Shoulder

Question 1

Name the rotator cuff muscles, origins/ insertions, innervation and action

Answer 1

Supraspinatus - Supraspinous fossa to greater tubercle
Suprascapular nerve. early abduction

Infraspinatus - infraspinous fossa to greater tubercle
Suprascapular nerve. external rotation

Teres Minor - Lateral border of scapula to greater tubercle
Axillary nerve. external rotation and adduction

Subscapularis - subscapular fossa to lesser tubercle
Subscapular nerve. internal rotation

All stabilise glenohumeral joint

Question 2

What movements occur at the shoulder and which muscles control them?

Answer 2

Flexion - anterior deltoid, bicep brachii, coracobrachialis

Extension- posterior deltoid, tricep brachii, latissimus dorsi, teres major/minor

Abduction - supraspinatus, deltoid, trapezius,

Adduction - pectoralis major, latissimus dorsi, teres major, triceps, and coracobrachialis

Horizontal Adduction - teres minor, pectoralis major, coracobrachialis

Horizontal Abduction - Posterior Deltoid, Trapezius, infrapsinatus, Middle Deltoid, Supraspinatus, Teres Minor, Rhomboid Major, Rhomboid Minor

Internal Rotation - teres major, subscapularis, pectoralis major, latissimus dorsi

External Rotation - teres minor, supraspinatus

Question 3

Name the joints and major bony landmarks of the shoulder complex

Answer 3

Glenohumeral
Scapulothoracic
Acromioclavicular
Sternoclavicular

Inferior and Superior angle of Scapula
Spine of scapula
Subscapular fossa
Supra/Infraspinous Fossa
Bicipital/ intertubercular Groove
Greater and Lesser tubercles
Acromion process
Coracoid process
Anatomical and Surgical necks of Humerus
Supraglenoid tubercle
Infraglenoid tubercle

Question 4

What are the key attributes of the shoulder complex

Answer 4

Designed for movement/mobility
Synovial ball and socket joint
3 degrees of freedom (moves in every plane)
shallow socket relying on support from rotator cuff muscles and Glenoid Labrum

Question 5

Describe the SLAP test

Answer 5

SLAP provocation
Abduct to 90, externally rotate w/ elbow flexed to 90.
pronate forearm and extend elbow
Superior Labrum Anterior-Posterior.
Positive = SLAP lesion (labral tear) or long head of bicep issue

Question 6

Describe the Apprehension test

Answer 6

Apprehension test
Pt supine w/ shoulder abducted 90-120, elbow flexed to 90. Externally rotate check for apprehension/increased motivation = anterior instability

Question 7

Describe the Painful arc test

Answer 7

Painful Arc
Abduct shoulders - observe for pain/compensation
= impingement/RC cuff/ AC pathology

Question 8

Describe the empty can test

Answer 8

Empty Can
Raise arms in scapular plane, rotate thumbs down ‘empty can’ then provide external resistance to upward movement
pain = injury/lesion of supraspinatus/impingement

Question 9

Describe the Hawkins-Kennedy test

Answer 9

Hawkins- Kennedy
Pt seated shoulder abducted to 90, elbow flexed to 90
examiner internally rotates and horizontally adducts to pinch greater tuberosity of Humerus against acromion
(physio arm on Pt shoulder)

Pain = Supraspinatus impingement/ RC tear/ crepitus could indicate OA

Question 10

Describe Neer’s test

Answer 10

Neers
Pt seated, fix scap position
examiner raises pt arm through full flexion in IR and ER

Pain on IR = supraspinatus impingement/ subacromial bursitis

pain on ER = Long head of Bicep impingement

Question 11

Describe Sulcus sign

Answer 11

Sulcus
Pt seated/standing with arm at side. Physio applies long axis distraction to humerus.
positive = increased inferior ROM meaning inferior instability

Question 12

Describe the 2 AC joint special tests

Answer 12

Scarf/ Cross body test

Pt seated w/ shoulder flexed to 90 and horizontally adducted across body. Physio stabilises and applies horizontal adduction force over elbow

superior shoulder pain over AC = AC joint pathology
posterior shoulder pain = infraspinatus/teres minor/posterior joint capsule lesion

Squeeze/shear test
compression of clavicle onto scapula to shear AC joint
pain over AC = AC joint dysfunction

Question 13

Name common shoulder pathologies

Answer 13

• Subacromial Impingement
• Rotator cuff tears
• Labral tears
• AC Joint dysfunction
• Dislocation/ Subluxation
• Frozen shoulder/ Capsulitis

Question 14

What is in the subacromial space? What can irritation of these structures cause?

