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Assessment of shoulder joint

The document discusses the assessment of the shoulder joint, including its components, restraints, and common injuries. It describes the anatomy of the shoulder joint and surrounding structures. Various tests are outlined to assess different conditions of the shoulder like instability, impingement, and nerve injuries.

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Assessment of Shoulder Joint S M ALI ZAIDI
Shoulder Joint Shoulder joint is made up of following bones Humerus Clavicle Scapula
Shoulder Joint components Glenohumeral joint Acromioclavicular joint Sternoclavicular joint Scapulothoracic joint
Shoulder Joint Restraints • Passive restraints • Active restraints
Shoulder Joint Passive Restraints Capsule Bursa Labrum Shoulder Ligaments
Shoulder Joint Active Restraints • Shoulder Muscles
Glenohumeral Joint • Resting position: 55° abduction, 30° horizontal adduction (scapular plane) • Close packed position: Full abduction, lateral rotation • Capsular pattern: Lateral rotation, abduction, medial rotation
Acromioclavicular Joint • Resting position: Arm by side • Close packed position: 90° abduction • Capsular pattern: Pain at extremes of range of motion, especially horizontal adduction and full elevation
Sternoclavicular Joint • Resting position: Arm at side • Close packed position: Full elevation • Capsular pattern: Pain at extremes of range of motion, especially horizontal adduction and full elevation
Patient History Rotator cuff degeneration usually occurs in patients who are between 40 and 60 years of age Primary impingement due to degeneration and weakness is usually seen in patients older than 35
Patient History secondary impingement due to instability caused by weakness in the scapular or humeral control muscles It is more common in people in their late teens or 20s Especially those involved in vigorous overhead activities such as swimmers or pitchers in baseball
Patient History Calcium deposits may occur between the ages of 20 and 40. frozen shoulder is seen in persons between the ages of 45 and 60 years Frozen shoulder due to trauma can occur at any age but is more common with increased age.
External primary impingement (stage I) • Intermittent mild pain with overhead activities Over age 35
E.xternal primary impingement (stage II) • Mild to moderate pain with overhead activities or strenuous activities
External primary impingement (stage III) • Pain at rest or with activities • Night pain may occur • Scapular or rotator cuff weakness is noted
Rotator cuff tears (full thickness) • Classic night pain • Weakness noted predominantly in abduction and lateral rotators • Loss of motion
Adhesive capsulitis (idiopathic frozen shoulder) • Inability to perform activities of daily living owing to loss of motion • Loss of motion may be perceived as weakness
Anterior instability (with or without external secondary impingement) • Apprehension to mechanical shifting limits activities • Slipping, popping, or sliding may present as suitable instability • Apprehension usually associated with horizontal abduction and lateral rotation • Anterior or posterior pain may be present • Weak scapular stabilizers
Posterior instability • Slipping or popping of the humerus out the back • This may be associated with forward flexion and medial rotation while the shoulder is under a compressive load
Multi-directional instability • Looseness of shoulder in all directions • This may be most pronounced while carrying luggage or turning over while asleep • Pain mayor may not be present
Structures Limiting Movement in Different Degrees of Abduction • 0 degree Angle of Abduction • Lateral Rotation • Superior GH ligament and Anterior capsule • Medial Rotation • Posterior capsule
Structures Limiting Movement in Different Degrees of Abduction • 0 to 45 degree Angle of Abduction • Lateral Rotation • Superior GH ligament, Anterior capsule and Coracohumeral ligament • Medial Rotation • Posterior capsule
Structures Limiting Movement in Different Degrees of Abduction • 40 to 60 degree Angle of Abduction • Lateral Rotation • Middle GH ligament, Coracohumeral ligament, Inferior GH ligament (anterior band) And Anterior capsule • Medial Rotation • Inferior GH ligament(posterior band) and Posterior capsule
Structures Limiting Movement in Different Degrees of Abduction • 60 to 90 degree, 90 to 120 degree, 120 to 180 degree Angle of Abduction • Lateral Rotation • Inferior GH ligament (anterior band) and Anterior capsule • Medial Rotation • Inferior GH ligament (posterior band) and Posterior capsule
