KIN 191B – Advanced Assessment of Upper  Extremity Injuries Shoulder Anatomy and Evaluation
Sternum <ul><li>Manubrium – attachment site for clavicle </li></ul><ul><ul><li>Jugular notch </li></ul></ul><ul><li>Body <...
Sternum
Clavicle
Humerus <ul><li>Head and neck </li></ul><ul><li>Greater tuberosity </li></ul><ul><li>Lesser tuberosity </li></ul><ul><li>B...
Humerus
Scapula <ul><li>Vertebral (medial), axillary (lateral) and superior border </li></ul><ul><li>Inferior and superior angles ...
Scapula
Plane of the Scapula <ul><li>In anatomic position, glenoid angles 30 degrees from frontal plane – this is the plane of the...
Sternoclavicular Joint <ul><li>Proximal clavicle and manubrium </li></ul><ul><li>Anterior and posterior SC ligaments </li>...
Sternoclavicular Joint
Acromioclavicular Joint <ul><li>Distal clavicle and acromion process </li></ul><ul><li>Superior and inferior AC ligaments ...
Acromioclavicular Joint
Glenohumeral Joint <ul><li>Glenohumeral ligaments (joint capsule) </li></ul><ul><ul><li>Superior, middle and inferior GH l...
Glenohumeral Joint
Glenoid Labrum
Scapulothoracic Articulation <ul><li>Not a synovial joint – no bony articulation </li></ul><ul><li>Articulation via muscul...
Muscular Anatomy <ul><li>Muscles acting on the scapula </li></ul><ul><ul><li>Rhomboid major/minor </li></ul></ul><ul><ul><...
Rhomboids <ul><li>O: major – T2-5 spinous processes, minor – C7, T1 spinous processes </li></ul><ul><li>I: vertebral (medi...
Levator Scapulae <ul><li>O: C1-4 transverse processes </li></ul><ul><li>I: superior angle of scapula </li></ul><ul><li>N: ...
Serratus Anterior <ul><li>O: anterior portion of ribs 1-8 </li></ul><ul><li>I: vertebral (medial) border of scapula from s...
Pectoralis Major <ul><li>O: clavicular head – medial half of clavicle, sternal head – lateral portion of sternum </li></ul...
Pectoralis Minor <ul><li>O: anterior portion of ribs 3-5 </li></ul><ul><li>I: coracoid process </li></ul><ul><li>N: latera...
Trapezius <ul><li>Upper fibers </li></ul><ul><ul><li>Base of occiput/upper cervical spinous processes to distal clavicle, ...
Latissimus Dorsi <ul><li>O: T6-12 spinous processes, thoracolumbar fascia, iliac crest </li></ul><ul><li>I: intertubercula...
Muscular Anatomy <ul><li>Muscles acting on the humerus </li></ul><ul><ul><li>Rotator cuff (SITS) </li></ul></ul><ul><ul><u...
Supraspinatus <ul><li>O: supraspinous fossa </li></ul><ul><li>I: greater tuberosity </li></ul><ul><li>N: suprascapular </l...
Infraspinatus <ul><li>O: infraspinous fossa </li></ul><ul><li>I: greater tuberosity </li></ul><ul><li>N: suprascapular </l...
Teres Minor <ul><li>O: axillary (lateral) border of scapula </li></ul><ul><li>I: greater tuberosity </li></ul><ul><li>N: a...
Subscapularis <ul><li>O: subscapular fossa </li></ul><ul><li>I: lesser tuberosity </li></ul><ul><li>N: upper and lower sub...
Deltoid <ul><li>Anterior fibers – distal clavicle, shoulder flexion, horizontal adduction and internal rotation </li></ul>...
Teres Major <ul><li>O: inferior angle of scapula, axillary (lateral) border of scapula </li></ul><ul><li>I: medial lip of ...
Triceps Brachii <ul><li>Long head – inferior glenoid rim/tuberosity </li></ul><ul><li>Lateral head – lateral and posterior...
Biceps Brachii <ul><li>Long head – superior glenoid rim/tuberosity </li></ul><ul><li>Short head – coracoid process </li></...
