Upper Extrem: Shoulder Anatomy & Palpation

AC Joint

Acromioclavicular joint (AC joint) Three degrees of freedom Scapular rotation, scapular winging, scapular tipping Elevation/depression, Protraction/Retraction, Rotational

Biceps Brachii Strain

Often eccentric cause with throwing deceleration May lead to bicipital tendinitis or tenosynovitis Grade III (rupture) strain may occur May be caused by eccentric or concentric load Specifically to the long head Usually near origin at bicipital groove Deformity and asymmetry, balled up at attachment site.

Adhesive Capsulitis (Frozen Shoulder)

Etiology Contracted and thickened joint capsule w/ little synovial fluid Chronic inflammation w/ contracted inelastic rotator cuff muscles Generalized pain w/ motions (active and passive) resulting in resistance of movement Signs and Symptoms Pain in all directions both w/ active and passive motion Management Aggressive joint mobilizations and stretching of tight musculature Electric stim for pain and ultrasound for deep heating

Inferior Glenohumeral instability

Inferior Primary restraint depends on humeral position May increase with rotator cuff tears Neutral tests Superior GH ligament; ABD test Inferior GH ligament

Modification to AC traction test

Use both hands to pull down the humerus, on someone who is bigger than you, separation at AC joint area *If separation at actual humerus, is something different* Patient position: standing or seated Examiner position: anterior or lateral to patient Patient action: active shoulder elevation Examiner action: Hand #1 and #2 - firm stabilization of distal humerus Positive: excessive motion at AC joint, pain, increase in symptoms Pathology: AC ligament sprain (AC and or CC ligs)

Acromioclavicular joint Sprain

MOI: Scapular depression (can be from shronic overuse or repetitive stress) Direct blow or hard contact with external force or object, someone coming only the actual clavicle and pushing it down, from superior aspect, FOOSH - whole humerus and scapula will shift downward and end up with clavicle separation OR fall on elbow and clavicle shifts downwards and humerus pushes up S&S: in general anterior aspect of the shoulder, don't consider pain as the only indicator Etiology: acromion driven away from clavicle or vice versa, FOOSH, fall on elbow, fall or blow on tip of shoulder *will see the separation on the Xray Their dominant hand side sits lower than the non-dominant side Grading system: 1-6 (1 may not show deformity and grade 6 is a rupture) Acromioclavicular joint Mechanism - scapular depression May be acute or from chronic overuse/repetitive stress Etiology - Acromion driven away from clavicle or vice versa FOOSH (usually w/forward flexion) or fall on elbow Fall or blow directly on tip of shoulder Pathology Stretch or tear of AC ligs or coracoclavicular ligs Very common in sports ("separated shoulder") Most common sprain in shoulder

Axio-scapular muscles

Axio-scapular muscles Function to move glenoid fossa & fixate scapula Trapezius Superior (elevate and sup rotation) Middle (retract) Inferior (depression and retraction) Levator scapulae (elevation and inf. rotation) Rhomboids, maj and min (retraction, elevation) Serratus anterior (protraction and sup. rotation) Pectoralis minor (sup. rotation and ant. tilting)

Impingement Syndrome

Can lead to an actual strain Involves rotator cuff tendons, long head of biceps, subacromial bursa, & joint capsule (supraspinatus) - all compressing the actual muslce and as a result can't fire appropriately and the joint can't move (lack of ROM) Most common cause is anatomical variation of coracoacromial arch May also be caused by fatigue or overuse, normally chronic Kyphotic posture or rounded shoulders may also play role If scapula doesn't follow along with abduction (from surgery/wearing away), can lead to impingment syndrome Shoulder laxity is related to impingement (ROM testing comes into play here to figure out what muscle is firing and not) Poor scapular biomechanics may lead to impingement Athlete usually complains of painful arc (motion, range from shoulder where it starts to enclose on it's own) Pain begins 30˚ ABD and peaks at 90˚ ABD w/IR Indicates supraspinatus impingement *Can experiences neurological S&S, dead arm, weakness, or lack of feeling in the arm Overhead movement increases signs and symptoms

scapulohumeral muscles

Deltoid Anterior (flexion) Middle (abduction) Posterior (extension, Hor. ABD, ER) Triceps brachii long head (extension, adduction) Biceps brachii (flexion) Teres major (IR, ADD, and extension) Rotator cuff muscles (stabilization of head in glenoid) Supraspinatus (abduction and some ER) Infraspinatus (ER & some assistance in Hor. ABD) Teres minor (ER & some assistance in Hor. ABD) Subscapularis (IR)

Clavicular Fracture

Diaphysis of the clavicle, distal aspect is inferior to the proxminal *can be life threatening - why we palpate first* Deformity & Asymmetry: May notice an indentation at diaphysis of the clavicle Repair: Surgery, if can't fuse together by using the sling.

