The document provides information on shoulder anatomy and tests. It describes the shoulder joint as a ball-and-socket joint formed by the head of the humerus and glenoid cavity. It details the ligaments, bones, muscles, nerves and vascular supply related to the shoulder. The document also describes various clinical tests used to evaluate the rotator cuff, acromioclavicular joint, biceps tendon and shoulder instability. These include Neer's impingement test, Hawkins-Kennedy test, empty can test and tests for the supraspinatus, infraspinatus, subscapularis and other muscles.

1. SHOULDER ANATOMY AND TESTS

2. INTRODUCTION
 Enarthrodial or Ball-and-Socket joint
 Bones Involve
 Large globular head of humerus
 Glenoid cavity of scapula
 Protected against displacement by tendons
and by atmospheric pressure.
 Ligaments around gleno-humeral joint; Limit
the amount of joint movement
 Capsular
 Coracohumeral
 Transverse Humeral
 Glenoid Ligament
 Above protected by arched vault formed by:
 Under surface of coracoid process
 Under surface of acromion process
 Coraco-acromial ligament

3. GLENOID CAVITY
• Pear Shape
• Shallow
• Directed Laterally and
Upward
• Only1/3rd of the humeral
head comes in contact with
the glenoid cavity at any
position.
• Glenoid Fossa is deepened
by a fibro-cartilaginous rim
of Glenoid labrum.

4. ARTICULATING SURFACE

6. CAPSULAR LIGAMENT
• Encircles entire glenohumeral
joint.
• Attached:
 Medially: Above to the
circumference of glenoid
cavity beyond the glenoid
ligament
 Laterally: Below to
anatomical neck of the
humerus
• Thicker above and below.
• Loose and lax
• Allow bone to be separated
from each other more than
an inch

7. MUSCLES SUPPORTING CAPSULAR LIGAMENT
 Superiorly 
Supraspinatus
 Inferiorly  Long Head of
Triceps
 Posteriorly  Tendons of
Infraspinatus and Teres
Minor
 Anteriorly  Tendon of
Subscapularis

8. OPENINGS OF CAPSULAR LIGAMENT
3 Openings
 Anteriorly
 Below coracoid Process,
connection between synovial
membrane of the joint and a
bursa beneath the tendon of
subscapularis muscle.
 Between the 2 tuberosities,
passage of the biceps long
head.
 Posteriorly
 Not constant, where a
communication exists
between joint and a bursal
sac belonging to
Infraspinatus muscle.

9. GLENOHUMERAL LIGAMENTS
 3 fibrous bands derived from
thickening of the anterior part of
fibrous capsule.
 All 3 Converge upward and
medially blend with glenoid
labrum:
 SUPERIOR BAND : attached
to the upper end of lesser
tubercle
 MIDDLE BAND : attached to
lower part of lesser tubercle
 INFERIOR BAND : lower
part of anatomical neck of
humerus.

10. CORACO-HUMERAL LIGAMENT

11. TRANSVERSE HUMERAL LIGAMENT

12. GLENOID LABRUM
 Fibro-cartilage rim
attached around margin of
glenoid cavity.
 Triangular on section
 Thickest portion at
circumference of cavity,
free edge is sharp and thin
 Continuous above with
long head of biceps
 Deepens cavity for
articulation and protects
edges of bone
 Lined by synovial
membrane

13. SYNOVIAL MEMBRANE

14. BURSAE IN RELATION TO THE SHOULDER JOINT
1) SUBSCAPULAR
BURSA
2) INFRASPINATUS
BURSA
3) SUBACROMIAL
BURSA
(SUBDELTOID)
4) SUBCORACOID
BURSA

15. MUSCLES IN RELATION TO THE JOINT
 Above  Supraspinatus
 Below  Long head of Triceps
 Front  Subscapularis
 Behind  Infraspinatus and
Teres Minor
 Deltoid is placed most
externally and covers the
articulation from its outer side,
as well as in front and behind.

