Shoulder Syndromes

VOMA
September 2011

P. Gunnar Brolinson, DO, FAOASM, FACOFP, FAAFP

Head Team Physician, Virginia Tech
Chief of Sports Medicine
Edward Via Virginia College of Osteopathic Medicine
Director Primary Care Sports Medicine Fellowship

Objectives
Review anatomy of the shoulder
complex
Review motions of the shoulder complex
Describe the functional biomechanical
evaluation of the shoulder
Understand and be able to perform an
evaluation of shoulder using various
functional and special tests
Review some common shoulder
problems

Introduction
Shoulder injury is very
common in the active
patient population.
It is a complex joint and
presents unique challenges
to diagnosis and subsequent
treatment.

Introduction
Shoulder Pain is the third most
common MS complaint in
primary care offices
Second to knee pain for referrals
to ortho/sports medicine
physicians

Incidence 25/1000 patients

Peak incidence in 50-70 year
olds

8-13% of athletic injuries

involve the shoulder

Introduction
The shoulder complex is a
loosely constructed highly
mobile complex of bones,
muscles and ligaments.
It is designed for increased
mobility to the upper
extremity with only sufficient
stability to provide a proper
foundation for muscular
function which is vital for the
performance of sports or
activities of daily living
(ADL)

Introduction
Effective diagnosis and
treatment of the shoulder
requires a mastering of
the relationship of
structure and function of
this complicated joint.

Anatomy
It is composed of 3 joints
(sternoclavicular,
acromioclavicular and
glenohumeral) and one
articulation
(scapulothoracic).
All four work together in a
synchronous rhythm for full
range dynamic motion.

AnatomySC Joint
The sternoclavicular joint (SCJ) enables the
humerus to achieve 180 degrees of Abduction.
It is a saddle shaped joint made up of the medial
end of the clavicle, the manubrium sternum and
the cartilage of the 1st rib.
There is an articular disc separating the surfaces
which adds strength to the joint.

SC Joint

AnatomyAC Joint
A plane synovial joint that
augments the range of
motion (ROM) in the
humerus.
It is made up of the
acromiom process of the
scapula and the lateral
edge of the clavicle.

AnatomyAC Joint
It is surrounded by a fibrous
capsule and an articular disc
separates the surfaces.
Primary strength is supplied
by the acromioclavicular and
coracoclavicular ligaments
trapezoid ligament
conoid ligaments

AC Joint

AC Joint
Type I 17%
Type II 43%
Type III 40%
Type III found in up to
80% of RC tears
Compared with 3% in
Type I

AC Joint/Subacromial Articulation
Impingement

Greater tubercle
Acromion
Coracoacromial ligaments
Supraspinatus tendon

Between 48-72% of
shoulder pain in PCP office
is subacromial impingement

AnatomyGH Joint
A multi-axial ball and
socket joint surrounded
by a capsule.
Most of the support is
provided by the rotator
cuff muscles.

Anatomy of GH Joint
The glenoid labrum is a
ring of fibrocartilage that
surrounds and deepens the
glenoid fossa which
increases the available
contact area by
approximately 70%.

Functional AnatomyGH Joint

The relaxed position of the humerus has it placed
in the upper portion of the glenoid cavity.
Contraction of the rotator cuff muscles pulls the
humerus down into the lower/wider portion of the
glenoid cavity.
Without the dropping down, full Abduction is
impossible.

GH Joint
Static stabilizers
Labrum
Capsule
Adhesion-cohesion
Intra-articular pressure

Dynamic stabilizers

RC muscles
Deltoid
Long head of biceps
Scapulothoracic muscles
Proprioceptive feedback

GH JointStatic Restraints
Labrum
Ring of fibrocartilage
Deepens the glenoid fossa
Increases contact area ~70%

Ligaments
Superior Glenohumeral
Middle Glenohumeral
Inferior Glenohumeral (important
when shoulder is abducted and
externally rotated)

The Scapulothoracic Articulation

The scapula serves as a
mobile platform from
which the upper limb
operates.
It is made up of the body
of the scapula and the
muscles covering the
posterior chest wall.

The Scapulothoracic Articulation

The GHJ moves 120
degrees as the scapula
swings about 60 degrees
around the chest wall in a
smooth 2:1 ratio.

The Scapulothoracic Articulation

The articulation allows
the scapula to glide
medially, laterally,
superiorly and inferiorly
and rotate over the
posterolateral chest cage.
Asymmetry of position
usually indicates
asymmetry of motion.

The Scapulothoracic Articulation

In any given arm position, the scapula aligns itself
to allow the glenoid cavity to be in the best
position to receive the head of the humerus.
The apparent simple motion of the scapula is
neurologically complex due to relatively little
direct muscle action.