Load and Shift Test

Don't angle the humerus, just go front or back Looking for any laxity compared bilaterally or translation between humoral head and glenoid fossa *make sure patient is relaxed and sitting straight *1st test should be the best test, so the muscles don't start to guard and the patient becomes apprehensive to prevent injury to themselves *used for actual GH ligament sprain Patient position: standing, sitting or supine with affected side hand on thigh Examiner position: posterolateral to patient Hand #1 - superior aspect stabilizing clavicle and scapula Hand #2 - thumb on posterior and fingers on anterior humeral head Patient action: passive Examiner action: "load" - pushing into glenoid fossa (remember scapular plane) "shift" - glides head anterior and/or posterior Positive: excessive motion at GH joint >25% of humeral head diameter anteriorly = abnormal >50% of humeral head diameter posteriorly = abnormal Pathology: GH ligament sprain (anterior and/or posterior)

Scapular Dyskinesis

Etiology: Abnormal movement of the scapula SICK scapula: classify an abnormal scapular function, can be on one and not the other - Scapular malposition - should be T3-T7, inferior angle should be in line with the superior angle - Inferior medial scapular winging - medial border or inferior angle sticking out at you in relaxed position - Coracoid tenderness - tender coracoid process, signal improper biomechanics and pectoralis minor could pull the scapula anteriorly and coracoid process down. - Kinesis abnormalities of the scapula - movement of scapular ROM and GH motion, if Scapula isn't going along with GH Occurs due to: - repetitive (overhead) use/fatigue, often in overhead athletes - Muscle strain or tense pectoralis muscles - Tense pectoralis major - Changes are detrimental to normal function and increase risk of injury Type I Inferior medial scapular border prominence; tends to be associated w/labral tears Type II Medial scapular border prominence; tends to be associated w/labral tears Type III Superior medial scapular border prominence; tends to be associated with impingement syndrome & rotator cuff lesions

GH joint

Glenohumeral joint (GH joint) Three true degrees of freedom Flexion/extension, ABD/ADD, IR/ER Also allows horizontal flexion/extension, circumduction, & elevation Ligamentous anatomy Glenohumeral ligaments (capsular thickenings) Superior GH ligament Middle GH ligament Inferior GH ligament (thickest) Coracohumeral ligament Coracoacromial Ligament* Transverse Humeral Ligament*

GH anterior dislocation

Glenohumeral joint (anterior or subcoracoid) Mechanism - excessive abduction, external rotation, anterior force on humeral head (forced hor. ABD) Etiology - wide variety Pathology - anterior capsule sprain Most common type of GH dislocation Beware of axillary nerve/artery pathology Related pathology: Hill-Sachs lesion Bankart lesion SLAP tear *reach for something above you

GH inferior dislocation

Glenohumeral joint (inferior or subglenoid) Mechanism - forced abduction Etiology - varied Pathology - inferior capsule sprain Look for flatted deltoid *one clear cut dislocation that occurs

GH posterior dislocation

Glenohumeral joint (posterior) Mechanism - axial load w/humerus in flexion Etiology - Forced ADD & IR or FOOSH w/IR Pathology - posterior capsule sprain Related pathology Reverse Hill-Sachs lesion *Similar signs and symptoms and MOI as anterior

Skeltal Anatomy

Humerus (proximal) Landmarks Head Greater tubercle (ant. lat.) Sup., Middle, & Inf. Facets Lesser tubercle (ant. med.) Bicipital groove (between tubes) Anatomical neck (proximal to tubes) Surgical neck (distal to tubes) Diaphysis Ant., Med., & Lat. Border Post., Lat., & Med. Surface Deltoid Tuberosity

MDI

Multi-diagnosis Combination of two or more unidirectional instabilities Chronic, insidious onset most often mimics anterior instability Congenital, repetitive overhead movements, or traumatic Inferior laxity, pain and clicking w/ arm at side, possible S&S associated w/ anterior and posterior instability Missing MDI may worsen condition if only one instability is treated

Yocum's Test

Neer & Hawkins-Kennedy Modification the patient is asked to place the hand on his or her other shoulder and to raise the elbow without elevating the shoulder. The test is positive when they elicit the pain in the shoulder.

