Shoulder Problem Evaluation Shoulder assessment Second most common

Shoulder Problem Evaluation

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

Bony Anatomy Anterior

Bony Anatomy Anterior and Posterior

Bones Scapula & clavicle n n Move as a unit Clavicle’s articulation with sternum is only bony link to axial skeleton The Shoulder Girdle 4 -6 Manual of Structural Kinesiology

Bones Key bony landmarks n n n n Manubrium Clavicle Coracoid process Acromion process Glenoid fossa Lateral border Inferior angle Medial border The Shoulder Girdle 4 -7 Manual of Structural Kinesiology

Bones Key bony landmarks n n n n Acromion process Glenoid fossa Lateral border Inferior angle Medial border Superior angle Spine of the scapula The Shoulder Girdle 4 -8 Manual of Structural Kinesiology

Radiographic Anatomy

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

Coraco Clavicular

Sterno Clavicular

Acromio Clavicular

A/C Joint Grade 1+ A/C Separation

Gleno Humeral

Scapulo Thoracic

Sub Acromial

Where do things go wrong? ? Fractures

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

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

Voluntary Posterior Subluxation

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

Bony Anatomy “Static Stabilizers”

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

LABRUM

What goes wrong? Tears and tendonopathies

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

Finally…the subacromial space

What can go wrong? ? ? Impingement!!!!!!!

Impingement

Picture 6: Rotator Cuff MRI

Shoulder Complex Muscles Scapular Muscles

Levator Scapulae O – Transverse processes of C 1 -C 4 I – Medial border of scapula between superior angle and root of spine of scapula N – Nerve root C 3 -5 F n n scapular elevation retraction

Rhomboid Major O– n n Major – T 2 -T 5 spinous processes Minor – Ligamentum nuchae, C 7 -T 1 spinour processes I– n n Major – Medial borde of scapula between spine and inferior angle Minor – medial border at root of spine of scapula N – Dorsal Scapular

Upper Trapezius O– n n Occiptal protuberance Medial 1/3 of nuchal line Upper part of ligamentum nuchae C 7 spinous process I– n n Posterior border of lateral 1/3 of clavicle Acromion process N – spinal accessory F– n n n Scapular elevation, retraction Rotation of head to opp. Side Lateral flexion of head to opp. side

Middle Trapezius O– n n Inferior part of ligamentum nuchea T 1 -T 5 spinous processes I– n n Medial margin of acromion process Superior lip of spine of scapula N – Spinal accessory F– n Scapular retraction

Lower Trapezius O– n T 6 -T 12 spinous processes I– n Tubercle at apex of root of spine of scapula N – spinal accessory F– n Scapular depression, retraction and upward rotation

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

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

Glenohumeral Muscles

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

Coracobrachialis O– n Coracoid process I– n Medial surface of midhumerus, opposite to deltoid tuberosity N –Musculocutaneous F– n GH flexion, adduction, Hor. Adduction

Pectoralis Major O– n n Sternal – anterior surface of sternum, cartilages of ribs 1 -6 or 7 Clavicular – anterior surface of sternal ½ clavicle I– n crest of humerus’s greater tuberosity N– n n Sternal – medial pectoral Clavicular – lateral pectora F– n GH ADD, H. ADD and IR

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

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

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

Triceps Brachii O– n n n 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– n Posterior surface of olecranon proess N – Radial F– n n Shoulder – long head – Ext and ADD Elbow -- extension

Latissimus Dorsi O– n n Posterior layer of lumbodorsal fascia, then attaching to the T 6 -T 12, lumbar and sacral vertabrae External lip of iliace creast lateral to erector spinae Ribs 9 -12 Slip from inferior angle of scapula I– n Intertubercular groove (distal aspect) N – Thoracodorsal F– n GH IR, ADD, Ext,

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

Rotator Cuff

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

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

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

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

Basic Shoulder Complex Mechanics

Performing Abduction Initiation Scapulohumeral Ryhthm n n First 30 degrees > 30 degrees Clavicle

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

Clinical Exam History Pain Acute Chronic Weakness Deformity

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

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

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

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

Throwing Mechanics Arm Cocking Phase n n Begins Ends

Throwing Mechanics Arm Acceleration n n Begins Ends

Throwing Mechanics Follow-through n n Begins Ends

Pathomechanics of Throwing Shoulder Rotator Cuff Labrum Impingement SLAP Lesion

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

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

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

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

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

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

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

X RAYS DIAGNOSIS? ? ?

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

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

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

Which of the following structures can be “impinged”? 1. Biceps tendon 2. Subacromial Bursa 3. Rotator Cuff Tendons 4. All of the above 30 10 0 0

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

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 90 -120 degrees Special Tests? ? ? Diagnosis? ? ?

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

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

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

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?

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

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

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

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

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

In the human body, which is the most incredible joint? 1. 2. 3. 4. 5. PIP Knee Ankle Shoulder None of the above

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

Biceps Tendonopathy Speed Test Yergason Test Direct palpation

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

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.

QUESTIONS?

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

Physical Exam Range of Motion Abduction 0 -180 o

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

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

Physical Exam Range of Motion Internal rotation n T 5 segment External rotation n 80 -90 o

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

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

Physical Exam Strength of Subscapularis Liftoff test Belly press test

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

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

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

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

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

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

Impingement Signs Hawkins Neer

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

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 n weakness w/o pain = muscle weakness or rupture

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

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

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