Transverse Humeral Ligament <ul><li>Bridges bicipital groove from greater to lesser tuberosity </li></ul><ul><li>Stabilize...
Coracobrachialis <ul><li>O: coracoid proces </li></ul><ul><li>I: medial humeral shaft </li></ul><ul><li>N: musculocutaneou...
Neurovascular Anatomy <ul><li>Neurological anatomy </li></ul><ul><ul><li>Brachial plexus review </li></ul></ul><ul><li>Vas...
Brachial Plexus
Vascular Supply
Bursae <ul><li>Subacromial bursa </li></ul><ul><li>Sits superior to rotator cuff tendons in subacromial space </li></ul><u...
Rotator Cuff Muscle Activity <ul><li>During shoulder (GH) abduction: </li></ul><ul><ul><li>At ~70 degrees, humeral head de...
Scapulothoracic Rhythym <ul><li>During first 30 degrees of GH abduction, scapular is “setting” – may have slight upward ro...
Location of Pain <ul><li>Localized pain in shoulder typically associated with localized injury </li></ul><ul><li>Pain radi...
Onset of Symptoms <ul><li>Acute onset </li></ul><ul><ul><li>Fracture, GH subluxation or dislocation, AC sprain </li></ul><...
Mechanism of Injury <ul><li>Direct trauma or forces </li></ul><ul><ul><li>Acute soft tissue and/or bony injury </li></ul><...
Current Symptoms <ul><li>Unusual sounds or sensations </li></ul><ul><li>Quantity and quality of pain, aggravating and alle...
History of Previous Injury <ul><li>Previous cervical spine injury can predispose individual to shoulder injury from neurol...
General Postural Assessment <ul><li>Head </li></ul><ul><ul><li>Lateral flexion or rotation may indicate muscle spasm and/o...
Anterior Structures <ul><li>Level of shoulders </li></ul><ul><ul><li>AC joints, SC joints, clavicle </li></ul></ul><ul><li...
Lateral Structures <ul><li>Deltoid contour (as before) </li></ul><ul><li>Acromion process </li></ul><ul><ul><li>“ step off...
Posterior Structures <ul><li>Vertebral alignment - scoliosis </li></ul><ul><li>Scapular position symmetry </li></ul><ul><u...
Palpation – Anterior Structures <ul><li>Jugular notch </li></ul><ul><li>SC joint </li></ul><ul><li>Clavicle </li></ul><ul>...
Palpation – Posterior Structures <ul><li>Spine of scapula </li></ul><ul><li>Superior angle </li></ul><ul><li>Inferior angl...
Special Tests <ul><li>Range of motion testing </li></ul><ul><ul><li>Active, passive and resistive ROM </li></ul></ul><ul><...
Active Ranges of Motion <ul><li>Flexion – 180 degrees </li></ul><ul><ul><li>Biceps brachii, coracobrachialis, anterior and...
Active Ranges of Motion <ul><li>Abduction – 180 degrees </li></ul><ul><ul><li>Deltoid, supraspinatus, biceps brachii </li>...
Active Ranges of Motion <ul><li>Internal rotation – limited by body in neutral position, 70-80 degrees at 90/90 </li></ul>...
Active Ranges of Motion <ul><li>Horizontal abduction – 45 degrees from plane of scapula at 90 degrees abduction </li></ul>...
Active Ranges of Motion <ul><li>Scapular protraction </li></ul><ul><ul><li>Serratus anterior, pectoralis minor </li></ul><...
Scapular Ranges of Motion
Apley’s Scratch Tests <ul><li>Touch opposite shoulder in front </li></ul><ul><ul><li>Adduction, horizontal adduction, inte...
Passive Ranges of Motion <ul><li>Critical to stabilize proximal segment in order to accurately assess end feel – patient p...
Resisted Ranges of Motion <ul><li>Must stabilize proximal segment to isolate movement and/or muscle/s </li></ul><ul><li>Gr...
Gerber Lift-Off Test <ul><li>Humerus internally rotated and dorsal aspect of hand placed against back </li></ul><ul><li>Po...
