Shoulder
injuries and
assessment
Dr D Leibbrandt
2023
Anatomy
Biomechanics
• GHJ is a ball and socket joint
• The glenoid cavity is shallow (not like in the hip
which has a deeper socket)
• The shoulder stability therefore comes from other
structures not necessarily the shoulder itself
– Glenohumeral ligaments, glenoid labrum, capsule
(static components)
– Rotator cuff and stabilizing muscles (dynamic
components)
Stability
• Anterior and posterior bands of inferior
glenohumeral ligament attach to labrum to
provide static stabilization
• The anterior band of the inferior
glenohumeral ligament prevents anterior
translation and the posterior translation of
the humeral head
• Shoulder stability is also enhanced by the
glenoid labrum
Stability
Labrum
• Ring of fibrous tissue attached to rim of
glenoid
Dynamic stabilizers
• Rotator cuff muscles
Muscle
Origin on scapula
Attachment on
humerus
Function
Supraspinatus
muscle
supraspinous fossa
superior facet of the
greater tubercle
abducts the humerus
Infraspinatus muscle
infraspinous fossa
posterior facet of
the greater tubercle
externally rotates the
humerus
Teres minor muscle
middle half of lateral
border
inferior facet of
the greater tubercle
externally rotates the
humerus
lesser tubercle
internally rotates the
humerus
Subscapularis muscle subscapular fossa
Rotator cuff muscles
• Control position of the humeral head
• Adequate scapulohumeral rhythm is
necessary for full upper limb elevation, it
enhances joint stability at greater than 90˚
• Abnormal scapulohumeral rhythm may
predispose one to injury – normally due to
weakness of the scapular stabilizers
Scapula stabilizers
• Trapezius (upward rotation of the scapula)
• Serratus anterior (protraction of the scapula)
• Rhomboids maj and min (elevate, retract and
downwardly rotate the scapula)
Scapulohumeral rhythm
https://www.youtube.com/watch?v=uOTO6YtfFUA
Physical examination
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Observation
Posture
Functional demonstration
Active physiological movements
Passive physiological movements
Muscle tests
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Length
Strength
Control
Physical examination
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Neurological tests
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Palpation
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Neurodynamic tests
Conduction test
Muscles
General
Passive accessory movements
Joint integrity tests
Active physiological movements
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Flexion/ extension
Abd/ Add
IR/ER
Functional tests:
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HBB
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HBH
Muscle testing
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Isometric testing - test rotator cuff |
stabilizers
https://youtu.be/zW8SE6WOxD0
• Test supraspinatus by resisting the initiation of shoulder
abduction (place a hand on the lateral aspect of the lower
humerus). Alternatively, test supraspinatus by placing the
straight arm into 90° of elevation in the scapular plane and
45° of lateral rotation then isometrically resist further
elevation in the scapular plane.
Muscle testing
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Isometric testing - test rotator cuff |
stabilizers
• Test subscapularis by resisting shoulder medial rotation
(elbow at 90° and into the side; place a hand against the
inner aspect of the forearm). Alternatively, test subscapularis
by placing the arm into the hand behind-back position with
the wrist over L5 then isometrically resist medial rotation.
Muscle testing
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Isometric testing - test rotator cuff |
stabilizers
• Test infraspinatus and teres minor by resisting shoulder
lateral rotation (start as above and place a hand against the
outside of the forearm). Alternatively, place the arm into 45°
of medial rotation by taking the arm across the body then
isometrically resist lateral rotation.
Isometric testing
Impingement
• More a clinical sign rather than a diagnosis
• Suggestion that rotator cuff tendons are
impinged as they pass through the
subacromial space (formed between the
acromion, coracoacromial arch, AC joint)
Impingement
• External vs Internal
• External/subacromial
– Is the mechanical encroachment of the soft tissue
(bursa, rotator cuff tendons) in the subacromial space
between the humeral head and the acromial arch.
This encroachment particularly takes place in the
midrange of motion, often causing a ‘‘painful arc’’
during active abduction.