Scapula Facts

Not a true joint - called the Scapulothoracic articulation (ST), no ligamentous attachment directly to the axial skeleton, only attachments are muscular Three degrees of freedom: ROM Elevation/depression Protraction/retraction Upward/downward rotation Very important to normal shoulder mechanics Produces movement at AC and SC joints & vice versa "Scapulohumeral Rhythm" - connection between scapular and GH movement Not consistent or smooth 2:1 ratio of GH movement to ST in shoulder abduction 180° Total 120° from GH and 60° from ST To 30˚, zero scapular movement 30-90˚ = Disagreement among sources Scapula abducts & upwardly rotates 1˚for every 2˚ of humeral elevation 1˚ to 1˚ 90˚-Full = Disagreement among sources 1˚ to 1˚ 2˚ to 1˚ ST motions separated into contributions from SC joint and AC joint Clavicle must elevate ~40˚ & rotate posteriorly 10˚ If scapula isn't moving with the GH joint, big issue

Biceps Tendonitis/synovitis

Often occurs w/rotator cuff tendinitis Usually associated w/repeated stretching of biceps Pitching, serving (volleyball & tennis), throwing javelin May result from: Rotator cuff dysfunction Overuse Impingement of supraspinatus which causes more compression of the biceps Hard to distinguish where the region is because its in the shoulder area MOI is very important in this case

Yergasion's Test

Patient position: seated or standing Shoulder in anatomical position Elbow flexed to 90° Forearm pronated or in neutral position Examiner position: anterolateral to patient Hand #1 - Stabilize olecranon process inferiorly & maintain next to thorax Hand #2 - distal forearm stabilizing wrist Modification: Hand #1 - stabilize shoulder w/palpation of bicipital groove Patient Action: External rotation of shoulder Flexion of elbow Forearm supination Examiner Action: Resist patient action Positive: pain and/or snapping at bicipital groove Pathology: subluxing biceps tendon or bicipital tendinitis Modification: Examiner moves patient through ROM while patient resists action

Hawkins-Kennedy Impingement Test

Patient position: seated or standing in anatomical position (palms forward) Examiner position: anterolateral to patient Hand #1 - distal humerus/elbow Hand #2 - distal forearm Action: Passive flexion of shoulder and elbow to 90° May start by performing in scaption Followed by forced internal shoulder rotation (bring wrist down), passively bring patient into IR Positive: pain, apprehension by patient, inability to move, etc. Pathology: impingement of supraspinatus May be impingement of biceps tendon May be false positive from AC Joint pathology (might also have to do an AC test to make sure there is no AC involvement)

Neer Impingement Test

Patient position: seated or standing in anatomical position (palms forward) Examiner position: anterolateral to patient Hand #1 - stabilize posterior shoulder Hand #2 - forearm Action: forearm pronation, IR & forced passive flexion of shoulder, palmar part of hand posteriorly - trying to enclose the arch, bringing arm near the ear Positive: pain, apprehension by patient's face, inability to move into the position, may replicate the neurological S&S, etc. Pathology: impingement (supraspinatus, subacromial bursa, biceps tendon) Modifications: Perform actively

Apley's Scratch Test

Patient position: standing erect Examiner position: variable (anterior, lateral, or posterior) Patient action UE#1 - internal rotation, adduction, and extension UE#2 - external rotation, abduction, and flexion Work on the serratus anterior as well

Empty Can Test or Supraspinatus Test (Jobe Test)

Patient position: standing or seated Examiner position: anterior to patient Patient action: Abduction to 90° (may or may not be w/examiner resistance) Internal rotation and flexion of 30° (scapular plane) Thumb down Examiner action: Isometric manual resistance to abduction Positive: weakness and/or pain with resistance Pathology: supraspinatus impingement, inflammation, or lesion/strain, Test for strain of RC and impingement syndrome of supraspinatus and integrity for the supraspinatus muscle (can't rule out one or the other cause it tests for both) *Break test - provide resistance through one point in the ROM

Gerber Lift Off Test

Patient position: standing with dorsum of hand on lumbosacral joint Examiner position: lateral to patient Patient action: Active extension of arm ("lift hand off back") Examiner action: Nothing Modification: Resistance to patient's palm Positive: weakness and/or pain with inability to lift hand off back Pathology: subscapularis strain/weakness *Making the patient go into more internal rotation

