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Anatomical Name?

Type of Joint?

What is the significance of a shallow glenoid fossa?

What are the 4 rotator cuff muscles (TISS)?

What is the purpose of the rotator cuff?

Name the 4 joints that comprise the shoulder complex


Glenohumeral Joint

Ball and Socket

Great capacity for ROM, but unstable, so requires strong muscular support (rotator cuff)

Teres minor, Infraspinatus, Supraspinatus, Subscapularis

The rotator cuff muscles hold the humeral head down on abduction of the arm to prevent impingement of the supraspinatus tendon and jamming of the humeral head

Sternoclavicular, Acromioclavicular, Glenohumeral, Scapulothoracic Joints


Deltoid

Supraspinatus

Serratus Anterior (to a lesser extent)


Pectoralis Major

Latissimus Dorsi

Subscapularis

Infraspinatus

Teres Major

Teres Minor


Posterior Deltoid

Triceps

Latissimus Dorsi

Teres Major

Teres Minor


Biceps

Anterior Deltoid

Pectoralis Major

Coracobrachialis


Infraspinatus

Teres Minor

Posterior Deltoid


Subscapularis

Teres Major

Latissimus Dorsi

Pectoralis Major

Anterior Deltoid


Upper Trapezius

Levator Scapula

Rhomboids


Middle & Lower Trapezius

Rhomboids


Serratus Anterior

Pectoralis Minor


Origin Medial 1/3 of sup. nuchal line of occipital bone EOP Ligamentum nuchae SP’s of C7-T12

Insertion Lateral 1/3 clavicle, acromion & spine of scapula

Action Upper Elevates scapula

Middle Retracts scapula

Lower Depresses, downwardly rotates & stabilises

scapula


Origin SP’s T7-T12 Lx vertebra Crests of Sx & ilium Inferior 4 ribs

Insertion Floor of Intertubercular groove of humerus

ActionMedial rotation of humerus Adduction of humerus Extension of humerus


Origin TP’s C1-C4

Insertion Superior medial angle of scapula

Action Elevates scapula Medially rotates scapula Stabilises scapula


Origin SP’s C6-T5

InsertionMedial border of scapula

Action Retracts Elevates AdductsMedially rotates Stabilises scapula


Origin Clavicular Head Anterior medial ½ clavicle

Sternal Head Anterior sternum Superior 6 costal cartilages

Insertion Lateral lip of Intertubercular groove Greater tubercle

Action AdductsMedially rotates humerus Clavicular head flexes humerus Sternal head extends humerus


Origin Ribs 1-3 near costal cartilage

Insertion Coracoid process

Action Stabilises scapula by drawing it anteriorly & inferiorly

against thoracic wall


Origin Superior 8-9 ribs

InsertionMedial border & inferior angle of scapula

Action Protracts (abducts) of scapula Upward rotation of scapula Elevates ribs when scapula is stabilised


Origin Lateral 1/3 clavicle Acromion Spine of scapula

Insertion Deltoid tuberosity

Action Anterior Flexes & medially rotates humerus

Middle Abducts humerus

Posterior Extends & laterally rotates humerus


Origin Dorsal surface of inferior angle of scapula

InsertionMedial lip of intertubercular groove

ActionMedial rotation Adduction


Origin Supraspinous fossa of scapula

Insertion Greater tubercle of humerus

Action Abduction


Origin Infraspinous fossa of scapula


Action Lateral rotation of humerus Adduction Holds humeral head in glenoid cavity


Origin Inferior lateral border of scapula


Action Lateral rotation of humerus Adduction Holds humerus in glenoid fossa


OriginSubscapular fossa of scapula

InsertionLesser tubercle of humerus

ActionMedial rotationAdductionHolds humeral head in glenoid cavity


Origin Supraglenoid tubercle (long head) Coracoid process of scapula (short head)

Insertion Radial tuberosity

Action Flexes arm at shoulder weakly Flexes elbow Supinates forearm


Origin –Long Head – infraglenoid tubercle of scapulaLateral Head – greater tubercle & posterior &

lateral humerusMedial Head – posterior & medial humerus

Insertion – Olecranon of ulna

Action – Extends forearm and arm

ROM - Extend elbow past 90°, stabilise elbow & contact at wrist bring elbow into flexion


