Shoulder Complex physical examination of capsulo-ligaments structures to know and to treat instability problems

1. Nicola Taddio, Physical Therapist, BPT, OMTP, ATC
Masters Degree in Science of Health and Rehabilitation Professions
First Level Master IFOMT in Manual Therapy and Musculo-Skeletal Rehabilitation, University of Padua, Italy
Lecturer a.c. Master in “Sports Physioterapy”, University of Siena, Italy
Lecturer a.c. Master in “Sports Physiotherapy and Performing Arts”, University of Genoa, Savona pole, Italy
www.fisioterapiafkt.com nicolataddio@fisioterapiafilanda.It

2. Acknowledgements

3. The interpretation of diagnostic test: a primer for physiotherapists.
Davidson M.
Aust J Physiother. 2002;48(3):227-32. Review.
Shoulder girdle:
physical examination of
passive structures

4. Introduction

5. • Gleno-humeral
• Acromion-clavicular
• Sterno-clavicular
• Scapulo-toracic
• Sub-acromion deltoid
“SHOULDER COMPLEX”
complex of 5 joints
Anatomical
joints
(properly
defined)
Muscle
tendons
fasciae slide
one each
other, on
the torax
and ribs

6. Kinetic Chain Role
John McMullen, MS, ATC*; Timothy L. Uhl, Phd, ATC, PT A
Kinetic Chain Approach for Shoulder Rehabilitation
Journal of Athletic Training 2000:35(3):329-337
1. Any movement of upper limbs generate a “PRE-
ACTIVATION” (anticipatory contraction) of
deep lumbo-pelvic muscle
2. Therefore, the sequence of muscular activation
begin from “CORE” to periferic joint (proximal to
distal)
3. The rationale in shoulder rehabilitation is
“INTEGRATE, FROM THE
BEGINNING”, the exercises of trunk and lower
limbs in the exercise of upper limb and shoulder
complex

7. Mobility with Stability

8. Stability and instability
Clinical spinal instability and low back pain.
Panjabi MM.
J Electromyogr Kinesiol. 2003 Aug;13(4):371-9.
Active
System
• Musculoskeletal
• Stiffness
• Force/resistence/power
Passive
System
• Bone surfaces
• Ligaments
• Labrum
Control
System
• Nervous System
• Central and
Peripheral

9. Lee SB, Kim KJ, O'Driscoll SW, Morrey BF, An KN.
Dynamic glenohumeral stability provided by the rotator cuff muscles in the mid-range and
end-range of motion. A study in cadavera.
J Bone Joint Surg Am. 2000 Jun;82(6):849-57.
Curl LA, Warren RF.
Glenohumeral joint stability. Selective cutting studies on the static capsular restraints.
Clin Orthop Relat Res. 1996 Sep;(330):54-65. Review.
The glenohumeral
joint relies on static
and dynamic contribution
s of the local soft tissues
to maintain joint stability.
Dynamic stabilizers
consist of the local
musculature (the rotator
cuff and periscapular
muscles), whereas static
stabilizers include the
glenoid labrum and
associated capsulo
ligamentous components.

10. 1. Ligaments [CHL, SGHL,
MGHL, IGHL (AB, PB, AP)]
2. Capsule (AX.P, P)
3. Labrum
4. Gleno-humeral
congruency
5. Concavity compression
6. Adhesion-cohesion
mechanism
7. Neuromuscular balance
8. Proprioception and
neuromuscular control
MOBILITY with STABILITY

11. Why and How instability
LAXITY
INSTABILITYIPER-LAXITY
SIGNS SIMPTOMS
NORMAL
PATHOLOGICAL

12. History and clinical picture
TRAUMA OVERUSELAXITY

13. Unstable Shoulder Picture
T.U.B.S.
OVERUSELAXITY
T.RAUMATIC A.TRAUMATIC A.CQUIRED
U.NIDIRECTIONAL M.ULTIDIRECTIONAL I.NSTABILITY
B.ANKART B.ILATERAL O.VERSTRESSED
S.URGERY R.EHABILITATION S.HOULDER
R.EPAIR S.URGERY
I.NTERVAL
TRAUMA
A.M.B.R.R.I A.I.O.S.S.

