Shoulder Flashcards
Movements of the scapula?
Upward rotation
- occurs with abduction or flexion of the shoulder
Downward rotation
- occurs with shoulder extension and adduction
Scapular abduction
Protraction
Serratus anterior
Pectoralis minor
Vertebral border of the scapula moves laterally
The shoulder joint adducts horizontally
Scapular adduction
Retraction
Middle and lower trapezius
Rhomboid major and minor
The vertebral border of the scapula moves medially
The shoulder joint abducts horizontally
Scapular elevation
Upper trapezius
Levator scapulae
Shoulder shrugs
The shoulder
Glenohumeral joint
3 planes of movement:
- Flex/ext: 0-180, 0-50; no hyperextension
- Abd/add: 0-180
- Int/ext rotation: 0-120
Shoulder flexion
Expected ROM: 180º
Muscles: anterior deltoid, coracobrachialis (less than 90º), supraspinatus
Test position: supine or seated to prevent hyperextension of lumbar
- arm pronated
Goniometer
Fulcrum: slightly below the acromion, through head of humerus
Stationary arm: mid-axillary line of trunk
Moveable arm: longitudinal midline of humerus
Things to watch for:
- Hyperextension of lumbar
- Elevation of scapula
- Don’t be fooled by elbow
Shoulder extension
Expected ROM: 50º
Muscles: latissimus dorsi, teres major, posterior deltoid, coracobrachialis (above 90º)
Test position: prone to prevent hyperextension of lumbar
- arm pronated
Goniometer
Fulcrum: slightly below the acromion, through head of humerus
Stationary arm: mid-axillary line of trunk
Moveable arm: longitudinal midline of humerus
Things to watch for:
- Hyperextension of lumbar
- Elevation of scapula
- Don’t be fooled by elbow
Shoulder abduction and adduction
Expected AROM: 0-180º
- adduction is the return to 0º
Position: supine, prone, or seated
- shoulder should be fully externally rotated
Goniometer
fulcrum: lateral aspect of the chest, slightly below acromion
Stationary arm: parallel to sternum, lateral aspect of trunk
Moveable arm: midline of humerus
Possible substitutions
Spinal flexion toward contralateral side
Elevation of scapula
Flexion of humerus
Shoulder horizontal adduction
Occurs in the transverse plane. Is a combination of motions between scapula, clavicle, and humerus.
Expected ROM: 0-120º (depends on start position)
Position: supine
Goniometer
Fulcrum: superior aspect of shoulder over acromion
Stationary arm: along superior aspect of scapula
Moveable arm: along midshaft of humerus
Horizontal abduction
Expected AROM: 0-120º
Position: supine or seated
Goniometer
Fulcrum: superior aspect of shoulder over acromion
Stationary arm: along superior aspect of scapula
Moveable arm: along midshaft of humerus
Substitutions:
- trunk rotation
Internal (medial) rotation
Expected ROM: 65º-90º
Position: supine
- elbow bent to 90º
- shoulder is brought to 90º of abduction; if not possible, measure from point able and document
Goniometer
Fulcrum: through humeral shaft, the tip of the elbow
Stationary arm: perpendicular to the floor or lined up with the trunk
Moveable arm: along the ulnar shaft
External (lateral) rotation
Expected ROM: 90º
Position: supine
- elbow bent to 90º
- shoulder is brought to 90º of abduction; if not possible, measure from point able and document
Goniometer
Fulcrum: through humeral shaft, the tip of the elbow
Stationary arm: perpendicular to the floor or lined up with the trunk
Moveable arm: along the ulnar shaft
Potential substitution patterns:
- trunk flex/ext
- elbow extension
- wrist flex/ext
Scapular elevation MMT
Muscles: upper trapezius and levator scapulae
Palpation: upper trapezius, lateral to cervical spinous process
Position: seated (AG), supine or prone (GM)
- have patient pull shoulders towards ears
- resistance: medial to acromion process in a downward motion
To minimize the affect of the trapezius and focus on the levator, have the patient put their hand behind their back.
