overview on shoulder examination

1. THE SHOULDER JOINT


 MAJ VM PHILIP
 JUNIOR RESIDENT
 ORTHOPAEDICS

3. FUNCTIONS OF SHOULDER
 PRIMARY: hand placement in
various positions to accomplish
the upper limb tasks
 SECONDARY:
1) Suspension of the upper
limb
2)Sufficient fixation for upper
limb movement
3)Fulcrum for arm elevation

4. SHOULDER COMPLEX
 Three bones
 Three joints
 One pseudojoint

5. 1/3
-
1/4
Diameter: 37-
55 mm
Diameter: ≈ 41
mm
Humeral head is half a sphere roughly
articulating with one third to one fourth of
the surface of glenoid fossa
ball and socket

6. Anatomy
 Glenohumeral joint
 “Ball and socket” vs
“Golf ball and tee”
 Very mobile
 Price: instability
 45% of all dislocations
 Joint stability depends
on multiple factors

7. Glenohumeral Joint
 Humeral head faces medially,
posteriorly and superiorly
 Glenoid :laterally,anteriorly and
superiorly at rest and lateral,
inferior and posterior in
dependant position
 Head shaft angle : 130 – 150 deg
(long axis) and 30 – 40 deg
retroverted in the frontal plane

8. Glenohumeral Joint
 GLENOID LABRUM
 Dense fibro cartilage attached the
glenoid fossa and joint capsule
 Forms a part of articular surface
 Long head of biceps: half of the
fibres originate from the superior
labrum
 Increases joint stability (75%
vertical and 56% transverse)

9. Glenohumeral Joint
 Joint capsule:
- laterally attached to the neck
of humerus
- medially to the periphery of
glenoid and labrum
 Capsule is lax with multiple
recesses
 Axillary recess: inferiorly is lax
and redundant permitting
normal arm elevation

10. Joint Capsule - Posterior View
A. Acromion
B. Scapular spine
C. Coracohumeral ligament
D. Supraspinatus muscle
(cut away)
E. Infraspinatus muscle (cut
away)
F. Teres minor muscle (cut
away)
G. Triceps muscle (cut away)
H. Capsule

11. Glenohumeral Joint: capsule
 Joint capsule:
 -Anteriorly reinforced by
the ‘Z’ ligaments
 Rotator cuff : stregthens
capsule anterior, superior and
posteriorly

lined by synovial membrane
from glenoid labrum to neck
of humerus

12. Anatomy
 Scapula
 Glenoid
 Acromion
 Coracoid
 Subscapular fossa
 Scapular spine
 Supraspinatus
fossa
 Infraspinatus
fossa

13. GLENOHUMERAL JOINT
 Humerus
 Anatomical neck
 Greater and lesser
tuberosities
 IT groove: angle of
wall(60° to 75°)
 Tendon of long h
 ead of biceps makes an
abrupt right angle turn to
lie in the IT groove

14. GLENOHUMERAL JOINT
 Surgical neck of
humerus
region below greater
and lesser tuberosities
where head meets the
shaft
Axillary nerve
Posterior circumflex
humeral artery

15. Glenohumeral Joint
 Joint capsule:
 -Anteriorly reinforced by the ‘Z’
ligaments
 Rotator cuff : stregthens capsule
anterior, superior and posteriorly

lined by synovial membrane from glenoid
labrum to neck of humerus

16. Glenohumeral Joint
 Ligaments : function in a load
sharing fashion by reciprocal
tightening and loosening.
 Lax in mid range of motion
where rotator cuffs maintain
stability
 Anterior aspect of GH joint:
Gleno humeral
ligaments(sup,middle and inf) +
coraco humeral ligaments:
Z ligaments

17. Glenohumeral Joint : Ligaments
 Superior GH ligament
 Origin - 12o’ clock of
glenoid rim
 Direction - inferior and
lateral
 Insertion - anatomical
neck
 Function - limits external
rotation and inferior
translation of the humeral
head with arm on the side

18. Glenohumeral Joint : Ligaments
 Middle GH ligament: poorly
developed
 Origin :2 or 3 o’ clock of glenoid
rim
 Direction: inferior and lateral
 Insertion: anatomical neck
 limits external rotation and
anterior translation of the
humeral head with arm in 0 to 45°
of abduction

19. Glenohumeral Joint : Ligaments
 Inferior GH ligament complex(IGHLC)
 Components:
1. Anterior band
2. Posterior band
3. Axillary pouch
 Anterior band
 Origin : b/w 2 and 4 o’ clock of
glenoid rim
Insertion : below lesser tuberosity
Function : limits external rotation
and inferior translation of the humeral
head with arm abducted to 90°

20. Glenohumeral Joint : Ligaments
 Inferior GH ligament
complex
- Posterior band
- b/w 7 and 9 o’ clock of
glenoid rim
- limits internal rotation in
abduction
- Anteror + posterior : anterior
translation at 90° abduction