Speed Test

Patient position: standing/sitting in anatomical position (palms forward) Examiner position: anterior or lateral to patient Hand #1 - stabilize shoulder w/palpation of bicipital groove to determine if long head of the bicep is popping out or staying in line Hand #2 - distal and anterior forearm Action: resist active flexion of shoulder Positive: pain and/or tenderness at bicipital groove Pathology: bicipital tendinitis (tenosynovitis) May also indicate tear of transverse humeral ligament Modifications: Pronate forearm and perform eccentrically through full ROM; Full ROM Eccentric Test in supination; Full ROM concentrically w/forearm pronation When trying to figure out if muscle is strained or subluxed

Clunk Test

Patient position: supine Examiner position: superior and lateral to patient Hand #1 - under posterior aspect of humeral head Hand #2 - distal arm or elbow Patient Action: passive Examiner Action Full humeral abduction at shoulder Anterior glide of humeral head by hand #1 Lateral rotation of humerus by hand #2 Positive: crepitus or "clunk" at GH joint Pathology: labral lesion

posterior apprehension test

Patient position: supine (edge of exam table) Shoulder and elbow flexed to 90° GH Joint being tested off to side of table Examiner position: lateral to patient Hand #1 - distal humerus or elbow Hand #2 - stabilize posterior scapula Patient action: passive Examiner action: Gentle but firm posterior axial pressure at elbow Modification: Alter degrees of flexion Simultaneous slow medial rotation of shoulder Simultaneous horizontal adduction Positive: apprehension and/or pain Pathology: GH ligament and/or capsule sprain (posterior) May also indicate posterior labrum tear *make sure that patient's shoulder is off the treatment table and feel for gapping or laxity underneath it

Apprehension Test/Crank Test

Patient position: supine preferred (edge of exam table) GH Joint ABD to 90° & elbow flexed to 90° Examiner position: lateral to patient Hand #1 - distal humerus or elbow Hand #2 - distal forearm or wrist Patient action: passive Examiner action: Support shoulder at 90° ABD Slow external rotation of shoulder Modification - anterior force on posterior humeral head to ↑ translation Positive: look or action of apprehension by patient Pain centered in anterior capsule Pathology: Anterior capsule, inferior GH ligament, or glenoid labrum has been compromised Humeral head has potentially previously dislocated/subluxated Do NOT perform is this assessment is obvious *Pain isn't the best indicator, look for apprehension in the face and aggrivation * Always do with the relocation test

Grind Test

Patient position: supine w/shoulder ABD to 90˚ & elbow flexed to 90˚ Examiner position: lateral to patient Hand #1 - proximal humerus Hand #2 - distal arm or elbow Patient Action: passive Examiner Action Apply compression to glenoid labrum Rotate humeral head 360˚ around glenoid fossa surface Be careful not to cause more damage Positive: grinding, crepitus or "clunk" at GH joint Pathology: labral lesion Modifications: Place both hands on proximal humerus & use body to apply compression Compression Rotation Test (see next slide)

Axio-humeral muscles

Pectoralis major (ADD, Hor. ADD, and IR) Latissimus dorsi (ADD, IR, extension)

posterior glenohumeral instability

Posterior Rare (~3% of all instability) Usually chronic Overhead movements or secondary trauma from repeated blows on forward flexed shoulder (blocking) Shoulder feels loose when brought across body Results from: Weakness of subscapularis muscle (primary)

Scapula

Scapula 2nd bone to ossify (8th week gestation) Located between Ribs 2-7 No direct bony or ligamentous attachments Articulates w/clavicle & humerus Held against torso by muscle attachment & atmospheric pressure Functions as both a pulley and lever Body Subscapular fossa Medial (vertebral) border Lateral (axillary) border Superior Border Inferior angle Superior angle Lateral Angle Supraspinous fossa Infraspinous fossa Subscapular Facet Greater Scapular Notch Suprascapular Notch Spine of scapula Crest, Sup. & Inf. Lips Acromion process Clavicular Facet Coracoid process Glenoid fossa Smaller than head of humerus Sup. & Inf. Glenoid Tubercles Labrum Remnants of capsular fold Continuous with the articular cartilage of the glenoid

Scapulothoracic articulation (ST)

Scapulothoracic articulation (ST) "Scapulohumeral Rhythm" Not a true joint Three degrees of freedom Elevation/depression Protraction/retraction Upward/downward rotation Very important to normal shoulder mechanics Produces movement at AC and SC joints & vice versa Not consistent or smooth 2:1 ratio of GH movement to ST in shoulder abduction 180° Total → 120° from GH and 60° from ST To 30˚, zero scapular movement 30-90˚ = Disagreement among sources Scapula abducts & upwardly rotates 1˚for every 2˚ of humeral elevation 1˚ to 1˚ 90˚-Full = Disagreement among sources 1˚ to 1˚ 2˚ to 1˚ ST motions separated into contributions from SC joint and AC joint Clavicle must elevate ~40˚ & rotate posteriorly 10˚

