Shoulder Flashcards
What joints are included in the Shoulder Complex?
• Glenohumeral (GH) joint
• Acromioclavicular (AC) joint
• Sternoclavicular (SC) joint
• Scapulothoracic (ST) joint
Describe the Glenohumeral (GH) joint.
•!Synovial, multi-axial, ball and socket joint
• Shallow articulation (low stability, high mobility) deepened by the glenoid labrum (~50% deeper)
• Partially stabilized by ligaments, including the axillary fold in the inferior glenohumeral ligament
Describe the Acromioclavicular (AC) joint.
• Synovial, plane joint
• Stabilized by ligaments, including the coracoclavicular ligament (controls vertical movement of the lateral clavicle; significant injury results in a step deformity)
Describe the Sternoclavicular (SC) joint.
• Synovial, saddle joint with an articular disc
• Stabilized by ligaments
Describe the Scapulothoracic (ST) joint.
• Not a true joint
• A stable scapula is needed for normal shoulder function
• Does not have a capsular pattern or close-packed position
What muscles stabilize the Glenohumeral (GH) joint?
The rotator cuff muscles act as dynamic stabilizers.
Are there muscles that directly stabilize the AC and SC joints?
• AC: No muscles directly stabilize, but the upper trapezius and anterior deltoid assist.
• SC: No muscles directly stabilize, but pectoralis major assists.
What role do muscles play in the Scapulothoracic (ST) joint?
Multiple muscles assist in movement and stability of the ST joint.
What is scaption?
Elevation of the arm in the neutral plane of the scapula, approximately 30° of horizontal flexion
What external and internal rotations are needed for normal ROM of the GH joint?
• Abduction: Requires ~90° external rotation.
• Flexion: Requires ~90° internal rotation.
What is required for normal shoulder movements?
All shoulder joints (GH, AC, SC, ST) must be functioning properly.
What movements occur at the Glenohumeral (GH) joint?
Flexion, extension, abduction, adduction, internal rotation, external rotation, and circumduction.
What movements occur at the Clavicle?
Elevation/depression, retraction/protraction, and anterior/posterior rotation
What movements occur at the Scapulothoracic (ST) joint?
Elevation/depression, retraction/protraction, upward/downward rotation, tipping, and winging (internal rotation).
What are the movement characteristics of the AC and SC joints?
AC: Acromial surface slides in the same direction as scapular movement (surface is concave).
SC:
• Protraction: Anterior roll and slide.
• Retraction: Posterior roll and slide.
• Elevation: Superior roll, inferior slide.
• Depression: Inferior roll, superior slide.
• Rotation: Accessory motion when humerus moves above horizontal and scapula upwardly rotates.
What is the close-packed position of the Shoulder Complex joints?
• GH: Full abduction and lateral rotation
• AC: Arm abducted to 90°
• SC: Full elevation (causing maximal clavicular rotation)
• ST: N/A
What is the loose-packed position of the Shoulder Complex joints?
• GH: 55° abduction, 30° horizontal adduction
• AC: Arm at side
• SC: Arm at side
• ST: Arm at side
What are the capsular patterns for the Shoulder Complex joints?
• GH: Lateral rotation > abduction > medial rotation
• AC: Pain at extreme ROM (especially horizontal adduction and abduction)
• SC: Pain at extreme ROM (especially horizontal adduction and abduction)
• ST: N/A
What is the only articulation between the upper limb and the trunk?
The Sternoclavicular (SC) joint.
Why is pelvic stability important in evaluating upper limb movements?
Many upper limb movements rely on force generated by the lower body, so evaluating pelvic stability is crucial
What are common questions to ask during a shoulder patient history?
• Primary complaint.
• General health.
• History of diabetes (10-20% may develop frozen shoulder).
• History of arthritides (OA, RA, gout).
• Mechanism of Injury (MOI): FOOSH (Fall On Outstretched Hand).
• Previous injuries (e.g., dislocations).
• Referral pain or neurological symptoms.
• Dominant hand (R-dominant often has greater ROM).
What systemic conditions and symptoms should be considered during patient history?
• RA, diabetes, OA, gout (symptom awareness).