16. BLOOD AND NERVE SUPPLY
• Blood Supply
1. Anterior circumflex
humeral vessels
2. Posterior circumflex
humeral vessels
3. Suprascapular vessels
• NERVE SUPPLY
1) Axillary nerve
2) Musculocutaneous
nerve
3) Suprascapular Nerve
4) Lateral pectoral nerve

17. SPECIAL TESTS OF SHOULDER JOINT

18. NORMAL RANGE OF MOTION OF SHOULDER
JOINT:

19. SPECIAL TESTS FOR SHOULDER JOINT:
TESTS FOR
ROTATOR
CUFF/IMPINGM
ENT
TESTS FOR
ACROMIOCLAVI
CULAR JOINT
TESTS FOR
BICEP TENDON
TESTS FOR
INSTABILITY
1. NEER
IMPINGMENT
TEST
2. HAWKINS
KENNEDY TEST
3. EMPTY CAN TEST
4. DROP ARM TEST
5. LIFT OFF.TEST
6. INFRASPINATUS
TEST
7. SPRING BACK
TEST
8. TERES MINOR
TEST
9. TERES MAJOR
TEST
10. APLEY SCRATCH
TEST
1. PAINFUL ARC
2. FORCED
ADDUCTION
TEST
3. FORCED
ADDUCTION
TEST IN
HANGING
ARM
4. DUGA’S TEST
1. SPEED TEST
2. YERGASON
TEST
3. BICEP
TENDON
WITH
TRANSVERS
E HUMERAL
LIGAMENT
TEST
1. ANTERIOR
APPREHENSI
ON TEST
2. POSTERIOR
APPREHENSI
ON TEST
3. ANTERIOR
POSTERIOR
DRAWER
TEST
4. INFERIOR
INSTABILITY
TEST
5. SULCUS
TEST

20. TESTS FOR ROTATOR CUFF
AND IMPINGMENT SYNDROME

21. IMPINGEMENT:
Primary impingment Secondary impingment
Occur because of degenerative
changes to the rotator cuff,the
acromian process,the coracoid
process and anterior tissues from
stress overload.
Occurs due to problem with
muscle dynamics with an upset in
the normal force couple action
leading to muscle imbalance and
abnormal movement patterns at
both the glenohumeral joint and
the scapulothoracic articulation.
Impingement is primary cause of
pain.
It is secondary to altered muscle
dynamics.
Occurs mostly in 40+ age group
people.
Occurs in young patients.(15-
35years old)
It is said to be intrinsic when
rotator cuff degeneration occurs
and extrinsic when the shape of
the acromian and degeneration of
the coracoacromial ligament
occurs.
Commonly seen with joint
instability.

22. GRADING OF IMPINGEMET:
 Mostly impingement and instability often occurs
together in throwing athletes and accordingly it is
classified as:
GRADE I:
Pure
impingement
with no
instability.(ofte
n seen in older
patients)
GRADE II:
Secondary
impingment
and instability
caused by
chronic
capsular and
labral
microtrauma.
GRADE III:
Secondary
impingement
and instability
caused by
generalized
hypermobility
or laxity.
GRADE IV:
Primary
instability with
no
impingement.

23. NEER IMPINGMENT TEST:
PATIENT’S AFFECTED ARM IS PASSIVELY AND FORCIBLY FULLY
ELEVATED IN THE SCAPULAR PLANE WITH THE ARM MEDIALLY
ROTATED BY THE EXAMINER.
•This passive stress
causes “jamming of
the greater tuberosity
against the
anteroinferior border of
the acromian.
•The patient’s face
shows pain reflecting a
+ve test.

24. HAWKIN’S KENNEDY IMPINGMENT TEST:
PATIENT STAND WHILE THE EXAMINER FORWARD FLEXS THE ARM TO
90º AND FORCIBLY MEDIALLY ROTATES THE SHOULDER.
•This movement
pushes the
supraspinatus tendon
against the anterior
surface of the
coracoacromial
ligament and coracoid
process.
•Pain indicates +ve
test.

25. SUPRASPINATUS TEST/EMPTY CAN TEST:
THIS TEST MAY BE PERFORMED WITH THE PATIENT STANDING OR
SEATED.WITH THE ELBOW EXTENDED, THE PATIENT’S ARM IS HELD AT
90° OF ABDUCTION,30° OF HORIZONTAL FLEXION, AND IN INTERNAL
ROTATION (WITH THUMB FACING DOWN). THE EXAMINER EXERTS
PRESSURE ON THE UPPER ARM DURING THE ABDUCTION AND
HORIZONTAL FLEXION MOTION.
•When this test elicits severe
pain and the patient is
unable to hold his or her arm
abducted 90° against gravity, this
is called a positive empty can
test/supraspinatus tendinitis.
•The superior portions of the
rotator cuff (supraspinatus) are
particularly assessed in internal
rotation (with the thumb down),
and the
•anterior portions in external
rotation.