SC Dislocation

Sternoclavicular joint dislocation, medial/proximial aspect of the clavicle is poking forward. Posterior, anterior, or superior (anterior is about 10x's more likely than posterior The posterior dislocation is more severe, going more deep into the actual body, can be life threatening to the trachea, esophagus and subclavian veins and arteries in this area. We start palpation here to rule out this problem because it's so important. There can be referred pain to the shoulder because there are nerves connected to this bone. Observe & Palpate S&S: lack of blood flow down to the hand, numbness to hand, weakness or lack of muscular control to the arm, may complain of dizziness or nausea, patient could pass out, dyspnea, dysohagia MOI: FOOSH, Compression Repair: surgery Sternoclavicular joint May be superior, posterior or anterior Anterior about 10x's more likely than posterior Posterior Dislocations Possibly life threatening due to compression of trachea, subclavian artery, subclavian vein, & esophogus Unstable or irreducible dislocations require surgery Dizziness, nausea, dyspnea, dysphagia, neurovascular symptoms, shoulder pain, etc.

Sternum

Sternum Manubrium Jugular/Sternal notch Clavicular notches Costal Facets (Ribs 1 &2) Sternal Angle Body Costal Facets (Ribs 2-7) Xiphoid process Spine & Ribcage??

Biceps bursitis

Subacromial bursa - protect the joint and associated with the tendon which wraps around the bursa, prevents tendon from being right on the bone and fraying, bursa can be inflammed and can be multiple injuries Acute: direct trauma to site Impingement syndrome Direct trauma or overuse (chronic - where tendon is constantly rubbing on the structures in the capsule, causing inflammation to capsule) Usually occurs secondary to RC impingement

Blood Supply

Subclavian Artery Becomes axillary artery inferior border of first rib Axillary Artery Becomes brachial artery at inferior border of teres major

Bursae

Subdeltoid bursa Under deltoid muscle Protects deltoid from greater tuberosity Subacromial bursa Under acromion Protects supraspinatus tendon Subcorocoid bursa Under coracoid process Protects subscapularis tendon Subscapular bursa Under neck of scapula Protects subscapularis tendon

SLAP tear

Superior labrum - anterior & posterior to biceps insertion 4 classifications Type I: RC degeneration and/or fraying at LHBT Type II: Avulsion tear associated w/associated LHBT damage Complete detachment Tear can be anterior, posterior, or both Type III: Bucket handle tear w/displacement. No damage to LHBT Type IV: Bucket-handle tear w/tearing of LHBT Will lead to increased strain/stress on GH ligaments May be acute or chronic MOI: FOOSH or GH instability or overhead athletes Decreased ability to withstand rotational forces Clicking, catching, pain increasing w/ABD & ER

Joint Range of Motion Tests

Test AROM, PROM, and RROM Test all GH motions: flexion, extension, Abduction, horizontal abduction and adduction, adduction, internal and external rotation Need to assess for some ROM with scapular movements, Must know Active ROM for Scapula (OP) Scapula motions: protraction and retraction, elevation and depression Will have to know all ROM for GH joint Assess ROM at GH, AC, and SC joints When someone has a lot of ER, they have a lack of IR and vice versa Be aware of sport differences Tennis player produces more IR strength in dominant arm Active JROM Dominant arm often has decreased JROM because they have more musculature and dynamic stability and lack mobility Watch for "painful arc" in motion and/or "cheating" - have them sit up straight and have proper motion

Shoulder Girdle ligaments

Stability Gained statically by the capsule, capsular ligaments and glenoid labrum, and dynamically by the deltoid and rotator cuff muscles.