Origin – acromion, lateral spine of scapula

Insertion – Deltoid tuberosity of humerus

Action – Abducts humerus & slightly extends

ROM - Abduct arm & flex elbow to 90°. Stabilise shoulder & at elbow adduct arm towards torso while pushing slightly into flexion


Origin – Lateral 1/3 clavicle, acromion and spine of scapula

Insertion – Deltoid tuberosity of lateral humerus

Action – Foward flexes and medially rotates humerus

ROM - Forward flex arm to 30°. Contact anterior wrist and push arm towards table


Origin – Lateral clavicle, acromion, lateral spine of scapula

Insertion – Deltoid tuberosity of humerus

Action – Abducts humerus

ROM - Abduct arm & flex elbow to 90°. Stabilise shoulder & at elbow adduct arm towards torso


Origin Anterior distal ½ of humerus

Insertion Coronoid process & tuberosity of ulna

Action Flexes elbow


Origin – Coracoid process of scapula

Insertion – Middle 1/3 of medial humerus

Action – Flexes & adducts humerus

ROM - Elbow flexed t0 90°.Arm forward flexed to 45°. Stabilise shoulder & at cubital fossa apply pressure into abduction


Palpation Coracoid process on anterior shoulder near deltopectoral triangle, mobilise

anterior to posterior, if stiff/stuck ask client to use 10% of strength pushing shoulder towards ceiling for 10 seconds then relaxing as you gently push coracoids towards table.

Medial humerus & tendon moving laterally to medially.

Interesting Facts Musculocutaneous nerve pierces this muscle. Helps prevent downward dislocation of humerus. Median nerve and brachial artery lie deep to this muscle & can be

compressed when it is tight causing numbness in medial 3 fingers.

Practical Tendon along with axillary artery, median and musculocutaneous nerve can

be palpated & relocated when biceps & coracobrachialis are weak (elbow flexion) on medial arm by ‘flicking’ medial to lateral while moving from lateral rotation to medial rotation of the bent elbow.


The ability of contractile structures to maintain joint integrity

1. Proprioception Contains many mechanoreceptors within the anterior &

inferior capsule They activate as the humeral head comes into contact

with the capsule, this sends a signal to muscles to stabilise & contain the humeral head

2. Rotator Cuff Muscles Maintain the centering of the humeral head Teres minor & Infraspinatus reduce strain on antero-

inferior GHL in abduction & external rotation Subscapularis provides anterior stability when arm is in

neutral & abduction


What could the following symptoms indicate? Do they need referral? And to whom? Pain with overhead activities Pain at rest Loss of ROM?


Tendonitis

Degenerative Joint Disease (DJD)

Bursitis

Calcific deposits

Rotator Cuff Injuries

Instability Poor inferiorly (common dislocation)


Biceps Tendinitis & Tear Affects long head of biceps

Synovial sheath surrounding tendon may also be affected

Transverse ligament

Usually accompanied with some crepitus

Treatment Ice, NSAIDS & STT/massage therapy in the

form of transverse frictions to the tendon


Rupture of the long head of biceps usually common in the older athlete (see pic)

Deformity is obvious becoming detached from proximal attachment & bunching up at distal arm

Often little pain & surprisingly strength is maintained


Painful joints due to deterioration of cartilage and tissues supporting weight-being joints


Calcium deposits form on tendons causing inflammation & pain

Quite common Unknown cause, not related to injury, diet or osteoporosis Pressure on surrounding tissues caused by reduction in space

between acromion & rotator cuff leads to impingement Calcific tendonitis affects people over 40


Not a specific clinical diagnosis There are 4 rotator cuff muscles

Supraspinatus most commonly compressed Has decreased vascularity near insertion (slow to heal ) Progressive degradation of fibres may lead to calcific tendonitis

Many acute injuries involve high force loads to rotator cuff

Posterior rot cuff more commonly injured in throwing type activities (eccentric contraction)

