND POSTERIORLY.
INFERIOR APPREHENSION TEST/FEAGIN TEST:PATIENT STANDS WITH THE ARM ABDUCTED TO 90º AND ELBOW EXTENDED AND RESTING ON TOP OF THE EXAMINER’S SHOULDER. EXAMINER CLASP HIS/HER HANDS AROUND THE PATIENT’S HUMERUS AND PUSHES THE HUMERUS DOWN AND FORWARD. IN THIS SULCUS MAY ALSO BE SEEN ABOVE THE CORACOID PROCESS.
SULCUS TEST: PATIENT STANDS WITH ARM BY THE SIDE AND SHOULDER MUSCLE RELAXED. THE EXAMINER GRASPS THE PATIENT’S FOREARM BELOW THE ELBOW AND PULLS THE ARM DISTALLY. THE PRESENCE OF SULCUS/INDENTATION INFERIOR TO ACROMIAN IS THE INDICATIVE.
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