21. IGHLC

22. Glenohumeral Joint : Ligaments
 Coracohumeral ligament:
Functions
 covers the Superior GH ligaments
 fills the space b/w supraspinatus
and subscapularis and complete
the rotator cuff anteriorly
 Ant band limits extension of GH
 Post band limits flexion of GHJ
 Both limit the inferior and posterior
translation of humeral head


23. Glenohumeral Joint : Ligaments
 Coraco acromial ligament: roof
of the shoulder
 From coracoid to antero inferior
acromion ext into AC joints
 Two bands near acromion
 Prevent separation of AC jt

24. Glenohumeral Joint : Ligaments
 Coraco acromial arch: Ant inf
acromion + coracoacromial
ligament +inf ascpect of AC jt
 Scaption: supraspinatus tendon
passes under the arch
 Scaption + int rotation : SS tendon
passes under coraco acromial
ligament
 Scaption + ext rotation: SS tendon
passes under acromion

25. Glenohumeral Joint : Suprahumeral space
 Boundaries:
Inf : tuberosity of humerus
ant med : coracoid process
sup : coraco acromial arch
 Structures (inf to sup)
- Head of humerus
- Long head of biceps tendon
- Superior aspect of joint capsule
- Supraspinatus,upper margins of
subscapularis and infraspinatus
- Subacromial-subdeltoid bursae

26. Glenohumeral Joint : Suprahumeral space
 Arm adducted by the side : 11 mm
 Arm at 90° abduction : 5.7mm
 Space is narrowest b/w 60° and 120°

27. Anatomy
 Rotator Cuff
Muscles
 S – Supraspinatus
 I – Infraspinatus
 T - Teres minor
 S- Supscapularis

28. Glenohumeral Joint : Bursae
 Approx eight in shoulder
complex
 Subacromial Bursa: one of the
largest
 Two smooth serosal layers to
deltoid and rotator cuff
 Also connected to
acromion,GT,coraco acromial
ligament
 Allows rotator cuff to slide easily
beneath deltoid

29. Glenohumeral Joint Nerve supply
 Derived from C5 to C8 nerve roots embryologically
 Anterior shoulder joint : axillary(C5-C6)
subscapular(C5-C6)
lateral pectoral(C5-C6)
 Posterior shoulder joint : suprascapular(C5-C6)
axillary(C5-C6)

30. Glenohumeral Joint : Blood supply
 Branches of Axillary artery
- ant circumflex humeral
- post circumflex humeral
- suprascapular
- circumflex scapular

31. Glenohumeral Joint : Blood supply
 Labrum: post cx humeral and subscapular ( capsule)
 Rotator cuff:
- supraspinatus : thoracoacromial
- subscapularis : ant cx humeral
- infraspinatus post cx humeral
- teres minor suprascapular

32. Glenohumeral Joint : Blood supply
 Biceps :Branches of Brachial artery
 Critical zones : supraspinatus and biceps
relatively avascular
 Supraspinatus vulnerable:
 compressed by subacromial sructures
 Blood supply parallel to tendon fibres, susceptible to
stretch
 Critical zone proximal to insertion

33. Acromioclavicular Joint
 Connects acromion
process with lateral
clavicle
 Plane- synovial joint
 Gliding motion
occurs in all planes
 Suspends upper limb
from the trunk

34. Acromioclavicular Joint
 hyaline cartilage initially,
fibrous in adolescence
 10 to 50 deg inclination
 Acromion faces ant, med
and sup
 Thin capsule ,capsular lig
 AC ligament prevents
posterior translation and
posterior axial rotation

35. Acromioclavicular Joint: ligaments
 CORACOCLAVICULAR
 from coracoid to inferior
surface of clavicle
 Two parts:
 Conoid ligament
 Trapezoid ligament
 Vertical stability to AC
jt, superior & ant
translation , ant axial
rotation

36. Acromioclavicular Joint: ligaments
 Conoid ligament
 Fan shaped
 Apex inferior
 Medial of the two
 Frontal pane
 prevent coracoid movt
away from clavicle

37. Acromioclavicular Joint: ligaments
 Trapezoid ligament
 Quadrilateral sheet
 From medial border of
upper surface of coracoid
 Runs supero laterally to
the inferior surface of
clavicle
 Larger,longer and
stronger
 Plane perpendicular to
conoid
 Blocks medial coracoid
movt

38. Sternoclavicular Joint
 Formed by
- medial end of clavicle
- claviclar notch of manubrium
- first rib cartilage
 Saddle/plane joint
 Fibrocartilagenous articular
disc
 Angulated 20° posterolaterally
 Lateral aspect of the joint acts
as an ovoid

39. Sternoclavicular Joint
 In vertical: proximal
end of clavicle is
convex and
manubrium concave
 In AP view: proximal
clavicle is concave
and the manubrium
convex

40. Sternoclavicular Joint (cont’d)
 Articular disk
- attached to the upper and
posterior end of clavicle and
cartilage of first rib
- thick in perphery
- divides the joint into two unequal
parts
- more movt occurs b/w clavicle and
disk
- prevents medial displacement of
clavicle
-

