Anatomy in Action

The Shoulder
Jennifer Thompson MD FRCSI

HISTORY

Events leading to injury

Pain
Stiffness, restriction of movement
Weakness e.g. lifting the arm
Loss of function
Swelling
Instability

PAIN
INFLAMMATION
- the -itis problems
FRACTURE
DISLOCATION
- Gleno-humeral
- Acromio-clavicular

Anatomical structures commonly

causing pain in the shoulder
Muscle
-

Myositis, tear

Tendons
- Tendinitis eg supraspinatus
Bursa
- Bursitis eg subacromial
Joints
- Synovitis; dislocation

Referred
- from cervical spine
- abdomen; cardiac

-itis

Causes: Glenohumeral Instability

Anterior dislocation secondary to:
1. blow to the abducted, externally rotated, and
extended arm
2. a fall on the outstretched hand
3. blow to the posterior humerus
Posterior dislocation
1. violent muscle contraction (eg with a seizure or
electric shock)
2. recurrent micro-trauma eg swimmers, throwers
3. blow to the anterior shoulder

EXAMINATION
LOOK
FEEL
MOVE

EXAMINATION
FIRST OF ALL:
Examine the
neck

LOOK
SURFACE ANATOMY
Contour
Alignment
Winging of the scapula
MUSCLE BULK
Deltoid
Supraspinous fossa
Infraspinous fossa
SWELLING, BRUISING etc

CONTOUR + ALLIGNMENT

Swelling of the Shoulder

EFFUSION (free fluid within the joint capsule)
- Inflammation
Acute inflammatory arthritis
(eg Rheumatoid)
Crystal arthritis eg Gout
Infection of the joint
- Rotator cuff tear
OR LOCAL SWELLING: BURSITIS
- eg subacromial

FEEL
TENDERNESS?
WARMTH?
SWELLING?
Dont forget the limb girdle

FEEL
Tender sites around the shoulder:
Joint line: glenohumeral joint
acromioclavicular joint
Tendons:

bicipital

Bursae:

subacromial/
subdeltoid

MOVE
Range of movement - ROM: record measurements
First: active ROM
PAIN? LIMITATION?

Then: passive ROM

Is there a difference between Active and Passive ROM?
Is there a painful arc?

Muscle strength

Anatomical Abnormalities causing

impaired shoulder movement
Muscle:
Degeneration
Denervation

Tendons:
Tears
Tendinitis

Joint:
Inflammation
Dislocation

Bursa:
Inflammation

Range of Movement of the

Shoulder
Flexion: 0-180o
Extension 0-60o
Abduction: 0-180o
Adduction: 0-50o
Internal rotation: 0-70o
External rotation: 0-70o

Shoulder: Range of Movement

SPECIAL CONSIDERATIONS
THE ROTATOR CUFF

Rotator Cuff Tear

Most are traumatic:
following a fall onto an outstretched arm
lifting a heavy object
throwing injury
Features: pain and weakness on
abduction & external rotation
If chronic: wasting of the supraspinatus &
infraspinatus muscles

Movements of the Rotator Cuff

Supraspinatus: Abduction (20)
Infraspinatus:
Teres minor:

External rotation
External rotation

Subscapularis: Internal rotation

Supraspinatus Tendon
What is the function of the supraspinatus muscle?
- abduction of the shoulder
How to examine for possible tendinitis or tear?
- pain +/or weakness on abduction of shoulder
Tear: partial or complete
Loss of 1st 200 abduction

Supraspinatus Tendinitis
- accounts for 80% of calcific tendinitis
- from deposition of hydroxyapatite crystals

Clinical features:
Acute / chronic pain lateral shoulder / upper arm
Pain +/- weakness on abduction of the shoulder
Painful arc 600-1200
Pouring beer: resist adduction from scapular
plane in pronation.the EMPTY CAN TEST

Tests for Impingement

Empty Can Test

Tests for Impingement

Neer or passive painful arc test - passive flexion of
the internally rotated glenohumeral joint while preventing
shrugging. Rotator cuff or long head of biceps tendinitis.

Tests for Impingement

Hawkins test with shoulder and elbow flexed at 90
the clinician internally rotates the shoulder

Tests for Impingement

Yocums test - the hand of the affected side
is placed on the shoulder of the patients
unaffected shoulder; the elbow is then
raised without elevation of the shoulder

Testing rest of Rotator Cuff

Resist tennis forehand / backhand: tests
subscapularis or infraspinatus / teres minor,
respectively

Additional tests for subscapularis:

Belly press: elbow drifts posteriorly if weak
internal rotation

Push off test

SPECIAL CONSIDERATIONS
THE BICEPS TENDON

Bicipital Tendon
Where is the bicipital tendon located?
- bicipital groove

What are its functions?

- flexion of the forearm (elbow)
- forward elevation of the shoulder
- supination of pronated forearm if elbow flexed

Tenderness over the bicipital tendon - tender area will migrate

with bicipital groove as arm is abducted & externally rotated.

Diagnosis of Bicipital Tendinitis

Speeds Test: pain in the bicipital groove with forward
flexion of the shoulder about 30 against resistance with
elbow extended and arm fully supinated

Diagnosis of Bicipital Tendinitis

Yergasons test: pain in the bicipital groove with resisted
supination of the pronated forearm with the elbow at 90
and shoulder adducted.

LOOK, FEEL, MOVE

LOOK
swelling, muscle wasting, alignment, bruising

FEEL
swelling, tenderness, warmth, crepitus

MOVE
active and passive ROM; resisted movement

OTHER:
CSM

http://www.hss.edu/conditions_14641.asp