Upper Body-Shoulder Flashcards
The Shoulder
The shoulder complex can be difficult to assess because of its many structures, its movements and the many lesions that can occur in and around the joint
Often an assessment of the shoulder requires evaluation of the surgical spine and thoracic spine
Anatomy of the Shoulder (GH Joint)
Glenohumeral Joint is a multiaxial, ball and socket, synovial joint
It depends primarily on the muscles and ligaments rather than bones for support, stability and integrity
The labrum (ring of fibrocartilage) surrounds and deepens the glenoid cavity of the scapula about 50%
The GH joint has 3 degrees of freedom
The rotator cuff muscles play an important role in shoulder movement
They control osteokinematic and arthrokinematic motion of the humeral head in the glenoid and along with the biceps depresses the humeral head during movements into elevation
Ligaments of the GH Joint:
Primary ligaments of the Glenohumeral joint:
Superior glenohumeral ligament
Middle glenohumeral ligament
Inferior glenohumeral ligament
Coracohumeral ligament
Superior Glenohumeral Ligament
Limits inferior translation in adduction and restrains anterior translation and lateral rotation up to 45 degrees abduction
Middle Glenohumeral Ligament
Limits lateral rotation between 45-90 degrees abduction
Absent in 30% of the population
Inferior Glenohumeral Ligament
The most important of the three ligaments
It has an anterior and posterior band with a thin “axillary pouch” in between so it acts like a hammock
It supports the humeral head above 90 degrees abduction, limiting inferior translation while the anterior band tightens on lateral rotation and the posterior band on medial rotation
Coracohumeral Ligament
Primarily limits inferior translation and helps limit lateral rotation below 60 degrees abduction
Found in the rotator interval between the anterior border of the supraspinatus tendon and the superior border of the subscapularis tendon, therefore uniting the two tendons anteriorly
Coracoacromial Ligament
Forms an arch over the humeral head, ating as a block to superior translation
Transverse humeral ligament
Forms a roof over the bicipital groove to hold the long head of biceps tendon within the groove
Anatomy of the AC Joint
Acromioclavicular joint is a plane, synovial joint made up of the acromion process of the scapula and the lateral end of the clavicle
The joint has 3 degrees of freedom
The capsule, which is fibrous, surrounds the joint and an articular disc may be found within the joint
This joint depends on ligaments for its strength
Ligaments of the AC Joint:
- Acromioclavicular ligament
- Coracoclavicular ligament
- Acromioclavicular Ligament
Surrounds the joint and controls horizontal motion of the clavicle
Commonly the first ligaments injured when the joint is stressed - Coracoclavicular Ligament
The primary support of the AC joint
Two portions:
The conoid (medial) and trapezoid (lateral)
Control vertical motion of the clavicle
If a step deformity occurs, this ligament has been torn
Anatomy of the SC Joint
Sternoclavicular joint is a saddle-shaped, synovial joint made up of the medial end of the clavicle , the manubrium of the sternum and the cartilage of the first rib
It is the joint that joins the appendicular skeleton to the axial skeleton
A substantial disc is between the two bony joint surfaces which adds significant strength to the joint and the capsule is thicker anteriorly than posteriorly
3 degrees of freedom
Ligaments of the SC Joint:
Anterior sternoclavicular ligament
Posterior sternoclavicular ligament
Costoclavicular ligament
Anterior and Posterior Sternoclavicular Ligaments
Support the joint anteriorly and posteriorly
Interclavicular Ligament
Supports the joint
Costoclavicular Ligament
Running from the clavicle to the first rib and its costal cartilage
The main ligament maintaining the integrity of the sternoclavicular joint
Scapulothoracic Joint
Scapulothoracic joint is not a true joint but it functions as an important part of the shoulder complex
The “joint” consists of the body of the scapula and the muscles covering the posterior chest wall
The medial border of the scapula is not parallel with the SP’s but is angled about 3 degrees away and the scapula lies 20-30 degrees forward relative to the sagittal plane
The scapula extends from the level of T2 SP to T7-T9 SP depending on the size of the scapula
The scapula acts as a stable base for the rotator cuff muscles so the muscles controlling its movements must be strong and balanced because the joint funnels the forces of the trunk and legs into the arm
Patient History
*Age?
*Upper limb supported in protected position?
*Pain?
*Mechanism of injury?
*Impact of movement, activities, and position?
*What aggravates condition?
*Functional impact?
*Muscle spasm, deformity, bruising, wasting, paresthesia, or numbness?
*Weakness and heaviness in limb after activity?
*Indication of nerve damage?
*Dominant hand?