41. Sternoclavicular Joint : ligaments
 Anterior Sternoclavicular
 Posterior Sternoclavicular
 Interclavicular
 Costoclavicular
 Ant sternoclavicular
 Covers ant aspect
 Runs obliquely from clavicle to
sternum

42. Sternoclavicular Joint (cont’d)
 Post SC ligaments
 Posterior aspect of jt
 Runs down and medially
 Interclavicular ligaments
 Connects the
superomedial sternal
ends of both clavicles
with the capsular
ligaments and upper
sternum

43. Scapulothoracic Articulation
 Not a joint anatomically
 Scapula moves over the rib cage of the
thorax
 Not directly attached
 Connected indirectly via the clavicle and
several muscles
 Provides motion and flexibility to the
body
 15-18 cms of translation at ST jt
normally

45. Anterior Shoulder Muscles
 Coracobrachialis
 Pectoralis Major
 Subscapularis
 Biceps Brachii

46. Biceps Brachii
 Origin
 Short head:
coracoid process of
scapula
Long head:
supraglenoid
tubercle of scapula
 Insertion
Tuberosity of radius
 Action Flexion of the
elbow and shoulder,
Supinates forearm
 ***the long head is
the “5th
rotator cuff”

48. Coracobrachialis
 O: Coracoid process
 I: Anteromedial
surface of midshaft
of humerus
 Actions: (WEAK!)
 Flexion
 Adduction of the
shoulder

50. Pectoralis Major
 Origin:
 Medial two-thirds of clavicle
 Sternum
 Insertion: intertubercular
groove
 Actions
 Upper fibers (Clavicular)
• Flexion
• Horizontal Adduction
 Lower fibers (Sternal)
• Internal/medial Rotation
• Horizontal adduction

51. Subscapularis
 O: Subscapular fossa
 I: Lesser tubercle and
crest of humerus
 Actions:
 Internal Rotation
 Stabilization
 Anterior Rotator Cuff
Muscle.

52. Superior Shoulder Muscles
 Deltoid
 Supraspinatus

53. Deltoid
 Origin
 Lateral 1/3 of clavicle
(Anterior fibers)
 Acromion process (Middle
fibers)
 Spine of scapula
(Posterior fibers)
 Insertion – deltoid tuberosity
Actions
Anterior –Flexion
Middle – Abduction
Posterior –Extension

56. Inferior Shoulder Muscles
 Latissimus Dorsi
 Teres Major

57. Latissimus Dorsi
 O: Spinous process of
lower 6 thoracic and all
lumbar and sacral
vertebrae; iliac crest
 I: Intertubercular groove
 Actions:
 Adduction
 Internal Rotation
 Extension

60. Teres Major
 O: Inferior angle of
scapula
 I: Intertubercular groove
 Actions:
 Adduction
 Internal rotation
 “Lats little helper”

62. Posterior Shoulder Muscles
 Infraspinatus
 Teres Minor
 Triceps
Brachii

63. Triceps Brachii
 Origin
Long head: infraglenoid
tubercle of scapula
Lateral head: posterior
surface of humerus,
Medial head: posterior
surface of humerus
Insertion Olecranon
process of ulna
 Action Chief extensor of
elbow (long head
extends the shoulder)

64. Infraspinatus
 O: Infraspinous fossa
 I: Greater tubercle
 Actions:
 External rotation
 Stabilization
 Posterior Rotator Cuff
Muscle
 Second most commonly
injured rotator cuff muscle

65. Teres Minor
 O: lateral border of
scapula
 I: Greater tubercle
 Actions:
 External rotation
 Stabilization
 Posterior Rotator
Cuff Muscle

66. Trapezius
 Origin occipital
bone, nuchal
ligament, and
spinous processes of
C7 - T12 vertebrae
 Insertion Lateral
third of clavicle,
acromion, and spine
of scapula
 Action
 superior fibers
elevate,
 middle fibers retract,
 inferior fibers
depress scapula;

67. Levator Scapula
 Origin C1 - C4
vertebrae
 Insertion
Superior angle
 Action Elevates
scapula

68. Rhomboid major and minor
 Origin
Minor: spinous
processes of C7 and
T1 vertebrae
Major: spinous
processes of T2 - T5
vertebrae
 Insertion Medial
border of scapula
 Action Retract
scapula

69. Serratus Anterior
 Origin the eight
upper frontal ribs
 Insertion lateral
border of scapula
 Action protracts
scapula

70. Glenohumeral Joint: Biomechanics
 Complex interaction amongst the joints
in a smooth harmonious movt
 G-H :: ball on a seal’s nose
 Greatest ROM
 2:1 at gh:st joints

71. Glenohumeral Joint: Biomechanics
 Three DOF:
- flexion/extension
- abduction/adduction
- internal/ext rotation

72. Glenohumeral Joint:biomechanics
 Scapula: stable base
 Attaches indirectly to the rib
cage
• Anteriorly concave and glides over
the convex rib
• Located between the second and
seventh ribs
• Position : 30 degrees (frontal)
3 degree superior