14. Burkart AC, Debski RE.
Anatomy and function of the glenohumeral ligaments in anterior shoulder instability.
Clin Orthop Relat Res. 2002 Jul;(400):32-9. Review.
1. The function of glenohumeral ligaments is
highly dependent on the position of the
humerus with respect to the glenoid.
2. The coracohumeral ligament with
superior glenohumeral ligament the was
shown to be an important stabilizer in
the inferior direction.
3. The
middle glenohumeral ligament provides
anterior stability at 45 degrees and 60
degrees abduction whereas
4. The inferior glenohumeral ligament compl
ex is the most important stabilizer against
antero-inferior shoulder dislocation.
5. Therefore, this component of the capsule is
the most frequently injured structure.
6. In addition, a detached labrum can lead to
recurrent anterior instability and a
compromised inferior glenohumeral ligam
ent complex.
Bankart
SLAP
PB AP AB

15. Wang VM, Flatow EL.
Pathomechanics of acquired shoulder instability: a basic science perspective.
J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):2S-11S. Review.
1. Normal
asymptomatic glenohumeral motion is
dependent on the coordinated function of
dynamic and static stabilizers.
2. Data from both selective sectioning
studies of the capsuloligamentous
components and tensile testing of
the inferior glenohumeral ligament have
provided important insights into the in
situ function of these structures.
3. However, little is known regarding the
mechanism of microdamage
accumulation in acquired shoulder
instability.
4. Recent findings suggest that cyclic
subfailure loading of the
inferior glenohumeral ligament may
induce gradual stretching of the
anteroinferior capsule, compromising its
capacity to restrain excessive humeral
translations.

16. The interpretation of diagnostic test: a primer for physiotherapists.
Davidson M.
Aust J Physiother. 2002;48(3):227-32. Review.
Shoulder girdle:
physical examination of
passive structures

17. E.B.M. approach to orthopaedic
clinical examination
Reliability [true and error about test or measure (intra and
inter examiner) acceptable reliability] = affidabilità, attendibilità
Diagnostic accuracy (comparison between golden
standard to clinical test) = accuratezza, esattezza, precisione
diagnostica
2x2 Contingency Table
Overall Accuracy
Pos. and Neg. Predictive Value
Sensitivity = detect people have disorder or tear
Specificity = detect people don’ t have disorder or tear
Likelihood Ratio
Confidence Interval
Pre-Test and Post-Test Probability
Calculating Post-Test Probability
Assessment of Study Quality

18. Clinical
examination to
assess the baseline
function and
the rehabilitative
program progresses
or outcome
Physical Therapist Orthopaedic Surgeon
Clinical
examination to
assess if the patient
and lesion need the
surgical or
conservative
approach

19. Labrum and Biceps Anchor

20. Definition
• The labrum is a firm ring of fibro-
cartilage that surrounds the edge of
glenoid
• It serves two pupose:
1. it increase the depth and size of
glenoid fossa, giving the joint greater
stability and surface area;
2. it acts a “chock block” to stop the
humeral head from translating off the
glenoid
• The term labral tear is used to classify
several types of labral injury, the most
common is Bankart lesion and SLAP
lesion

21. Suspected injuries
• Labral tear (traumatic)
• Labral lesion (degenerative)
• Bankart lesion (in which the antero-
inferior labrum is torn)
• SLAP lesion (in which the superior
anterior or posterior or both may have
been injuried)

22. Labrum tears
BANKART SLAP TYPE 2°
BONY BANKART

23. Epidemiology and demographics
• The most common cause of labral tear is
trauma from a dislocation
• In addition, younger individuals are prone to
labral injury with repetitive overhead motion,
such as swimming, tennis or throwing
• Older people are more prone to degenerative
lesions, which often are associated with poor
vascular supply to the labral tissue

24. Relevant special tests
• Active compression test of O’Brien
• Anterior slide test
• Biceps tension test
• Clunk test
• Biceps load test
• Labral crank test
• SLAP prehension test
Note: no one test can provide a definite diagnosis of labral lesion
Parentis MA, Glousman RE, Mohr KS, Yocum LA.
An evaluation of the provocative tests for superior labral anterior posterior lesions.
Am J Sports Med. 2006 Feb;34(2):265-8.

