Rec and Care: Clinical Lab Exam 2: Shoulder

Bony Anatomy: Clavicle: Superior and Anterior border

Along the neckline, down the shaft of the collarbone
Superior is on top of the bone
Anterior is along the front of the bone

Bony Anatomy: Scapula: coracoid process

distal 1/3 of curved clavicle, go straight down from the S curve in the collarbone, the bone sticking out here is

Bony Anatomy: Scapula: Acromion Process

At the end of the clavicle, the ridge of bone off the AC joint, just off the shoulder

Bony Anatomy: Scapula: Spine

if you rub your thumb up and down along the scapula it is the bony projection, horizontal on back

Bony Anatomy: Scapula: Vertebral border

closest edge of shoulder blade to the spine, the ends make up the superior and inferior angles, runs parallel to spine

- also the medial border

Bony Anatomy: Scapula: Axillary border

Posteriorly in the armpit, if individual puts hand on their head you can feel it pop out
- also known as the lateral border

Bony Anatomy: Scapula: Superior angle

get individual to shrug their shoulders, it will be close to the spine, at the top of the medial border Bony Anatomy: Scapula:

Bony Anatomy: Scapula: Inferior angle

at the bottom of the shoulder blade, can find easily if individual places their hand behind their back - it will pop out

Bony Anatomy: Humerus: head

on the deltoid, go into the soft divot on the back of the shoulder and anterior into the squishy spot there with thumb and forefinger

Bony Anatomy: Humerus : greater tuberosity

find the acromion process, go straight down to the lesser, if you go more to the side posteriorly , this will be the greater tub, can feel it roll if you rotate your arm

Bony Anatomy: Humerus: lesser tuberosity

find the acromion process and go straight down, the bump will roll away with adduction, more inferior and anterior

Articular Anatomy: Sternoclavicular joint

on the chest, very medial, at the proximal end of the clavicle, flat little projection

Articular anatomy: Acromioclavicular joint
- ligament

formed by the acromion process and the clavicle
- the ligament attaches across this space horizontally and is a common site in many shoulder injuries

articular anatomy: coracoclavicular joint

found between the coracoid process and the conoid tubercle of the clavicle
- more medial than the acromioclavicular, and is on the anterior portion of the shoulder running vertically

articular anatomy: coracoclavicular ligaments
- trapezoid
-conoid

two ligaments make up the joint
trapezoid; attaches the coracoid process and the trapezoid line of the clavicle, inferiorly and laterally
conoid; attaches to the conoid tubercle, medially inferiorly and posteriorly

articular anatomy: coracoacromial ligament

ligament from the coracoid process to the acromion process

articular anatomy: glenohumeral joint

joint at the distal shoulder, ball and socket between the head of the humerus and the glenoid cavity

Muscular anatomy: supraspinatus

along the spine of the scapula

how to test the supraspinatus

test at 30 degrees, thumbs down, pushing down at the wrists
- resisted abduction

muscular anatomy: infraspinatus

underneath the spine of the scapula

how to test the infraspinatus and teres minor

arms bent at 90 degrees, pushing internally, holding at the elbow and wrist, resisted extension

muscular anatomy: teres minor

narrow, intrinsic muscle extends from the lateral border of the scapula to the greater tuberosity of the humerus

muscular anatomy: subscapularis

largest, and strongest muscle in the rotator cuff
lies on the anterior surface of the scapula

how to test the subscapularis

lay face down, with arm off the edge of the table and block at the elbow, push forward at the wrist and hand , individual tries to lift arm backwards
isolated internal rotation
- fall off-axial border into the armpit to feel contraction with fingers
- can also do the lift off test

which four muscles make up the rotator cuff

supraspinatus
infraspinatus
teres minor
subscapularis

Muscular anatomy: deltoid - anterior

help move arm forward, connects to the clavicle

how to test the anterior deltoid

make fist, put arms straight out in front of you and then push down at wrists

Muscular anatomy: deltoid - middle

largest and strongest part of the deltoid

how to test the middle deltoid

bend elbows and push down at the wrists

muscular anatomy: deltoid - posterior

deltoid on the posterior scapula, attaches on the spine

how to test the posterior deltoid

extension 45 degrees, hand on the shoulder, and pull at wrist

muscular anatomy: pectoralis major

the superior most and largest muscle of the anterior chest wall. It is a thick, fan-shaped muscle that lies underneath the breast tissue and forms the anterior wall of the axilla

how to test the pectoralis major - anterior

anteriorly the thumb goes into the armpit and pinches, intertwine your arm with theirs, resist elbow flexion, internal rotation, adduction, and pull arm up sideways
ie/ benchpress position

muscular anatomy: serratus anterior

is a fan-shaped muscle that originates on the superolateral surfaces of the first to eighth ribs or the first to ninth ribs at the lateral wall of the thorax and inserts along the superior angle, medial border, and inferior angle of the scapula.