Glenohumoral Joint Continuum

Stability vs. Mobility, as you give up stability you gain mobility and vice versa Stable: keeps GH joint in place Mobility: laxity at GH joint and GH ligaments

Reverse Hill-Sachs lesion

Osteochondral fx of anterior humeral head

Hill-Sachs lesion

Osteochondral fx of posterior humeral head Usually occur w/anterior GH dislocation

O'Brian's Test

Patient position: seated or standing GH joint flexed to 90º and Hz adducted 15º from front Full humeral internal rotation and pronated forearm Examiner position: anterior to patient One hand place over superior aspect of patient's distal forearm Patient Action: resists examiner's downward force Examiner Action Pushes downward on forearm Test repeated with humerus externally rotated and forearm supinated Positive: Pain experienced with arm in internal rotation but is decreased during external rotation Pathology: SLAP lesion Be aware of "popping" at AC Joint Rotator cuff pathology may give false positive

Wall Push up Test

Patient position: standing arms length from wall Examiner position: posterior & lateral to patient Examiner action: Asks patient to do a "wall push-up" 15 to 20 times Patient action: Patient performs push-ups against wall Younger & stronger patients may perform normal push-ups Positive: vertebral border of scapula lifts off the thorax Usually in 5-10 reps Pathology: serratus anterior muscle weakness Long Thoracic Nerve Injury

Anterior & Posterior Drawer Test

* can get a positive for anterior and posterior GH sprain or anterior and posteriorinstability - can only use this test to rule in, not rule out Stabilizing the proximal end of the joint and pulling/pushing the distal segment of that joint * Don't leave the drawer open, always close the drawer

Relocation Test

* performed if apprehension test is positive, designed to correct the apprehension test, relocate humoral head back to the stable position and looking for a decrease in pain from the apprehension test Patient position: supine (edge of exam table) Shoulder at 90° ABD, and elbow flexed to 90° Examiner position: lateral to patient Hand #1 - distal humerus or elbow Hand #2 - distal forearm or wrist Patient action: passive Examiner action: Slow external rotation of shoulder until pain or apprehension is felt Posterior stress is then applied to anterior side humeral head Mod. - Apply pressure through ROM & release = "Surprise Test" Positive: apprehension decreases with posterior stress Pathology: GH ligament sprain (anterior) or capsular laxity Posterior pain may indicate impingement of posterior capsule or larbum *Surprise Test: relocation test and keep in external location and lift the other hand, the humeral head might pop up and make S&S worse, always bringing the joint back to it's original position

Bankart Lesion

Avulsion of the glenoid labrum at its attachment to IGHL Usually found in 2 to 6 o'clock in right shoulder & 6 to 10 o'clock position in left shoulder Often to result from ant. shoulder dislocation Often the primary lesion in recurrent anterior instability Difficult to identify S&S: Pain or crepitus as humeral head moves on anterior labrum Anterior-Inferior humeral head translation May have pain w/ER

Glenohumeral instability (anterior)

anterior: laxity of anterior structures, may result in bankart lesion, often chromic without mechanism or injury, diffuse pain, "loose shoulder", may have clicking or pain, complain of dead arm during cocking phase when throwing, feel when they reach out or up with over 90 degrees of flexion or hang onto something high, pain posteriorly, possible impingement

Neer Impingement Test Modification

pt in sitting or standing. PT positions one hand on the posterior aspect of the patient's scapula and the other hand stabilizing the elbow. PT passively IR the shoulder f/b full shoulder ABD. (+) facial grimace or pain. Indicates shoulder impingement involving the supraspinatus tendon and long head of the biceps.

Step Deformity

Always look for this AC dislocation, seen at rest, it indicates both the AC and Coracoclavicular ligament are torn

anterior glenohumeral instability

Anterior Laxity of anterior structures May result in Bankart Lesion** Often chronic w/out mechanism of injury Diffuse pain, "loose shoulder" May have clicking or pain, complain of dead arm during cocking phase (when throwing), pain posteriorly, possible impingement

Neurological Anatomy

Brachial plexus C5-T1 5 roots 3 trunks 6 divisions 3 anterior 3 posterior 3 cords 5 terminal branches

Clavicle

Clavicle "Collarbone" Slender, S-shaped bone articulating w/sternum & scapula Placed horizontally above first rib Helps maintain alignment of scapula Anchors UE to axial skeleton Long bone w/no medullary cavity First bone to ossify (7th week gestation) Subclavian groove Medial 2/3 - convex curve anteriorly - more cylidrical Lateral 1/3 - concave curve anteriorly - more flat Structural Weakness? Medial Epiphysis Last growth plate to ossify at ~25

Drop Arm Test or Codman's Test

Consider patient weakness and inability to move through the painful arc area. Patient position: standing or seated Examiner position: anterior or lateral to patient Patient action: passive shoulder abduction THEN Can perform actively Examiner action: Asks patient to slowly lower arm to anatomical position (added resistance as needed - may use break test at 90˚ ABD) Positive: inability to return arm to side slowly or severe pain, or weakness or lack of control in this painful arc area Pathology: Tear of the rotator cuff complex Usually supraspinatus tendon Modification: Patient performs test actively

