Lecture 1 - The shoulder

Question 1

What are the joints that make up the shoulder girdle

Answer 1

Acromioclavicular - planar synovial joint between acromion of the scapula and the clavicle

Sternoclavicular - planar synovial joint between the medial clavicle and the superolateral manubrium

Scapulothoracic - articulation between anterior surface of the scapula and posterior thoracic cage (not synovial joint)

Glenohumeral - synovial ball and socket joint between glenoid fossa of scapula and head of humerus

Question 2

Describe the subacromial bursa

Answer 2

From deltoid to coracoacromial arch superiorly and rotator cuff inferiorly
Well vascularised
Has proprioceptive and nociceptive nerve endings

Question 3

What are the two key muscles for scapula movement and describe what they do

Answer 3

Trapezius:
Lower fibres - upward rotation, retraction and depression
Upper fibres - upward rotation, retraction and elevation

Serratus anterior:
Upwardly rotates and protracts the scapula

Question 4

What happens if trapezius is deinnervated

Answer 4

The scapula doesn’t upwardly rotate or elevate
This means the action of serratus anterior is uncoupled so the scapula is very protracted

Question 5

What happens if serratus anterior is deinnervated

Answer 5

The scapula experiences ‘winging’ where the medial border is highly pronounced as protraction isn’t performed

Question 6

What different forces pull on the humeral head and in what direction?

Answer 6

Deltoid - upward force
Long head of biceps tendon - downward force
Rotator cuff - counteracts upward force of the deltoid and medial force orientates humeral head on the glenoid

Question 7

Give some contributors to shoulder instability

Answer 7

Rotator cuff weakness
Inefficiency of coracohumeral or glenohumeral ligaments
Trapezius of serratus anterior efficiency impacting scapular control

Question 8

What are the limits to anterior translation

Answer 8

Posterior rotator cuff (teres minor and infraspinatus)
Anterior inferior glenohumeral ligament - abduction and lateral rotation tighten the ligament which squeezes the humeral head posteriorly

Secondary contributors = global cuff, long head of biceps, anterior capsule, middle and superior GHL and coracohumeral ligament

Question 9

What are the limits to posterior translation

Answer 9

Anterior rotator cuff (subscapularis)
Posterior inferior glenohumeral ligament - horizontal adduction and medial rotation tighten these ligaments

Secondary contributors = global cuff and posterior capsule

Question 10

What are the sporting causes of anterior and posterior instability

Answer 10

Anterior - bowlers, tennis (shoulder is extended and externally rotated)

Posterior - cycling, windsurfing (sports where forces go through arms in a downward direction) - also falling with arms outstretched

Question 11

What might patients with shoulder instability report in their history

Answer 11

Dull ache
Apprehension - described as ‘feels not quite right’
Family history likely
Pain at night on either side
Dead arm syndrome (anterior)

Question 12

What are the limits to inferior translation

Answer 12

Superior portion of rotator cuff (supraspinatus) or global cuff weakness
Superior and inferior GHL, coracohumeral ligament and joint capsule

Negative intra-articular pressureP

Question 13

Describe the relevance of negative intra-articular pressure in the glenohumeral joint

Answer 13

Pressure is greater outside the joint compared to the inside helping to stabilise the humeral head, if the pressure becomes balanced due to the capsule being compromised, less force is required to translate the humeral head

Question 14

Describe dead arm syndrome and why it happens

Answer 14

In a position of abduction and external rotation the humeral head falls forward due to anterior instability and applies downward pressure on the brachial plexus

This causes a sudden uncomfortable, electric feeling that will lead the person to drop what they are holding and furiously rub their shoulder

Question 15

Describe how you do the anterior apprehension and relocation test

Answer 15

Apply anterior glide to the humeral head
Flex the elbow to 90 degrees and externally rotate the shoulder
Take the shoulder through points of the range of abduction (bring back and forth because bringing it through the full range of abduction is painful)