Suprascapular nerve (C5, C6) • Mechanism of Injury • Compression in suprascapular notch • Stretch into scapular protraction plus horizontal adduction • Compression in spinoglenoid notch • Direct blow • Space occupying lesion (e.g. ganglion) Peripheral Nerve Injuries (Neuropathy) About the Shoulder
Suprascapular nerve (C5, C6) • Muscle Weakness • Supraspinatus, • infraspinatus (arm lateral rotation) • Sensory Alteration • Top of shoulder from clavicle to spine of scapula • Pain in posterior shoulder radiating into arm • Reflexes Affected • None
Axillary (circumflex)nerve (posterior cord: C5, C6) Mechanism of Injury • Anterior glenohumeral dislocation • Fracture of surgical neck of humerus • Forced abduction • Surgery for instability Muscle Weakness Deltoid teres minor (arm abduction) Sensory Alteration Deltoid area Anterior shoulder pain Reflexes Affected None
Radial nerve (C5–C8,T1) Mechanism of Injury • Fracture humeral shaft • Pressure (e.g., crutch palsy) Muscle Weakness Triceps Wrist extensors, Finger extensors (shoulder, wrist, and hand extension) Sensory Alteration Dorsum of hand Reflexes Affected Triceps
Long thoracic nerve(C5, C6, [C7]) Mechanism of Injury • Direct blow • Traction • Compression against internal chest wall (backpack injury) • Heavy effort above shoulder height • Repetitive strain Muscle Weakness Serratus anterior (scapular control) Sensory Alteration None Reflexes Affected None
Musculocutaneous nerve (C5–C7) Mechanism of Injury • Compression • Muscle hypertrophy • Direct blow • Fracture (clavicle and humerus) • Dislocation (anterior) • Surgery (Putti-Platt, Bankart) Muscle Weakness Coracobrachialis Biceps Brachialis (elbow flexion) Sensory Alteration Lateral aspect of forear Reflexes Affected Biceps
Spinal accessory nerve (cranial nerve XI: C3,C4) Mechanism of Injury • Direct blow • Traction (shoulder depression and neck rotation to opposite side) • Biopsy Muscle Weakness Trapezius (shoulder elevation) Sensory Alteration Shoulder aching Reflexes Affected None
Subscapular nerve (posterior cord; C5,C6) Mechanism of Injury • Direct blow • Traction Muscle Weakness Subscapularis Teres major (medial rotation) Sensory Alteration None Reflexes Affected None
Dorsal scapular nerve (C5) Mechanism of Injury • Direct blow • Compression Muscle Weakness Levator scapulae Rhomboid major Rhomboid minor (scapular retraction and elevation) Sensory Alteration None Reflexes Affected None
Lateral pectoral nerve (C5, C6) Mechanism of Injury • Direct blow Muscle Weakness Pectoralis major, pectoralis minor Sensory Alteration None Reflexes Affected None
Thoracodorsal nerve (C6, C7, [C8]) Mechanism of Injury • Direct blow • Compression Muscle Weakness Latissimus dorsi Sensory Alteration None Reflexes Affected None
Shoulder painful Arc
Reverse Glenohumeral Rhythm
Step deformity resulting from acromioclavicular dislocation
Apley’s scratch test
Apley’s scratch test
Neck reach
Back reach
Causes of Scapular Imbalance Patterns • Increased protraction • Tight pectoralis minor • Weak/lengthened lower trapezius • Weak/lengthened serratus anterior Increased depression Weak upper trapezius
Tests for shoulder aseessment
Tests for Anterior Shoulder Instability
Andrews’ Anterior Instability Test • The patient lies supine • shoulder abducted 130° and laterally rotated 90° • Hadeling • The examiner stabilizes the elbow and distal humerus with one hand • and uses the other hand to grasp the humeral head and lift it forward
Andrews’ Anterior Instability Test • A reproduction of the patient’s symptoms gives a positive test for anterior instability. • If the examiner hears a clunk, an anterior labral tear may be present
Andrews’ Anterior Instability Test
Anterior Drawer Test of the Shoulder • The patient lies supine • The examiner places the hand of the affected shoulder in the examiner’s axilla • The shoulder to be tested is • abducted between 80° and 120°, • forward flexed up to 20°, • and laterally rotated up to 30°.
Anterior Drawer Test of the Shoulder • The examiner then stabilizes the patient’s scapula with the opposite hand • pushing the spine of the scapula forward with the index and middle fingers • The examiner’s thumb exerts counterpressure on the patient’s coracoid process • the examiner places his or her hand around the patient’s relaxed upper arm and draws the humerus forward. • The movement may be accompanied by a click, by patient apprehension, or both
Anterior Drawer Test of the Shoulder • The click may indicate a labral tear or slippage of the humeral head over the glenoid rim
Anterior Drawer Test of the Shoulder