26. DROP ARM(CODMAN’S)TEST:
THE PATIENT IS SEATED, AND THE EXAMINER PASSIVELY ABDUCTS THE
PATIENT’S EXTENDED ARM APPROXIMATELY 120°. THE PATIENT IS
ASKED TO HOLD THE ARM IN THIS POSITION WITHOUT SUPPORT AND
THEN SLOWLY ALLOW IT TO DROP.
Weakness in maintaining the position
of the arm, with or
without pain, or sudden dropping of
the arm suggests a rotator cuff
lesion. Most often this is due to a
defect in the supraspinatus. In
pseudoparalysis, the patient will be
unable to lift the affected arm. This
global sign suggests a rotator cuff
disorder.

27. SUBSCAPULARIS TEST/LIFT OFF TEST:
PATIENT IN STANDING POSITION PLACES THE DORSUM OF THE HAND
ON THE BACK. THE PATIENT THEN LIFTS THE HAND AWAY FROM THE
BACK. IF PATIENT IS ABLE TO DO THEN LOAD PUSHING ON HAND IS
DONE BY THE EXAMINER TO CHECK THE STRENGH.
•A patient with a subscapularis
tear will be unable to do
this.
•Abnormal motion in the scapula
during the test may indicate
scapular instability.

28. INFRASPINATUS TEST:
COMPARATIVE TESTING OF BOTH SIDES IS BEST. THE PATIENT’S
ARMS SHOULD HANG RELAXED WITH THE ELBOWS FLEXED 90° BUT
NOT QUITE TOUCHING THE TRUNK. THE EXAMINER PLACES HIS OR
HER PALMS ON THE DORSUM OF EACH OF THE PATIENT’S HANDS AND
THEN ASKS THE PATIENT TO EXTERNALLY ROTATE BOTH FOREARMS
AGAINST THE RESISTANCE OF THE EXAMINER’S HANDS.
Pain or weakness in external rotation
indicates a disorder of the infraspinatus
(external rotator).
As infraspinatus tears are usually
painless, weakness in rotation strongly
suggests a tear in the muscle.
This test can also be performed with
the arm abducted 90° and flexed
30° to eliminate involvement of the
deltoid in this motion.

29.  SPRING BACK TEST:
PATIENT EITHER IN SITTING OR STANDING HOLD THE
ELBOW IN FLEXION AT 90º BY THE SIDE. EXAMINER
PASSIVELY BRING THE SHOULDER TO 90º ABDUCTION
AND LATERALLY ROTATE TO THE END RANGE AND ASK
THE PATIENT TO HOLD THE ARM TO THIS POSITION.
FOR +VE TEST OF INFRASPINATUS WEAKNESS/LESION
PATIENT CANNOT HOLD THE POSITION AND HAND
SPRING BACK ANTERIORLY.
TERES MINOR TEST:
PATIENT LIES PRONE AND PLACES HIS HAND ON THE
OPPOSITE POSTERIOR ILIAC CREST. ASK THE PATIENT
TO EXTEND AND ADDUCT THE MEDIALLY ROTATED ARM
AGAINST RESISTANCE. PAIN OR WEAKNESS INDICATE
+VE TEST.

30. TERES MAJOR TEST:
THE PATIENT IS STANDING AND RELAXED. THE EXAMINER ASSESSES
THE POSITION OF THE PATIENT’S HANDS FROM BEHIND. THE TERES
MAJOR IS AN INTERNAL ROTATOR. WHERE A CONTRACTURE IS
PRESENT, THE PALM OF THE AFFECTED HAND WILL FACE BACKWARD
COMPARED WITH THE CONTRALATERAL HAND.

31. APLEY’S SCRTCH TEST:
THE SEATED PATIENT IS ASKED TO TOUCH THE CONTRALATERAL
SUPERIOR MEDIAL CORNER OF THE SCAPULA WITH THE INDEX
FINGER.
Pain elicited in the rotator cuff and failure to
reach the scapula because of restricted
mobility in external rotation and abduction
indicate rotator cuff pathology (most probably
involving the supraspinatus).

32. ACROMIOCLAVICULAR JOINT
TESTS

33. TOSSY CLASSIFICATION:
 TOSSY TYPE 1: CONTUSION OF THE
ACROMIOCLAVICULAR JOINT WITHOUT
SIGNIFICANT INJURY TO THE CAPSULE AND
LIGAMENTS.
 TOSSY TYPE 2: SUBLUXATION OF THE
ACROMIOCLAVICULAR JOINT WITH RUPTURE OF
THE ACROMIOCLAVICULAR LIGAMENTS.
 TOSSY TYPE 3: DISLOCATION OF THE
ACROMIOCLAVICULAR JOINTWITH ADDITIONAL
RUPTURE OF THE CORACOCLAVICULAR
LIGAMENTS.