• Visceral referral pain:
- Heart: Chest tightness, left anterior shoulder, down left arm.
- Lung/Diaphragm: Same side shoulder as lung problem.
- Liver/Gallbladder: Right upper shoulder (upper traps area).
• Note: Shoulder pain unrelated to movement suggests visceral referral.
What should you observe in a shoulder assessment?
• Regular landmarks.
• HFC (Head Forward Carriage).
• Alignment of the head of humerus with acromion.
• Internal rotation (IR).
• Step deformity (indicates dislocation).
• Winging.
• Tipping.
What should you palpate for in a shoulder assessment?
Inflammation
What are common traumatic mechanisms of injury (MOI) for the shoulder?
• Strains.
• Dislocations.
• Separations.
• Labral tears (e.g., FOOSH, repetitive overhead activities).
What are common non-traumatic MOIs for the shoulder?
• Tendonitis.
• Tenosynovitis.
• Arthritis.
• Instability.
What other conditions may be associated with shoulder pain?
• Frozen shoulder.
• Bursitis.
• Impingement.
What areas should you rule out when assessing the shoulder?
• Cervical spine: AF/AROM (all movements with overpressure except extension).
• Thoracic spine: AF/AROM (all movements with overpressure).
• Elbow: AF/AROM (all movements with overpressure).
• TOS: Adson’s, costoclavicular, Wright’s tests.
• TMJ: 3-knuckle test.
What should you remember during Active Free/AROM testing for the shoulder?
Pain can occur from contraction or stretch of an injured structure, typically at the end of range (EOR).
What is the normal range of motion (ROM) for shoulder flexion?
160°-180°
• Watch for lumbar extension compensation.
• GH internal rotation occurs at ~90°.
What is the normal ROM for shoulder extension?
0° followed by 50°-60° hyperextension.
• Watch for spine flexion or scapular retraction compensation.
What is the painful arc during shoulder abduction?
• No pain: 0°-45° and 120°-170°.
• Pain: 60°-120°.
• Pain from 170°-180°: AC joint issue or impingement (anterior GH pain).
What is the normal ROM for shoulder internal and external rotation?
Internal rotation: 60°-100° (hand on the low back)
External rotation: 80°-90°
What is the normal ROM for shoulder scaption and horizontal movements?
• Scaption: 170°-180°.
• Horizontal adduction: 130°.
• Horizontal abduction: 0°.
What are the available movements of the shoulder complex?
• GH joint: Flexion, extension, abduction, adduction, IR, ER, circumduction.
• Clavicle: Elevation/depression, protraction/retraction, anterior/posterior rotation.
• Scapulothoracic joint: Elevation/depression, protraction/retraction, upward/downward rotation, tipping, winging.
What causes clicking during scapular movements?
“Snapping scapula” occurs when the scapula rubs over the ribs.
How does PROM differ from AF/AROM in terms of range?
PROM usually allows slightly more range than AF/AROM.
What can cause pain during PROM, especially at the end of range (EOR)?
Stretching of antagonist muscles.
How can you differentiate between a capsular and muscle/tissue stretch during PROM?
Capsular: Harder end feel.
Muscle tightness: If ROM increases with 10-20% antagonist contraction, it’s muscular.
What are the normal end feels for Glenohumeral PROM movements?
• Flexion: Tissue stretch.
• Extension: Tissue stretch.
• Abduction: Tissue stretch or bony.
• Adduction: Tissue approximation.
• Internal Rotation: Tissue stretch.
• External Rotation: Tissue stretch (some list it as capsular).
• Scaption: Tissue stretch.
• Horizontal adduction/abduction: Tissue stretch.
What does scapular movement during AR testing indicate?
Weakness in scapular control muscles.
What does weakness without pain during AR testing suggest?
Nerve or nerve root problems.
Name the prime movers and synergists for Glenohumeral flexion.
• Prime movers: Anterior deltoid, coracobrachialis.
• Synergists: Biceps brachii (long head), pectoralis major (clavicular head).
Name the prime movers and synergists for Glenohumeral extension.
• Prime movers: Posterior deltoid, teres major, latissimus dorsi.
