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Joints of shoulder girdle
Sternoclavicular joint – a synovial joint with articular
disc surrounded by joint capsule held together by:
 Sternoclavicular ligaments
 Interclavicular ligaments
 Costoclavicular ligaments
Acromioclavicular ligament – a synovial joint with
wedge shaped articular disc surrounded by a fibrous
joint capsule stabilised by the coroclavicular ligament
composed of the conoid & trapezoid ligament
Glenohumeral joint – ball and socket joint. The
glenoid cavity is lined by labrum cartilage and helps
humerus fit into the cavity securely.
3 ligaments help stabilise the joint:
 Coracohumeral ligament
 Transverse humeral ligament
 Coracoacromial ligament
Additional support is provided by rotator cuff muscles and two bursa form cushions between the tendons
and bones of the glenohumeral joint.
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Subacromial bursa / subdeltoid bursa – found between acromion & coracoacromial ligament ,
deltoid and supraspinatus muscle
Subscapular bursa – found between scapula & tendon of subscapularis muscle.
Arterial supply
Summary: Arterial blood flow is provided by branches of subclavian artery and axillary artery that runs from the
axilla and continues down the arm as the brachial artery
The arterial supply begins in chest as Subclavian artery.
The Left Subclavian arises from aortic arch.
The Right Subclavian branch arises from the Brachiocephalic
trunk.
When the subclavian arteries cross the lateral edge of the 1st
b/t scalenes, they enter the axilla and called axillary arteries.
This area is vulnerable to TOS.
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In the Axilla
The axillary artery passes through the axilla just
underneath the pectoralis minor mm enclosed in axillary
sheath.
At the level of humeral surgical neck, the posterior &
anterior circumflex humeral artery arise. They circle
posteriorly around the humerus to supply the shoulder
region. The largest branch of humerus also arise here; the
subscapular artery.The axillary artery becomes the
brachial artery at the level of the teres major muscle.
Clinical relevance: ANEURYSM of
Axillary Artery
In patients with High Blood Pressure, or
Marfans Syndrome, the proximal portion of
the axillary artery may dilate – called an
aneurysm
The dilated portion of the artery could put pressure on the brachial plexus. This would manifest clinically as pain,
loss of sensation in the cutaneous distribution of the affected nerve.
Aneurysm of axillary artery is also seen in baseball pitchers – thought to be due to the speed and force of their arm
movement.
In the upper Arm
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When the axillary artery reaches the lower border of teres major, it becomes the brachial artery – main source
of blood for arm.
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Distal to teres major, the brachial artery gives rise the profunda brachii (deep artery). It travels along the
posterior surface of humerus running in the radial groove. Its supplies structures in the posterior aspect of the
arm (triceps brachii and terminates by contributing to a network of vessels at the elbow joint.)
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The brachial artery descends down the arm immediately posterior to the median nerve. As it crosses the cubital
fossa, underneath the brachialis muscle, the brachial artery terminates by bifurcating into the radial and ulnar
nerves.
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The arm has a good anastomosis supply which protects it from temporary or partial occlusion of the brachial
artery, however if the artery is completely blocked or severed, it is a medical emergency.
The resulting ischaemia of the forearm can
cause necrosis and paralysis of muscles in
forearm = scar tissue, and shortened =
flexion deformity, caused VOLKMANS
contracture.
Contents of the Cubital Fossa to remember
the contents of the cubital fossa, you can use
the mnemonic Really Need Beer To Be At My
Nicest.
Borders
 The floor is formed by brachialis and supinator
muscle
 The roof consists of skin and fascia reinforced by
bicipital aponeurosis
 Within the roof runs the median cubital vein
Contents:
Radial Nerve it passes underneath brachioradialis
muscle and divides into deep and superficial branches
Biceps tendon runs through cubital fossa attaching to
radial tuberosity just distal to the neck of radius
Brachial artery supplies oxygenated blood to forearm
and bifurcates into radial and ulnar arteries at apex of cubital fossa
Median nerve leaves cubital fossa b/t to heads of prontator teres – it supplies majority of the flexor mm in forearm
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In the Forearm
In distal region of cubital fossa, the brachial artery bifurcates into the radial and ulnar artery. The radial artery
supplies the posterior aspect of forearm, the ulnar artery supplies the anterior aspect. The two arteries anastomose
in the hand, by forming two arches – the superficial palmar arch and deep palmar arch.