25. Active compression test of O’Brien
• Purpose = assess the integrity of superior aspect of the shoulder labrum
• Patient position = standing, arm forward flexed to 90° and the elbow
fully extended
• Examiner position = stands slightly behind and adjacent to the test
shoulder
• Test procedure = the examiner puts one hand on the patient’s shoulder
to stabilize the scapula and clavicle and the other hand on the forearm
of the affected arm. The arm is horizintally adducted 10° to 15° (starting
position) and intrarotated with the thumb faces downward (pronated).
The examiner applies a downward eccentric force to the arm. The arm is
returned to the starting position, the thumb is upward (supination) and
the downward eccentric load is repeated.
• Indication of a positive test = if pain or painful clicking is produced
inside the shoulder(not over the A/C joint) in the first part of the test
(intrarotation) and eliminated or decreased in the second part
(extrarotation), the trest is considered positive for labral abnormalities
• Clinical note/caution = the test also “locks and loads” the A/C joint in
I/R
• Reliability/Specificity/Sensitivity =
Specificity: 31% to 99% Sensitivity: 54% to 00%

26. Anterior Slide Test
• Purpose = assess the integrity of anterior shoulder
labrum
• Patient position = sitting or standing, with the
hands on the waist, thumbs posterior
• Examiner position = standing behind, stabilize
scapula and clavicle and with the same
hand/fingers palpate the humeral head. The other
hand on the posterior aspect of elbow
• Test procedure = the examiner applies an
anterosuperior force at the patient’s elbow
• Indication of a positive test = if labrum is torn
(SLAP lesion) the humeral head slides over the
labrum with a pop or crack and with pain or painful
clicking. Sometimes is possible to palpate anterior
superiorly the pop or click/crack
• Reliability/Specificity/Sensitivity = Specificity
range: 85% to 91,5% Sensitivity range: 8% to 78%

27. Biceps Tension Test
• Purpose = to assess for a lesion of the superior
shoulder labrum
• Patient position = the patient standing, abduct
and externally rotates the shoulder, the elbow
fully extended, the forearm supinated
• Examiner position = standing behind, stabilize
scapula and clavicle and with the same
hand/fingers palpate the humeral head. The other
hand grasp the wrist and forearm
• Test procedure = the examiner applies an eccentric adduction force to
the straightened and supineted arm
• Indication of a positive test = the test is positive if labrum is torn (SLAP
lesion) and we see a reproduction of patient’ s symptoms
• Clinical note/caution = the test stress also the biceps tendon and then
Speed test should be done di differential diagnosis
• Reliability/Specificity/Sensitivity = Unknown

28. Clunk Test
• Purpose = to assess the integrty
of anterior shoulder labrum
• Patient position = the patient
lies supine
• Examiner position = standing
adjacent and superior to the
shoulder to be tested
• Test procedure = the examiner places one hand under the posterior aspect of
the shoulder so that it lies under the humeral head; the other holds the
humerus above the elbow. The examiner fully abducts the arm over the
patients head and push anteriorly the hand or the fist while the other hand
externally rotates the humerus at the shoulder level
• Indication of a positive test = a clunk or grinding sound indicates both a
positive test result and a labral tear. The test also may cause apprehension if
anterior instability is present
• Clinical note/caution = the test stress different parts of labrum if arm is
positioned in different amount o abduction (if done in adduction relocation)
• Reliability/Specificity/Sensitivity = Unknown