73. FRONTAL PLANE
SAGITTAL PLANE
SCAPULAR PLANE
30 degrees

74. Glenohumeral Joint
 Scaption : arm elevation occuring
at 30 to 45 degrees anterior to
the frontal plane

75. Glenohumeral Joint: Biomechanics
 Static shoulder stabilisation
- requires very little muscle support
- provided by trapezius and supraspinatus
- vertical stability:glenoid facing up by trapezius
- inferior stability: intra articular pressure and
adhesion/cohesion of articular surfaces
- anatomic curvature of humerus
- glenoid labrum
- negative intraarticular pressure

76. Glenohumeral Joint: Biomechanics
 Dynamic shoulder stabilisation
- requires complex factors
Major dynamic stabilisers
- long head of triceps and biceps
- humeral head max stabilisation: subscapularis
Posterior restraints
- <90° abduction : post capsule
- 90° abduction : IGHLC

77. Scapulohumeral Rhythm
 Describes the movement relationship between the
scapula and humerus to maintain angle b/w scapula
and humerus <30°
 First 30° of shoulder joint motion pure GH motion
 After that, for every 2° of shoulder flexion or abduction,
the scapula rotates 1°
 2:1 ratio → scapulohumeral rhythm
 Full abduction: glenoid completely support humerus

78.  0-80° →more humeral motion
 80-140° → more scapular motion
 140-170° →neighbouring joints

80. Scapulothoracic Articulation:Biomechanics
 0-90°=60°+30° at GH and ST
- St movt = 20-25°of clavicular elevation at SC jt
05-10° of upward rotation at AC jt
 90 to 180° = 60° of GH movt + 30° ST movt
- St movt = 05-10°of clavicular elevation at SC jt
20-25° of upward rotation at AC jt

81. Glenohumeral Joint:Biomechanics
 Close Pack position : 90° abduction
and full external rotation
 Open Pack position : 55°abduction
with 30° horizontal adduction
 Zero position : 0 degree
abduction,12° flexion,10° external
rotn
 Capsular pattern-Ext rotn:abduction:
internal rotation = 3:2:1

82. Acromioclavicular Joint:Biomechanics
 Three types:
rotation,spin,glide
 Rotation:
- AP rotatation
- superoinferior
AP rotation: longitudinal
 Through SC and AC jts
 30 to 50 deg -mostly SC

83. Acromioclavicular Joint:Biomechanics
 Protraction:ant movt of
acromial end of clavicle
 Retraction: post movt of
acromial end

84. Acromioclavicular Joint: Biomechanics
 Close Packed position
 90° GH joint abduction
 Open Packed position
 Arm is on the side
 Clavicle is 15° retracted
and 2° elevated
 Capsular pattern
pain in extremes of
horizontal adduction
and full elevation

85. Sternoclavicular Joint: Biomechanics
 Two types of translations
A-P & sup-inf (2:1) allowing
1. Elevation/depression
2. Protraction/retraction
3. Backward /forward rotation
 Elevation and depression
- 35 to 40 deg of elevation
- 15 deg depression

86. Sternoclavicular Joint: Biomechanics
 Protraction/retraction
- 15 to 20 deg both
- on protraction the concave
surface of clavicle moves on
convex sternum producing an
anterior glide of clavicle and
anterior rotation of lateral
clavicle
- on retraction medial clavicle
articulates with flat surface
and posterior rotation of
lateral end

87. Sternoclavicular Joint: Biomechanics
 Rotation
spin of the clavicle on manubrium
40° anterior and 5° posterior rotation
 Close Packed position
maximum arm elevation and protraction
 Open Packed position
arm by the side (postulated)
 Capsular pattern
full elevation and horizontal adduction

88. Scapulothoracic Articulation:Biomechanics
 scapula has five degrees of
freedom for movement on the
thorax:
 two translations and rotate in
three planes around three
different axes.
 translations:
- Elevation /Depression
- retraction &Protraction

89.  Rotations:
- scapular winging .
- scapular tipping
- up & down rotation

90. Rotational Movement of the
Scapula
 All three parts work together
(synergists) to retract the scapula

91. Rotational Movement of the
Scapula (cont’d)
 Middle trapezius - prime mover
 Upper and lower trapezius are antagonistic in
elevation/ depression
 Upper and lower trapezius are agonistic in upward
rotation

92. Clinical Examination
 History
 Inspection
 Palpation
 Range of Motion
 Measurements
 Special Tests

94. History - PainHistory - Pain
 Type and location of pain or symptoms
 Onset of pain (traumatic, insidious)Onset of pain (traumatic, insidious)
 Location of painLocation of pain
 Alleviating/Aggravating factorsAlleviating/Aggravating factors
 Night painNight pain
 Pain/weakness overhead activitiesPain/weakness overhead activities

95. Pain
 Typically pain of gleno-humeral origin is
felt in the upper arm, often at the insertion
of the deltoid.
 Severe shoulder problems can cause pain
to radiate as far as the radial side of the
wrist.
 Impingement/rotator cuff
pathology:anterior/lateral shoulder pain
aggrevated with overhead activities

97. Pain
 The shoulder is derived from the fifth
cervical segment and therefore refers pain
into the C5 dermatome.
 The acromio-clavicular joint is a C4
structure and refers pain into the C4
dermatome.

