Shoulder examination

Question 1

Name the 4 joints in the shoulder complex

Answer 1

SC joint
ST joint
GH joint
AC joint

Question 2

What % does the glenoid cover the humeral head?

Answer 2

25-30%

Question 3

What position is the glenoid directed to ?

Answer 3

Anterior and lateral

Question 4

Subacromial bursa
Size of bursa compared to others in body? Position? Vascularised? Innervation?

Answer 4

Largest in the body

Lies between deltoid + coracoacromial arch superiorly and Rotator cuff inferiorly

Well vascularised

Highly innervated with both proprioceptive and nociceptive endings

Question 5

Kolk et al (2017) and Budoff et al (2005) findings related to bursectomy renders acromioplasty

Answer 5

Inneffectvie method

Question 6

Rotator cuff description

Answer 6

Tendons of RC interweave and interdigitate as they attach to the humerus, forming a broad, confluent attachemnt, which involves the GHJ capsule and coracohumeral ligament.

Impossivle for tendons to be seperate entities, stress of any part of RC will involve all structures.

Question 7

What is the primary purpose of the shoulder complex?

Answer 7

To place and control the hand in front of the body.

Question 8

Scapular activity during elevation of the arm

Muscles involved? What movements do they allow?

Answer 8

Trapezius and serratus anterior

Upper trapezius - upward rot, retr + elev
Lower trapezius – upward rot, retr + dep
Serratus anterior – upward rot + pro

Question 9

Scapular winging

Answer 9

When the muscle sof the scapula are weak or paralysed, resulting in limited ability to stabilise the scapula.

As a result the lateral borders of the scapula protrudes from back, like wings.

Question 10

Muscle activity during elevation of the arm

Answer 10

Deltoid prime mover at the GHJ.

Infra/teres minor + subscapularis act as force couple to counteract upward pull of deltoid

RC exerts medial force on humeral head which approximates it to glenoid.

Long head of bicep exerts downard force, as long as humeral head centres on glenoid and not inf translated.

Question 11

Shoulder instability
What does it depend on? What does it result from?

Answer 11

Depends upon fibrous tissue restraints and dynamic muscular action.

Instability results from inefficiency of the coraco and glenohumeral ligaments +/- rotator cuff.

Serratus anterior and traps contribute by way of scapular control

Not necessarily linked to a specific event but is often due to repeptive forces applied at rate that exceeds that of tissue repair.

Question 12

GH ligament

Answer 12

Three ligaments on the anterior side of the shoulder joint.
They extend from the humerus to the glenoid fossa and reinforce the joint capsule.

Question 13

Movements that tighten the anterior and posterior portions of the inferior glenohumeral ligament.

Answer 13

Abduction and external rotation - tighten anterior

Horizontal abduction and medial rotation tighten - postieror portion

Question 14

Types of instability

Answer 14

Anterior
Posterior
Inferior

Question 15

Clinical features of shoulder instability
History and exam.

Answer 15

History: dull ache; often do not c/o of instability, but more apprehension, a feeling something “not quite right”; fatigue; dead arm syndrome; family Hx; pain at night whether lying on either
side. If they do c/o shoulder “coming out” - does it come out all the way? how does it go back in? - disloc/sublux. Crucially, what posn is the shoulder when pt experiences Sx? → nature of any instability.

Question 16

Clinical features of shoulder instability- exam

Answer 16

Atrophy; posn humeral head; ROM often full, but some pain end of flex/abd; weak cuff – possible tear; demonstrate instability?; generalized laxity?; +ve instability tests; possible +ve lag signs;
possible biceps tear/tendinopathy; possible labral tear

Question 17

Clinical features of shoulder instability
Patterns of weakness and/or restriction

Answer 17

May be a degree of global cuff weakness
Often most painful shoulder conditions, is characterised by identifiable patterns of specific cuff weakness and resitriction/laxity of non-contractile tissues, primarily capsuloligamentous complexes.

Identifying, recognising and understanding these patterns of weakness and resticiton/laxity is important in diagnosis and crucial in delivering effective treatment.

Question 18

Factors limiting anterior translation

Answer 18

**Dynamic resistance- **
Primary: Posterior cuff (infra + teres minor)
Secondary: long head of biceps; global cuff

**Non-contractile resistance- **
Primary: Anterior band inferior GHL
Secondary: coracohumeral lgt, superior GHL, middle GHL, anterior capsule.