• Synergists: Teres minor.
Name the prime movers for Glenohumeral abduction and adduction.
• Abduction: Deltoid, supraspinatus.
• Adduction: Pectoralis major, latissimus dorsi (synergist: subscapularis).
Name the prime movers for Glenohumeral internal and external rotation.
• Internal rotation: Pectoralis major, latissimus dorsi, teres major, subscapularis, anterior deltoid.
• External rotation: Infraspinatus, posterior deltoid, teres minor.
Name the prime movers for scaption.
• Prime movers: Deltoid (anterior/middle fibers), supraspinatus.
• Synergists: Biceps brachii.
Name the prime movers for horizontal adduction and abduction.
• Horizontal adduction: Pectoralis major, anterior deltoid.
• Horizontal abduction: Posterior deltoid, teres major (synergists: teres minor, infraspinatus).
Why is elbow testing relevant in a shoulder assessment?
The biceps and triceps act on both the elbow and shoulder.
Name the prime movers and synergists for elbow flexion and extension.
Flexion:
• Prime movers: Brachialis, biceps brachii, brachioradialis.
• Synergists: Some forearm flexors.
Extension:
• Prime movers: Triceps brachii.
• Synergists: Anconeus.
Name the prime movers and synergists for shoulder complex elevation.
• Prime movers: Upper trapezius, levator scapula.
• Synergists: Rhomboids.
What should the relative strength of shoulder abduction be compared to adduction?
Abduction should be 50-70% of adduction strength.
What is the relative strength of forward flexion compared to adduction?
Forward flexion should be 50-60% of adduction strength.
How do medial and lateral rotations compare in relative strength?
• Medial rotation: 45-50% of adduction.
• Lateral rotation: 65-70% of medial rotation.
How do flexion and extension compare in relative strength?
Flexion should be 50-60% of extension strength.
What is the relative strength of horizontal adduction compared to horizontal abduction?
Horizontal adduction should be 70-80% of horizontal abduction strength.
What is the purpose of the Apprehension Test for Anterior Shoulder Dislocation?
To test for anterior shoulder instability or dislocation.
How is the Apprehension Test performed?
• Abduct the arm to 90°.
• Laterally rotate the shoulder slowly.
What is a positive sign for the Apprehension Test?
The patient looks or feels alarmed/apprehensive and resists further motion.
How is the Anterior Drawer Test of the Shoulder performed?
• Patient’s shoulder is abducted 80°–120°, forward flexed up to 20°, and laterally rotated 30°.
• Stabilize scapula and draw the humerus forward.
What is a positive sign for the Anterior Drawer Test?
A click, apprehension, or excessive movement compared to the unaffected side.
What is the Sulcus Sign test used for?
To assess inferior shoulder instability.
How is the Sulcus Sign test graded?
Grade 1: <1 cm.
Grade 2: 1–2 cm.
Grade 3: >2 cm.
How is the Jerk Test performed?
- Patient’s arm is medially rotated and flexed to 90°.
- Axially load the arm while horizontally adducting it.
What is a positive sign for the Jerk Test?
A sudden clunk/jerk as the arm subluxes, with a possible second clunk when returned to the starting position.
How is the Hawkins-Kennedy Impingement Test performed?
- Flex the arm to 90°.
- Internally rotate the shoulder while horizontally adducting.
What is a positive sign for the Hawkins-Kennedy Test?
Local pain, indicating supraspinatus tendinosis or impingement.
How is the Neer Impingement Test performed?
Medially rotate the arm.
Fully elevate the arm in scaption.
What is a positive sign for the Neer Impingement Test?
Local pain, suggesting supraspinatus or biceps overuse injury.
How is the Clunk Test performed?
- Abduct the arm fully.
- Apply anterior pressure on the humeral head while externally rotating the arm.
What is a positive sign for the Clunk Test?
A clunk or grinding sound, indicating a torn labrum.
How is the Horizontal Adduction Test performed?
The patient reaches across their body to the opposite shoulder (or the therapist performs this passively).
What is a positive sign for the Horizontal Adduction Test?
Pain localized to the AC joint.