Scapular Winging <ul><li>Perform “push-up” against wall </li></ul><ul><li>Positive test for serratus anterior weakness and...
Neurological Evaluation <ul><li>Brachial plexus dermatomes and myotomes </li></ul><ul><li>Sensory and motor tests for term...
Vascular Evaluation <ul><li>Axillary pulse can sometimes be palpable in axilla </li></ul><ul><li>Brachial pulse felt along...
Ligamentous/Capsular Testing <ul><li>To be discussed in detail with specific shoulder pathologies </li></ul>
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Kin 191 B – Shoulder Anatomy And Evaluation

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Kin 191 B – Shoulder Anatomy And Evaluation

  1. 1. KIN 191B – Advanced Assessment of Upper Extremity Injuries Shoulder Anatomy and Evaluation
  2. 2. Sternum <ul><li>Manubrium – attachment site for clavicle </li></ul><ul><ul><li>Jugular notch </li></ul></ul><ul><li>Body </li></ul><ul><li>Xiphoid process </li></ul>
  3. 3. Sternum
  4. 4. Clavicle
  5. 5. Humerus <ul><li>Head and neck </li></ul><ul><li>Greater tuberosity </li></ul><ul><li>Lesser tuberosity </li></ul><ul><li>Bicipital (intertubercular) groove </li></ul><ul><ul><li>Long head of biceps tendon </li></ul></ul><ul><li>Deltoid tuberosity </li></ul><ul><li>Angle of inclination </li></ul><ul><ul><li>Shaft of humerus and head of humerus in frontal plane (normally 130-150 degrees) </li></ul></ul><ul><li>Angle of torsion </li></ul><ul><ul><li>Shaft of humerus and head of humerus in transverse plane (significant variance amongst individuals) </li></ul></ul>
  6. 6. Humerus
  7. 7. Scapula <ul><li>Vertebral (medial), axillary (lateral) and superior border </li></ul><ul><li>Inferior and superior angles </li></ul><ul><li>Glenoid, subscapular, supraspinous and infraspinous fossas </li></ul><ul><li>Scapular spine </li></ul><ul><li>Acromion process </li></ul><ul><li>Coracoid process </li></ul>
  8. 8. Scapula
  9. 9. Plane of the Scapula <ul><li>In anatomic position, glenoid angles 30 degrees from frontal plane – this is the plane of the scapula </li></ul><ul><li>More functional arc of motion than cardinal planes and places rotator cuff muscles in optimal length-tension relationship </li></ul>
  10. 10. Sternoclavicular Joint <ul><li>Proximal clavicle and manubrium </li></ul><ul><li>Anterior and posterior SC ligaments </li></ul><ul><ul><li>Resist anterior and posterior displacement of proximal clavicle </li></ul></ul><ul><li>Costoclavicular ligament </li></ul><ul><ul><li>Inferior proximal clavicle and rib 1 – axis of movement for clavicle (elevation, depression, medial, lateral) </li></ul></ul><ul><li>Interclavicular ligament </li></ul><ul><ul><li>Connects both SC joints </li></ul></ul><ul><li>Fibrocartilaginous SC disc </li></ul><ul><ul><li>Functions similar to meniscus of knee, axis of rotation for clavicle </li></ul></ul>
  11. 11. Sternoclavicular Joint
  12. 12. Acromioclavicular Joint <ul><li>Distal clavicle and acromion process </li></ul><ul><li>Superior and inferior AC ligaments </li></ul><ul><li>Coracoclavicular ligament – provides most intrinsic stability to AC joint </li></ul><ul><ul><li>Conoid portion – medial, triangular </li></ul></ul><ul><ul><ul><li>Restricts superior clavicular motion </li></ul></ul></ul><ul><ul><li>Trapezoid portion – lateral, quadrilateral </li></ul></ul><ul><ul><ul><li>Restricts lateral movement of distal clavicle over acromion process </li></ul></ul></ul>
  13. 13. Acromioclavicular Joint