Scapulothoracic Articulation

Extrinsic Muscles of the Shoulder Region

Deltoid
Anterior (Flex/IR)
Mid-portion (ABd)
Posterior (Ext/ER)

Pectoralis Major
(ADd/flex/IR)
Biceps (Flex)
Triceps (Ext)
Teres Major (ADd/IR)
Latissimus dorsi
(Ext/ADd/IR)

Intrinsic Muscles of the Shoulder Region

Rotator Cuff

Supraspinatus (ABd)
Infraspinatus (ER)
Teres Minor (ER)
Subscapularis (IR)

Muscles of the Scapulothoracic Articulation

Scapular Stabilizers
Trapezius
Superior (Elev)
Middle (Retract)
Inferior (Depress)

Levator Scapulae (Elev)

Pectoralis Minor (Depress)
Rhomboids (Retract)
Serratus anterior (Protract)

Shoulder Stability
The shoulder consists of
passive and dynamic
stabilizers.

Static Shoulder Stability

The static stabilizers are:

Glenoid
glenoid labrum
capsule
ligaments
(superior glenohumeral,
middle glenohumeral and
inferior glenohumeral),

joint cohesion
Intra-articular negative
pressure.

Dynamic Shoulder Stability

The dynamic stabilizers
are the rotator cuff
muscles along with the
long head of the biceps.
The scapulothoracic
stabilizers are the
rhomboids, trapezius,
serratus anterior, and the
pectoralis minor.

Ultimately Our Goal is Joint Congruence

Maintenance of the articular
surfaces apposition is the
keystone to avoiding injury
Altered engrams (motor activation
patterns) increases loads on
tissues, resulting in a singular
macrotrauma or repetitive
microtraumas
More than a tight capsule and
strong rotator cuff

Shoulder Examination
HISTORY
Listen to the patient long enough and they will tell you what is
wrong with them

Where/when/what/how/why
Specific mechanism of injury (MOI) (if any?)
Chronic vs. acute
What makes symptoms better or worse
Instability/weakness
Pain (0/10)
Crepitation
Radicular symptoms (pain radiation)

Shoulder Examination
HISTORY
Pain in shoulder coming from rotator cuff or
bursa radiates to lateral deltoid NOT past
elbow!
Pain that wakes on rolling over in bed
suggests bursitis
Pain that wakes from sleep suggests rotator
cuff tear
88% sensitive, 20% specific

Shoulder Exam
Physical exam should be done in the same manner
each time so that nothing is forgotten:
Inspection
Palpation
ROM
Active and Passive

Strength and Neurologic Testing

Regional Osteopathic Structural Examination
Special Testing

Shoulder Pain Diagram

Shoulder Exam
Inspect

Expose the area

Step offs
Deformities
Ecchymosis
Asymmetry

ROM

Forward flexion 1800

Extension 450
ABduction 1800
ADduction 450
IR 550
ER 40-450

A/PROM tests
Apley scratch test:
ER and aBduction (C7)
IR and aDduction (T7)
Asymmetry can be indicative
of:
limited GH adduction
internal/external rotation
scapular movement

Painful arc of motion

33% sensitive
81% specific

Scapular Dyskinesis
Functional base for shoulder
Alterations in the resting position
affects timing and magnitude of:
Acromial upward rotation
Excessive movement of the glenoid
Decrease maximal RC activation

Often associated with other upper

extremity disorders

Range of Motion
Asymmetry is the Key!
Master the feel of normal/abnormal endpoints and
restrictions of motion.
Extra-articular blockage: rubbery feel and gives
slightly under pressure
Intra-articular blockage: inflexible and ROM ends
abruptly

Physical Exam
Neurologic exam
Muscle & tendon pain worse
with:
Passive stretch
Active contraction in a neutral
position
Palpation

Ligaments/capsule pain worse

with:
Passive & active loading,
usually only at the end ROM
Palpation

Reflex and Sensory Testing

Spurlings Test
Puts pressure on
posterolateral complex
(articular pillars, facets, &
neural foramina
Could be a ligament,
muscle/tendon, disc,
osteoarthritis, nerve root
inflammation (virus, etc.),
or tumor

Lhermittes Sign/Test
the Barber Chair phenomenon
Trauma to cervical spinal cord
Space occupying lesion (tumor,
disc)
Multiple sclerosis
Cervical spondylosis
Vitamin B12 deficiency

Muscle Testing
Range of normal
muscle strength.
When testing for strength,
keep in mind that you are
also testing for
neurological function.

