The Shoulder

Applied anatomy – self-study – know – important and can be tested – Magee (2014) pg 252-257

Shoulder – wide range of motion (ROM) but expense of what? Stability

-Potentially most unstable of joints

-Static restraints provided by ligaments
-Dynamic restraints provided by muscles and tendons

The shoulder is not a single joint but a complex of 4 joints:

-Main one is glenohumeral joint

-Scapulothoracic joint

-AC joint

-SC joint

-Maybe a fifth joint? – Which one? – Coracoacromial arch?

Remember check neck and chest (elbow) if patient presents with shoulder pain (besides the shoulder
examination) (and sometimes the abdomen)

Clavicle:

Most commonly fracture bone in the body – especially middle third – swelling and ecchymosis

Functions: - Site of muscle attachment

- Protection of underlying structures
- Allows for movement away from the body
- Connects shoulder to the rest of the body

The GH joint:

Shallow glenoid fossa –

deepened by the labrum

Surface area of the HH is 3-4 x of the

glenoid fossa – most of the
articular surface is out of the
socket

Loose joint capsule –

strengthened by GH ligament
bands and coracohumeral
ligament

Joint is weakest anteriorly and inferiorly why? Because joint is protected from forces – above by clavicle,
acromion and coracoid process, there is also a lack of bony structures on the anterior and inferior surfaces to
prevent dislocation and excessive movement

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Depends on muscles (rotator cuff, deltoid, pectoralis major, lats, teres, etc.) for support rather than ligaments or
bones

Rotator cuff – SITS? Supraspinatus, infraspinatus, teres. minor, subscapularis

When arm is relaxed – HH sits in the upper part of the glenoid fossa. It needs to drop during abduction
to prevent impingement and allow full abduction. The rotator cuff muscles depress the HH during
abduction (pull it down into lower and wider part of fossa) and thus stabilise the HH in the fossa during
abduction, providing a fulcrum across which the power muscles of the shoulder (e.g.? deltoid, pectoralis
major, lats) act to elevate the shoulder

The SC joint:

Superficial joint – saddle shaped – synovial

Articular disc between 2 surfaces

Swelling and deformity over this area  fracture of medial clavicle near the joint, dislocation of the joint itself,
or arthritis of various aetiologies (in arthritis – why? synovitis or osteophyte formation)

The AC joint:

Asymmetric enlargement of the joint  acute/chronic inflammation, bony hypertrophy (DJD) or acute
ligamentous injury

Ligamentous injuries or sprains – divided by Rockwood into 6 types – read up

 Type I: A sprain of the AC ligament. Muscles intact. AC and CC ligament intact

 Type II: ACJ Jt Disruption. A torn AC ligament and partially torn CC ligament

 Type III: AC Jt Dislocation. A rupture of both the AC and coracoclavicular (CC) ligaments, accompanied
by a CC distance increase of 25% to 100%. Deltoid and traps may be detached.

 Type IV: Both ligaments are torn with posterior displacement of distal clavicle. Deltoid and Traps
detached at distal clavicle. Ac Jt Dislocated. Clavicle displaced posteriorly. CC ligament torn
 Type V: AC Ligament disruption and dislocated. CC torn, >100-300% distance. Deltoid and Trap
detached from distal half clavicle
 Type VI: AC Ligament Disruption and dislocated. CC Ligament torn. Clavicle in sub-coracoid position.
Deltoid and trap detached from distal half clavicle.

Coracoid process:

It is a deep scapula apophysis that points anterior below the distal head of the clavicle.