  14. 14. Glenohumeral Joint <ul><li>Glenohumeral ligaments (joint capsule) </li></ul><ul><ul><li>Superior, middle and inferior GH ligaments are thickenings of joint capsule </li></ul></ul><ul><li>Coracohumeral ligament </li></ul><ul><ul><li>Blends with superior joint capsule from coracoid process </li></ul></ul><ul><li>Coracoacromial arch/ligament </li></ul><ul><ul><li>Connects 2 prominences of the same bone, often involved in impingement syndromes/conditions </li></ul></ul><ul><li>Glenoid labrum – deepens “ball and socket” </li></ul>
  15. 15. Glenohumeral Joint
  16. 16. Glenoid Labrum
  17. 17. Scapulothoracic Articulation <ul><li>Not a synovial joint – no bony articulation </li></ul><ul><li>Articulation via muscular attachments </li></ul>
  18. 18. Muscular Anatomy <ul><li>Muscles acting on the scapula </li></ul><ul><ul><li>Rhomboid major/minor </li></ul></ul><ul><ul><li>Levator scapulae </li></ul></ul><ul><ul><li>Serratus anterior </li></ul></ul><ul><ul><li>Pectoralis minor/major </li></ul></ul><ul><ul><li>Trapezius </li></ul></ul><ul><ul><li>Latissimus dorsi </li></ul></ul><ul><li>Responsible for </li></ul><ul><ul><li>Moving glenoid to allow for increased shoulder ROM </li></ul></ul><ul><ul><li>Fixation of scapula on thorax to provide rotator cuff muscles base of support during contractions </li></ul></ul>
  19. 19. Rhomboids <ul><li>O: major – T2-5 spinous processes, minor – C7, T1 spinous processes </li></ul><ul><li>I: vertebral (medial) border of scapula </li></ul><ul><li>N: dorsal scapular </li></ul><ul><li>A: scapular retraction, elevation, downward rotation </li></ul>
  20. 20. Levator Scapulae <ul><li>O: C1-4 transverse processes </li></ul><ul><li>I: superior angle of scapula </li></ul><ul><li>N: dorsal scapular </li></ul><ul><li>A: scapular elevation, downward rotation </li></ul>
  21. 21. Serratus Anterior <ul><li>O: anterior portion of ribs 1-8 </li></ul><ul><li>I: vertebral (medial) border of scapula from superior angle to inferior angle </li></ul><ul><li>N: long thoracic </li></ul><ul><li>A: scapular protraction and upward rotation, fixates vertebral border of scapula to thorax </li></ul>
  22. 22. Pectoralis Major <ul><li>O: clavicular head – medial half of clavicle, sternal head – lateral portion of sternum </li></ul><ul><li>I: greater tuberosity of humerus (lateral lip of bicipital groove) </li></ul><ul><li>N: medial and lateral pectoral </li></ul><ul><li>A: sternal head – shoulder depression and horizontal adduction, clavicular head – flexion, internal rotation and horizontal adduction </li></ul>
  23. 23. Pectoralis Minor <ul><li>O: anterior portion of ribs 3-5 </li></ul><ul><li>I: coracoid process </li></ul><ul><li>N: lateral pectoral </li></ul><ul><li>A: anterior tilt of scapula </li></ul>
  24. 24. Trapezius <ul><li>Upper fibers </li></ul><ul><ul><li>Base of occiput/upper cervical spinous processes to distal clavicle, elevate and upwardly rotate scapula </li></ul></ul><ul><li>Middle fibers </li></ul><ul><ul><li>Lower cervical/upper thoracic spinous processes to acromion process, retract scapula </li></ul></ul><ul><li>Lower fibers </li></ul><ul><ul><li>Lower thoracic spinous processes to spine of scapula, depress and upwardly rotate scapula </li></ul></ul><ul><li>N: accessory nerve (CN XI) </li></ul>
  25. 25. Latissimus Dorsi <ul><li>O: T6-12 spinous processes, thoracolumbar fascia, iliac crest </li></ul><ul><li>I: intertubercular (bicipital) groove </li></ul><ul><li>N: thoracodorsal (middle subscapular) </li></ul><ul><li>A: adduction, internal rotation, extension </li></ul>