how to test the serratus anterior

straight arm with a fist, pushing straight back into a protracted position, push down at fist and around elbow

muscular anatomy: latissimus dorsi

The latissimus dorsi muscle is a broad, flat muscle that occupies the majority of the lower posterior thorax. The muscle's primary function is in the upper extremity but is also considered to be a respiratory accessory muscle.

how to test the latissimus dorsi

in a seated position, interlock fingers behind head, pull arms down

muscular anatomy: biceps

The biceps brachii , commonly know as the biceps, is a large, thick muscle on the ventral portion of the upper arm. The muscle is composed of a short head and a long head. The long head is located on the lateral side of the biceps brachii while the short head is located on the medial side.

how to test the biceps : neutral

test bilaterally
flexed elbow, hammer fist

how to test the biceps : supinated

how to test the biceps : pronated

muscular anatomy: triceps

The primary function of the triceps is the extension of the elbow joint. It is composed of three heads (tri = three, cep = head): a long head, a lateral head, and a medial head.

how to test the triceps

hold arm flexed with fist
pull up on the wrist , and block at shoulder
- resisted elbow extension

muscular anatomy: trapezius

either of a pair of large triangular muscles extending over the back of the neck and shoulders and moving the head and shoulder blade

how to test the trapezius : upper fibers of trapezius

shrug shoulders up and push down

how to test the trapezius : middle fibers of trapezius

pull shoulderblades back, or on stomach arms to the ride, lift up and push down

how to test the trapezius : lower fibers of trapezius

on stomach or standing; hands behind back, depress and adduction to the opposite side, opposite pocket

muscular anatomy: rhomboids

The rhomboids are a collective group of muscles formed by the rhomboid major and minor. The rhomboids are important in upper limb movement and stability of both the shoulder girdle and scapula.

how to test the rhomboids

on stomach, arms in skydive position, thumb down, pushing along the vertebral border, resist at elbow
- protract and retract

Special tests: Apley's scratch test 1.

ROM
Hand behind head, landmark this spot on the spine, get the patient to do the other side - ensure the same bilaterally

Special tests: Apley's scratch test 2.

Hand behind the back, landmark this spot

Special tests: Apley's scratch test 3.

across the shoulder to the opposite side, both arms, if the space is more than a fist there may be a functional flexibility problem, behind head and above back

Special tests: Load and Shift

labral
Place the fingers on the shoulder with your top hand, on the clavicle and spine of the scapula
With the other hand, place the front finger on the lesser tuberosity of the humerus and the back finger on the divet on the back, on the head of the humerus
Push hand down on the shoulder, and then shift in and forward on the glenohumeral joint
- shoulder must be in the fossa for this test

Special tests: Apprehension and relocation

anterior instability
apprehension: Arm abducted to 90 degrees, shoulder slowly rotated externally from pulling at the hand, and blocking at the shoulder
relocation: patient lying supine, the shoulder at 90 degrees and the elbow

Special tests: posterior apprehension

push pull test; posterior instability
Elbow abducted, hand by face, compression shoulder and elbow

Special tests: sulcus test

inferior instability , AC joint superior glenohumeral ligament and coracohumeral ligament
Landmark acromion process grab elbow with bottom hand, top hand finger or thumb in divet, pull down at the elbow

Special tests: Feagan test

inferior instability
Arm straight out to the side , resting on your shoulder, hands intertwined with your own fingers at the shoulder, pull towards the ground
- positive test; laxity or apprehension

Special tests: drop arm test

RC tear
Both arms out to the side and let go, arm will drop if injured OR arms all the way to the top, and then get them to slowly lower

Special tests: supraspinatus test

supraspinatus tear
arms out at 30 degrees horizontal abduction , hands internally rotated with thumbs down, , push down at wrists : empty can test

full can: thumbs up, externally rotated and push down at the wrists

Special tests: Speed's biceps test

bicep tendon
palms up at side, supination, , lift to 30 degrees, extend , place finger on biceps tendon and apply resistance to 60 degrees of extension
positive: pain in bicipital groove

Special tests: Lift off sign

Subscapularis injury
hand behind back, lift off and resist
However, a tight RC could cause a hand to not lift off as much

Special tests: clunk test

labral
Laying down, straight arm raise, hand pulls at wrist , other hand underneath the scapula, will feel a clunk, motion is a rotation and abduction

Special tests: O'Brien's test

SLAP (speeds) - labral tears
1. Patient seated, glenohumeral joint at 90 degrees, horizontally adducted to 10 degrees, humerus is internally rotated , with palm up, pressure is resisted an inward push
2. Repeat with arm in externally rotated and supinated position , resist downward push

Special tests: Impingement Test

painful arc
- Arms up to 90 degrees. straight arm, flip at halfway, and bring arms all the way to the top

Special tests: Hawkins-Kennedy

impingement
Sitting,shoulder at 90 degrees forward flexion, internally rotate, push up at elbow, and bring wrist down counter clockwise

Special tests: Scarf Test

AC joint
cross arm over opposite shoulder, pull shoulder, and push at elbow