Question 19

Factors limiting posterior translation

Answer 19

Dynamic resistance
Primary: anterior cuff (subscapularis)
Secondary: global cuff

Non-contractile resistance
Primary: posterior band inferior GHL
Secondary: posterior capsule

Question 20

Factors limiting inferior translation

Answer 20

Dynamic resistance
Primary: Superior cuff (Supraspinatus), global cuff

Non-contractile resistance
Primary: dependent posn- sup jt cap + superior GHL,
coracohumeral lgt + superior jt capsule
>45deg abduction - inferior GHL
Secondary:-ve intra-articular pressure

Question 21

What is typical pattern for athletes with anterior instability and what does it indicate

Answer 21

Increased external rotation
Decreased internal rotation

Often indicates comparative restriction/laxity
of post/ant capsule

Question 22

Impingement syndrome

Answer 22

Refers to symptoms of pain and dysfunction resulting from any pathologywhich either decreases the volume of the subacromial space or increases the size of its contents.

Question 23

Primary impingement

Answer 23

acromial morphology;
osteophytes; thickened cuff; calcific
bursa/tendon; fracture; a-c dislocation; OA/RA;
bony kyphosis/scoliosis

Question 24

Secondary impingment

Answer 24

Posture; weakness;
instability; ergonomics; neuropathy; muscle
imbalance

Question 25

Primary inflammation/degenrative changes for shoulder impingement

Answer 25

Tendinitis/osis; bursitis; synovitis; capsulitis; cuff
tears; ageing

Question 26

Clinical features of subacromial impingement - History

Answer 26

V common in > 45 yrs
Usually gradual onset with Hx of oversue involving repetitive abd/flex posn eg gardening, DIY, moving house, pain on reaching, lying on affected side.

If severe, pain can spread down arm to hand. If sudden onset, may indicate tear; weakness; struggling to sleep.

Question 27

Clinical features of subacromial impingement- exam

Answer 27

Painful flex/abd, but full passive movt; weak cuff – pain
inhibition or possible tear?; +ve impingement tests; possible +ve lag
signs; may have co-existing instability

Question 28

Anatomical and aetiological relationship between impingement and instability

Answer 28

Both interconnected.

If primary lesion is instability, RC will attempt to resist abnormal translation of hum head leading to primary inflam of RC + consequent impingement. Also, increased movt of hum head may in itself decrease s-a space enough to pinch RC.
If primary lesion is impingement, RC will become painful, weak + fatigue easily leading to overload of passive restraints which will eventually lead to laxity + instability.

Question 29

Treatment for impingement

Answer 29

Selective rest
Rehabilitation – must be rational, appropriate and
progressive; scap muscles before cuff. Also include
correction of faulty technique/posture

Injection– no unanimity re route, drug, dosage,
technique, asepsis, post-inj protocol
Surgery– subacromial decompression; cuff repair

Question 30

Clinical features of adhesive capsulitis-
History

Answer 30

Gradual onset increased pain + stiffness; can be precipitated by trauma, but usually idiopathic; most common atraumatically 45- 75 yrs but any age is poss; pain on reaching up + back, doing
up bra, back pocket; pattern of pain will depend upon stage of condition.

Question 31

Adhesive capsulitis

Answer 31

Involves initial inflam stage followed by restriction/contraction of g-h capsule

Question 32

Clinical features of adhesive capsulitus

Exam

Answer 32

Characteristic pattern of limitation of the shoulder
capsular pattern – ltd abd, less ltd flex, more ltd LR; if passive lateral rotation is full range, then it is NOT a frozen shoulder; if passive lateral rotation is full range and painless, then there is nothing wrong with the capsule; -ve impingement tests.

Question 33

Adhesive capsulitis stages

Answer 33

Stage I - Pain
Stage II - Pain and stiffness
Stage III - Stiffness and pain
Stage IV– Recovery

Question 34

Adhesive capsulitis treatment

Answer 34

Stage I and II – injection. Any other pain relieving
modality - TENS, mobilisations, NSAIDS/analgesics,
active movts
Stage III – time. Mobs/manips may give short term
increase in range, but long term do little and possibly
increase soreness over time
Stage IV – Rx usually unnecessary. Sometimes
exercises/mobilisations to increase HBB