98. Pain
 The shoulder is deep and proximal in the
C5 dermatome, hence it can potentially
refer pain a great distance.
 Conversely the acromio-clavicular joint is a
superficial structure at the distal end of the
dermatome causing it to give rise to
accurate, local pain

102. Physical Exam – Inspection
 Front & Back
 Height of shoulder
& scapulae
 Asymmetry
 Obvious deformity
 Ecchymosis
 Muscle atrophy
 Supraspinatus
 Infraspinatus
 Deltoid

103. Physical Exam –Inspection
 Front & Back
 Height of shoulder
& scapulae
 Asymmetry
 Obvious deformity
 Ecchymosis
 Muscle atrophy
 Supraspinatus
 Infraspinatus
 Deltoid

104. Physical Exam – Inspection
 Front & Back
 Height of shoulder
& scapulae
 Asymmetry
 Obvious deformity
 Ecchymosis
 Muscle atrophy
 Supraspinatus
 Infraspinatus
 Deltoid

105. Palpation
 At rest & with
movement
 Bony structures
 Joints
 Soft tissues

106. Palpation
 Surface Anatomy
(Anterior)
 Clavicle
 SC Joint
 Acromion process
 AC Joint
 GH joint
 Coracoid process
 LT
 GT
 Subacromial bursa
 Pectoralis major
 Trapezius
 Biceps (long head)
AC joint
SC joint
biceps

107. Palpation  Surface Anatomy
(Posterior)
 Scapular spine
 Acromion process
 Supraspinatus
 Infraspinatus
 Teres Minor
 Trapezius
 Latissumus dorsi
 Scapula
• Inferior angle
• Medial border
Supraspinatus
Infraspinatus
Inferior angle
of scapula

108. Range of Motion
 Forward flexion:
160 - 180°
 Extension: 40 - 60°
 Abduction: 180◦
 Adduction: 45 °
 External rotation:
80 - 90 °
 Internal rotation:
60 - 90 °

109. Range of Motion
 Scapular dyskinesis
(Scapulothoracic
dysfuntion)
 Compare scapular
motion through ROM on
both sides
 Wall push-ups
 Symmetrical
 Smooth
 No or minimal winging

110. Strength Testing
 External rotation
 Tests RTC muscles that
ER the shoulder
• Infraspinatus
• Teres minor
 Arms at the sides
 Elbows flexed to 90
degrees
 Externally rotates arms
against resistance

111. Strength Testing
 Internal rotation
 Tests RTC muscle that
IR the shoulder
• Subscapularis
 Arms at the sides
 Elbows flexed to 90
degrees
 Internally rotates arms
against resistance
 Subscapularis Lift-Off
Test
 Other techniques

112. Strength Testing
 Supraspinatus
“Empty can" test
Jobe’s Test
Tests Supraspinatus
Attempt to isolate from
deltoid

113. Special Tests
 Impingement
 Rotator Cuff
Integrity
 Labrum and Biceps
 AC (SC) Joints
 Instability

114. :TESTS FOR
ROTATOR
CUFF/IMPING
MENT
TESTS FOR
ACROMIOCLAV
ICULAR JOINT
TESTS FOR
BICEP
TENDON
TESTS FOR
INSTABILITY
 Neer
impingment
test
 Hawkins
kennedy test
 Empty can test
 Drop arm test
 Lift off.Test
 Infraspinatus
test
 Spring back
test
 Teres minor
 Painful arc
 Forced
adduction test
 Forced
adduction test
in hanging
arm
 Duga’s test
1. Speed test
2. Yergason test
3. Bicep tendon
with
transverse
humeral
ligament test
1. Anterior
apprehension test
2. Posterior
apprehension test
3. Anterior posterior
drawer test
4. Inferior instability
test
5. Sulcus test

115. Impingement

116. TESTS FOR ROTATOR CUFF
AND IMPINGMENT
SYNDROME

117. IMPINGEMENT:
Primary impingment Secondary impingment
Occur because of degenerative
changes to the rotator cuff,the
acromian process,the coracoid
process and anterior tissues from
stress overload.
Occurs due to problem with
muscle dynamics with an upset
in the normal force couple action
leading to muscle imbalance and
abnormal movement patterns at
both the glenohumeral joint and
the scapulothoracic articulation.
Impingement is primary cause of
pain.
It is secondary to altered muscle
dynamics.
Occurs mostly in 40+ age group
people.
Occurs in young patients.(15-
35years old)
It is said to be intrinsic when
rotator cuff degeneration occurs
and extrinsic when the shape of
the acromian and degeneration of
the coracoacromial ligament
occurs.
Commonly seen with joint
instability.

