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SHOULDER ASSESSMENT. BONY PALPATIONS. Shoulder Complex. Scapulothoracic Articulation. Not a true anatomical joint Resting position of scapula is: Superior angle is level with spinous process T2 Inferior angle level with spinous process T7

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  3. Shoulder Complex

  4. Scapulothoracic Articulation • Not a true anatomical joint • Resting position of scapula is: • Superior angle is level with spinous process T2 • Inferior angle level with spinous process T7 • Medial border of scapula is 5-6 cm or three fingers width from spinous processes



  7. Motions @ Sternoclavicular Joint • SC Joint acts like ball and socket joint • Motions at joint: • Elevation- Depression • Rotation : upward-downward • Rotation: forward-downward; backward-upward

  8. AC Joint Characteristics • Synovial joint • Keeps glenoid fossa continually facing the humeral head • Articular disc between acromion and distal clavicular head • Capsule – lax to allow for complex shoulder motion

  9. AC Joint • Superior and inferior acromioclavicular lig. • Strengthen upper aspect of joint • Limits approx. 90% of anterior-posterior translation

  10. Coracoclavicular Ligament • .: Limits 80% of superior translation of the clavicle- acts as a tie bar to hold clavicle down • Maintains a constant relationship of the scapula on the clavicle

  11. Coracoacromial ligament • Forms roof over humeral head • Prevents upward displacement of humeral head and protects underlying structures • Sharp lateral edge may impinge on bursa and supraspinatus tendon

  12. Superior Transverse Ligament • Bridges lesser scapular notch • Provides a passage for suprascapular nerve

  13. Glenohumeral Joint • Synovial Joint: humeral head articulates with glenoid cavity • Humeral head points medially, backward and tilts upward • Glenoid is ½ as long and 1/3 as wide as the humeral head • Contact area is limited • Surface area of humeral head is 3-4 times larger than the fossa

  14. Glenohumeral Capsule

  15. GLENOHUMERAL AND CORACOHUMERAL LIGAMENTS • Coracohumeral Lig.- One of the most important ligament structures • 1. Blends with rotator cuff, fills space b/t subscapularis and supraspinatus • MaintainsGH relationship • Involved with frozen shoulder


  17. Glenoid labrum • Rim of cartilaginous tissue attached around margin of glenoid fossa • Serves as attachment for ligaments • Deepens articular cavity • Increases glenoid contact with humeral head & serves “chock block” function

  18. Glenoid Fossa with Rotator Cuff Muscles

  19. Muscles of Shoulder

  20. Shoulder Bursae • 1. Subacromial or Subdeltoid bursa • 2. B/t coracoid & glenohumeral Jt. Capsule • 3. Summit of the acromion • 4. B/t infraspinatus & joint capsule • 5. B/t teres major & long head biceps • 6. B/t subscapularis & Joint capsule • 7. Tendinous insertion of latissimus dorsi • 8. Behind the coracobrachialis muscle

  21. Blood Supply to Shoulder Complex

  22. Blood Supply

  23. Neurovascular Bundle

  24. Brachial Plexus

  25. Upper Extremity Dermatomes

  26. Posterior Dermatomes

  27. 1st Phase Scapulohumeral Rhythm • Phase I: • Humerus:30 degrees Abduction • Scapula:Minimal movement • Clavicle:0-15 degree elevation

  28. 2nd Phase Scapulohumeral Rhythm • Phase II: • Humerus:40 degrees Abduction • Scapula:20 degree rotation • Clavicle:30-36 degree elevation

  29. 3rd Phase Scapulohumeral Rhythm • Phase III: • Humerus:60 degrees Abduction • 90 degree lateral rotation • Scapula:30 degree rotation • Clavicle:30-50 degree posterior rotation • up to 30 degree elevation

  30. Biceps tendon mobility • Biceps tendon does not move in the bicipital groove during movement • Humeral head moves over the fixed tendon

  31. Shoulder Patterns: • Closed packed position= 90 degrees abduction and external rotation • Open packed position= arm down by side up to 20-25 degrees abduction