Special Testing
Special testing can be done to add information for
the diagnosis of the problem.
Structured to uncover a specific type of pathology
or dysfunction.
Shoulder special testing includes but not limited
to the following.

Specific Special Tests

Biceps tendonitis
Yergasons
Speeds

Rotator Cuff

Empty Can
Full Can
Lift Off/Napolean
Scapular Retraction

Instability

Apprehension
Jobe relocation
Anterior Release
Glide/Load and Shift
Sulcus Test

Impingement
Hawkins
Neers

Cross Arm Adduction

SLAP lesion

OBriens
Clunk or Crank
Resisted Supination/ER
Biceps load I and II
Zaslav

TOS
Adsons
Roos

Biceps Tendonitis
Yergasons Test
Patient flexes elbow to 900
Physician grasps the elbow with
one hand and the wrist with the
other
The examiner resists as patient
attempts to supinate and flex the
elbow
The test is positive if pain is
elicited as the biceps tendon or
bicipital groove

Biceps Tendonitis
Speeds Test
Patient fully extends the
elbow, flexes the shoulder
and supinates the forearm
Physician resists further
flexion
The test is positive when
there is tenderness in the
bicipital groove

Supraspinatus Testing
Position the arms in a position of 900
ABduction and 300 forward flexion
with the thumbs pointing down
Apply a downward force as the patient
resists
The test is positive with weakness or
pain
89% sensitive; 68% specific

Full Can Test

Less impingement
Minimized infraspinatus
86% sensitive; 74% specific

Supraspinatus Test
Scapular Retraction Test
Scapular dyskinesis may decrease
maximum RC activation
With arm in empty can test
position, scapula is lightly held in
retraction by forearm pressure on
the medial scapular border while
the patient exerts maximum
resistance
Strength values increased by 24%
in injured group, and 13% in
control

Subscapularis Test
Gerber Lift Off Test/Napoleon Test
Internal rotation
Minimal activation of
pectoralis and latisimus
Ability to lift off
62% sensitive
100% specific

Infraspinatus Test
00 abduction and 450 IR of
humerus
Minimal activation of
supraspinatus and deltoid
Contribute more from 00 to
450 ER

GH Instability
Apprehension Test
Causes anterior translation (subluxation)
Sens 40%, Spec 87%

Jobe Relocation Test

Posterior pressure on the head alleviates
the discomfort (relocation)
Sens 56%, Spec 93%

Anterior Release Test

Allows for quick anterior
translation/apprehension returns
Sens 92%, Spec 89%

GH Instability
Glide Test
This test is performed to
assess of A/P instability
Compare bilaterally
The test is positive if
there is excessive
mobility

GH Instability
Load and Shift Test
Patient lie flat on the back so
that the center of the scapula
is on the edge of the table
The physician holds the arm
out 900 abduction
Assess movement in the
shoulder joint in the anterior
and posterior directions
Grade 0-3
Lachman of the shoulder

Inferior GH Instability
Sulcus Test
Apply traction in an inferior
direction with the arm relaxed
The test is positive if it causes
inferior subluxation of the
humeral head and widening of
the sulcus between the
humerus and the acromion
About 25% of patients with
MDI will have sulcus of 2cm
or more

Multidirectional Instability (MDI)

Usually not difficult to
diagnose
Laxity in at least the anterior
and posterior planes, inferior
is usually lax as well
Can be overlaid by another
pathology
Often a laxity in a joint is the
compensatory result of
restriction elsewhere
Imaging not usually
necessary or helpful

Multidirectional Instability (MDI)

Treatment considerations
Neuromuscular retraining
Maintenance of joint
congruence
Kinetic chain
TX Somatic Dysfunction
Reduction of capsule laxity
Prolotherapy
Bankhart or capsular
plication

Impingement Syndrome
Primary
Repetitive overhead motion
Supraspinatus impinges on acromion
Prominent coracoacromial ligament

Secondary
GH laxity and instability of shoulder
Cephalad migration of humeral head
Labral lesion possible

Internal (posterior-superior glenoid)

Inferior supraspinatus trapped between greater tuberosity and posterior
superior labrum
Posterior superior synovitis and partial under-surface tears

Tensile failure
Often as a result of fatigue and tears with eccentric loading

Impingement Tests
Neers Test
Patient seated, passively IR arm so
that thumb is downward
Flex the arm while stabilizing
scapula
The test is positive if discomfort or
pain is elicited
Impingement of the humerus against
the coracoacromial arch
81% sensitive
50% specific

Impingement Tests
Hawkins Test
Tests supraspinatus impingement
against the coracoacromial ligament
Elevate the patients shoulder to 900,
flex the elbow to 900 and place the
forearm in neutral position
IR the humerus
The test is positive when there is
pain or discomfort
90% sensitive, 60% specific

