Shoulder joint Assessment and General View Done by; Mshari S. Alghadier BSc Physical Therapy RHPT 366 m.alghadier@sau.edu.sa http://faculty.sau.edu.sa/m.alghadier/
Functional anatomy The shoulder contains of four articulations: The sternoclavicular. The acromioclavicular. The scapulothoracic. The glenohumeral. The articulations work in synchrony, not isolation. The pathology of any single articulation will have significant adverse consequences on the functioning of the other remaining articulations and the entire upper extremity. 2
Functional anatomy The entire upper extremity is attached to the torso through the small sternoclavicular articulation. There is limited movement with outstanding load on the upper extremity. That s why its common observe osteoarthritic degeneration of this joint, associated with significant soft-tissue swelling and osteophyte formation. The acromioclavicular joint, like the sternoclavicular, is a small synovial articulation that has limited range of motion and frequently undergoes osteoarthritic degeneration. 3
Functional anatomy 4
Functional anatomy The scapulothoracic articulation is a nonsynovial articulation. It is composed of the broad, flat, triangular scapula overlying the thoracic cage and is separated from the thoracic cage by a large bursa. The scapulothoracic articulation serves to supplement the large ball-and-socket articulation of the true shoulder joint. 5
Scapulothoracic joint 6
Functional anatomy The glenohumeral joint, or shoulder joint, is a shallow balland-socket articulation. Huge freedom of movement. Which cause instability. The glenoid is so shallow that the ball (humeral head), if unprotected, can easily slip inferiorly out of the socket, creating a shoulder dislocation. 7
Functional anatomy 8
Functional anatomy This is prevented by soft tissues; Anteriorly, there is the subscapularis tendon. Superiorly, there are the tendons of the supraspinatus and long head of the biceps. Posteriorly are the tendons of the infraspinatus and teres minor muscles. 9
Functional anatomy These tendons surround the humeral head, forming a cuff, and the corresponding muscles are responsible for rotating the humeral head within the glenoid socket. Rotator cuff; stabilize the humeral head within the glenoid socket. 10
Functional anatomy 11
Functional anatomy 12
Functional anatomy The rotator cuff does not extend to the inferior (axillary) aspect of the glenohumeral articulation. Inferior glenohumeral ligament the strongest. The biceps is the only part of the rotator cuff that depresses the humeral head. 13
Functional anatomy To reduce friction, there is a bursal sac, the subacromial bursa, positioned between the tendons below and the roof above. The subacromial space can be absolutely narrowed by; Osteophytes extending inferiorly from the clavicle, acromion, or acromioclavicular joint. Swelling of the soft tissues within the space (i.e., bursitis and tendinitis). 14
Bursa! 15
Functional anatomy The swelling may be due to acute injury or chronic overuse syndrome. The result is insufficient space for the free passage of the rotator cuff beneath the coracoacromial arch. This creates a painful pinching of the tissues between the roof above and the humeral head below. This is called an impingement syndrome. 16
Functional anatomy This syndrome can result in compensate for the loss of glenohumeral motion with scapulothoracic movement. Stress on the cervical spine can be produced due to muscular effort. Biceps tendon inflammation, will cause the humeral head to dropped after the tear is occurred in the tendon. Biceps inflammation à Tear à Drop humeral head. 17
The cycle can be produced Pain Guarded ROM Upper Extremity Dysfuncti on 18
Observation Posture; While the patient waiting in the waiting room. While he is walking into your clinic. Observe the patient standing position. Ask yourself some question about what do you see? 19
Subjective examination The shoulder is non-weight-bearing; therefore, problems are most commonly related to overuse syndromes, inflammation, and trauma. You should inquire about the Nature and location of the patient s complaints. Duration and intensity of the pain. Behavior of the pain during the day and night. Note if the pain travels below the elbow, this may be cervical spine origin. 20
Subjective examination Functional limitation should be monitored. If its about trauma, the mechanism of injury should be asked about. Previous history of the same injury. It is important to inquire about any change in daily routine and any unusual activities in which the patient has participated. The location of the symptoms may give you some insight as to the etiology of the complaints. 21
Gentle palpation The palpatory examination is started with the patient in the supine position. You should first examine for areas of; localized effusion, discoloration, birthmarks, open sinuses or drainage, incisions, bony contours, muscle girth and symmetry, and skinfolds. Use firm and gentle pressure to allocate the malposition or deformities. If you harm the Pt in this part of examination the Pt will be afraid and you ll lose his confidence. 22
Gentle palpation A. Anterior aspect; 1. Bony structures; Suprasternal notch. Sternoclavicular joint (SC). Clavicle. Acromioclavicular joint (AC). Acromion process. Greater tuberosity of the humerus. Coracoid process. Biciptial groove. 23
Gentle palpation 2. Soft tissue structures; Sternoclaisomastoid. Trapezius. Pectoralis major. Deltoid. Biceps. 24
Gentle palpation B. Posterior aspect; 1. Bony structures; Spine of the Scapula. Medial (Vertebral) Border of the Scapula. Lateral Border of the Scapula. 2. Soft tissue structures; Rhomboideus Major and Minor. Latissimus Dorsi. 25
Gentle palpation C. Medial aspect; 1. Soft tissue structures; Axilla. Serratus Anterior. D. Lateral aspect; 1. Soft tissue structures; Rotator cuff. Subacromial (Subdeltoid) Bursa. 26
Special tests A. Tests for structural stability and integrity; 1. Anterior instability tests; Anterior instability test (Rockwood Test). Apprehension test for anterior shoulder dislocation (Crank Test). 2. Posterior instability test; Oisterior drawer test of the shoulder. 3. Inferior instability test; Feagin test. Sulcus sign. 4. Multidirectional instability tests; Multidirectoinal instability test. Rowe multidirectional instability test. 27
Special tests B. Tests for labral tears; Clunk test. C. SLAP lesions; 1. Biceps Tension Test. 2. Biceps Lesion Test. 3. Active Compression Test of O Brien. 4. SLAP prehension test. 28
Special tests D. Tests for the Acromioclavicular joint; 1. Cross flexion test. 2. Acromioclavicular shear test. E. Scapula stability test; 1. Wall push-up test. F. Test for tendinous pathology; 1. Yergason s Test of the Biceps. 2. Speed s Test of the Biceps. 29
Special tests G. Tests for Imprngement of the Supraspinatus Tendon; 1. Hawkins-Kennedy supraspinatus impingement test. 2. Yocum test 3. Neer impingiment test. 4. Supraspinatus test (Empty Can Test). 30
Special tests H. Tests for Muscle Pathology; 1. Drop arm test. 2. Lift off Test (Gerber s Test). 3. Lateral Rotation Lag Sign (Infraspinatus Spring Back Test). 4. Hornblower s Sign. I. Test for Thoracic Outlet Syndrome; 1. Adson s Maneuver. 2. Wright s test. 3. Roos test. 31
Want to do! 1. Shoulder girdle. 2. Impingement syndrome. 3. Frozen shoulder. 4. Shoulder dislocation. 5. Thoracic outlet syndrome. 32
Thank you 33
References, Musculoskeletal Examination, 3rd Edition Jeffrey M. Gross, chapter 8. Orthopedic Physical Assessment, 5th edition, David J. Magee, chapter 5. 34