  32. Strength Assessment • Supraspinatus: assessed at 90° of forward flexion in the scapular plane with the thumbs pointed to the floor; downward pressure is resisted by the patient • Test is specific for supraspinatus function, and evaluates cuff strength and integrity

  33. Strength Assessment • External rotators: with the patient’s arm at his side and the elbow flexed to 90°, he will externally rotate as if hitting a tennis ball in a backhanded manner against resistance • Test is specific for the teres minor and infraspinatus muscles

  34. Strength Assessment • Abduction: assessed in the coronal plane against resistance • May be suggestive of either deltoid or cuff deficiency • Subscapularis: with the dorsum of the patient’s hand on his ipsalateral back pocket, instruct him to push backward against resistance

  35. Fractures of Proximal Humeral • Cause: direct blow, a dislocation or the impact received from FOOSH injury • Can be mistaken for shoulder dislocation • Can occur at anatomical neck, tuberosity or surgical neck • Most occur at surgical neck

  36. Humeral Shaft Fractures

  37. Humeral Shaft Fractures • Cause: direct blow or Foosh Injury • Type: comminuted or transverse fractures • Signs & Symptoms: Severe pain, swelling, deformity • Complication: radial nerve involvement- loss of wrist and finger extension and sensation over the back of dorsal surface- within 6 months radial nerve should be fine • Treatment: Nonoperative- x-ray views followed by splints and pressure wrap and casting with sling for 1st week

  38. Glenohumeral Dislocations • Most common are anterior displaced with arm abducted and externally rotated • Capsule can remain in tact or be severely damaged as head of humerus in forced out ot glenoid fossa in anterior inferior direction • Secondary labrum injuries – Bankhart Lesion and /or Hill-Sachs Lesions

  39. Anterior Glenohumeral Dislocation • Signs & Symptoms: • Flattened Deltoid contour • Palpation of axilla reveals prominence of humeral head • Athlete carries affected arm in slight abduction and external rotation • Severe Pain with initial dislocation • Tingling and numbness extends down the arm into hand

  40. Bankhart Lesion

  41. X-Ray finding of Bankhart Lesions

  42. Hill-Sachs Lesion • Small articular Cartilage defect on the humeral head caused by the impact of humeral head on the glenoid fossa as the humerus dislocates

  43. Hill-Sachs Lesion

  44. Recurrent Dislocations and Subluxations • Cause capsule to stretch out allowing for multiple reoccurrences • Athlete complains of arm feeling like it is “Going Dead”- commonly referred to as Dead Arm Syndrome

  45. Tests Used for Shoulder Instability • Sulcus • Aprehension and Relocation

  46. Sulcus • Patient: sitting with arm hanging at the side • Examiner: • grip the arm distal to the elbow • apply a downward force to the humerus while stabilizing the scapula • Positive Test: • a sulcus or indentation appears beneath teh acromion process • Alternate Test: • flex the humerus to 90 and look for a sulcus • this is indicative of inferior instability

  47. Aprehension Test (Anterior) • Patient: Supine with the glenohumeral joint anducted to 90 and the elbow flexed to 90 • Examiner: • support the humerus at midshaft and grasp the forearm proximal to the wrist • passively externally rotate the GH joint by applying pressure to the anterior forearm • Positive Test: • patient displays apprehension that the shoulder might dislocate and resists further movement. • Pain in the anterior capsule of the GH joint • If test is positive then perform the relocation test

  48. Relocation Test • Patient: Supine with the GH joint abducted to 90 and the elbow flexed to 90. • Examiner: • grasp the forearm proximal to the wrist and hold the opposite hand over the humeral head • apply a posterior force to the head of the humerus and maintain it while externally rotating the humerus. • Positive Test: • decreased pain or increased ROM compared to the anterior relocation test

  49. Posterior Apprehension • Patient: supine with the shoulder flexed to 90 and the elbow flexed to 90. The GH joint being tested hangs off of the side of the table • Examiner: • with one hand grasp the forearm, with the other hand stabilize the posterior scapula • apply a downward force to the humerus • Positive Test: • patient displays apprehension and produces muscle guarding to prevent shoulder form subluxating posteriorly

  50. Subacromion Bursitis

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