118. NEER IMPINGMENT TEST:
PATIENT’S AFFECTED ARM IS PASSIVELY AND
FORCIBLY FULLY ELEVATED IN THE SCAPULAR
PLANE WITH THE ARM MEDIALLY ROTATED BY THE
EXAMINER.
•This passive stress
causes “jamming of
the greater tuberosity
against the
anteroinferior border
of the acromian.
•The patient’s face
shows pain reflecting
a +ve test.

119. HAWKIN’S KENNEDY IMPINGMENT
TEST:
PATIENT STANDS / SITS WHILE THE EXAMINER FORWARD
FLEXS THE ARM TO 90º AND FORCIBLY MEDIALLY ROTATES
THE SHOULDER.
•This movement
pushes the
supraspinatus
tendon against the
anterior surface of
the coracoacromial
ligament and
coracoid process.
•Pain indicates +ve
test.

120. THIS TEST MAY BE PERFORMED WITH THE PATIENT
STANDING OR SEATED.WITH THE ELBOW EXTENDED,
THE PATIENT’S ARM IS HELD AT 90° OF
ABDUCTION,30° OF HORIZONTAL FLEXION, AND IN
INTERNAL ROTATION (WITH THUMB FACING DOWN).
THE EXAMINER EXERTS PRESSURE ON THE UPPER
ARM DURING THE ABDUCTION AND HORIZONTAL
FLEXION MOTION.
•When this test elicits severe
pain and the patient is
unable to hold his or her arm
abducted 90° against gravity,
this is called a positive empty
can test/supraspinatus
tendinitis.
•The superior portions of the
rotator cuff (supraspinatus) are
particularly assessed in
internal rotation (with the
thumb down), and the
•anterior portions in external
rotation.

121. DROP ARM(CODMAN’S)TEST:
THE PATIENT IS SEATED, AND THE EXAMINER
PASSIVELY ABDUCTS THE PATIENT’S EXTENDED ARM
APPROXIMATELY 120°. THE PATIENT IS ASKED TO
HOLD THE ARM IN THIS POSITION WITHOUT SUPPORT
AND THEN SLOWLY ALLOW IT TO DROP.
Weakness in maintaining the
position of the arm, with or
without pain, or sudden dropping of
the arm suggests a rotator cuff
lesion. Most often this is due to a
defect in the supraspinatus.

122. APLEY’S SCRTCH TEST:
THE SEATED PATIENT IS ASKED TO TOUCH THE
CONTRALATERAL SUPERIOR MEDIAL CORNER OF THE
SCAPULA WITH THE INDEX FINGER.
Pain elicited in the rotator cuff and failure
to reach the scapula because of restricted
mobility in external rotation and abduction
indicate rotator cuff pathology (most
probably involving the supraspinatus).

123. YOCUM TEST
 LIFT PATIENT’S ELBOW TO SHOULDER
HEIGHT WITH ARM RESTING ON THE
NORMAL SHOULDER

124. HORNBLOWER’S SIGN (PATTE TEST)
 determines the strength of
the teres minor.
 The examiner elevates the
patient’s arm to 90 degrees
in the scapular plane. The
therapist then flexes the
elbow to 90 degrees, and the
patient is asked to laterally
rotate the shoulder. A
positive test occurs with
weakness and/or pain.

125. SUBSCAPULARIS TEST/LIFT OFF
TEST:
PATIENT IN STANDING POSITION PLACES THE
DORSUM OF THE HAND ON THE BACK. THE PATIENT
THEN LIFTS THE HAND AWAY FROM THE BACK. IF
PATIENT IS ABLE TO DO THEN LOAD PUSHING ON
HAND IS DONE BY THE EXAMINER TO CHECK THE
STRENGH.
•A patient with a subscapularis
tear will be unable to do
this.
•Abnormal motion in the scapula
during the test may indicate
scapular instability.

126. COMPARATIVE TESTING OF BOTH SIDES IS BEST.
THE PATIENT’S ARMS SHOULD HANG RELAXED WITH
THE ELBOWS FLEXED 90° BUT NOT QUITE TOUCHING
THE TRUNK. THE EXAMINER PLACES HIS OR HER
PALMS ON THE DORSUM OF EACH OF THE PATIENT’S
HANDS AND THEN ASKS THE PATIENT TO
EXTERNALLY ROTATE BOTH FOREARMS AGAINST
THE RESISTANCE OF THE EXAMINER’S HANDS.
Pain or weakness in external rotation
indicates a disorder of the
infraspinatus (external rotator).
.

127.  SPRING BACK TEST:Infraspinatus
Patient either in sitting or standing hold the
elbow in flexion at 90º by the side. Examiner
passively bring the shoulder to 90º abduction and
laterally rotate to the end range and ask the
patient to hold the arm to this position. For +ve
test of infraspinatus weakness/lesion patient
cannot hold the position and hand spring back
anteriorly.