In the Hand
The hand has a very good supply with many anastomosing arteries, allowing the hand to be perfused when grasping
or applying pressure.
Radial Artery contributes mainly to supply the thumb and lateral side of index finger – this artery enters the hand
dorsally, crossing the floor of the anatomical snuffbox. It turns medially and moves between the heads of adductor
pollicus. It then anastomoses with deep palmer branch of ulnar artery forming deep palmer arch.
Ulnar artery contributes mainly to supply rest of digit and medial side of index finger
Main Movements & muscle action
Flexion 180 =
Ant deltoid, Biceps Brachii, Corocobrachialis, Pec Major
Extension 60 = Post deltoid, Lats Dorsi, Triceps, Teres Major
INT Rot 90 =
Subscapularis, Pec Major, Lat Dorsi
EXT rot 80 =
Infraspinatus, Teres Minor
Abduction 180 = Mid Deltoid, Supraspinatus
Adduction 35 = Lats dorsi, Teres Major, Pec Major,
Rotator cuff
Supraspinatus – abducts arm (up to 80’)
Infraspinatus – external rotation
Teres Minor – external rotation
Subscapularis - internal rotation
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Common shoulder disorders
Rotator cuff disorders
Rotator cuff tendinopathy (Most common cause
of shoulder pain)
Hx of occupational or sporting activities and pain
with overhead movements.
Inspection may reveal: muscle wasting. Pain
reproduced on abduction with thumb down and
worst against resistance
The presence of a painful arc reinforces the
diagnosis of a rotator cuff disorder.
Common Diagnosis for Rotator cuff disorders: - Tendinopathy, partial tears, complete
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often associated with repetitive overhead activities tears
Partial tears most common at older than 40yoa
Complete tears most common at older than 60yoa
Pain localised to the deltoid region
Pain worse with overhead activities
Pain & or weakness of the rotator cuff muscles on manual testing
Positive impingement tests
Supraspinatus test
Jobes test / Empty can test – arm abducted, internally rotated and
in plane of scapula – 20-30 degrees forward from side, thumb down,
resist further active abduction.
Note that Deltoid is responsible for abduction beyond 70’
If partial tear of Supraspinatus, pt experiences pain & some
weakness
Complete disruption of muscle prevents patient from achieving any
abduction.
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Infraspinatus & Teres Minor Test
External Lag sign – elbow at side flexed at 90 degrees, resist
external rotation.
Tears in tendon = weakness and or pain
Subscapularis
Lift off test - Apleys scratch test with INT ROT and EXT and push
the arm away from the body
If tendon partially torn, movement limited or causes pain.
Complete tears prevent any movement in this direction
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Impingement – Rotator cuff Tendonitis & Sub acromial Bursitis
Hawkins-Kennedy
Hawkins-Kennedy Test - Hold patients arm 90 degrees forward flexed and
internally rotated so forearm horizontal. Hold patient’s elbow with one hand
and the patient’s wrist with your other. Now quickly internally rotate the arm
further. Positive if pain in sub acromial region.
4 tendons or RC pass underneath acromion / coracoacromion ligament – insert
on humerus.
The space between these tendons become narrowed, causes tendon
(supraspinatus in particular) to become “impinged” – results in friction and inflammation of tendon and sub
acromial bursa.
Net results: Shoulder pain raising arm overhead (reaching up on top shelf, arm positioning during sleep etc)
Neers for impingement
Neer Impingement Sign - Maximally internally rotate arm at patient’s side, now maximally abduct the arm.
Pain in sub acromial region with arm fully abducted = positive, 88% sensitive, 30% specific.
The Impingement test is performed by placing the shoulder out at
90 degrees with the arm hanging down, press back on the arm and
check for any pain
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Biceps Tendinopathy
Long head of biceps tendon runs in bicipital groove of
humerus inserting @ top of glenoid.
Palpate biceps tendon bicipital groove. Pain – tendonitis
Confirm your on tendon – patient supinates while you
palpate.
Speeds Test
Speed test – elbow extended and forearm supinated, resist forward flexion at 60
degrees, pain biceps groove / anterior shoulder. (very sensitive but highly nonspecific)
Yergasons test
Yergasons test – elbow flexed and forearm pronated, resist against
supination (moderate sensitivity and specificity)
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Glenohumeral Joint Instability
Anterior Apprehension test – lie patient on couch inclined 30
degrees, hold patient’s arm and bring it up into abduction and
external rotation slowly – if pt becomes apprehensive that
shoulder will dislocate anteriorly then this is a positive test
for anterior instability.