AC Compression Test

Direct Blows or constant overhead movement, push on the clavicle and stabilize at posterior aspect of the scapula so clavicle goes posteriorly while scapular goes anteriorly Looking for gapping or laxity between AC joint Patient position: standing or seated w/arm at side Examiner position: lateral to patient Hands - cupping the AC joint with interlocking fingers Heel on distal clavicle with fingers over the AC Heel on scapular spine with fingers over the AC Patient action: passive Examiner action: gentle squeezing heels together Positive: excessive motion at AC joint, pain, increase in symptoms Pathology: AC ligament sprain Possible CC ligament damage

Thoracohumeral Muscles

Latissimus Dorsi, Pectoralis Major

AC traction test (for AC joint)

PP: standing or seated w/ arm hanging to side EP: anteriolateral to patient PA: passive EA: Hand #1 - gently palpates AC joint Hand #2 - firm traction of distal humerus H1 - gently palpates AC joint H2 - firm traction of distal humerus, pull down on humerus, start gently then increase +: excessive motion at AC joint, looking for separation of AC and clavicle Pathology: AC ligament sprain (AC and/or CC ligs) May want to refer for x-ray to rule out clavicle fracture

Anterior Drawer

Patient Position: Supine w/arm ABD to 80˚, 10˚ of Hor. ADD, and 10˚ of ER Examiner Position: lateral to patient Patient Action: passive Examiner Action: Hand #1: stabilize scapula & clavicle Hand #2: glide humeral head anteriorly w/slight distraction Positive: pain or laxity Pathology: Anterior GH Instability Modification: Perform w/patient prone

Posterior Drawer

Patient Position: Supine w/arm ABD to 90˚, 20˚ of Hor. ADD, and elbow flexed to 90˚ Examiner Position: lateral to patient Patient Action: passive Examiner Action: Hand #1: stabilize scapula & clavicle Hand #2: glide humeral head posteriorly w/slight IR Positive: pain or laxity Pathology: Posterior GH Instability Modification: Push-Pull Test

Anterior Slide Test

Patient position: seated or standing with hands on hips (thumbs posterior) Examiner position: posterior to patient Hand #1 - stabilizing scapula and clavicle Hand #2 - distal arm or elbow Patient Action: passive Examiner Action Stabilize shoulder with hand #1 Anterior/superior force at elbow with hand #2 Positive: crepitus, pop, or crack at GH joint Pathology: labral tear (SLAP lesion)

Labral Tear

Predisposing Conditions: Capsular laxity, general hypermobility, etc. Can be tearing or actual detachment from the glenoid Detachment: Bankart Lesion or SLAP Lesion Types (Terry, et al.): Transverse, longitudinal, flap, horizontal, cleavage, & fibrillated Location: Sup. Ant. most common; followed by Sup. Post. 90/90 Position in throwing athletes Leads to repeated anterior translation of humeral head Tests: Anterior Slide Test, Clunk Test, Grind Test, O'Brian's Test

Rotator Cuff Muscles

Rotator cuff muscles: SITS, Supraspinatus, Infraspinatus, Teres Minor, Subscapularis Functions: Holds head of humerus in glenoid fossa, Rotation of humerus on long axis, Protects shoulder joint via common musculotendinous sheath, Stabilizes shoulder joint in every direction EXCEPT inferiorly, Acts as extensile ligament for shoulder motions Rotator Cuff Problems: Rupture of rotator cuff muscles Calcification of tendons Humeral subluxation or dislocation Superiorly: stabilized by supraspinatus & coracoacromial arch Posteriorly: stabilized by infraspinatus & teres minor Anteriorly: stabilized by subscapularis Inferiorly: NO muscular support S&S: patient may complain of pain all over their shoulder with any of these pathologies ROM: Internal and external rotation

Thoracoscapular Muscles

Trapezius, Levator Scapulae, Rhomboid Minor, Rhomboiud Major, Serratus Anterior, Pectoralis Minor, Subclavius

Clinical Anatomy

Very complicated region Numerous and varied structures Bones, tendons, muscles, nerves, ligaments, bursae, etc. Highly maneuverable 16,000 positions differentiated in 1˚ increments Combination of four articulations Can be debilitating due to inability to properly use hand(s) Injuries from: Direct force/trauma Secondary forces transmitted proximally Overuse - predisposition w/overhead movements Connection of axial skeleton to upper extremity Only at SC Joint