• Internal
– Internal impingement comprises encroachment of the
rotator cuff tendons between the humeral head and
the glenoid rim.
Internal impingement
• Occurs mainly in overhead athletes
• Impingement of rotator cuff against posteriorsuperior surface of the glenoid
External impingement
• In primary impingement, a structural narrowing
of the subacromial space causes pain and
dysfunction, such as acromioclavicular
arthropathy, type I acromion, or swelling of the
soft tissue in the subacromial space.
• In secondary impingement, there are no
structural obstructions causing the encroachment,
but rather functional problems, occurring only in
specific positions. Secondary impingement may
occur in the subacromial space as well as
internally in the glenohumeral joint.
Testing for impingement
• Hawkins-Kennedy test
• Neer’s Test
• Jobe’s empty can (RC impingement)
Hawkins-Kennedy
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Description of test
– Patients shoulder (&
elbow) flexed to 90˚
– Shoulder then passively
moved into internal
rotation by physio
Interpretation
– Positive for pain in
subacromial area
– -ve for internal
impingement
Sensitivity 88.7%
Neer’s test
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Description
– Patient seated
– Physio stabilize scapula
(to prevent scapula
rotation)
– Physio then moves the
shoulder into maximal
forward flexion
Interpretation
– Subacromial
impingement if test
positive for pain in
anterior shoulder
– Internal impingement
if test positive for pain
in posterior shoulder
Jobe’s/Empty can test
• Description
– Patient in standing both shoulders elevated to 90˚
in scapular plane
– Physio maximally internally rotates shoulders then
places downward pressure over lower arm and
resists further elevation
• Interpretation
– Positive for pain in subacromial impingement
– Negative in patients with internal impingement
Rotator cuff injuries
• Tendinopathy
• Strains/tears
• Assessment
– Palpation
– Active movement
– Isometric testing
– Gerbers lift off
Full can test
• Description
– Patient in standing. Both shoulders elevated to
90˚ in the scapula plane. Shoulders are maximally
externally rotated. Then places downward
pressure over lower arm and resists further
elevation.
• Interpretation
– Very active rotator cuff in this test. Pain, indicates
rotator cuff pathology. But if –ve, with a positive
empty can – possibly impingement
Empty can and full can tests
Instability
• Identify any joint instability
• Laxity may imply the ability to sublux or
dislocate
Anterior drawers test
• Description
– Patient supine
– Shoulder abducted to 80-120˚, 20˚ horizontal
flexion, 30˚ lateral rotation. Physio must stabilize
the scapula with one hand and glide the humeral
head anterior
• Interpretation
– Excessive ROM, patient anxious or click +ve for
anterior instability
– https://youtu.be/G8s_7Q5zfTM
Posterior instability
• Jerk test
• Description
– Patient supine or sitting. Shoulder is abducted to
90˚ and medially rotated. Physio applies a
longitudinal cephalad force to elbow while
humerus moved in horizontal flexion
• Interpretation
– Positive test indicated by click or jerk when the
arm moves into and out of horizontal flexion
– https://youtu.be/mn7f6KVvScE
Inferior instability
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Sulcus sign
Description
– The patient sits or stands. The
physio applies a longitudinal
force to the patients humerus.
Interpretation
Positive for inferior instability if
there is sulcus or indentation (of
about 5mm) below the acromion
Biceps tendinopathy
• Occurs in athletes who perform weight
training
• Overuse injury
• Examination
– Tender on palpation
– Speeds test
Speeds test
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Description
– The patient’s arm
elevated to 90˚ in forward
flexion, the elbow
extended, forearm
supinated. Physio applies
resistance distal to the
elbow in the direction of
arm extension.
Interpretation
– Positive when there is
localized pain over biciptal
groove
Biceps load test II
• Description
– The patient is supine with the shoulder at 120˚ of
the abduction and the elbow at 90˚ flexion. Physio
applies resistance to elbow flexion.
• Interpretation
– Positive if the patients complains of pain when
resistance is applied.