Scapular elevation muscles
Upper trapezius
O: superior nuchal line and ligamentum nuchea
I: lateral third of clavicle and acromion process
N: spinal accessory nerve
Levator scapulae
O: transverse process of upper four cervical vertebra
I: medial border of scapula
N: dorsal scapular nerve
Scapular adduction MMT
Muscles: middle trapezius
Palpation: between the vertebral border of scapula and spinous process of cervical and upper thoracic vertebra
Position: prone (AG), sitting (GM)
AG
- Patient is prone with elbows flexed over the edge of the table, instruct the patient to lift elbows
- Apply pressure to mid-medial scapula and push out
GM
- in sitting with arm supported
- ask patient to bring shoulder blades together
Scapular adduction muscle
Middle trapezius
O: spinous process of T1-T5
I: superior border of scapular spine
N: spinal accessory nerve
Scapular depression and adduction
Muscles: lower trapezius
Palpation: between medial scapular spine and thoracic vertebra
Position: prone (AG and GM)
- AG: shoulder is abducted to 130 degrees, ask client to lift arm off table, apply resistance to the inferior angle of scapula, up and out
- GM: same position, but you might have to support the arm
Scapular depression and adduction muscles
Lower trapezius
O: spinous process of T6-T12
I: scapular spine
N: spinal accessory nerve
Scapular adduction and medial rotation MMT
Muscles: rhomboid major and minor
Palpation: vertebral border of scapular and spinous processes of C7-T5
Position: prone (AG), sitting (GM)
AG: lie prone, hand on lumbar spine, lift hand off back
- apply resistance along vertebral border
GM: in sitting, hand on lumbar spine, lift hand off back
Scapular adduction and medial rotation muscles
Rhomboid major
O: spinous process of T2-T5
I: medial border of scapula
N: dorsal scapular nerve
Rhomboid minor
O: spinous processes of C7-T1
I: medial border of scapula
N: dorsal scapular nerve
Scapular abduction and lateral rotation MMT
Muscles: serratus anterior
Palpation: lateral aspect of upper 8-9 ribs, just anterior to lateral border of scapula
Position
AG: subject is supine with shoulder flexed to 90º and elbow bent, push elbow up, apply resistance
GM: subject seated with arm supported, slide forward
Clinical test: push up test
Scapular abduction and lateral rotation muscles
Serratus anterior
O: anterior surface of upper 8 ribs
I: medial border of anterior scapula
N: long thoracic nerve
Shoulder horizontal adduction and abduction
In the transverse plane, combination of motions between the scapula, clavicle and humerus
Expected: 0-120º (depends on the start position)
Several different ways
- If you start at abduction-120º
- If you start at flexion-30º
Position: seated
Goniometer
Axis: superior aspect of shoulder, over acromion
Stationary arm: along superior aspect of scapula
Moving arm: along midshaft of humerus
Scapular abduction and lateral rotation MMT
Palpation: lateral aspect of upper 8-9 ribs, just anterior to the lateral border of scapula
Position:
AG - supine with shoulder and elbow at 90º, push elbow up, apply resistance
GM - seated with arm supported, slide forward
Shoulder flexion muscles
Anterior deltoid
O: anterior, superior lateral third of clavicle
I: deltoid tuberosity or humerus
N: axillary n
Coracobrachialis
O: coracoid process of scapula
I: medial surface of midshaft of humerus
N: musculocutaneous n.
Shoulder flexion MMT
Palpation
- Anterior deltoid: proximal to anterior aspect of humerus
- Coracobrachialis: anteromedial uipper 1/3 of humerus (in the armpit)
Position:
Anterior Deltoid (through 90)
AG - pt seated, elbow flexed, flex to 90 (can test straight), 5, 4, 3
Resistance proximal to the elbow
GM - pt is on his side, same position 2, 1, 0
Corocobrachialis (shoulder flex and adduction)
AG - sitting in the same position as above
Resistance is toward extension of the shoulder and abduction
GM - same as above
Shoulder extension muscles
Latissimus Dorsi
O: spinous process of T6-12, lumbar and sacral vertebra, thoracolumbar fascia, posterior lip of illiac crest
I: intertubercular groove of humerus
N: thoracodorsal n.