  26. 26. Muscular Anatomy <ul><li>Muscles acting on the humerus </li></ul><ul><ul><li>Rotator cuff (SITS) </li></ul></ul><ul><ul><ul><li>Supraspinatus, infraspinatus, teres minor, subscapularis </li></ul></ul></ul><ul><ul><li>Deltoid </li></ul></ul><ul><ul><li>Pectoralis major </li></ul></ul><ul><ul><li>Latissimus dorsi </li></ul></ul><ul><ul><li>Teres major </li></ul></ul><ul><ul><li>Long head of triceps </li></ul></ul><ul><ul><li>Biceps, short/long head </li></ul></ul><ul><ul><li>Coracobrachialis </li></ul></ul>
  27. 27. Supraspinatus <ul><li>O: supraspinous fossa </li></ul><ul><li>I: greater tuberosity </li></ul><ul><li>N: suprascapular </li></ul><ul><li>A: abducts and externally rotates humerus </li></ul>
  28. 28. Infraspinatus <ul><li>O: infraspinous fossa </li></ul><ul><li>I: greater tuberosity </li></ul><ul><li>N: suprascapular </li></ul><ul><li>A: externally rotates humerus </li></ul>
  29. 29. Teres Minor <ul><li>O: axillary (lateral) border of scapula </li></ul><ul><li>I: greater tuberosity </li></ul><ul><li>N: axillary </li></ul><ul><li>A: externally rotates humerus </li></ul>
  30. 30. Subscapularis <ul><li>O: subscapular fossa </li></ul><ul><li>I: lesser tuberosity </li></ul><ul><li>N: upper and lower subscapular </li></ul><ul><li>A: internally rotates humerus </li></ul>
  31. 31. Deltoid <ul><li>Anterior fibers – distal clavicle, shoulder flexion, horizontal adduction and internal rotation </li></ul><ul><li>Middle fibers – acromion process </li></ul><ul><li>Posterior fibers – spine of scapula, shoulder extension, horizontal abduction and external rotation </li></ul><ul><li>I: deltoid tuberosity </li></ul><ul><li>N: axillary </li></ul><ul><li>A: shoulder abduction </li></ul>
  32. 32. Teres Major <ul><li>O: inferior angle of scapula, axillary (lateral) border of scapula </li></ul><ul><li>I: medial lip of bicipital groove </li></ul><ul><li>N: lower subscapular </li></ul><ul><li>A: internal rotation, adduction, extension </li></ul>
  33. 33. Triceps Brachii <ul><li>Long head – inferior glenoid rim/tuberosity </li></ul><ul><li>Lateral head – lateral and posterior proximal humerus </li></ul><ul><li>Medial head – medial distal humerus </li></ul><ul><li>I: olecranon process </li></ul><ul><li>N: radial </li></ul><ul><li>A: extends elbow, long head adducts and extends humerus </li></ul>
  34. 34. Biceps Brachii <ul><li>Long head – superior glenoid rim/tuberosity </li></ul><ul><li>Short head – coracoid process </li></ul><ul><li>I: radial tuberosity </li></ul><ul><li>N: musculocutaneous </li></ul><ul><li>A: elbow and shoulder flexion </li></ul>
  35. 35. Transverse Humeral Ligament <ul><li>Bridges bicipital groove from greater to lesser tuberosity </li></ul><ul><li>Stabilizes long head of biceps tendon in groove </li></ul>
  36. 36. Coracobrachialis <ul><li>O: coracoid proces </li></ul><ul><li>I: medial humeral shaft </li></ul><ul><li>N: musculocutaneous </li></ul><ul><li>A: flexion and adduction </li></ul>
  37. 37. Neurovascular Anatomy <ul><li>Neurological anatomy </li></ul><ul><ul><li>Brachial plexus review </li></ul></ul><ul><li>Vascular anatomy </li></ul><ul><ul><li>Subclavian artery becomes axillary artery as it passes first rib, which becomes brachial artery as it passes distal to teres major </li></ul></ul>
  38. 38. Brachial Plexus
  39. 39. Vascular Supply