Answer 14

Supraspinatus
Long head bicep tendon
Subacromial bursa

Subacromial impingement syndrome
due to potential compression/ movement of humeral head/ inflammation of bursa/ irritation of tendon/ structural (hooked acromion)/ bone spurs/ osteoarthitis

Question 15

What are common S+S of subacromial impingement syndrome?

Answer 15

• c/o pain on sleep, especially if sidelying
• Altered function
• Pain on movement
• Reduced ROM
• Positive pain provocation test
• Positive special tests – Painful arc, Neers, Hawkins Kennedy, Empty can

Question 16

What are the treatment options of SAIS?

Answer 16

Physiotherapy management
•Postural correction
•NSAIDS and analgesia
•Hot/ Cold therapy
•Electrotherapy
•Shoulder girdle stability exercises
•Isometric and closed chain exercises for rotator cuff muscles
•Regain active ROM
•Subacromial steroid injection into bursa

Surgical management
• RC repair
• Subacromial decompression surgery

Question 17

Describe labral tear MOI, S+S, and the 2 categories of.

Answer 17

Tear to fibrocartilage of socket, often secondary to dislocation and throwing injuries

S+S: click/clunk, pain, weakness, loss of rom, positive SLAP

SLAP - Superior Anterior
- Often caused by the long head of biceps pulling the labrum off from its origin on the supraglenoid tubercle

Bankart - Inferior Anterior
Often associated with dislocation

Question 18

Describe shoulder features of dislocation

Answer 18

The glenohumeral joint can dislocate anteriorly, posteriorly or inferiorly
•If the joint becomes unstable for any reason it increases the chance of subluxation or dislocation
•Can be traumatic i.e following an injury, or atraumatic i.e. as a result of minimal force
•Anterior is the most common direction for dislocation

Could also cause Bankart/SLAP/ Hill-Sachs lesion: This is where the bone of the humeral head becomes damaged by the edge of the labrum, causing a dent in the bone

Question 19

Describe MOI and S+S of AC joint dysfunction

Answer 19

Sprains or dislocations are the most common pathologies at this joint, usually due to falls - landing on point of shoulder/ contact injuries

Usually classified related to the extent of the injury

Signs + symptoms
•Determined by the severity of the injury
•Dislocation will appear ‘stepped’
•Player will immediately hold their shoulder
•Pain and inflammatory changes around injury site
•Difficulty lifting arm through full range – consider biomechanics of the AC joint
•Positive scarf and squeeze tests

Question 20

Describe the stages and S+S of frozen shoulder/ capsulitis

Answer 20

Freezing – this is the most painful stage

Symptoms
Usually lasts between 3-9 months
•Painful at night, especially lying on painful side
•Active and passive ROM become restricted
•Typically associated with deep, achey pain progressing to acute pain with time

Pathology
•Increased vascularity and thickening of synovial membrane
•Normal capsular tissue
•Possibly associated with tendinitis and/or bursitis
•Some loss of muscle length and bulk in rotator cuff

Frozen stage – mostly pain and stiffness

Symptoms
Can last between 4-12 months
Pain can become more severe or can start to settle
•Significant loss of ROM in typical capsular pattern – external rotation, flexion, internal rotation

Pathology:
•Synovium continues to thicken, but is less inflamed
•Associated contraction of the capsule with loss of the axillary pouch
•Capsule becomes thickened and more collagenous

Thawing stage – predominantly stiffness

Symptoms
Lasts between 12 and 42 months
•Pain levels reduce considerably
•Gradual increase in ROM

Pathology
•Adhesions of scar tissue between capsule, synovial membrane and surrounding soft tissues
•No evidence of active inflammation
•Shortening and atrophy of muscles around the glenohumeral joint and pectoral girdle