With the arm held in this position use your other hand push on
anterior region of shoulder to ‘relocate’ it and ask if by applying
this pressure the patient feels better – if so then this is a positive
Jobe’s Relocation Test.
Acromio-Clavicular Joint Arthritis
Cross Arm test / Scarf test – forward flex to 90 degrees
then adduct patient’s arm as much as possible towards
the contralateral shoulder. Test positive if pain
experienced and well localised to the ACJ (not deltoid
region or posterior shoulder).
SLAP (Superior Labrum Antero Posterior lesion)
O’Briens Test - Patient forward flexes 90 degrees and
adducted 15 degrees with elbow fully extended.
Patient resists you pushing arm down. Positive = pain
felt in joint. NB pt may get pain at ACJ if concurrent
ACJ pathology (poor sensitivity and specificity)
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Complete Rotator Cuff Tears may occur from years of repetitive rubbing of bone spurs against the rotator cuff,
repetitive heavy lifting or from a sudden injury. When this occurs the rotator cuff “pulls” away from the humerus
bone. This causes pain and weakness. Surgery is usually required to repair the tears. Dr. Goradia performs almost all
rotator cuff repairs arthroscopically with a small camera instead of making a large cut on the shoulder.
Dislocations & Instability occurs when the ball (humeral head) slips out of the socket (glenoid). This can happen as a
result of sudden injury or from overuse of the shoulder ligaments. In general young, active patients after a first time
sudden dislocation have up to a 75- 90% chance that their shoulder will dislocate again. For this reason, there has
been a trend towards arthroscopic repair after a 1st time dislocation in patients under 25 years of age. Older or less
active individuals usually do very well with rest and an exercise program. Surgery may be needed for those that
continue to have problems. Many surgeons repair the torn ligaments by making large incisions on the shoulder. As
instruments have improved, most patients can be successfully treated by arthroscopic surgical repair on an
outpatient basis as Dr Goradia performs regularly.
Labral Tears can occur when falling on the arm/shoulder, having the arm suddenly pulled, a lifting injury or
repetitive overhead activity with the arm. The labrum is the cartilage “lip” that lines the shoulder socket or glenoid.
This lip helps to deepen the socket so the shoulder ball will stay in the socket better. When this labrum tears away
from the socket bone, patients experience pain, aching, clicking and/or locking. This condition is best treated with
arthroscopic surgery. You may hear or read about a SLAP Tear. This is a specific type of Labral Tear that occurs on
the top part of the socket.
Biceps tendon tears often result in a “Popeye” muscle appearance of the arm. The biceps muscle in the arm has a
tendon that attaches to the glenoid or socket within the shoulder. If the tendon tears loose the muscle sometimes
“falls” down into the arm. Although this looks strange, most patients do not have pain or significant weakness and
therefore do not need to have surgery. Partial tears however may be painful and often need surgery.
Shoulder Separations are common injuries that are often confused with shoulder dislocations. A
separation occurs when the ligaments between the acromion and the clavicle (acromioclavicular AC’ joint)
are injured. Most of these injuries are treated with a sling. Only severe separations require surgical repair.
A Frozen Shoulder can occur when an injury causes pain and the patient stops using the arm. Within a
short period of a few weeks the shoulder can become very stiff and painful with scar tissue. In a small
number of patients a frozen shoulder can occur for no reason at all without any injury. Patients with
diabetes and thyroid problems are more likely to develop a frozen shoulder. In most cases patients can be
treated with a cortisone shot and stretching exercises with a physical therapist. If the shoulder continues to
stay frozen some patients will need a manipulation of the shoulder or arthroscopic removal of scar tissue.
Osteoarthritis can cause destruction of the shoulder (glenohumeral joint) and surrounding tissue, as well
as tearing of the rotator cuff. For patients who do not respond to an exercise program, medications and or
cortison injections, shoulder replacement surgery may be necessary
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Differentials
VINDICATOR
Vascular
PMR & GCA
Polymyalgia Rheumatica is an inflammatory condition that causes severe inflammatory condition
that causes severe pain and stiffness.
Who? = F > M 3:1 Mostly 50+
Main ∑ is
 Bilateral Limb girdle pain and stiffness in AM, pain can shoot into neck. Pain chewing
 Constant pain, worse in AM
 Malaise, Fever, Night sweats, Anaemia, Low grade synovitis
Related condition with GCA (giant cell arteritis / temporal H/A – affecting pt’s sight.