  40. 40. Bursae <ul><li>Subacromial bursa </li></ul><ul><li>Sits superior to rotator cuff tendons in subacromial space </li></ul><ul><li>Reduces friction from movement of overlying deltoid </li></ul><ul><li>Provides protection against inferior surface of acromion process </li></ul>
  41. 41. Rotator Cuff Muscle Activity <ul><li>During shoulder (GH) abduction: </li></ul><ul><ul><li>At ~70 degrees, humeral head depressed by infraspinatus, teres minor and subscapularis to allow humeral head to clear acromion process </li></ul></ul><ul><ul><li>At ~115 degrees, humeral head externally rotated by infraspinatus and teres minor to clear greater tuberosity of humerus under acromial arch </li></ul></ul>
  42. 42. Scapulothoracic Rhythym <ul><li>During first 30 degrees of GH abduction, scapular is “setting” – may have slight upward rotation </li></ul><ul><li>From 30-180 degrees, for every 2 degrees of GH motion is 1 degree of scapular motion (rotation) </li></ul><ul><li>During first 90 degrees, scapula rotates with SC joint as pivot point </li></ul><ul><li>During last 90 degrees, scapula rotates with AC joint as pivot point </li></ul><ul><ul><li>Conoid portion of coracoclavicular ligament becomes taut and produces posterior rotation of clavicle allowing for more AC and scapular motion </li></ul></ul>
  43. 43. Location of Pain <ul><li>Localized pain in shoulder typically associated with localized injury </li></ul><ul><li>Pain radiating proximally and/or distally increases likelihood of neurological involvement </li></ul>
  44. 44. Onset of Symptoms <ul><li>Acute onset </li></ul><ul><ul><li>Fracture, GH subluxation or dislocation, AC sprain </li></ul></ul><ul><li>Chronic/insidious onset </li></ul><ul><ul><li>Inflammatory conditions (tendonitis, bursitis) </li></ul></ul><ul><ul><li>Pain after activity first, then during, and finally at all times </li></ul></ul>
  45. 45. Mechanism of Injury <ul><li>Direct trauma or forces </li></ul><ul><ul><li>Acute soft tissue and/or bony injury </li></ul></ul><ul><li>Repetitive overhead movements (throwing, swimming, tennis) </li></ul><ul><ul><li>Overuse syndromes, inflammatory conditions, impingement syndromes </li></ul></ul>
  46. 46. Current Symptoms <ul><li>Unusual sounds or sensations </li></ul><ul><li>Quantity and quality of pain, aggravating and alleviating factors </li></ul><ul><li>Radiating pain – neurological involvement </li></ul><ul><li>Dysfunction and/or decreased performance </li></ul>
  47. 47. History of Previous Injury <ul><li>Previous cervical spine injury can predispose individual to shoulder injury from neurological compromise (weakness) </li></ul><ul><li>Prior AC or GH injury can affect shoulder biomechanics and thereby increase the risk of overuse conditions/muscle imbalances </li></ul>
  48. 48. General Postural Assessment <ul><li>Head </li></ul><ul><ul><li>Lateral flexion or rotation may indicate muscle spasm and/or cervical nerve root injury </li></ul></ul><ul><li>Upper extremity </li></ul><ul><ul><li>Splinted to side of body/rib cage </li></ul></ul><ul><ul><li>Forearm supported </li></ul></ul><ul><ul><li>“ limp arm” from brachial plexus injury </li></ul></ul><ul><ul><li>Deformity from GH dislocation </li></ul></ul>
  49. 49. Anterior Structures <ul><li>Level of shoulders </li></ul><ul><ul><li>AC joints, SC joints, clavicle </li></ul></ul><ul><li>Clavicular contour </li></ul><ul><ul><li>Displacement with joint injury or fracture </li></ul></ul><ul><li>Deltoid contour symmetry </li></ul><ul><ul><li>Normally rounded, may be flattened secondary to GH dislocation or axillary nerve injury </li></ul></ul><ul><li>Biceps brachii symmetry </li></ul><ul><ul><li>Bulges from biceps tendon rupture </li></ul></ul>