Teres Major
O: posterior, inferior scapula
I: intertuberical groove of humerus
N: lower subscapular n.
Posterior Deltoid
O: inferior spine of scapula
I: deltoid tuberosity of the humerus
N: axillary n.
Shoulder extension MMT
Palpation
- Latissimus dorsi: lateral side of rib cage
- Teres major: posterior wall of axilla
- Posterior deltoid: posterior shoulder
Position:
AG: client in prone, shoulder dropped into flexion of the edge of table, can bend elbow, extend
Apply resistance proximal to elbow
GM: sidelying
Shoulder abduction muscles
Middle Deltoid
O: acromion process
I: deltoid tuberosity
N: axillary n.
Supraspinatus
O: supraspinatus fossa
I: greater tubercle of humerus
N: suprascapular n.
Shoulder abduction MMT
Palpation
- Middle deltoid over superior lateral humerus
- Supraspinatus too deep
Position
AG: seated, arm to side, instruct client to lift arm to side(to 90). Apply resistance proximal to the elbow
GM: pt is supine, slide arm to side, keep supported by you or table
Shoulder horizontal adduction muscles
Pectoralis Major
O: anterior, medial ½ of clavical, anterior sternum and ribs 1-7
I: intertubercular groove of the humerus
N: medial and lateral pectoral n.
Shoulder horizontal adduction MMT
Palpation
- Anterior boarder of axilla and mid clavicle
Position
AG: in supine, shoulder at 90 abduction, elbow at 90. Resistance at distal humerus; bring fist over and touch the other side of the table
GM: in sitting with arm supported by table or therapist
Shoulder horizontal abduction muscles
Posterior Deltoid
O: spine of scapula
I: deltoid tuberosity
N: axillary n.
Shoulder horizontal abduction MMT
Palpation
- Inferior to the lateral aspect of the spine of the scapula
Position
AG: prone, shoulder at 90 abduction and elbow at 90, resistance at distal humerus, down
GM: seated, arm supported on table or by therapist
Shoulder internal rotation muscles
Subscapularis, primary
O: subscapular fossa
I: lesser tubercle of humerus
N: upper and lower subscapular
Others: Pectoralis major, Latissimus Dorsi, Teres Major
Shoulder internal rotation MMT
Palpation: to deep to palpate
Position
AG: Prone, shoulder at 90 (make note if they can’t) upper arm supported on mat, elbow at 90, have patient to move toward pocket, apply resistance proximal to the wrist in upward motion
GM: pt in prone or seated/standing, drop arm of table,
dangle with elbow locked straight, thumb pointed straight
have patient turn thumb in
* Can’t give a 1 or 0 because you can’t palpate the muscle
Other test: have patient put hand on small of back and lift off
Shoulder external rotation muscles
Infraspinatus
O: infraspinatus fossa
I: greater tubercle
N: subscapular n.
Others: Teres Minor
Shoulder external rotation MMT
Palpation: below the spine of scapula
Position
AG: Prone, shoulder at 90 (make note if they can’t) upper arm supported on mat, elbow at 90, have patient to move toward head, apply resistance proximal to the wrist in downward motion
GM: pt in prone or seated/standing, drop arm of table,
dangle with elbow locked straight, thumb pointed straight
have patient turn thumb out
Apley’s Scratch Test
General assessment of shoulder function and shoulder girdle mobility
- Ask the patient to reach over head and touch the scapula on the contralateral side
- Come from the back and touch the inferior aspect of the contralateral scapula
These motions are needed to get wallet out of pocket, comb hair, don a shirt or bra.