How is the AC Shear Test performed?
- Cup one hand over the anterior deltoid (heel of the hand on the clavicle).
- Cup the other hand over the scapula (heel of the hand on the scapular spine).
- Squeeze both hands together.
What is a positive sign for the AC Shear Test?
Excessive movement or pain localized to the AC joint.
How is Ellman’s Compression Rotation Test performed?
- Patient is sidelying with the affected side up.
- Compress the humeral head into the glenoid fossa while the patient internally and externally rotates their shoulder.
What is a positive sign for Ellman’s Test?
Reproduction of symptoms, indicating arthritic changes in the GH joint.
What is the purpose of Yergason’s Test?
To test for biceps tendon pathology, such as a torn transverse humeral ligament or biceps tenosynovitis.
How is Yergason’s Test performed?
Patient’s elbow is flexed to 90°, arm stabilized against the body, and forearm pronated.
Therapist palpates the bicipital groove.
Patient resists supination while laterally rotating against resistance.
What is a positive sign for Yergason’s Test?
• The biceps tendon pops out during the resisted motion, indicating a torn transverse humeral ligament.
• Localized pain without popping suggests biceps tenosynovitis.
Where is the therapist’s top hand best positioned during Yergason’s Test?
Over the bicipital groove.
What is the purpose of Speed’s Test?
To assess for bicipital tenosynovitis or a labral tear.
How is Speed’s Test performed?
- Patient actively flexes the shoulder to 90° with the forearm supinated.
- Therapist resists isometric shoulder flexion at 90° with the elbow straight.
- Therapist resists an eccentric contraction from 90° back to the neutral position.
What is a positive sign for Speed’s Test?
Pain localized to the bicipital groove, especially with the forearm supinated, indicating bicipital tenosynovitis.
What might pain localized to the proximal attachment of the long head of the biceps during Speed’s Test suggest?
A labral tear.
What is the Drop Arm Test also known as?
Codman’s Test.
How is the Drop Arm Test (Codman’s Test) performed?
- Therapist abducts the patient’s arm to 90° and asks the patient to slowly lower the arm to their side, or
- The therapist taps the abducted arm to see if the patient can control or resist the surprise resistance.
What is a positive sign for the Drop Arm Test?
The patient is unable to return the arm to their side slowly or has pain when doing so.
What is the Empty Can Test also known as?
Supraspinatus Test (Palmer), Jobe Test
How is the Empty Can Test performed?
- The therapist abducts the patient’s arm to 90° and applies resistance to abduction.
- The shoulder is medially rotated and moved into the position of scaption (horizontally adducted ~30°).
- The therapist applies resistance to abduction again.
What does weakness with pain during the Empty Can Test indicate?
Supraspinatus tear.
What does weakness without pain during the Empty Can Test indicate?
Nerve damage, specifically to the suprascapular nerve.
What is the Apley’s Scratch Test used for?
To compare shoulder mobility and assess restrictions.
How is the Apley’s Scratch Test performed?
- The patient laterally rotates, flexes, and abducts one arm while medially rotating, extending, and adducting the other arm.
- Switch arms.
- Compare the differences in range between each side.
What is a positive sign for the Apley’s Scratch Test?
A significant difference between each side, indicating restricted or affected range.
What is the Scapulohumeral Rhythm Test used for?
To assess the movement of the scapula during shoulder abduction.
How is the Scapulohumeral Rhythm Test performed?
During active flexion (AF) or active range of motion (AROM) abduction, the therapist observes the movement of the scapula.
What is the normal scapulohumeral rhythm during the first 30° of abduction?
No or very little movement of the scapula.
What is the scapulohumeral rhythm during the next 60° of abduction?
A 2:1 movement ratio (humerus to scapula), with the clavicle elevating and starting to posteriorly rotate.
What happens during the last 90° of abduction in scapulohumeral rhythm?
A 2:1 movement ratio (humerus to scapula), with scapula elevating and clavicle elevating (~15°) and posteriorly rotating (30°–50°).
What does early movement or greater upward rotation of the scapula indicate?
Capsular tightness.
What does lesser upward rotation of the scapula indicate?