Impingement Syndrome
Treatment
Injection
Diagnostic
Therapeutic
Larger volume

PT
Up to 6 mos
60-90% resolve

OMT

AC Joint/Posterior Capsule
Cross Arm Test
With the patient seated, bring
the arm across the chest as far
as possible
The test is positive if there is
pain elicited at the AC joint
By comparison with the
opposite side one can
ascertain the tightness or
laxity of the posterior capsule

Superior Labral Anterior Posterior

Lesions (SLAP)

Anterior pain
Posterior tightness
Clicking or popping
Dominant arm
Mechanisms
Eccentric loading of biceps during
throwing
Fall with compressive load
Forced Abd/ER
Excessive traction from weight lifting
MVA from seatbelt

SLAP - OBriens Test

Shoulder 900 flexion, 10-200
adduction, thumb pointed
down
Patient resists downward
pressure
Rotate to supination and resist
flexion
Test is positive if pain
alleviated in palm-up position
Sensitivity 67%
Specificity 49%

SLAP - Crank Test

Patient shoulder aBducted to
900
Axial load placed by examiner
Humerus then IR
The test is positive if pain is
noted with or without an
clunk, or reproduction of
activity related symptoms
Sensitivity 59%
Specificity 82%

SLAP - Resisted Supination ER Test

Patient is supine with scapula near the
edge
Examiner supports the limb in 900
aBduction, elbow flexed 60-700, forearm
in neutral
Patient attempts to supinate, as examiner
resists and then gently externally rotated
to the maximal point
The test is positive if anterior or deep
pain, clicking, or reproduction of activity
related symptoms
83% sensitive, 82% specific

SLAP - Biceps Load Test

Loads the superior labrum via stress on the biceps tendon
during resisted flexion force
Positive test is pain or apprehension
Test I is 900/900 Sens 91%, Spec 97%
Test II is 1200/900 Sens 90%, Spec 97%

SLAP - Zaslav Test

Helps to differentiate labral tears from impingement
syndrome
Positive test denoted by weakness, NOT pain
Sensitivity 88%, Specificity 96%

Thoracic Outlet Syndrome (TOS)

Compression of the neurovascular structures at the superior
aperture of the thorax
Etiology
Neurologic
Brachial plexus (95%)

Vascular
Subclavian vein (4%)
Subclavian artery (1%)

Neurologic - Female-to-male ratio approximately 3.5:1

Venous - More common in males than in females
Arterial - No sexual predilection

TOS - Etiology
Anatomic

Scalene triangle (most common)

Cervical ribs (more common in arterial)
Congenital fibromuscular bands (up to 80% in neurologic)
Transverse process of C7 is elongated

Trauma or repetitive activities

MVA, hyperextension injury, with subsequent fibrosis and scarring
Effort vein thrombosis (ie, spontaneous thrombosis of the axillary veins
following vigorous arm exertion)
Playing a musical instrument: maintain the shoulder in abduction or extension for
long periods

Neurovascular entrapment
Costoclavicular space between the 1st rib and the head of the clavicle
C8-T1 (90%)-ulnar n. distribution

TOS - Adsons Test

Patency of subclavian artery
Classic maneuver
Patients arm aBducted, extend and
ER
Patient then takes a deep breath and
holds it while turning the head
towards the side being tested
Then turn head to the opposite
direction
Test is positive if diminished or
absent pulse or reproduces
symptoms

TOS - Roos Test

Patient aBducts the shoulders to 900, ER, and flex the elbows to
900
Then patient then slowly opens and closes the hands for 3 minutes
The test is positive if the arm becomes heavy or there are
paresthesia of the hand
Compression of subclavian artery and vein and the brachial plexus

Diagnostic Work-Up
Depending on the injury,
there are many diagnostic
tests that can be done to
evaluate an injury:

X-rays
CT Scan
MRI
CT/MR Arthrograms

Selective injections
Using anesthetic and/or
steroids

Serial exams in office

Ultrasound
Dynamic ultrasound
In office
US guided injections

Imaging
X-rays
AP
GH dislocation best seen
on axillary views, also on
scapular Y view

Imaging
X-rays
Outlet views are obtained
to evaluate impingement
For instability, West Point
view or the Stryker notch
view are used to better
detect Bankart and Hill
Sachs' lesions

Imaging
Arthrogram
Detailed anatomical
information is obtained
when combined with CT or
MRI of the shoulder
Excellent detail of capsular
attachments and of the
labrum

Thought for the Day

Education is what
you remember after
you have forgotten
what you studied for
the test."
-Emerson