Positive result is apprehension or pain between 90 and 130

Repeat with a posterior glide
Positive test is reinforced if symptoms are removed

Question 16

Describe how you would do the jerk test for posterior instability

Answer 16

Have the patient in supine with the elbow flexed to 90 degrees and shoulder flexed 90 degrees in scapula plane
Examiner has one hand round the back of the humerus with pinky directly under the humeral head
Push down on elbow through your naval

A positive is a jerk as the humerus displaces off the glenoid (or if more subtle, increased posterior movements of the humerus compared to the other side)

Question 17

Describe how you would complete a sulcus sign test for multidirectional instability

Answer 17

The patient can be standing or sitting with their arm by their side, the examiner holds the epicondyle and applies a downward traction like force

A positive is if the sulcus appears larger than a single finger (the patient’s) below the acromion

Question 18

Describe the 5 principles of treatment of shoulder issues

Answer 18

1. Pain management
2. Correct joint and soft tissue mobility
3. Correct muscle strength, endurance and recruitment
4. Establish functional patterns of movement
5. Reinforce effective patterns of movement

Question 19

What is shoulder impingement?

Answer 19

Symptoms of pain and dysfunction resulting from any pathology which either decreases the size of the subacromial space or increases the size of its contents

Question 20

What are the three categories of classification for shoulder impingement?

Answer 20

Primary
Secondary
Primary inflammatory/degenerative changes

Question 21

Give some primary causes of shoulder impingement

Answer 21

Osteophytes
Calcific bursa/tendon
Fracture
A-C joint dislocation
OA/RA of acromioclavicular joint
Shape/morphology of the acromion

Question 22

Give some secondary causes of shoulder impingement

Answer 22

Posture
Weakness
Ergonomics
Neuropathy
Muscle imbalance

Question 23

How does a weak rotator cuff lead to impingement

Answer 23

Weak rotator cuff leads to humeral head superior translation which makes the subacromial space smaller

Question 24

Give some causes of shoulder impingement related to primary inflammatory/degenerative changes

Answer 24

Tendinitis/osis
Bursitis
Capsulitis
Synovitis
Rotator cuff tears

Question 25

What borders the subacromial space

Answer 25

Between coraco-acromial arch and humeral head/greater tuberosity of the humerus

Question 26

What are the contents of the subacromial space?

Answer 26

Shoulder joint capsule
Rotator cuff tendons
Long head of biceps tendon
Subacromial bursa
Glenohumeral and coraco-humeral ligaments

Question 27

What might you expect to learn from a subjective assessment with a patient with shoulder impingement

Answer 27

> 45
Usually gradual onset due to repetitive overuse
Repetitive use in positions of abduction/flexion i.e. gardening, decorating, moving house
Pain putting on coat, reaching for things etc
Pain lying on affected side
If severe pain can spread from arm to hand

Question 28

How would you perform a painful arc test?

Answer 28

Abduct the arm in the scapular pain
Pain between 60 and 120 degrees indicates rotator cuff tendon irritation

Question 29

How would you perform an empty can test?

Answer 29

The patient actively abducts the arm to 90 degrees in scapular plane with thumb facing downward and examiner applies downward resistance, the test is then repeated with the thumb facing upward

Pain with the ‘empty can’ that resolves with full can indicates a rotator cuff tear

Question 30

How would you perform a modified Hawkins/Kennedy test?

Answer 30

Flex shoulder to 90 and flex elbow to 90 in transverse plane
Apply an internal rotation force
Pain indicates impingement

Question 31

How would you perform a scarf test?

Answer 31

Shoulder flexed to 90, elbow flexed to 90 and horizontally adduct
If symptoms are reproduced over the AC joint this indicates AC joint pathology such as arthritis or ligamentous tear which can also be indicative of shoulder impingement

Question 32

Why does posterior capsule tightness cause shoulder impingement?

