assessment of shoulder joint

1. Assessment of Shoulder Joint
S M ALI ZAIDI

2. Shoulder Joint
Shoulder joint is made up of following bones
Humerus
Clavicle
Scapula

3. Shoulder Joint components
Glenohumeral joint
Acromioclavicular joint
Sternoclavicular joint
Scapulothoracic joint

4. Shoulder Joint Restraints
• Passive restraints
• Active restraints

5. Shoulder Joint Passive Restraints
Capsule
Bursa
Labrum
Shoulder Ligaments

6. Shoulder Joint Active Restraints
• Shoulder Muscles

7. Glenohumeral Joint
• Resting position: 55° abduction, 30° horizontal adduction (scapular
plane)
• Close packed position: Full abduction, lateral rotation
• Capsular pattern: Lateral rotation, abduction, medial rotation

8. Acromioclavicular Joint
• Resting position: Arm by side
• Close packed position: 90° abduction
• Capsular pattern: Pain at extremes of range of motion, especially
horizontal adduction and full elevation

9. Sternoclavicular Joint
• Resting position: Arm at side
• Close packed position: Full elevation
• Capsular pattern: Pain at extremes of range of motion, especially
horizontal adduction and full elevation

10. Patient History
Rotator cuff degeneration usually occurs in patients who are between 40
and 60 years of age
Primary impingement due to degeneration and weakness is usually seen
in patients older than 35

11. Patient History
secondary impingement due to instability caused by weakness in the
scapular
or humeral control muscles
It is more common in people in their late teens or 20s
Especially those involved in vigorous overhead activities such as
swimmers or pitchers in baseball

12. Patient History
Calcium deposits may occur between the ages of 20 and 40.
frozen shoulder is seen in persons between the ages of 45 and 60 years
Frozen shoulder due to trauma can occur at any age but is more common
with increased age.

13. External primary impingement (stage I)
• Intermittent mild pain with overhead activities Over age 35

14. E.xternal primary impingement (stage II)
• Mild to moderate pain with overhead activities or strenuous activities

15. External primary impingement (stage III)
• Pain at rest or with activities
• Night pain may occur
• Scapular or rotator cuff weakness is noted

16. Rotator cuff tears (full thickness)
• Classic night pain
• Weakness noted predominantly in abduction and lateral rotators
• Loss of motion

17. Adhesive capsulitis (idiopathic frozen
shoulder)
• Inability to perform activities of daily living owing to loss of motion
• Loss of motion may be perceived as weakness

18. Anterior instability (with or without external
secondary impingement)
• Apprehension to mechanical shifting limits activities
• Slipping, popping, or sliding may present as suitable instability
• Apprehension usually associated with horizontal abduction and lateral rotation
• Anterior or posterior pain may be present
• Weak scapular stabilizers

19. Posterior instability
• Slipping or popping of the humerus out the back
• This may be associated with forward flexion and medial rotation while the
shoulder is under a compressive load

20. Multi-directional instability
• Looseness of shoulder in all directions
• This may be most pronounced while carrying luggage or turning over while
asleep
• Pain mayor may not be present

21. Structures Limiting Movement in
Different Degrees of Abduction
• 0 degree Angle of Abduction
• Lateral Rotation
• Superior GH ligament and Anterior capsule
• Medial Rotation
• Posterior capsule

22. Structures Limiting Movement in
Different Degrees of Abduction
• 0 to 45 degree Angle of Abduction
• Lateral Rotation
• Superior GH ligament, Anterior capsule and Coracohumeral ligament
• Medial Rotation
• Posterior capsule

23. Structures Limiting Movement in
Different Degrees of Abduction
• 40 to 60 degree Angle of Abduction
• Lateral Rotation
• Middle GH ligament, Coracohumeral ligament, Inferior GH ligament
(anterior band)
And Anterior capsule
• Medial Rotation
• Inferior GH ligament(posterior band) and Posterior capsule

24. Structures Limiting Movement in
Different Degrees of Abduction
• 60 to 90 degree, 90 to 120 degree, 120 to 180 degree Angle of Abduction
• Lateral Rotation
• Inferior GH ligament (anterior band) and Anterior capsule
• Medial Rotation
• Inferior GH ligament (posterior band) and Posterior capsule

25. Suprascapular nerve (C5, C6)
• Mechanism of Injury
• Compression in suprascapular notch
• Stretch into scapular protraction plus horizontal adduction
• Compression in spinoglenoid notch
• Direct blow
• Space occupying lesion (e.g. ganglion)
Peripheral Nerve Injuries (Neuropathy) About the Shoulder

26. Suprascapular nerve
(C5, C6)
• Muscle Weakness
• Supraspinatus,
• infraspinatus (arm lateral rotation)
• Sensory Alteration
• Top of shoulder from clavicle to spine of scapula
• Pain in posterior shoulder radiating into arm
• Reflexes Affected
• None