Origin of coracobrachialis and short head of biceps and insertion of pectoralis minor

May be seen in very thin individuals and patients with a posterior shoulder dislocation – how? Anterior and
lateral deltoid heads are flattened against the front of the glenoid rim

Scapula:

Probably the foundation of the shoulder

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Spine is the most visible part – more prominent when there is atrophy of which 3 muscles? Supraspinatus,
infraspinatus or trapezius

Hyperinternal rotation of the scapula causes the medial portion of the scapula to stand out from the chest wall.
Winging of the scapula may result from weakness of serratus anterior but which 3 other muscles may be
implicated in this? Rhomboids, trapezius or levator scapula

Sprengel’s deformity – congenitally high or undescended scapula, muscles are replaced by fibrous bands

Patient history:

Shoulder pain

Deep boring – TOS, tumor

Worse at night – rotator cuff strain, tear, tumor

Red hot – acute calcific tendonitis, rotator cuff strain, tear

Exquisite pain on external rotation – adhesive capsulitis

Excessive abduction and external rotation – sudden paralysing pain and weakness – anterior shoulder
instability

Functional ability lost – combing hair, fastening bra, etc. important to check for this

Hoarse voice – check SC joint – posterior dislocation and Pancoast tumor

Age:

>50 – tumor, arthritis, adhesive capsulitis, muscle strains

20-40 – muscle strains and ligamentous sprains, dislocations, calcium deposits

Examination (excluding observation):

ROM:

Abduction (+/- 180):

Often patient will stop at 90 of abduction – need to be encouraged to continue

At 90 - patient will externally rotate – why? So that greater tuberosity can pass under the acromion

Best to observe from behind – so that relative contribution of GH joint and scapulothoracic
motion may be assessed

The scapulohumeral rhythm: Occurs in three phases: 2:1 ratio (GH:scapula motion)

Phase one: 30 of abduction, distal end of clavicle elevates 12-15

While the scapula is setting – little or no rotation
Angle between spine and clavicle will increase 10 but there is no
rotation of the clavicle

Phase two: 30-90 abduction

Clavicle will elevate 30-36 - there is no rotation of the clavicle

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 Phase three: 90-180 abduction.
Angle between scapula spine and clavicle increases an additional 10
Clavicle will elevate 30-60 and rotate posteriorly 50 on the long axis.
The humerus externally rotates 90 to allow the greater tuberosity to
avoid the acromion

If the clavicle does not rotate and elevate, elevation through abduction is limited to
120
If the GH does not move, elevation through abduction is limited to 60 and occurs
where?
If there is no external rotation of the GH, the total movement is 120, 60 from the GH
and 60 from the scapulothoracic articulation

Shrugging of the shoulder – patient unconsciously tries to supplement GH abduction by

increasing scapulothoracic articulation – when does this occur? Rotator cuff injury, arthritis

Understand mechanisms of scapular dyskinesia.

Causes of scapular imbalance patterns:

Increased protraction: Decreased Flexibility, Shoulder impingement, Posture-related (Excessive
T-spine kyphosis, increased cervical lordosis. Levator Scap Tight, tight
traps
Increased depression: Poor Posture, Shoulder impingement, Weak Levator Scap, tight
latissimus dorsi, tight traps.
Loss of scapular stabilisation: ACJ Instability, Shoulder impingement, Rotator cuff injuries,
glenoid labrum injury, clavicle fracture,
Weak/tight/detached muscle on the scapula, nerve injury.

Sick scapula signs and symptoms include:

Insidious onset
Prominent inferior medial border of scapula
Scapula protraction
Less prominent acromion
Coracoid tender to palpation
Tight pec minor
Lack of full forward flexion
Tight short head of biceps

The painful arc syndrome:

Roughly between 45/60 - 120. The patient experiences no pain in the initial
movement (abduction) but pain increases as abduction approaches shoulder level
Pain may subside between 120-180 of abduction. A painful arc suggests what?

Examiner should assess passive abduction. When passive abduction far exceeds active
abduction, painful or torn rotator cuff is the most common cause

Forward flexion (+/- 180):

Patient to lift arm in the sagittal plane as far as possible

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 Forward flexion may be restricted in the presence of arthritis, adhesive capsulitis, rotator cuff tears and
very large rotator cuff impingement

Injury or weakness of muscles and tendons especially the scapula stabilisers can limit active forward
flexion than passive forward flexion

Elevation through the neutral plane (+/- 180):

Somewhere between strict forward flexion and abduction – 20-30 from the sagittal plane
Movement may be less painful than straight abduction – less stress on capsule and surrounding muscles
Position in which most daily activities occur