34. ACROMIOCLAVICULAR JOINT PROBLEM
 MAY BE ELICITED BY ANTERIOR PAIN WITH MOTION AND
TENDERNESS TO PALPATION OVER THE
ACROMIOCLAVICULAR JOINT.

FINDINGS WILL OFTEN INCLUDE PALPABLE BONY THICKENING
OF THE ARTICULAR MARGIN.

TOSSY CLASSIFIES ACROMIOCLAVICULAR JOINT INJURIES
INTO THREE DEGREES OF SEVERITY:

35. PAINFUL ARC:
THE PATIENT’S ARM IS PASSIVELY AND ACTIVELY ABDUCTED FROM THE
REST POSITION ALONGSIDE THE TRUNK. PAIN IN THE
ACROMIOCLAVICULAR JOINT OCCURS BETWEEN 140°AND 180° OF
ABDUCTION. INCREASING ABDUCTION LEADS TO INCREASING COM-
PRESSION AND CONTORTION IN THE JOINT. (IN AN IMPINGEMENT
SYNDROME OR A ROTATOR CUFF TEAR, BY COMPARISON, PAIN
SYMPTOMS WILL OCCUR BETWEEN 70°
AND 120°.
In the evaluation of the active
and passive ranges of motion,
the patient can often avoid the
painful arc by externally rotating
the arm while abducting it. This
increases the clearance
between the acromion and the
diseased tendinous portion of
the rotator cuff, avoiding
impingement in the range
between 70° and 120°.

36. FORCED ADDUCTION TEST:
THE 90°-ABDUCTED ARM ON THE AFFECTED SIDE IS FORCIBLY
ADDUCTED ACROSS THE CHEST TOWARD THE NORMAL SIDE.
FORCED ADDUCTION TEST ON HANGING ARM:
THE EXAMINER GRASPS THE UPPER ARM OF THE AFFECTED SIDE
WITH ONE HAND WHILE THE OTHER HAND RESTS ON THE CONTRALATERAL
SHOULDER AND IMMOBILIZES THE SHOULDER GIRDLE. THEN THE EXAMINER
FORCIBLY ADDUCTS THE HANGING AFFECTED ARM BEHIND THE PATIENT’S
BACK AGAINST THE PATIENT’S RESISTANCE.
Pain across the anterior
aspect of the shoulder
suggests
acromioclavicular joint
disease or subacromial
impingement.

37. DUGA’S TEST:
THE PATIENT IS SEATED OR STANDING AND TOUCHES THE
CONTRALATERAL SHOULDER WITH THE HAND OF THE 90°-
FLEXED ARM OF THE AFFECTED SIDE THEN ATTEMPT TO LOWER
THE ELBOW TO THE CHEST IS MADE.
Acromioclavicular joint pain
suggests joint disease
(osteoarthritis,
instability, disk injury, or
infection).
A differential diagnosis
must exclude anterior
subacromial impingement

38. BICEP TENDON TEST
THE CLOSE ANATOMIC PROXIMITY OF THE
INTRAARTICULAR PORTION OF THE TENDON
TO THE CORACOACROMIAL ARCH
PREDISPOSES IT TO INVOLVEMENT IN
DEGENERATIVE PROCESSES IN THE
SUBACROMIAL SPACE. A ROTATOR CUFF TEAR
IS OFTEN ACCOMPANIED BY A RUPTURE OR
INJURIES OF THE BICEPS TENDON.

39. SPEED TEST:
IN SITTING THE EXAMINER RESISTS SHOULDER FORWARD
FLEXION BY THE PATIENT WHILE THE PATIENT’S FOREARM IS IN
SUPINATION. PAIN IN THE REGION OF THE BICIPITAL GROOVE
SUGGESTS A DISORDER OF THE LONG HEAD OF THE BICEPS
TENDON.

40. YERGASON TEST:
WITH THE PATIENT’S ELBOW FLEXED TO 90º AND STABILIZED AGAINST
THORAX AND WITH FOREARM PRONATED, THE EXAMINER RESISTS
SUPINATION WHILE THE PATIENT ALSO LATERALLY ROTATES THE ARM
AGAINST RESISTANCE. DURING THIS MOVEMENT WHEN THE TENDON
IS FELT IN GROOVE AS “POP OUT” .
•Pain in the bicipital groove is a sign of
a lesion of the biceps tendon, its tendon
sheath, or its ligamentous connection
via the
•transverse ligament.
•The typical provoked pain can be
increased by pressing on the tendon in
the bicipital groove.