29. Biceps Load Test
• Purpose = to assess for a lesion of the superior
shoulder labrum
• Patient position = the patient lies supine, with the
shoulderabducted 90° and externally rotates, the
elbow 90° flexed, the forearm supinated
• Examiner position = the examiner stands slightly
superiorly and adjacent to the test shoulder
• Test procedure = the examiner holds the patient’s elbow for support with one
hand and grasp the wrist with the other hand, perform an apprehension test
by a fully external rotoation. If apprension appears the examiner stops the E/R
and hold the position and ask the patient flex the elbow against the examiner
resistence
• Indication of a positive test = the test is positive if elbow flexion reproduce the
patient’ s symptoms (pain and apprension) and negative if decrease
apprension and pain
• Reliability/Specificity/Sensitivity = Specificity 96,6% Sensitivity 89%

30. Labral Crunk Test
• Purpose = to assess the integrity
and lesion of shoulder labrum
• Patient position = the patient is
in supine-lyng or sitting position
• Examiner position = standing
adjacent to the testing shoulder
• Test procedure = the examiner places one hand on the patient’s elbow for
support and stability and grasp the wrist with the other hand. The arm is
elevated to 160° in the scapular plane. In this position the exminer applies an
axial load to the humerus with one hand while the other hand rotates the
humerus in I/R and E/R
• Indication of a positive test = a positive test result is indicated by on pain in
rotation expecially in E/R, with or without a click or reproduction of symptoms
• Reliability/Specificity/Sensitivity = Unknown

31. SLAP Prehension Test
• Purpose = to assess for a lesion of shoulder
superior labrum
• Patient position = the patient is in standing or
sitting position
• Examiner position = standing behind and
adjacent to the testing shoulder
• Test procedure = the examiner places one hand on the patient’s shoulder to
stabilize scapula and clavicle and holds the wrist with the other hand. The
examiner abduct the arm to 90° in the scapular plane with the elbow
extended and yhe forearm pronated (thumb down and shoulder in I/R). The
patient then, is asked to adduct the arm orizzontally. The movement is
repeated with the forearm supinated (the thumb up and the shoulder in E/R)
• Indication of a positive test = if patients feel pain in the bicipital groove with
pronation and lessens or absent with supination, the test is positive for SLAP
• Reliability/Specificity/Sensitivity = Unknown

32. Inferior Gleno Humeral
Ligament (IGHL)

33. Curl LA, Warren RF.
Glenohumeral joint stability. Selective cutting studies on the static capsular restraints.
Clin Orthop Relat Res. 1996 Sep;(330):54-65. Review.
The function of
the capsuloligamentous restraints is highly
dependent on arm position

34. Debski RE, Weiss JA, Newman WJ, Moore SM, McMahon PJ.
Stress and strain in the anterior band of the inferior glenohumeral ligament during a
simulated clinical examination.
J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):24S-31S.

35. Relevant special tests
Physical examination tests of the shoulder:
a systematic review with meta-analysis of individual tests.
Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3rd, Cook C.
Br J Sports Med. 2008 Feb;42(2):80-92; discussion 92. Epub 2007 Aug 24. Review.
•Load and Shift Test (Anterior)
•Crank Apprehension Test (Relocation Test)
•Rockwood Test (Modification of Crank Test)
•Fulcrum Test (Modification of Crank Test)
•Load and Shift Test (Posterior)
•Norwood Stress Test
•Posterior Apprehension or Stress Test
•Sulcus Sign
•Feagin Test
Anterior
Instability
Posterior
Instability
Inferior and/or
Multidirectional
Note: no one test can provide a definite diagnosis of capsulo-ligamentous lesion

36. Many instability tests have validity,
sensitivity and specificity unknown

37. Crank Apprehension Test
(Relocation Test)
• Purpose 1 = to determine whether the humerus will sublux or
dislocate anteriorly out of the glenoid
• Purpose 2 = to differentiate between dislocation/subluxation
(apprehension) and impingement (pain)
• Purpose 3 = to differentiate between instability and impingement
(relocation part of the test)

38. Crank Apprehension Test
(Relocation Test)
• Patient position = the patient lies supine, with the shoulder
abducted 90° and externally rotates, the elbow 90° flexed,
the forearm pronated. The test arm is close to the edge of
the couch
• Examiner position = the examiner stands at the patient’s
side facing to the test shoulder