PAN
Diagnosis: Blood tests
 ESR (erythrocyte sedimentation rate)
 CRP (C-Reactive protein)
 Tests for Rheumatoid Arthritis
 X-ray or ultrasound scan of shoulders and hips
 Anaemia is common in PMR
 If GCA suspected, a biopsy of a small piece of artery may be taken from scalp.
TTT: Corticosteriods which is diagnostic.
Vasculitis of small/medium sized arteries leading to necrosis. Unknown cause, AI reaction?
Myositis: Calf muscle pain and stiffness, reduced weight, non erosive migratory arthritis, Aching
limb girdles
Palmar erythema, asthma, Iritis,
Who: Males>Females 4:1,
Can cause angina, peri/myocarditis, renal failure, abdominal pain, hypertension, mononeuritis
multiplex, psychosis, deafness, small jt Synovitis.
Ttt: steroids and immunosuppressive
Infection
Osteomyelitis
Tumour
Autoimmune
RA
Bacterial infection necrosing bone
Lung or breast
Visceral shoulder pain
- Angina = left shoulder tip pain
- Gall bladder disease / liver = right shoulder pain
- Subphrenic abscess = can present as severe rapid onset shoulder tip pain +/unwell or abdominal symptoms.www.leeds
Aetiology: unknown, Genetic predisposition
RH +ve, Increased ESR, WBC, CRP, RhF autoantibody in 70%. 30-40 YOA peak onset.
Females: Males 3:1, viral or bacterial trigger?
Onset: insidious joint pain worse in AM, Worse at night, Fever, Malaise, Warm swollen joints,
Swelling, Shoulder in 60% of cases. Systemic polyarthritis, morning stiffness, Nodules,
Pathology: Synovitis. synovial membrane inflammation and proliferation, pannus, effusion
distends the capsule stretching lig, laxity, Nodules develop.
Affects: Ankle 85%, Knee 80%, Hands 80%, Shoulder 60%, Elbow 50%, C.sp 40%, TMJ 30%
TTT: Education, Oily fish, Exx, DMARD’S methotrexate, Gold, Chemo, Gene therapy. NSAIDS... Cox
2 inhibitors (save the lining of the stomach) seems to be pretty rare
Complications: infections
Progression: Relapse/Remit, Progressive
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Degenerative
O/A
Immune
PMR
Congenital
Sprengel
shoulder
Kipperfeil
JHS
Erbs
Kumpske
Arnold Chiari
malformation
syringomyelia
Traumatic
Rotator cuff
strain
Progressive degeneration, loss of articular cartilage & joint margin space
Affects w/b joints – most commonly affects lumbar spine, knees, hips, feet – can get GH OA
As above
Failure of decent of one or both arm buds resulting on one or both shoulders anatomically higher
than expected.
X-ray diagnosis
Anatomically shortened neck, failure of embryonic segmentation of the c.sp resulting in fused or
block vertebrae. Fusion c2-3 most common.
May be other abnormalities, e.g. webbed platysma, spina bifida, cardiac and kidney anomalies.
Shortened neck, low hairline, Reduction in c.sp ROM.
Hypermobile, Marfans, Ehlos danlers,BJHS, Pregnancy
Otherwise: Females >Males
Previous/ Family hxx of dislocations
Check the hypermobility Beighton score 4 or more: Maximum of 9 points for Touch toes, Hyper
extend knees, Elbows, Little fingers, Thumbs
Injury to a baby as its arm is pulled when the head is still stretching the brachial plexus.
Upper brachial plexus injury
Waiters tip position
Txx injury catching a branch as you fall from a tree or pulling child from birth canal with arm
abducted
Burning pain across shoulders in a cape like distribution
Onset: trauma to rotator cuff mm or tendon, repetitive overuse, FOOSH
Risks: contact sport, throwing, poor nutrition, Hxx of shoulder injury, CVS bleed or connective
tissue disorder, Age, cervical, thoracic or lumbar dysfunction, congenital anomaly, muscle
imbalance
Hxx; immediate pain with injury, popping/tearing sensation, oedema, erythema,  with
movement, loss of strength
Dxx: labral tear, sprain, dislocation, biceps strain/tendinopathy, impingment, axillary /
suprascapular neuropathy.