Step deformity - Observation: Anterior View
Ensure the head and neck are in the midline of the body and observe their relation to the shoulders
In most people, the dominant side is lower than the nondominant side
Step deformity
Can be caused by an AC dislocation with the distal end of the clavicle lying superior to the acromion process
It indicates both the acromioclavicular and coracoclavicular ligaments have been torn
It may be accentuated by asking the patient to horizontally adduct the arm or to medially rotate the shoulder and bring the hand up the back as high as possible
If swelling is present anterior to the AC joint, it is called a fountain sign indicating that degeneration has caused communication between the AC joint and swollen subacromial bursa underneath
Anterior Dislocation of the GH Joint
Flattening of the normally rounded deltoid muscle may indicate an anterior dislocation of the GH joint
Palpation in the axilla would allow you to feel the head of the humerus
Sulcus Deformity - Observation: Anterior View
Sulcus Deformity
Can appear when traction is applied to the arm, indicating a possible multidirectional instability or loss of muscle control due to nerve injury or a stroke which leads to inferior subluxation of the GH joint
This deformity is seen lateral to the acromion and should not be confused with a step deformity
Posterior View:
Major Roles of the Scapula to the Shoulder
Scapula provides an origin for the rotator cuff muscles as well as the biceps and triceps muscles, which provides a stable dynamic base for these muscles to act
Maintains the glenohumeral alignment within physiological limits that facilitates congruency and concavity compression capability at the GH joint through full ROM
The attachment of the acromion to the clavicle leads to scapular upward rotation and posterior tilt to allow maximum arm elevation
The scapula facilitates force transfer from the shoulder to the core and vice versa, acting like a funnel for efficient energy transfer
Posterior View:
Scapular Dyskinesia Or Scapular Dysfunction
Type I
The inferior medial border is prominent at rest and the inferior angle tilts dorsally with movement, while the acromion tilts anteriorly over the top of the thorax
If the inferior border tilts away from the chest wall, it may indicate the presence of weak muscles (lower traps, lats, serratus anterior) or a tight pectoralis minor or major pulling or tilting the scapula forward
Type II
The classic winging of the scapula with the whole medial border of the scapula being prominent and lifting away from the posterior chest wall both statically and dynamically
May be seen at rest or during eccentric or concentric movements
May indicate the presence of a superior labrum anterior to posterior (SLAP) to the biceps lesions, weakness of the serratus anterior, rhomboids, trapezius, long thoracic nerve problem or tight humeral rotators
Type III
The superior border of the scapula being elevated at rest and during movement, a shoulder shrug initiates the movement and there is minimal winging
Seen with active movement and may result from overactivity of the levator scapula and upper trapezius along with imbalance of the upper and lower trapezius force couple
Associated with impingement and rotator cuff lesions
Type IV
Both scapulae are symmetrical at rest and during motion, they rotate symmetrically upward with the inferior angles rotating laterally away from midline (rotary winging)
Seen during movement and may indicate that the scapular control muscles are not stabilizing the scapula
Posterior View:
Scapular Winging
Primary Scapular Winging
Implies the winging is the result of muscle weakness of one of the scapular muscle stabilizers
Secondary Scapular Winging
Implies that the normal movement of the scapula is altered because of pathology in the GH joint
Dynamic Scapular Winging (winging with movement)
May be caused by a lesion of the long thoracic nerve affecting serratus anterior, trapezius palsy, rhomboid weakness, multidirectional instability, voluntary action or a painful shoulder resulting in splinting of the GH joint which in turn causes reverse scapulohumeral rhythm
Static Winging (winging occurring at rest)
Usually caused by a structural deformity of the scapula, clavicle, spine or ribs
Posterior View:
Sprengel’s Deformity
A developmental condition leading to a high or undescended scapula
It is rare, but is the most common congenital deformity of the shoulder complex
The scapular muscles are poorly developed or are replaced by a fibrous band
May be unilateral or bilateral and shoulder abduction is decreased, leading to decreased shoulder function
Usually the scapula is smaller than normal and is medially rotated
Active Movements of the Shoulder
Painful Arc
Causes
Calcium deposits, subacromial bursitis, a peritendinitis or tendinosis of the rotator cuff muscles, or most commonly by an unstable scapula
Pain
Results from pinching of inflamed or tender structures under the acromion process and the coracoacromial ligament
Initially the structures are not pinched under the acromion process so there is little pain or difficulty with abducting the arm to 45-60 degrees
As the client abducts further (60-120), the structures become pinched and the client is often unable to abduct fully because of pain
If full abduction is possible, the pain diminishes after approximately 120 degrees because the pinched soft tissues have passed under the acromion process and are no longer being pinched
Often pain is greater going up against gravity than coming down and there is usually more pain with active abduction than on passive abduction
If the movement is very painful, the client often elevates the arm through forward flexion or hikes the shoulder using upper trapezius and levator scapulae in an attempt to decrease the pain
Second Painful Arc:
May be seen during the same abduction movement
This painful arc occurs toward the end of abduction, in the last 10-20 degrees of elevation and is caused by pathology in the AC joint or by a positive impingement test
Scapulohumeral Rhythm
When examining the movement of elevation through abduction, the scapulohumeral rhythm should be observed
During 180 degrees of abduction, there should be roughly a 2:1 ratio of movement of the humerus to the scapula with 120 degrees of movement from the GH joint and 60 degrees at the scapulothoracic joint
A lot of variations among individuals
Reverse Scapulohumeral Rhythm:
The scapula moves more than the humerus
This occurs in conditions like frozen shoulder
The client will appear to “hike” their entire shoulder complex rather than produce a smooth coordinated abduction movement
Combination Movements
Apley’s Scratch Test
Combines medial rotation with adduction and lateral rotation with abduction
Neck Reach
Combines abduction, flexion and lateral rotation at the GH joint
Back Reach
Combines adduction, extension and medial rotation at the GH joint
cause of scapular imbalance patterns
scapular winging faults
Passive Movements of the Shoulder
Resisted Isometric Movements of the Shoulder