27. Axillary (circumflex)nerve (posterior cord:
C5, C6)
Mechanism of Injury
• Anterior glenohumeral dislocation
• Fracture of surgical neck of humerus
• Forced abduction
• Surgery for instability
Muscle Weakness
Deltoid
teres minor (arm abduction)
Sensory Alteration
Deltoid area
Anterior shoulder pain
Reflexes Affected
None

28. Radial nerve (C5–C8,T1)
Mechanism of Injury
• Fracture humeral shaft
• Pressure (e.g., crutch palsy)
Muscle Weakness
Triceps
Wrist extensors,
Finger extensors
(shoulder, wrist, and hand extension)
Sensory Alteration
Dorsum of hand
Reflexes Affected
Triceps

29. Long thoracic nerve(C5, C6, [C7])
Mechanism of Injury
• Direct blow
• Traction
• Compression against internal chest wall
(backpack injury)
• Heavy effort above shoulder height
• Repetitive strain
Muscle Weakness
Serratus anterior (scapular
control)
Sensory Alteration
None
Reflexes Affected
None

30. Musculocutaneous nerve (C5–C7)
Mechanism of Injury
• Compression
• Muscle hypertrophy
• Direct blow
• Fracture (clavicle and
humerus)
• Dislocation (anterior)
• Surgery (Putti-Platt, Bankart)
Muscle Weakness
Coracobrachialis
Biceps
Brachialis (elbow flexion)
Sensory Alteration
Lateral aspect of forear
Reflexes Affected
Biceps

31. Spinal accessory nerve
(cranial nerve XI: C3,C4)
Mechanism of Injury
• Direct blow
• Traction (shoulder depression
and neck rotation to opposite
side)
• Biopsy
Muscle Weakness
Trapezius (shoulder elevation)
Sensory Alteration
Shoulder aching
Reflexes Affected
None

32. Subscapular nerve
(posterior cord; C5,C6)
Mechanism of Injury
• Direct blow
• Traction
Muscle Weakness
Subscapularis
Teres major (medial rotation)
Sensory Alteration
None
Reflexes Affected
None

33. Dorsal scapular nerve
(C5)
Mechanism of Injury
• Direct blow
• Compression
Muscle Weakness
Levator scapulae
Rhomboid major
Rhomboid minor (scapular retraction and
elevation)
Sensory Alteration
None
Reflexes Affected
None

34. Lateral pectoral nerve
(C5, C6)
Mechanism of Injury
• Direct blow
Muscle Weakness
Pectoralis major,
pectoralis minor
Sensory Alteration
None
Reflexes Affected
None

35. Thoracodorsal nerve
(C6, C7, [C8])
Mechanism of Injury
• Direct blow
• Compression
Muscle Weakness
Latissimus dorsi
Sensory Alteration
None
Reflexes Affected
None

36. Shoulder painful Arc

37. Reverse Glenohumeral
Rhythm

38. Step deformity resulting from
acromioclavicular dislocation

39. Apley’s scratch test

40. Apley’s scratch test

41. Neck reach

42. Back reach

43. Causes of Scapular Imbalance Patterns
• Increased protraction
• Tight pectoralis minor
• Weak/lengthened lower trapezius
• Weak/lengthened serratus anterior
Increased depression
Weak upper trapezius

44. Tests for shoulder
aseessment

45. Tests for Anterior Shoulder
Instability

46. Andrews’ Anterior Instability Test
• The patient lies supine
• shoulder abducted 130° and laterally rotated 90°
• Hadeling
• The examiner stabilizes the elbow and distal humerus with one hand
• and uses the other hand to grasp the humeral head and lift it forward

47. Andrews’ Anterior Instability Test
• A reproduction of the patient’s symptoms gives a positive test for anterior
instability.
• If the examiner hears a clunk, an anterior labral tear may be present

48. Andrews’ Anterior
Instability Test

49. Anterior Drawer Test of the Shoulder
• The patient lies supine
• The examiner places the hand of the affected shoulder in the examiner’s
axilla
• The shoulder to be tested is
• abducted between 80° and 120°,
• forward flexed up to 20°,
• and laterally rotated up to 30°.

50. Anterior Drawer Test of the Shoulder
• The examiner then stabilizes the patient’s scapula with the opposite hand
• pushing the spine of the scapula forward with the index and middle fingers
• The examiner’s thumb exerts counterpressure on the patient’s coracoid process
• the examiner places his or her hand around the patient’s relaxed upper arm and
draws the humerus forward.
• The movement may be accompanied by a click, by patient apprehension, or
both

51. Anterior Drawer Test of the Shoulder
• The click may indicate a labral tear or slippage of the humeral head over
the glenoid rim

52. Anterior Drawer Test of the Shoulder