128. TERES MAJOR TEST:
THE PATIENT IS STANDING AND RELAXED. THE
EXAMINER ASSESSES THE POSITION OF THE
PATIENT’S HANDS FROM BEHIND. THE TERES MAJOR
IS AN INTERNAL ROTATOR. WHERE A CONTRACTURE
IS PRESENT, THE PALM OF THE AFFECTED HAND
WILL FACE BACKWARD COMPARED WITH THE
CONTRALATERAL HAND.

129. LABRAL TEARS
 Clunk test
 Crank Test
 O Brien’s Test
 Compression-rotation test akin to Apley’s
grinding
 Biceps load test

130. CLUNK TEST
 Patient supine, examiner
puts hand on the posterior
aspect of the shoulder,
other hand hold the
humerus above the elbow
and abducts the arm over
the head. Then pushing
anteriorly with the hand
under the shoulder and
rotating the humerus
laterally with the other
hand, feel for a grind or
clunk which may indicate
a tear of the labrum.

131. O’BRIEN’S TEST
 Labral, AC, or biceps
pathology
 Arm flexed to 90°
 Arm cross-arm
adducted 10-15°
 Elbow extended
 Max pronation
 Resist downward force
 Positive test if painful
 Beware location of
pain
 AC
 Biceps

132. LABRAL TEAR: CRANK TEST
 Abduct arm to 90-120°
 Stabilize shoulder
 Elbow secured with
one hand
 Axially load with ER /
IR at shoulder
 Positive test: audible
or painful click / catch /
grind

133. ACROMIOCLAVICULAR JOINT
TESTS

134. PAINFUL ARC:
THE PATIENT’S ARM IS PASSIVELY AND ACTIVELY
ABDUCTED FROM THE REST POSITION ALONGSIDE
THE TRUNK. PAIN IN THE ACROMIOCLAVICULAR
JOINT OCCURS BETWEEN 140°AND 180° OF
ABDUCTION. IN AN IMPINGEMENT SYNDROME OR A
ROTATOR CUFF TEAR, BY COMPARISON, PAIN
SYMPTOMS WILL OCCUR BETWEEN 70°AND 120°.
In the evaluation of the active
and passive ranges of motion,
the patient can often avoid the
painful arc by externally
rotating the arm while
abducting it. This increases
the clearance between the
acromion and the diseased
tendinous portion of the
rotator cuff, avoiding
impingement in the range
between 70° and 120°.

135. THE NORMAL SIDE.
FORCED ADDUCTION TEST ON
HANGING ARM:
THE EXAMINER GRASPS THE UPPER ARM OF THE AFFECTED
SIDE
WITH ONE HAND WHILE THE OTHER HAND RESTS ON THE
CONTRALATERAL SHOULDER AND IMMOBILIZES THE
SHOULDER GIRDLE. THEN THE EXAMINER FORCIBLY
ADDUCTS THE HANGING AFFECTED ARM BEHIND THE
PATIENT’S BACK AGAINST THE PATIENT’S RESISTANCE.
Pain across the
anterior aspect of the
shoulder suggests
acromioclavicular joint
disease or subacromial
impingement.

136. DUGA’S TEST:
THE PATIENT IS SEATED OR STANDING AND
TOUCHES THE CONTRALATERAL SHOULDER
WITH THE HAND OF THE 90°-FLEXED ARM OF
THE AFFECTED SIDE THEN ATTEMPT TO LOWER
THE ELBOW TO THE CHEST IS MADE.
Acromioclavicular joint pain
suggests joint disease
(osteoarthritis,
instability, disk injury, or
infection).
A differential diagnosis
must exclude anterior
subacromial impingement

137. BICEP TENDON TEST
THE CLOSE ANATOMIC PROXIMITY OF
THE INTRAARTICULAR PORTION OF THE
TENDON TO THE CORACOACROMIAL
ARCH PREDISPOSES IT TO INVOLVEMENT
IN DEGENERATIVE PROCESSES IN THE
SUBACROMIAL SPACE. A ROTATOR CUFF
TEAR IS OFTEN ACCOMPANIED BY A
RUPTURE OR INJURIES OF THE BICEPS
TENDON.

138. SPEED TEST:
IN SITTING THE EXAMINER RESISTS SHOULDER
FORWARD FLEXION BY THE PATIENT WHILE THE
PATIENT’S FOREARM IS IN SUPINATION. PAIN IN
THE REGION OF THE BICIPITAL GROOVE
SUGGESTS A DISORDER OF THE LONG HEAD OF
THE BICEPS TENDON.

139. YERGASON TEST:
WITH THE PATIENT’S ELBOW FLEXED TO 90º AND
STABILIZED AGAINST THORAX AND WITH FOREARM
PRONATED, THE EXAMINER RESISTS SUPINATION
WHILE THE PATIENT ALSO LATERALLY ROTATES THE
ARM AGAINST RESISTANCE. DURING THIS
MOVEMENT WHEN THE TENDON IS FELT IN GROOVE
AS “POP OUT” .
•Pain in the bicipital groove is a sign
of a lesion of the biceps tendon, its
tendon sheath, or its ligamentous
connection via the
•transverse ligament.
•The typical provoked pain can be
increased by pressing on the tendon in
the bicipital groove.