41. BICEP TENDINITIS WITH TRANSVERSE HUMERAL
LIGAMENT TEST:
THE PATIENT IS SEATED WITH THE ARM ABDUCTED 90°, INTERNALLY
ROTATED, AND EXTENDED AT THE ELBOW. FROM THIS POSITION, THE
EXAMINER EXTERNALLY ROTATES THE ARM WHILE PALPATING THE
BICIPITAL GROOVE TO VERIFY WHETHER THE TENDON SNAPS.
•In the presence of
ligamentous insufficiency, this
motion will cause the biceps
tendon to spontaneously
displace out of the bicipital
groove.
•Pain reported without
displacement suggests biceps
•tendinitis.

42. INSTABILITY TESTS
SHOULDER PAIN MAY BE ATTRIBUTABLE TO AN
UNSTABLE SHOULDER. USUALLY HISTORY OF A PERIOD
OF INTENSIVE SHOULDER USE (SUCH AS COMPETITIVE
SPORTS), AN EPISODE OF REPEATED MINOR TRAUMA
(OVERHEAD USE), OR GENERALIZED LIGAMENT LAXITY.
BOTH YOUNG ATHLETES AND INACTIVE PERSONS ARE
AFFECTED, MEN AND WOMEN ALIKE.

43. ANTERIOR APPREHENSION TEST:
PATIENT LIE SUPINE OR IN SITTING . ARM IS ABDUCTED TO 90º
AND LATERALLY ROTATED SLOWLY BY THE EXAMINER. WHILE
PERFORMING PATIENT’S EXPRESSIONS ARE NOTED FOR
APPREHENSION/FURTHER RESISTENCE TO ROTATION. THE
TEST IS PERFORMED AT 60°, 90°, AND 120° OF ABDUCTION TO
EVALUATE THE SUPERIOR, MEDIAL, AND INFERIOR
GLENOHUMERAL LIGAMENTS. WITH THE GUIDING HAND, THE
EXAMINER PRESSES THE HUMERAL HEAD IN AN ANTERIOR AND
INFERIOR DIRECTION
Shoulder pain with reflexive
muscle tensing is a sign of an
anterior instability syndrome. This
muscle tension is an attempt by
the patient to prevent imminent
subluxation or dislocation of the
humeral
head.

44. NOTE:
When the patient complains of sudden stabbing pain
with simultaneous or subsequent paralyzing
weakness in the affected extremity, this is referred
to as the “dead arm sign.” It is attributable to the
transient compression the subluxated humeral head
exerts on the plexus.
 It is important to know that at 45° of abduction, the
test primarily evaluates the medial glenohumeral
ligament and the subscapularis tendon. At or above
90° of abduction, the stabilizing effect of the
subscapularis is neutralized and the test primarily
evaluates the inferior glenohumeral ligament.

45. POSTERIOR APPREHENSION TEST:
PATIENT LIES SUPINE OR IN SITTING POSITION AND EXAMINER
FORWARD FLEX SHOULDER TO 90º WHILE STABILIZING THE SCAPULA
WITH OTHER HAND. EXAMINER THEN APPLIES A POSTERIOR FORCE
ON THE ELBOW AND MOVES THE ARM IN ADDUCTION AND MEDIALLY
ROTATION.

46. ANTERIOR AND POSTERIOR DRAWER TEST:
THE PATIENT IS SEATED. THE EXAMINER STANDS BEHIND THE PATIENT.
TO EVALUATE THE RIGHT SHOULDER, THE EXAMINER GRASPS THE
PATIENT’S SHOULDER WITH THE LEFT HAND TO STABILIZE THE
CLAVICLE AND SUPERIOR MARGIN OF THE SCAPULA WHILE USING THE
RIGHT HAND TO MOVE THE HUMERAL HEAD ANTERIORLY AND
POSTERIORLY.

47. INFERIOR APPREHENSION TEST/FEAGIN TEST:
PATIENT STANDS WITH THE ARM ABDUCTED TO 90º AND ELBOW
EXTENDED AND RESTING ON TOP OF THE EXAMINER’S SHOULDER.
EXAMINER CLASP HIS/HER HANDS AROUND THE PATIENT’S HUMERUS
AND PUSHES THE HUMERUS DOWN AND FORWARD. IN THIS SULCUS
MAY ALSO BE SEEN ABOVE THE CORACOID PROCESS.

48. SULCUS TEST:
PATIENT STANDS WITH ARM BY THE SIDE AND SHOULDER
MUSCLE RELAXED. THE EXAMINER GRASPS THE PATIENT’S
FOREARM BELOW THE ELBOW AND PULLS THE ARM DISTALLY.
THE PRESENCE OF SULCUS/INDENTATION INFERIOR TO
ACROMIAN IS THE INDICATIVE.

49. THANK YOU