Impingement, rotator cuff problems, or glenohumeral (GH) instability, especially in serratus anterior.
What does scapular winging indicate?
Weakness in serratus anterior or rhomboids.
What does scapular tipping indicate?
Short pectoralis minor.
What does greater clavicular elevation indicate?
Excessive upper trapezius activation.
When is the Scapulohumeral Rhythm Test typically performed?
During active flexion (AF) or active range of motion (AROM), but some consider it a special test for OSCEs (Objective Structured Clinical Examinations).
How is the Pectoralis Major – clavicular head length test performed?
- The patient’s back is flat on the table.
- The patient’s arm is abducted to 90° (aligned with the clavicular fibers) and laterally rotated (elbow flexed).
What is a positive sign for the Pectoralis Major – clavicular head length test? elbow flexed).
The humerus does not reach the surface/plane of the table.
How is the Pectoralis Major – sternocostal head length test performed?
- The patient’s back is flat on the table.
- The patient’s arm is abducted to 120° (aligned with the sternocostal fibers) and laterally rotated (elbow flexed).
What is a positive sign for the Pectoralis Major – sternocostal head length test?
The humerus does not reach the surface/plane of the table.
How is the Pectoralis Minor length test performed?
- The patient’s back is flat on the table.
- The therapist observes the patient from the head of the table and compares the position of the scapula and shoulder.
What is a positive sign for the Pectoralis Minor length test?
The posterior shoulder is flat on the table (scapular tipping is observed).
How is the Pectoralis Minor & Latissimus Dorsi length test performed?
- The patient’s back is flat on the table.
- The patient fully flexes the shoulder.
What is a positive sign for the Pectoralis Minor & Latissimus Dorsi length test?
The humerus does not reach the plane of the table.
Note: The location of the stretch can indicate which muscle is short.
How are muscle strength tests graded?
Muscle strength tests are graded on the Oxford Manual Muscle Testing Scale (0-5).
What does weakness without pain suggest in muscle strength testing?
A neurological problem.
What does pain without weakness suggest in muscle strength testing?
A mild muscle strain.
What does weakness with pain suggest in muscle strength testing?
A moderate to severe muscle strain.
How is the Rhomboids strength test performed?
- The patient is prone with the arm abducted to 90° and internally rotated.
- The therapist applies resistance to push the arm down to the floor.
What should you watch for during the Rhomboids strength test?
Watch for compensatory pronation and ensure internal rotation for the test.
How is the Middle Trapezius strength test performed?
- The patient is prone with the arm abducted to 90° and externally rotated.
- The therapist applies resistance to push the arm down to the floor.
How is the Lower Trapezius strength test performed?
- The patient is prone with the arm abducted to 130°.
- The therapist applies resistance to push the arm down and out toward the floor.
How is the Serratus Anterior strength test performed?
- The patient is standing with arms flexed to 90°, slightly internally rotated, and palms against a wall.
- The patient pushes against the wall, and the therapist observes the scapula for winging.
What is the alternative method for testing the Serratus Anterior strength?
- The patient’s arm is flexed to 120°.
- The therapist applies a downward force on the arm while attempting to push on the lateral border of the scapula into downward rotation/retraction, observing for winging.
How is the Subscapularis strength test performed?
- The patient is prone with the shoulder abducted and elbow flexed.
- The arm is positioned at about 60° of medial rotation.
- The therapist applies resistance into external rotation (on the distal anterior wrist).
What are the neurological tests for upper limb tension and thoracic outlet tests covered in the course?
These will be covered in future classes.
What are neurological symptoms associated with?
Neurological symptoms can follow peripheral nerve patterns (sensory and motor) or nerve root patterns (dermatomes, myotomes).
What is the purpose of a Joint Scan?
To evaluate the motion of the various joints (joint play assessment).
What does palpation help assess?
Palpation helps explore various structures such as muscle, fascia, bone, etc. It can also help identify bony calluses on the clavicle and the position of the first rib.
What is involved in Clinical Decision Making?
• Suspecting an injury and determining the testing protocol.
• Interpreting positive results and determining their meaning in relation to the injury.