140. BICEP TENDINITIS WITH
TRANSVERSE HUMERAL LIGAMENT
TEST:
THE PATIENT IS SEATED WITH THE ARM ABDUCTED
90°, INTERNALLY ROTATED, AND EXTENDED AT THE
ELBOW. FROM THIS POSITION, THE EXAMINER
EXTERNALLY ROTATES THE ARM WHILE PALPATING
THE BICIPITAL GROOVE TO VERIFY WHETHER THE
TENDON SNAPS.
•In the presence of
ligamentous insufficiency,
this motion will cause the
biceps tendon to
spontaneously displace out of
the bicipital groove.
•Pain reported without
displacement suggests biceps
•tendinitis.

141. INSTABILITY TESTS
SHOULDER PAIN MAY BE ATTRIBUTABLE
TO AN UNSTABLE SHOULDER. USUALLY
HISTORY OF A PERIOD OF INTENSIVE
SHOULDER USE (SUCH AS COMPETITIVE
SPORTS), AN EPISODE OF REPEATED
MINOR TRAUMA (OVERHEAD USE), OR
GENERALIZED LIGAMENT LAXITY. BOTH
YOUNG ATHLETES AND INACTIVE
PERSONS ARE AFFECTED, MEN AND
WOMEN ALIKE.

142. ANTERIOR APPREHENSION TEST:
PATIENT LIE SUPINE OR IN SITTING . ARM IS
ABDUCTED TO 90º WITH OTHER HAND ON THE
HUMERAL HEAD AND LATERALLY ROTATED
SLOWLY BY THE EXAMINER. WHILE
PERFORMING PATIENT’S EXPRESSIONS ARE
NOTED FOR APPREHENSION/FURTHER
RESISTENCE TO ROTATION. . WITH THE GUIDING
HAND, THE EXAMINER PRESSES THE HUMERAL
HEAD IN AN ANTERIOR AND INFERIOR
DIRECTION
Shoulder pain with reflexive
muscle tensing is a sign of an
anterior instability syndrome.
This muscle tension is an
attempt by the patient to prevent
imminent subluxation or
dislocation of the humeral
head.

143. SURPRISE TEST
 Similar to apprehension test
 But at max ext rotation the posterior force on the
humerus is removed and we look for
apprehension
 Most accurate single test for anterior instability

144. ROCKWOOD TEST
 It is important to know that at 45° of abduction,
the test primarily evaluates the medial
glenohumeral ligament and the subscapularis
tendon. At or above 90° of abduction, the
stabilizing effect of the subscapularis is
neutralized and the test primarily evaluates the
inferior glenohumeral ligament.

145. POSTERIOR APPREHENSION TEST:
PATIENT LIES SUPINE OR IN SITTING POSITION AND
EXAMINER ABDUCTS ARM IN SCAPULAR PLNE TO 90º
WHILE STABILIZING THE SCAPULA WITH OTHER
HAND. EXAMINER THEN APPLIES A POSTERIOR
FORCE ON THE ELBOW AND MOVES THE ARM IN
ADDUCTION AND MEDIALLY ROTATION.

146. ANTERIOR AND POSTERIOR DRAWER
TEST:
THE PATIENT IS SEATED. THE EXAMINER STANDS
BEHIND THE PATIENT. TO EVALUATE THE RIGHT
SHOULDER, THE EXAMINER GRASPS THE PATIENT’S
SHOULDER WITH THE LEFT HAND TO STABILIZE THE
CLAVICLE AND SUPERIOR MARGIN OF THE SCAPULA
WHILE USING THE RIGHT HAND TO MOVE THE
HUMERAL HEAD ANTERIORLY AND POSTERIORLY.

147. INFERIOR APPREHENSION
TEST/FEAGIN TEST:
PATIENT STANDS WITH THE ARM ABDUCTED TO 90º
AND ELBOW EXTENDED AND RESTING ON TOP OF
THE EXAMINER’S SHOULDER. EXAMINER CLASP
HIS/HER HANDS AROUND THE PATIENT’S HUMERUS
AND PUSHES THE HUMERUS DOWN AND FORWARD.
IN THIS SULCUS MAY ALSO BE SEEN ABOVE THE
CORACOID PROCESS.

148. SULCUS TEST:
PATIENT STANDS WITH ARM BY THE SIDE AND
SHOULDER MUSCLE RELAXED. THE EXAMINER
GRASPS THE PATIENT’S FOREARM BELOW THE
ELBOW AND PULLS THE ARM DISTALLY. THE
PRESENCE OF SULCUS/INDENTATION INFERIOR
TO ACROMIAN IS THE INDICATIVE.

149. THANK YOU