Soft Tissue Treatment Deep friction to insertion of supra tendon will stimulate fibroblast

activity for proper healing Also reduce tension with deep longitudinal stripping


Also known as ‘Frozen shoulder’

Common condition in which external rotation of humerus is restricted

Capsular fibrosis occurs & anterior capsule adheres to anterior aspect of humeral head

Abduction is restricted by locking & impingement

Therefore this movement should not be forced until external rotation is achieved

No specific cause can be determined for the stiffening Usually secondary to rotator cuff lesions

Affects women > men


Tension is lost in superior joint capsule

Increased tone in rotator cuff muscles to compensate for loss of capsular stabilization

Increased tone of rotator cuff muscles which blend with capsule result in increased stress to capsule stimulating increase in collagen production


Congenital elevation of the scapula, due to failure of descent of the scapula to its normal thoracic position during fetal life.

The scapula muscles are poorly defined or may be replaced by a fibrous band


Look for asymmetry (anterior, posterior, side)

Anterior Position of head Shoulder (step deformity) Flattening of deltoid muscle (paralysis of C4/5) Inferior dislocation Bumps/fracture trauma

Posterior Scapula between T2-T7Winging (serratus anterior injury, long thoracic

nerve)


See learning activity handout


Watch the following video on Shoulder ExaminationUW – Department of Family Medicine and Community Health (2008, Feb 21). Shoulder Exam. Retrieved fromhttps://www.youtube.com/watch?v=VSrLbzZzJU8&feature=youtu.be


Flexion 160 -180deg

Extension 50 -60deg

Lateral Rotation 80 - 90deg

Medial Rotation 60 - 90deg

Abduction 170 - 180deg

Adduction 50 – 75deg


Instruct to abduct arm to 90° keeping elbows straight, turn palm face up & continue to 180°, until hands touch overhead

Abduction requires glenohumeral movement & scapulothoracic movement


From a neutral position, move the arm laterally across in front of the body

Limitations can be due to bursitis tears in the rotator cuff (especially Supraspinatus) and irritation of AC joint


Perform if AROM is limited and assess for end feel

Can be done in seated or side-lying position


With lateral rotation in a person with recurrent injury it can lead to dislocation

Abduction begins at the GH joint, but after 20 degreeswith the scapula starting to move after 20 the scapulothoracic joint comes into play

If the scapula seems to be fixed throughout the whole movement suspect a capsular problem.


Place hand over acromion to prevent patient moving the body

Move arm into flexion & extension

Positive If limitations occur

Significance Can be due to bicipital tendonitis or bursitis


Supine and seated position (as the orientation of the scapular will change in each position)


Accessory movements should be observed Possible Conditions Sub-acromial bursitis Calcium deposits Tendinitis

During abduction of the arm, we are looking for a painful arc

This may be due to subdeltoid / subacromial muscles or a tear of the rot cuff

This pain is due to inflamed or torn structures under the acromion process and the coraco-acromial ligament.


Initially the structures are not pinched under the acromion process Therefore the patient is able to abduct the initial 45-60

deg.

Further abduction causes pinching of structures & therefore pain

The patient is to abduct fully, if possible, the pain should decrease after 120

Often the pain is greater going up due to gravity, rather than coming down

The pain is also greater in active than in passive

If there is pain the client often will “hike” the shoulder using upper traps & lev scap


Backward & forward glide of the humerus

Lateral distraction of the humerus

Backward glide of the humerus in abduction

Lateral distraction of the humerus in abduction

Movements of the sternoclavicular joint

Movements of the acromioclavicular

Scapular movements – to determine general mobility


Only perform the tests relevant for your case/client

Some tests provoke symptoms, some relieve symptoms so take care

The reliability of the tests depends on the skill and ability of the practitioner so…. Practice makes perfect!


Apley’s Scratch Test Shoulder Apprehension Test Neer Impingement Test Acromioclavicular Shear Test Speed’s Test Yergason’s Test Drop-Arm Codman’s Test Lift-Off Sign Teres Minor Test Roos TestWright Test Adson Test


Quickest way to evaluate shoulder ROM

Tests abduction & external rotation Patient reaches behind head to touch the superior

medial angle of the opposite scapula

Tests internal rotation & adduction Patient to reach in front and touch opposite acromion

Tests internal rotation & adduction Patient to reach behind back & touch inferior angle of

the opposite scapula


Stand behind patient, anchor the scapula, & abduct the arm with your free hand.