Drop Arm Test

Very high specificity, but low sensitivity (patient could show false positive) Use to rule in, but not rule out Clinical Prediction (Walton & Murrell, Clinical Tests Diagnostic for Rotator Cuff Tear, 2012): In patients under the age of 60, RC Tear likely if these 3 signs are present: Positive Empty Can Test Weakness in ER Internal impingement (Hawkins-Kennedy) and/or external impingement

MDI: multidirectional instability

combination of two or more unidirectional instabilities, their signs and symptoms can be of someone who only has one instability - so test in each category Chronic, insidious onset most often mimics anterior instability, congenital, repetitive overhead movements or traumatic Inferior laxity, pain, and clicking with arm at the side, possible S&S associated with anterior and posterior instability Missing MDI may worsen condition if only one instability is treated

glenohumeral instability (inferior)

primary restraint depends on humeral position, may increase with rotator cuff tears, ROM: more pain with abduction and drop in humeral head, neutral tests superior GH ligament, ADB test inferior GH ligament

GH joint sprain

uncommon unless dislocation. subluxation occurs MOI: longitudinal force on clavicle Etiology: FOOSH or tip of shoulder, may be caused by traction forces, if athlete is suspended by arms Path: stretch or tear of SC ligs or costoclavicular ligs May lead to dislocation: anterior, superior, posterior

Rotator Cuff Strain

Strain Mechanism - dynamic overload, repetitive microtrauma, and ballistic overstretch Etiology - Impingement (area compressed where muscle is going through clavicle and scapula which can lead to a strain) (primary, secondary, undersurface), bone spurs (extra bony outgrowth, predispose to rotator cuff strains and provide microtears to the RC), tensile overload (stretched beyond its limit), traumatic tendon failure Pathology - stretch or tear (tensile) of any of the four muscles Supraspinatus most common Common in athletes; especially overhead athletes (baseball, external and internal rotation) Can be very debilitating and long lasting Cause can be either concentric or eccentric contraction * ROM key during this time to rule in or rule out Tears may be acute or chronic Chronic are more common (usually in older adults) Can present w/out any pain Can be caused by acquired or congenital bony structure May be Partial-thickness or Full-Thickness Full: May be from single traumatic force or untreated partial tear Acromial Architecture: info can be taken once strain happens, describe the distal aspect of the acromion Type I - Flat, wouldn't affect any muscles passing into clavicle and scapula hole Type II - Curved Type III - Hooked, can cause tearing at muscle innervation site. When physician goes into complete tears: (speaking mostly of supraspinatous) 70% of shoulder w/full thickness tears had this type in one study (cadaver study - Bigliani, et al., 1991) 80% had this type in another study (patients using MRI - Zuckerman, et al., 1992) Strain: Grade 1-3 (less severe/pain-full tear)

Scapulaohumeral Muscles

Subscapularis, Supraspinatus, Infraspinatus, Teres Minor, Teres Major, Deltoid, Coracobrachialis

Tendonitis/osis

Usually slow onset of symptoms, chronic Gradual progression of pain until it affects ADLs (predisposing) Contributing factors: Muscle imbalance between IRs (stonger) and ERs (weaker) (or vice versa) Capsular laxity, GH instability Poor scapular control Impingement Syndrome Acromion Shape (Box 13-18)

Compression Rotation Test: Modification for Grind Test

just like the crank, but done @ 20 degrees abduction

glenohumeral instability (posterior)

rare (3% of instability), usually chronic, overhead movements or secondary trauma from repeated blows on forward flexed shoulder (blocking), shoulder feels loose when brought across body, full external rotation feels as if the arm will pop out, results from weakness of subscapularis (primary)

Piano Key Test

* Doesn't have the highest specificity or Patient position: standing or seated Ex Position: anterior or lateral to patient Patient action: passive Examiner action: pushing down on clavicle, rule out SC separation or a clavicular fracture, start proximal and make your way distal, and hard enough to see or feel a separation at AC joint, looking for separation of clavicle and acromion process Hand #1: gentle stabilization of humoral head Hand #2: push down on the clavicle Hand #2 - inferior mobilization of clavicle (piano key) Positive: excessive motion at AC joint, pain, increase in symptoms Pathology: AC ligament sprain (AC and/or CC ligs) Modification: "Tap" on clavicle (Fx Test)

Sulcus Sign

*looks like the AC traction test, everything the same besides the hand placement Palpating at the humeral head for indentation and GH joint, looking for inferior instability, capsule is loose and humeral head will slip down and you see an indentation occurring Popping or clicking sound