  50. 50. Lateral Structures <ul><li>Deltoid contour (as before) </li></ul><ul><li>Acromion process </li></ul><ul><ul><li>“ step off” deformity at AC joint (“piano key”) </li></ul></ul><ul><li>Humeral position </li></ul><ul><ul><li>Anterior or posterior displacement with dislocation </li></ul></ul>
  51. 51. Posterior Structures <ul><li>Vertebral alignment - scoliosis </li></ul><ul><li>Scapular position symmetry </li></ul><ul><ul><li>Superior angle at T2 spinous process, inferior angle at T7 spinous process </li></ul></ul><ul><ul><li>“ winging” scapula </li></ul></ul><ul><li>Muscle tone </li></ul><ul><ul><li>Increased tone secondary to spasm/injury </li></ul></ul><ul><ul><li>Decreased tone (atrophy) secondary to neurological compromise or disuse </li></ul></ul><ul><li>Humeral position (as before) </li></ul>
  52. 52. Palpation – Anterior Structures <ul><li>Jugular notch </li></ul><ul><li>SC joint </li></ul><ul><li>Clavicle </li></ul><ul><li>Acromion process </li></ul><ul><li>AC joint </li></ul><ul><li>Coracoid process </li></ul><ul><li>Humeral head </li></ul><ul><li>Greater tuberosity </li></ul><ul><li>Lesser tuberosity </li></ul><ul><li>Bicipital groove </li></ul><ul><li>Humeral shaft </li></ul><ul><li>Pectoralis major </li></ul><ul><li>Coracobrachialis </li></ul><ul><li>Deltoid </li></ul><ul><li>Biceps brachii </li></ul>
  53. 53. Palpation – Posterior Structures <ul><li>Spine of scapula </li></ul><ul><li>Superior angle </li></ul><ul><li>Inferior angle </li></ul><ul><li>Rotator cuff </li></ul><ul><ul><li>Subscapularis </li></ul></ul><ul><ul><li>Supraspinatus </li></ul></ul><ul><ul><li>Infraspinatus </li></ul></ul><ul><ul><li>Teres minor </li></ul></ul><ul><li>Teres major </li></ul><ul><li>Rhomboids </li></ul><ul><li>Levator scapulae </li></ul><ul><li>Trapezius </li></ul><ul><li>Latissimus dorsi </li></ul><ul><li>Posterior deltoid </li></ul><ul><li>Triceps brachii </li></ul>
  54. 54. Special Tests <ul><li>Range of motion testing </li></ul><ul><ul><li>Active, passive and resistive ROM </li></ul></ul><ul><ul><li>Combination movements </li></ul></ul><ul><li>Neurological evaluation </li></ul><ul><li>Vascular evaluation </li></ul><ul><li>Ligamentous/capsular testing </li></ul>
  55. 55. Active Ranges of Motion <ul><li>Flexion – 180 degrees </li></ul><ul><ul><li>Biceps brachii, coracobrachialis, anterior and middle deltoid, pectoralis major (clavicular head) </li></ul></ul><ul><li>Extension – 60 degrees </li></ul><ul><ul><li>Posterior deltoid, latissimus dorsi, teres major, triceps brachii (long head) </li></ul></ul>
  56. 56. Active Ranges of Motion <ul><li>Abduction – 180 degrees </li></ul><ul><ul><li>Deltoid, supraspinatus, biceps brachii </li></ul></ul><ul><li>Adduction - ~45 degrees if shoulder flexed slightly to avoid body interference </li></ul><ul><ul><li>Pectoralis major, latissimus dorsi, teres major, coracobrachialis, triceps brachii </li></ul></ul>
  57. 57. Active Ranges of Motion <ul><li>Internal rotation – limited by body in neutral position, 70-80 degrees at 90/90 </li></ul><ul><ul><li>Subscapularis, pectoralis major, latissimus dorsi, teres major, anterior deltoid </li></ul></ul><ul><li>External rotation – 40-50 degrees in neutral position, 80-90 degrees at 90/90 </li></ul><ul><ul><li>Infraspinatus, teres minor, supraspinatus, posterior deltoid </li></ul></ul>