The scapula should not move for the first 20 deg., but is very active around 80 deg.

Positive: if the scapula moves before 20 deg.

Significance: adhesive capsulitis


Indication Suspected cases of shoulder dislocation/subluxation

Method Passively abduct and externally rotate the arm

Positive If patient resists any further movement of joint or has

a look of apprehension

Significance Chronic anterior shoulder dislocation / shoulder

instability


Method Patient in sitting position Examiner cups hand over the deltoid muscle, with one

hand on the clavicle & the other on the spine of the scapula

Positive Pain or abnormal movement at the AC joint

Significance Indicative of AC joint pathology


Indication Suspected bicipital tendinopathy

Method Examiner resists shoulder forward flexion by the patient

while the patient’s forearm is first supinated then pronated Alternative is to get the patient to resist eccentric

extension from 90° first with arm supinated then pronated

Positive Increased tenderness in bicipital groove especially with

arm supinated

Significance Bicipital peritonitis or tendonitis


Resisted shoulder external rotation test Indication Evaluate for bicipital tendonitis in bicipital groove, & for

stability of biceps tendon within the groove Method Patient is standing or seated, elbow flexed to 90° Grasp patient’s wrist & support under elbow Hold the elbow against the trunk Ask patient to externally rotate against resistance

Positive Pain felt over bicipital groove or an audible click is produced

from that area (movement of longhead of biceps)

Significance Stability of biceps tendon Rupture of transverse ligament of bicipital groove


Indication Helps asses rotator cuff tears, specifically

Supraspinatus contractile unit

Method Passively abduct the arm on the affected side Above horizontal, e.g. 110deg remove support and

ask patient to slowly lower their arm

Positive Unable to hold arm at 90deg abduction Hunching of the shoulder Unable to smoothly lower the arm Significance - tear

in rotator cuff muscle


Indication Suspected dysfunction of subscapularis muscle

(tendinopathy or myofascial TrPs)

Method Patient places hand behind them with knuckles resting on

lumbar spine Therapist places their hand against the patient’s hand and

asks them to push against resistance

Positive – pain or weakness

Significance - tear or tendinopathy; MF/ TrPs


Method Arm abducted at 90deg with elbow bent at 90deg client

tries to externally rotate against resistance

Significance Pain &/ or weakness indicates a positive test for teres

minor strain


Indication Instability of biceps tendon in the groove

Method Place patients affected arm into full abduction;

externally rotate with the elbow extended

Positive Pain elicited from bicipital groove or a click is heard

or palpated

Significance Possible tear of transverse ligament


Indication Suspected shoulder dislocation/ subluxation

Method Observe axillary folds with patient seated; compare

each side; heights, or distance between tip of acromion & axillary fold

Positive Axillary fold is lower on the suspected side

Significance Possible dislocation


Indication Helps asses rotator cuff tears, specifically

Supraspinatus contractile unit

Method Patient’s arm is passively & forcibly flexed forward by

examiner while holding the other hand on the top of the shoulder

Positive Pain present with accompanying facial expression Pain in shoulder flexion


MethodPatient’s arm is abducted to 90deg with resistance to

abduction provided by practitioner The shoulder is then medially rotated & angled

forward to 30deg (emptying can)

Positive Weakness or pain

Significance Supraspinatus abnormality; tear in Supraspinatus

tendon


Characteristic symptoms Painful to lie with one shoulder forward Painful during pulling activities (opening doors) Painful to open jar lids, reaching or throwing Pain during last 30deg abduction (muscle is on stretch)

Method The patient resists external rotation with the arm bent

at 90deg and at the side of the body

Positive If pain is elicited

Significance Possible infraspinatus tendonitis


Acromion Scapula Greater tubercle Lesser tubercle Intertubercular sulcus Sternoclavicular joint Acromioclavicular joint Sternum Coracoid process Head of the humerus Lateral & medial epicondyle

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