External rotation:

Can be assessed two ways:

A] Arm at the side: elbows firmly against the sides of the trunk
Between 50 - 90 - slightly greater in dominant than non-dominant
side
Tears of the posterior portion of the rotator cuff may compromise
external rotation
Exquisite pain on external rotation – adhesive capsulitis

B] With 90 abduction: Functionally a more important motion – why? Simulates

throwing, playing racquet sports and swimming
Normally 90 or greater
In throwing athletes – can be as much as 135
When this is limited – patient may arch his/her back – compensation –
look for this
In the presence of anterior shoulder instability – external rotation in this
position puts the patient at risk of involuntary subluxation or dislocation
– apprehension tests!

Internal rotation: Can also be tested in both positions

A] With 90 abduction: Easier to measure

Average 30-45 in this position

B] With arm at side: Measures pure internal rotation but limited by abdomen
About 80-90
Apley scratch test:

https://www.youtube.com/watch?v=oORkZ2gLlbA

Complex motion
Some extension of shoulder is necessary
Very functional motion? Required for daily
activities e.g. reaching a pocket, cleaning the
perineum, scratching the back or fastening
clothes
Normally T7 women and T9 men
Usually 2 levels higher on dominant side

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 Usually the first movement lost in adhesive
capsulitis – may not even reach the lumbar
spine – use nearest landmark to record e.g.
PSIS, etc.

Adduction (about 130):

Can be tested 2 ways: arm at side or cross-chest.

Cross-chest: Patient should at least cup hand over the opposite shoulder – may be limited by AC joint
pathology

Extension (about 60):

Tested in the manner opposite shoulder forward flexion.

Protraction:

Patient shrugs shoulders forward in a hunched attitude – scapulae seen to slide away from midline

Retraction: Opposite of protraction

The capsular pattern of the GH joint:

External rotation > abduction > internal rotation

Finding a limitation but not in the correct sequence indicates a non-capsular pattern

Resisted isometric movements (RIM):

-Usually done in the lying position

-Remember neutral position – Why? (You will be marked down in the tests and exams if this is not
done)

-Myotomes and muscle attachments and actions – self-study – important

Muscle actions about the shoulder: abduction, adduction, flexion, extension, internal and external rotation -
Important

Muscles controlling scapular motion: levator scapulae, trapezius, rhomboids, and serratus anterior

Primary muscle related to movement: SITS! (Supraspin, Infraspin, TeresMinor, Subscapularis)

Special tests – instability and pseudolaxity impingement – self-study Magee page 290-300

Shoulder instability tests:

A] Anterior instability tests:

1] ! Anterior drawer test: https://www.youtube.com/watch?v=cH09QPWeyzY

https://www.youtube.com/watch?v=mM-BPbpLgd8

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 -Patient is supine.

Dr abducts the arm between 80 - 120 and forward flexes about 20 and externally rotates to
about 30
The patient’s arm is supported in the axilla of the Dr’s shoulder
The Dr’s hand stabilises the anterior shoulder while the other hand attempts to forward
translate the humerus
+ Pain, apprehension and greater than 25% forward translation

 6] Apprehension (crank) test with relocation test:

https://www.youtube.com/watch?v=hy7zgoEsbzQ

-Patient is supine

Dr slowly abducts and externally rotates the patient’s shoulder

+ Pain, apprehension and greater than 25% forward translation
Note the amount of external rotation that is possible at the point of apprehension and then
apply an A-P force to the GH joint and check if it relieves the apprehension and if external
rotation is now possible

 5] Fulcrum test: https://www.youtube.com/watch?v=Bnl_t1PH3iU

-Patient is supine with arm abducted to 90

Dr places one hand under the GH joint (as below) to act as a fulcrum
Dr extends and externally rotates the arm gently over the fulcrum
+ Pain, apprehension and greater than 25% forward translation

B] Posterior instability tests:

3] Jerk test: https://www.youtube.com/watch?v=fllSbhxF_lU

-Patient sits with arm externally rotated and forward flexed to 90

Dr stands behind the patient and grasps the patients fully flexed elbow and axially loads the
humerus in a proximal direction (i.e. towards the Dr)
Dr’s chest stabilises the patient’s back – the patient’s arm is then gradually moved in horizontal
direction
+ Sudden jerk as HH subluxes from the posterior aspect of the glenoid
Dr may feel relocation jerk when patient’s arm is returned to the original position

5] Posterior apprehension test: https://www.youtube.com/watch?v=t8oLGlMprOg

- Patient is supine

Dr forward flexes and internally rotates the patient’s shoulder and applies a A-P force on the
patient’s flexed elbow
The Dr’s other hand palpates the posterior HH and assesses the posterior translation of the HH
+ Pain, apprehension and > 50% translation and possible clunk

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C] Multidirectional and inferior instability tests:

If inferior instability is present, the patient usually has multidirectional instability also

1] Sulcus sign: https://www.youtube.com/watch?v=vV7u2JtdYWI

-Patient is seated with the arm relaxed by his/her side

Dr grasps the patient’s arm below the elbow and distracts the elbow inferiorly
+ Sulcus formation – look at the shoulder region

2] Feagin test: https://www.youtube.com/watch?v=qvv9mvRpUCU

-Patient is standing with his/her arm abducted to 90 and elbow fully extended

The arm rests on the Dr’s shoulder. The Dr claps his/her hands over the patient’s humerus at the
deltoid insertion
Examiner then pushes the humerus down and forward
+ Apprehension and excessive antero-inferior translation

D] Anterior impingement tests:

1] Hawkin’s-Kennedy impingement test: https://www.youtube.com/watch?v=X9YiuvQJVJc

-The patient’s arm is forward flexed to 90 and then internally rotated by the Dr

This causes the supraspinatus tendon to jam against the anterior surface of the coracoacromial
ligament
+ Pain = supraspinatus tendonitis

2] Neer Impingement test: https://www.youtube.com/watch?v=nNyax0iocZo

-The patient’s arm is forcibly elevated through forward flexion (can be done in abduction also) =
causing a jamming of the greater tuberosity against the anteroinferior acromial surface

+ Pain = overuse of the supraspinatus muscle or even the biceps tendon

3] Internal (medial) rotation resistance strength test/ Zaslav test:

https://www.youtube.com/watch?v=Hd0rngwsn3Y

- This test is a follow-up to the Neer test. The patient stands with arm abducted to 90  and
laterally rotated 80°-85°. Examiner resists medial and lateral rotation.

+ less strength in medial rotation= internal impingement

+ weakness in lateral rotation = external anterior impingement
Test differentiates between outlet (subacromial) and intra-articular impingement
When examiner finds Neers test positive.

4] Supine impingement test: https://www.youtube.com/watch?v=GJOvrsP984M

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 - The patient lies supine. Examiner elevates test arm to end range
170°-180°. Examiner laterally rotates arm and adducts it against patients ear. Then medially
Rotates arm to narrow subacromial space.

+ Pain = impingement due to rotator cuff pathology (non specific)

E] Labral tests:

Labral injuries are common especially in throwing athletes. Take into account age, type of tears.
What is the circle concept of instability? SUGGESTS THAT THE SHOULDER IS A KINEMATIC CIRCLE.
WHEN THERE IS A POSTERIOR LESION THEN IT MEANS THAT THERE IS ALSO ANTERIOR INJURY.

Bankart lesion: Tear of the lower rim of the labrum that occurs after dislocation of the shoulder
SLAP lesion: SUPERIOR LABRUM ANTERIOR POSTERIOR TEAR
FOOSH injury: FALL ONTO an OUT-STRECHED HAND

Four types of SLAP lesions – self study

4 TYPES OF SLAP LESIONS

 Type I: Fraying of the superior labrum
 Type II: Detachment of the superior labrum and biceps anchor from underlying superior glenoid
 Type III: Torn labrum tissue is caught in the shoulder joint
 Type IV: Tear that started in the labrum tears the biceps tendon

1] Active Compression Test of O’Brien: https://www.youtube.com/watch?v=qkDvVBi0gg8

This test is for SLAP (Type II) lesions or superior labral lesions.
The patient stands with arm forward flexed to 90° and elbow fully extended. Examiner horizontally
Adducts the arm 10°-15° (starting position) and medially rotated so thumb faces downward.
Examiner stands behind patient and applies downward force on the arm.
The arm is returned to starting position and palm supinated. Downward pressure from examiner
Is applied again.