– https://www.youtube.com/watch?v=h2IyvaCEYpk
Glenoid labrum injuries
• Injuries to the glenoid labrum are divided into
superior labrum anterior to posterior (SLAP)
or non-SLAP
SLAP
Non-SLAP
Injuries to the labrum that extend from
anterior to the biceps tendon to
posterior to the tendon
Degenerative flap, vertical labral tears
and Bankart lesions |(injury to anterior
labrum following anterior dislocation)
Glenoid labrum injuries
• Common in repetitive overhead injuries
• Pain often poorly localized but exacerbated by
overhead activities
• Popping or catching may be present
O’Brien’s test
• Description
– Arm flexed to 90˚ forward flexion and 10˚ adduction.
Arm is internally rotated and pronated with thumb
pointing down. A downward force is applied by the
physio. Test is then repeated with thumbs up.
• Interpretation
– Positive if pain located at joint line and was elicited in
the internally rotated position and reduced or
eliminated in the externally rotated position
– https://youtu.be/v_EL9XqTJQQ
Active physiological movements
GHJ
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• Shoulder flexion |extension
• Shoulder abduction
• Hand behind back | Hand behind head
• Horizontal adduction/ flexion
• The acromioclavicular joint can be 'squeezed' or the
acromiohumeral joint compressed during the painful
movement as with flexion and abduction. If pain is localized to
the posterior area of the gleno-humeral joint and the head of
humerus seems to sub-lux posteriorly during the movement, a
posterior capsular instability may be suspected and
investigated further.
Active physiological movements |
GHJ
• Lateral rotation
• If this movement is accompanied by
apprehension and the appearance of the head of
the humerus subluxing anteriorly, an anterior
capsular instability should be suspected and
investigated further.
• Medial rotation
Active physiological movements
(with O/P) | GHJ
GHJ Accessory movements
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https://youtu.be/hKjQw-blrZ4
Maitland PAMs of the shoulder
(practical)
Glenohumeral joint:
PA: arm by side, abduction, prone
AP: arm by side, abduction
Longitudinal movement caudad
Lateral transverse: arm by side, 90°flexion.
GHJ | Posteroanterior movement
Uses:
Mobilizing or stretching of the anterior and
posterior parts of the glenohumeral
capsule.
GHJ PA- Abduction, Arm by side,
prone
GHJ | Anteroposterior movement
Uses:
• Not as useful as the longitudinal movement or
posteroanterior movement in treating very painful
shoulders.
• Grades III and IV are more useful when the joint is
stiff.
• Stretching the posterior glenohumeral capsule, or
relocating an anteriorly subluxed humeral head.
• A means of encouraging proprioceptive recovery
in unstable shoulders.
• A means of mobilizing the interface surrounding
local nerve tissue.
GHJ AP-arm by side, Abduction
GHJ | Longitudinal and Lateral
movement
Uses
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Pain and stiffness in conjunction with other
techniques.
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Capsular tightness.
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Joint surface pain (as a through-range grade I, II
or III-).
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To increase the range of flexion and abduction at
the limit of range
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To help regain shoulder abduction after fracture
of the neck of the humerus.
GHJ Longitudinal- arm by side
GHJ Longitudinal- Abd, Full flex
GHJ lateral movement- arm by
side, flexion
Maitland PAMs of the shoulder
(practical)
AC joint:
AP
PA
Longitudinal movement caudad
ACJ | Anteroposterior movement
Uses
- Acromioclavicular pain after injury,
subluxation or fracture of the clavicle.
- Stiffness and pain especially with horizontal
adduction and hand-behind-back movements.
ACJ | Posteroanterior movement
Uses
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Acromioclavicular pain.
To improve the range of movement of
horizontal adduction (flexion) or extension.
Stiffness at the end of range of shoulder
movements.
ACJ | Longitudinal movement
caudad
Uses
-Painful acromioclavicular joint
-Painful arc of flexion.
-Stiffness at the limit of flexion, abduction and
horizontal adduction.
ACJ- AP, PA, longitudinal