Speed’s Test
Used to assess bicipital tendinitis
Pt sits with shoulder at 60º flex
Elbow extended and forearm supinated
Examiner isometrically resists shoulder further shoulder flexion
IF positive, the client will have pain in the bicipital groove (anterior)
Others:
- Yergason’s
- Lippman’s
Ludington’s Test
Performed if you suspect a rupture of the long head of biceps
Short head will still allow motion
Have patient clasp hands behind head, can interlace fingers
Ask the client to flex while you palpate in the bicipital groove.
If you feel nothing, the test is positive and rupture has occurred.
Drop arm/ Coggins Test
Used with suspected rotator cuff tears, specifically the supraspinatus
Have the client sit or stand with shoulder fully abducted
Ask the client to SLOWLY lower the limb to the side
If the client has a sharp pain or “drops” the arm (usually around 90º), the test is positive
Painful Arc
This occurs as a result of pinching between the acromial arch and the coracoacromial ligament
Have the patient move through full abduction, can be active or passive
Pt will not have pain in the early stages of motion (0º-30º) pain from 30º-120º and 160º-180º, these numbers can vary if there is a great deal of inflammation and swelling
Often called impingement syndrome
Supraspinatus Test/ Empty Can Test
Suspected supraspinatus tear (most common)
The client sits with the shoulder at 90º of abduction (or scaption)
The examiner provides isometric resistance to the shoulder
Then place the shoulder in internal rotation (empty can position)
Apply resistance
Test again at 45º
A positive test occurs when there is pain or weakness
** new research suggests a “full can” is just as effective in assessment
Impingement Sign
Used when you suspect impingement of the long head of the biceps or the supraspinatus (against the acromion-acromioplasty)
The client is seated
You passively and firmly adduct the shoulder horizontally
If there is pain, the test is positive for one or both tendons
Hawkin’s Test
Start with shoulder at 90º flex and elbow at 90º flex, internally rotate the shoulder, pain equals positive
Anterior Apprehension Test
Indicated with suspected instability of the shoulder anteriorly, dislocation, or subluxation
Pt is in supine
Abduct the shoulder to 90º
Then YOU externally rotate the shoulder
You should support the anterior aspect of the joint
If the test is positive, the patient will be “apprehensive”.. Look at their face
If the client has pain or feels as if the shoulder is out, repeat with posterior support -relocation test.
Clunk Test
Also called Labral Test
Used to asses glenoid labral tears
Pt is put in supine with shoulder abducted.
You grab the distal humerus with one hand and put the other under the posterior shoulder, but still around the humerus
Move the humeral head anterior with the proximal hand
Externally rotate the humerus with the under (distal) hand
It is positive if you feel or hear a clunk or grinding sound/sensation
AC Shear Test
Used to assess the AC joint
The subject is seated or standing, your hands are cupped over the posterior scapular spine and the other over the clavicle, squeeze
Positive it there is abnormal movement or pain
Adson’s Maneuver
Used to test for thoracic outlet syndrome
Used to rule out a cervical rib or abnormal scalene muscle
The subject is seated
Head is extended and rotated toward affected side
The examiner holds the wrist and finds the radial pulse, it should be strong
The examiner then passively extends and externally rotates the shoulder and asks the patient to take a deep breath and hold it..palpate the pulse
IF it is decreased on gone, the patient is positive for thoracic outlet
Halstead’s Maneuver
Used to assess thoracic outlet syndrome
The client is seated
Hyperextends the head and rotates AWAY from the affected side hold breath
Arm is by side, check pulse
Examiner applies downward traction on the humerus,
If pulse decreases, it is positive
Allen’s Test for Thoracic Outlet
The subject is seated
Shoulder is abducted to 90º
Elbow is flexed to 90º (strong man position)
Take pulse
Have client look away
If pulse weakens, it is positive
Double Crush
You can have one, or several spots
- Cervical
- Thoracic outlet
- Cubital
- Carpal tunnel, tunnel of Guyon
Sulcus Sign
Demonstrates, shoulder instability
- Can be multidirectional
Observed in seating
- With or without traction