39. Crank Apprehension Test
(Relocation Test)
• Test Procedure
• Step 1 The Crank Test
• Step 2 The Relocation test

40. Crank Apprehension Test
(Relocation Test)
• Specificity Range: 56% to 100%
• Sensitivity Range: 35% to 91%

41. Medium Gleno Humeral
Ligament (MGHL)

42. Relevant special tests
The middle glenohumeral
ligament provides anterior
stability at 45 degrees
and 60 degrees
abduction whereas
Physical examination tests of the shoulder:
a systematic review with meta-analysis of individual tests.
Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3rd, Cook C.
Br J Sports Med. 2008 Feb;42(2):80-92; discussion 92. Epub 2007 Aug 24. Review.
Note: no one test can provide a definite diagnosis of capsulo-ligamentous lesion
?

43. Superior Gleno Humeral
Ligament (SGHL)

44. Relevant special tests
?
Physical examination tests of the shoulder:
a systematic review with meta-analysis of individual tests.
Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3rd, Cook C.
Br J Sports Med. 2008 Feb;42(2):80-92; discussion 92. Epub 2007 Aug 24. Review.
Note: no one test can provide a definite diagnosis of capsulo-ligamentous lesion

45. Coraco Humeral Ligament (CHL)

46. Relevant special tests
?
The
coracohumeral ligament with
superior glenohumeral ligament
the was shown to be an
important stabilizer in
the inferior direction.
Anatomy of the superior glenohumeral ligament.
Kask K, Põldoja E, Lont T, Norit R, Merila M, Busch LC, Kolts I.
J Shoulder Elbow Surg. 2010 Sep;19(6):908-16.

47. Rotator Interval

48. Relevant special tests

49. SURGICAL FINDINGS
The addition of an arthroscopic rotator interval closure after posterior
capsulolabral repair did not improve posterior stability; however,
anterior stability was improved further after a rotator interval closure.
Inferior stability was not improved. Arthroscopic rotator interval
closure significantly decreased external rotation at both neutral and
abducted arm positions.
CLINICAL RELEVANCE
Arthroscopic closure may be beneficial in certain cases of
anterior shoulder instability; however, posterior instability was not
improved. Predictable losses of external rotation after rotator interval
closure are of concern.
Mologne TS, Zhao K, Hongo M, Romeo AA, An KN, Provencher MT.
The addition of rotator interval closure after arthroscopic repair of either anterior or
posterior shoulder instability: effect on glenohumeraltranslation and range of motion.
Am J Sports Med. 2008 Jun;36(6):1123-31. Epub 2008 Mar 4.

50. Posterior Capsule(PC)

51. Posterior capsular contracture of the shoulder.
Bach HG, Goldberg BA.
J Am Acad Orthop Surg. 2006 May;14(5):265-77. Review.
• Common cause of shoulder pain in which
the patient presents with restricted internal
rotation and reproduction of pain.
• Increased anterosuperior translation of the
humeral head occurs with forward flexion
and can mimic the pain reported with
impingement syndrome; however, the
patient with impingement syndrome
presents with normal range of motion.
• In the throwing athlete, repetitive forces on
the posteroinferior capsule may cause
posteroinferior capsular hypertrophy and
limited internal rotation.
• This may be the initial pathologic event in
the so-called dead arm syndrome, leading
to a superior labrum anteroposterior lesion
and, possibly, rotator cuff tear.
Posterior Capsular Contracture

52. Relevant special tests
Note: no one test can provide a definite diagnosis of labral lesion
Parentis MA, Glousman RE, Mohr KS, Yocum LA.
An evaluation of the provocative tests for superior labral anterior posterior lesions.
Am J Sports Med. 2006 Feb;34(2):265-8.

53. Thanks for your
kind attention
science explain what is possible to make
ethics tell us what is right (Socrates)
la scienza spiega cio’ che e’ possibile fare,
l’etica dice cio’ che e’ giusto fare (Socrate)