Answer 32

Tight posterior capsule can push the humeral head forward and upward to narrow the subacromial space

Question 33

What are the four stages of adhesive capsulitis?

Answer 33

1. Pain
2. Pain and stiffness
3. Stiffness and pain
4. Recovery

Question 34

What might you expect from a subjective assessment of someone who has adhesive capsulitis?

Answer 34

Between 45 and 70 (although any age is possible)
Gradual onset
Pain on reaching up, reaching behind to put a bra on, get something out of a back pocket etc

Stage 1 and 2 - diffuse and disabling pain that worsens at night
Stage 3 - Pain is decreasing but range of movement is limited, scapulohumeral rhythm is reversed
Stage 4 - Pain continues to decrease and range of movement increases again

Question 35

What would you expect from an objective assessment of someone with adhesive capsulitis

Answer 35

Pain and limited passive lateral rotation and abduction (flexion is less impacted)
Negative impingement tests but reduced lateral rotation

Question 36

Give the treatment for adhesive capsulitis at its various stages

Answer 36

Stage 1 and 2 - Pain management - infection, mobilisation, NSAIDs/analgesics, TENs and active movement

Stage 3 - Limited things you can do, mobilisations can increase soreness over time even if providing short term increase in range of movement

Stage 4 - Limited treatment required, hand behind back is one of the last movements to return so you can give range of movement exercises for that

Question 37

What tests should you do if you suspect impingement

Answer 37

Painful arc test
Empty can test
Hawkins-Kennedy test

Question 38

What tests should you do if you suspect pathology of the AC joint?

Answer 38

O-briens test
Cross body adduction test

Question 39

What tests should you do if you suspect rotator cuff tears?

Answer 39

Lag signs:
External rotation
Internal rotation

Question 40

What tests should you do if you suspect instability?

Answer 40

Sulcus (inferior)
Apprehension/relocation (anterior)
Jerk (posterior)

Question 41

What test should you do to test for bicipital involvement in impingement and describe it

Answer 41

Speed test
30 degrees flexion, palm facing upward and examiner pushes down with patient resisting this
If pain experienced, positive for pain in the bicipital groove

Question 42

What test can you do to look for posterior capsule tightness

Answer 42

Patient in supine, hold their scapula (and orient it so the medial border is vertical if not already) and then flex shoulder and elbow to 90 and cross adduct, scapula movement shouldn’t occur until around in line with the shoulder, if it does, posterior capsule tightness is indicated

Question 43

Describe how you would assess for and treat thoracic spine involvement in shoulder pain

Answer 43

Aid patient to do thoracic side flexion and then see if their symptoms improve during flexion, if so thoracic spine may be involved

If thoracic spine is indicated, you can do transverse and PA glides

Question 44

Describe what the results of the external rotation and internal rotation lag signs indicate

Answer 44

External rotation tests posterosuperior cuff as per the following
Internal rotation tests anterior cuff as per the following

Progressive improvement = firing problem not weakness
Shakes/wobbles and resumes position = weakness
Lags/drops = full thickness tear

Question 45

How do you perform the o’brien’s test

Answer 45

90 degree shoulder flexion, 10-15 degrees horizontal adduction, internally rotate shoulder and pronate forearm, patient applies upward force
Repeat without the internal rotation and pronation

Positive for AC joint pathology if superficial pain occurs in the first test which is reduced or absent in the second test

Question 46

How would you test inner range traps and why

Answer 46

Test inner range traps as this is the weakest area of the muscle

Have the patient in prone with their arm horizontally above their head, get them to lift it and resist the practitioner pushing them down

Question 47

How would you test anterior cuff strength

Answer 47

90 degrees shoulder flexion and 90 degrees elbow flexion and then apply a force downward for the patient to resist

Weakness in anterior cuff if this is difficult

Question 48

How could you give a simple treatment technique to a patient with pain reaching forward due to ac pathology

Answer 48

Have them reach in the scapula plane, push the clavicle AP and have them stretch their arm out