Examination of the shoulder joint

Question 1

What are the bony structures of the shoulder?

Answer 1

1) Humerus

2) Glenoid

3) Acromion

4) Clavicle

Question 2

What are the joints that surround the shoulder joint?

Answer 2

1) Glenohumeral joint

2) Acromioclavicular joint

3) Sternoclavicular joint

4) Scapulothoracic joint (between the scapula and the posterior thoracic region, pseudo-articulation “not a true joint”)

Question 3

Describe the glenohumeral joint

Answer 3

1) Ball & socket joint

2) The most commonly dislocated joint, with the highest ROM (it sacrifices its stability for its range of motion)

3) The glenoidal fossa is relatively flat and much smaller than the contacting humeral head (25-30%)

4) It is stability is achieved by the static and dynamic stabilizers (provided by the capsulo-labral complex)

Question 4

What composes the static stabilizers?

Answer 4

1) The bony structures

2) Labrum

3) GH Ligaments (superior, middle, and inferior), the inferior one is the most important and the most affected in a case of shoulder dislocation, it has two bands anterior and posterior

4) Joint capsule

• They continue to function despite any neurologic or intrinsic muscle pathology
• Joints have a negative suction effect between their two surfaces which makes the joints intact

Question 5

What are the parts of the dynamic stabilizers?

Answer 5

1) Rotator cuff (above the capsule)

2) Scapular stabilizer (Teres major, rhomboid, serratus anterior, trapezius and levator scapula)

• These structures cannot function if any neuromuscular or intrinsic muscle damage is present, leading to laxity and shoulder pain

Question 6

What are the muscles that form the rotator cuff?

Answer 6

1) Supraspinatus

2) Infraspinatus

3) Teres minor

4) Subscapularis

Question 6

What is the main function of the rotator cuff muscles?

Answer 6

Depresses and centralizes the humeral head within the glenoid

Question 7

What is the function of each muscle of the rotator cuff muscles?

Answer 7

1) Supraspinatus: abduction, centralizes the humeral head within the glenoid

2) Infraspinatus: external rotation, pulls the humeral head inferiorly

3) Teres minor: external rotation, pulls the humeral head inferiorly

4) Subscapularis: internal rotation with the pectoralis and latissimus dorsi

• When they are damaged the humeral head can migrate proximally due to the unsupported deltoid pull action

Patients won’t be able to initiate abduction and the pain is mostly at night

Question 8

Which muscle is responsible for the forward flexion of the shoulder?

Answer 8

1) Deltoid

2) Pectoralis major

3) Coracobrachialis

4) Biceps

Question 9

Which muscle is responsible for the Extension of the shoulder?

Answer 9

1) Deltoid

2) Teres major

3) Teres minor

4) Latissimus dorsi

5) Pectoralis major

6) Triceps

Question 10

Which muscle is responsible for the Abduction of the shoulder?

Answer 10

1) Deltoid

2) Supraspinatus

3) Infraspinatus

4) Subscapularis

5) Teres major

Question 11

Which muscle is responsible for the Adduction of the shoulder?

Answer 11

1) Pectoralis major

2) Latissimus dorsi

3) Teres major

4) Subscapularis

Question 12

Which muscle is responsible for the Internal rotation of the shoulder?

Answer 12

1) Pectoralis major

2) Latissimus dorsi

3) Teres major

4) Subscapularis

5) Deltoid

Question 13

Which muscle is responsible for the External rotation of the shoulder?

Answer 13

1) Infraspinatus

2) Teres minor

3) Deltoid

Question 14

What are the causes of shoulder pain?

Answer 14

1) Pain arising from the shoulder

2) Pain arising from elsewhere (referred pain)

It could be caused by rotator cuff muscles, impingement, and instability (subluxation)

Question 15

What are the principles in taking the history of the shoulder?

Answer 15

1) Always begin with the patient’s age, dominant hand, and sport or work activity

2) Determine the trauma and its mechanism if present

3) Rotator cuff is very common in people above the age of 60 and it’s asymptomatic ( need to do further tests: eg. MRI)

4) Instability and frequent dislocation is common in young people who are usually active and playing sport

5) Impingement syndrome is common in people who practice overhead activities

6) Onset, type, quality, scale, progression, timing (eg. day or night, rotator cuff mainly at night, Inflammation, infection, and neoplasia are most common to cause pain at rest or at night ), location, associated symptoms,

7) Do specific activities/arm movements exacerbate or alleviate the pain

8) Ask about previous medications: NSAIDS like ibuprofen will help the rotator cuff

9) Previous medical history: 50% of patients with a frozen shoulder have Dibates Mellitus

• Frozen shoulder commonly seen among diabetics will have limitations in range of motion

Question 16

What are some of the associated symptoms regarding the shoulder?