  58. 58. Active Ranges of Motion <ul><li>Horizontal abduction – 45 degrees from plane of scapula at 90 degrees abduction </li></ul><ul><ul><li>Posterior deltoid, infraspinatus, teres minor </li></ul></ul><ul><li>Horizontal adduction – 120 degrees from plane of scapula at 90 degrees abduction </li></ul><ul><ul><li>Pectoralis major, anterior deltoid </li></ul></ul>
  59. 59. Active Ranges of Motion <ul><li>Scapular protraction </li></ul><ul><ul><li>Serratus anterior, pectoralis minor </li></ul></ul><ul><li>Scapular retraction </li></ul><ul><ul><li>Trapezius, rhomboids, levator scapulae </li></ul></ul><ul><li>Scapular elevation </li></ul><ul><ul><li>Upper trapezius, levator scapulae, rhomboids </li></ul></ul><ul><li>Scapular depression </li></ul><ul><ul><li>Lower trapezius, pectoralis minor, subclavius </li></ul></ul><ul><li>Scapular downward rotation </li></ul><ul><ul><li>Rhomboids, pectoralis minor </li></ul></ul><ul><li>Scapular upward rotation </li></ul><ul><ul><li>Trapezius, serratus anterior </li></ul></ul>
  60. 60. Scapular Ranges of Motion
  61. 61. Apley’s Scratch Tests <ul><li>Touch opposite shoulder in front </li></ul><ul><ul><li>Adduction, horizontal adduction, internal rotation, scapular protraction </li></ul></ul><ul><li>Touch opposite shoulder in back </li></ul><ul><ul><li>Abduction, external rotation, scapular protraction, elevation and upward rotation </li></ul></ul><ul><li>Touch opposite scapula from behind </li></ul><ul><ul><li>Adduction, internal rotation, scapular retraction and downward rotation </li></ul></ul>
  62. 62. Passive Ranges of Motion <ul><li>Critical to stabilize proximal segment in order to accurately assess end feel – patient positioning </li></ul><ul><li>Flexion and extension – firm end feel </li></ul><ul><li>Abduction – firm end feel (GH and total) </li></ul><ul><li>Adduction – not typically assessed </li></ul><ul><li>ER/IR – firm end feels </li></ul><ul><li>Horizontal abduction/adduction – firm end feels unless soft tissue obstructs adduction </li></ul>
  63. 63. Resisted Ranges of Motion <ul><li>Must stabilize proximal segment to isolate movement and/or muscle/s </li></ul><ul><li>Graded on 0-5 scale – keep in mind effects of gravity, especially in presence of significant weakness </li></ul>
  64. 64. Gerber Lift-Off Test <ul><li>Humerus internally rotated and dorsal aspect of hand placed against back </li></ul><ul><li>Positive test for subscapularis weakness if unable to lift hand off spine </li></ul>
  65. 65. Scapular Winging <ul><li>Perform “push-up” against wall </li></ul><ul><li>Positive test for serratus anterior weakness and/or long thoracic nerve injury if vertebral (medial) border of scapula lifts off thorax </li></ul>
  66. 66. Neurological Evaluation <ul><li>Brachial plexus dermatomes and myotomes </li></ul><ul><li>Sensory and motor tests for terminal branches of brachial plexus </li></ul><ul><ul><li>Axillary, radial, median, ulnar, musculocutaneous </li></ul></ul><ul><li>Awareness of innervation of muscles acting on scapula and humerus </li></ul>
  67. 67. Vascular Evaluation <ul><li>Axillary pulse can sometimes be palpable in axilla </li></ul><ul><li>Brachial pulse felt along medial shaft of humerus or in cubital fossa near biceps tendon </li></ul><ul><li>Radial pulse is most common evaluation site </li></ul>
  68. 68. Ligamentous/Capsular Testing <ul><li>To be discussed in detail with specific shoulder pathologies </li></ul>
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