+ Pain= on joint line with painful clicking in shoulder in first part of test, that is eliminated or decreased
In second part of test, is considered a positive for labral abnormalities
False + = AC joint pathology (during medial rotation)

2] Kim test (Bicep Load Test I): https://www.youtube.com/watch?v=-knsALCdv_A

- This test is for posteroinferior labral lesions. Patient sits on a chair.

Arm abducted to 90° and elbow supported in 90° of flexion. Examiner applies axial compression force
To the glenoid through the humerus. The force is maintained while arm is elevated diagonally
Upward using the same hand while other hand applies downward and posterior force.

` + Pain and click = posteroinferior labral lesion

F] Test for scapular dyskinesia: (Understand mechanisms of scapular dyskinesia)

1] Scapular load test: https://www.youtube.com/watch?v=ueKLHdTrcHQ

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 Examiner measures from spinous process to scapular spinous base while patients’ arms are at
the side. Normal = 1-1.5cm. Measure with arms abducted 45°, hands on waist with thumbs at
the back. Measure with arms abducted to 90°, thumbs down.

+ Asymmetry of movement between left and right sides

Dr provides resistance at 45° in an upward manner by grasping elbow and pushing upward.
+ scapular moves and creates more than 1.5cm distance – unstable scapular control muscles,
abnormal winging, abnormal movement patterns.

G] Test for AC joint pathology:

1] Horizontal adduction test: https://www.youtube.com/watch?v=DKLvt816x6o

Patient sits or stands. Examiner passively forward flexes arm to 90° and the horizontally adducts
arm as far as possible.

+ Pain localised over AC joint

False + = SC joint localised pain

H] Test for ligament pathology: Please refer to Magee

1] Crank test: Tests GH ligaments. Where do they attach? For superior GH ligament, arm tested
at the side. For middle GH ligament, arm in 45°-60° abduction. For inferior GH ligament arm over
90° abduction.

+ Pain

I] Test for muscle pathology:

 1] Speed’s test: https://www.youtube.com/watch?v=gbG_O9Gv8aQ

-Patient is seated with the arm forward flexed, supinated and the elbow is extended

Dr tries to push the arm down while the patient resists

+ Increased tenderness at the bicipital groove = bicipital tendonitis

2] ! Drop arm test: https://www.youtube.com/watch?v=JXgRBeqToik

Dr abducts the patient’s arm to 90 and asks the patient to slowly lower it to his/her side

+ Patient is unable to return the arm slowly to the side or has severe pain = rotator cuff tear or
tendonitis

 5] Supraspinatus test: -The patient’s shoulder is elevated to 90 with no rotation and asked to
resist abduction

The shoulder is then internally rotated and angled forward 30 (thumb towards the floor) and
asked to resist abduction. (Video shows second part of this test)
https://www.youtube.com/watch?v=DeO50UTxwoo

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 + Weakness and/or pain especially in the second position = tear of the supraspinatus muscle,
tendon or there is a neuropathy of the nerve supply to supraspinatus muscle

6] ! Pectoralis major contracture test: https://www.youtube.com/watch?v=6WSybz0modY

-Patient is supine with his/her hands clasped behind his/her head

The patient then asked to relax and allow the elbows to lower towards the table surface
+ Elbows do not reach the table or one is higher than the other = tight pectoralis major muscle/s

7] Infraspinatus test: https://www.youtube.com/watch?v=xVQy0qPU3Ho

Patient stands with arm at the side with the elbow at 90° and humerus medially rotated to 45°.
The examiner applies a medial rotation force that patient resists.

+ Pain and inability to resist = infraspinatus strain

8] Subscapularis test: https://www.youtube.com/watch?v=AgkTH52_PBI

Patient stands placing hand on back pocket area. Patients lifts hand away from the back.