Answer 16

1) Instability/laxity

2) Weakness (impingement, rotator cuff pathology)

3) swelling (acute trauma, rotator cuff tear, inflammation)

4) Numbness

5) Loss of motion, stiffness +/- pain (adhesive capsulitis, dislocation, or GH instability)

6) Catching (labral disorder)

7) Popping (labral disorder, crepitation “PRC tear”)

Question 17

How do we inspect the musculoskeletal system?

Answer 17

1) Look

2) Feel

3) Move

Question 18

What are the things we look for in the inspection?

Answer 18

1) Swelling

2) Asymmetry

3) Muscle atrophy

4) Scars

5) Creases

6) Ecchymosis

7) Venous distention

Question 19

What are the things we palpate when we feel the shoulder?

Answer 19

1) Sternoclavicular joint

2) Clavicle

3) Coracoid process

4) Acromion

5) Acromioclavicular joint

6) Scapula

7) Bicipital groove

8) Subacromial bursa

9) Cervical spine

Question 20

What are the active movements done?

Answer 20

• Testing the range of motion

1) External rotation/abduction (touch the scapula superiorly with the contralateral hand)

2) Internal rotation/adduction (touch the shoulder with the contralateral hand)

3) Internal rotation/adduction (touch the scapula inferiorly with the contralateral hand)

Question 21

What are the passive movements done for the shoulder?

Answer 21

• To test the ROM, done when the patient couldn’t fully perform the active tests
• If passive ROM is normal but the active ROM is restricted, muscle weakness is like to be the cause
• If both are affected (the problem might be intra-articular, like OA, or locked humeral head dislocation) or soft tissue (extra-articular) blockage (like adhesive capsulitis “frozen shoulder”)
• With rotator cuff tear most probably it is pain accompanied by weakness

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Question 22

What is a jobe test? and what muscle does it test?

Answer 22

• The empty can test
• It test the supraspinatus muscle

1) The patient should abduct his shoulder to 90 degrees in forward flexion, with the thumbs pointing down

2) Then the patient should attempt to elevate the arms against the examiner resistance

Question 23

What is the lift-off test (Gerber test)?

Answer 23

1) The patient should rest the dorsum of his hand in the lumbar area

2) If there was an inability to move the hand back by internally rotating it it suggests an injury to the subscapularis muscle

Question 24

What are some other provocative tests done to the shoulder?

Answer 24

1) Impinigment test:
- Neer sign (the pain is felt at the tip of the shoulder), Hawkins test

2) AC joint arthritis:
- Cross-arm test (Decreased ROM indicates tight posterior capsule)

3) GH instability:
- Apprehension test, relocation test, sulcus test

4) Bicep tendon instability/tendonitis:
- Yergson test, speed’s maneuver

5) Labral disorder (SLAP lesion: superior labral tear):
- O’Brien’s test

6) Cervical nerve disorder
- Spurling’s maneuver

Question 25

What is meant by impingement syndrome?

Answer 25

• Mechanism:
  1) Rotator cuff tendons can get impaired between the coracobrachialis arch and the humerus on the abduction
• The supraspinatus muscle is mostly involved

There are two types:
1) Primary (in older people with chronic overuse and degeneration)

2) Secondary (Young people, throwing athletes, GH instability leading to impingement)

Question 26

What is a Bankart lesion (anteroinferior capsulolabral tear)?

Answer 26

It is the most common lesion found in more than 90% of traumatic anterior dislocation (between the glenoid fossa and the glenoid labrum)

Question 27

Describe the O’Brien’s test

Answer 27

• Tests the labral, AC or bicep pathology

1) Arm flexed to 90 degrees

2) Arm cross-arm adducted 10-15 degrees

3) Elbow extended

4) Max pronation

5) Then the examiner provides resistance downwards

• If the patient felt pain you need to be aware of its location if it is AC, Biceps, Internal +/- click