+ Inability to lift hand away = subscapularis muscle lesion

+ Abnormal motion of scapular = scapular instability

Examiner resists as patient lifts hand away.

+Inability to resist = decreased strength in subscapularis due to possible tear

Patients asked to hold hand away from back and the hand springs back to back pocket area.

+ Pain, weakness = tear subscapularis (What is the mechanism of injury here?)

J] Nerve pathology tests:

Peripheral nerve injuries at the shoulder – self-study: axillary nerve, suprascapular nerve,
musculocuatneous nerve, long thoracic nerve, spinal accessory nerve. Magee pages 347-350

Neurology: Brachial plexus https://www.youtube.com/watch?v=UlDFSlRBeCE

1] Brachial plexus tension test 1: Tests primarily the radial nerve – see 4th year notes

2] Brachial plexus tension test 2: https://www.youtube.com/watch?v=fhsrNKWVh0s

Tests primarily the median nerve

-The patient is supine and the Dr grasps the patient’s palm and takes the arm in abduction and
external rotation behind the coronal plane while the other hand fixes the shoulder in depression
The elbow is then passively extended with the wrist held in extension and the forearm
supinated
+ Pain (stretch or ache in the cubital fossa) or tingling in the median nerve distribution =
stretching of the dura mater in the cervical spine and tension on the median nerve

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 Lateral flexion of the cervical spine to the other side can enhance the test

3] Tinel’s sign: Tap at the scalene triangle

+ Tingling in one or more of the nerve roots

4] Myotome examination: -Covered in Diagnostics – important – know

5] Reflexes: Biceps, triceps, pectoralis major (clavicular portion C5, C6 and sternocostal
portion C7, C8 and T1)

6] Dermatomes: -Covered in Diagnostics – important – know

K] Thoracic outlet syndrome (TOS) tests:

1] Allen’s test: -The patient’s elbow is flexed to 90, shoulder is abducted to 90 and externally
rotated and rotates the head away from the side being tested

Dr palpates the radial pulse

+ Disappearance of the pulse when head is rotated away = TOS

2] Roos test: - The patient’s elbow is flexed to 90, shoulder is abducted to 90 and externally
rotated (this is done actively). The patient is then instructed to open and close his/her hands
slowly for 3 minutes

+Unable to keep arms in position, patient suffers ischaemic pain, heaviness of the arm or
numbness or tingling of the hand = TOS

3] Halstead’s test: -See 3rd year notes

4] Adson’s test: -See 3rd year notes

5] Costoclavicular syndrome test: -See 3rd year notes

6] Hyperabduction test: -See 3rd year notes

7] Eden’s test: -See 3rd year notes

L] Palpation: Review – self-study – but is examinable

SC joint, 1st rib,

Clavicle,
AC joint,
Coracoid process,
Lesser tuberosity of the humerus
Biceps tendon + intertubercular groove
Greater tuberosity of the humerus
Sternum, ribs and costal cartilage
Humeral shaft
Rotator cuff muscles = SITS
Deltoid muscle, pectoralis major/minor muscle, coracobrachialis muscle
Biceps and triceps muscles
Axillary lymph nodes (including supraclavicular and infraclavicular nodes) *

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 Cervical lymph nodes *
Scapula and its spine
Cervical and thoracic spine
Trapezius muscle, rhomboid muscles, posterior and anterior cervical muscles
Thyroid gland

* You must know the names of the glands and demonstrate the correct technique of palpation of
these glands and how to record any abnormal findings

M] Referred pain: -From heart, gallbladder, spleen, lungs, diaphragm, cervical spine and elbow – when not
sure or can’t find anything wrong with the patient’s shoulder, check these areas

NB: Always do a CVS, abdominal and neck exam on any patient with shoulder pain (especially in the
elderly and risk patients (e.g. those with history of ischaemic heart disease) unless the cause of the
pain/discomfort is absolutely obvious e.g. trauma

N] How to diagnose frozen shoulder

https://www.youtube.com/watch?v=5zpXbvEf9j0

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