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Shoulder Exam
Unit 4 - Lecture 4 - Shoulder Exam - Dr. Berg - SUNY Upstate - Fall 2011
108
Anatomy
Graduate
11/17/2011

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Term
Quick note: The Shoulder exam cards start from pg 187 with Glenohumeral joint from Dr. Berg's notes. These cards may also be helpful for the POM MS exam, therefore I am putting in info that may not be tested thru the anatomy practical.
Definition
Left Blank intentionally
Term
The interface of the round head of the humerus and the flat glenoid fossa is formally called the...
Definition
Glenohumeral joint
Term
What kind of joint is the GH joint?
Definition
Synovial joint --> Ball and Socket
Term
The glenoid fossa is surrounded by...
Definition
the glenoid LABRUM (fibrocartilagenous)
Term
why is the Glenoid labrum important?
Definition
1) It deepens the connection b/w the glenoid fossa and the head of the humerus 2) provides stability to GH joint when shoulder moves
Term
Name the 4 ligaments associated with the GH joint
Definition
1) Coracoacromial
2) Coracohumeral
3) Transverse humeral
4) Glenohumeral
Term
Which ligament of the GH joint prevents UPWARD displacement of the shoulder joint? Why does this make sense?
Definition
The coracoacromial ligament. Why? because it reinforces the SUPERIOR aspect of shoulder joint, thus helping to prevent upward dislocation
Term
Which ligament helps resist excessive ABDUCTION? Why does that make sense?
Definition
Coracohumeral. Why --> it's a ligament that attaches the scapula (anterior) to the humerus (which participates in ABDUCTION).
Term
Which ligament hold the long head of the biceps in the bicipital groove? Why does that make sense?
Definition
Transverse humeral ligament.
Why --> the bicipital groove is only in the HUMERUS and the THL is in the humerus. The long head of the biceps is in that groove.
Term
What ligaments support the ANTERIOR capsule of GH joint?
Definition
The glenohumeral ligaments (superior, middle, and inferior).
Term
What muscles stabilizes the CAPSULE of the shoulder joint? Describe where.
Definition
By rotator cuff muscles (SITS)
Anterior capsule --> Subscapularis
Posterior capsule --> Infraspinatus and Teres Minor
Superiorly --> Supraspinatus
Term
What is a bursa?
Definition
Fluid filled sac that provides cushion between bones and tendons and/or muscles around a joint. This helps to reduce friction between the bones and allows free movement.
Can be infected --> bursitis
Term
What provides the GH joint ACTIVE stability?
Definition
SITS (the MUSCLES!)
Term
Which of the SITS muscles keeps the head of the humerus in contact with the glenoid fossa? What is this process called?
Definition

The Subscapularis, Teres Minor and Infraspinatus m.m. actively ADDUCT the shoulder.

 

When the head of the humerus and the glenoid fossa are close --> ADDUCTION

 

Recall: Supraspinatus ABDUCTS (first ~15 deg)

Term
Which of the 4 muscles (SITS) helps depress the head of the humerus?
Definition
The Supraspinatus muscle
Term
How can a shoulder dislocation occur? Give simple answer
Definition
Tearing of the SITS muscles.
Term
What are the 5 Components of the Shoulder Exam? Think POM
Definition
History
Inspection/Observation
Palpation
Range of Motion
Special Tests

Notice there's no Percussion and Auscultation!
Term
Describe a History
Definition
OLDCARTS (include MECHANISM of INJURY --> Trauma, Overuse, Metabolic, Idiopathic (unknown, spontaneous).
Term
What is ONE major thing you would look for when Inspecting the patient's limbs
Definition
ASYMMETRY
Term
What are the possible reasons for ASYMMETRY?
Definition
1) One shoulder drops => loss of passive stability => weak trapezius => Cr. XI damage?
2)Bone protruding => Shoulder separation (overriding clavicle over acromion) +/or visible acromion => deltoid m. damage
3) Step deformity => shoulder subluxation (~dislocation)
4) Bruising, redness => bursitis (infection)
Term
What is the next step after Inspection?
Definition
Palpation
Term
What is important to know for palpation?
Definition
Chart 1 - Palpable bony prominences and the structures that attach to it!
See pg 193
Term
Why would Palpation help the clinician?
Definition
Gives clues about:
1) fractures
2) bursitis
3) muscle strain
4) ligament sprain
Term
Where would you palpate to get a clue for the pathology of the long head of the biceps?
Definition
Bicipital groove (place thumb under anterior part of acromion)
Term
If there is pain upon palpation of the AC joint, what may the patient have?
Definition
Arthritis
Term
If ligaments of the AC joint are torn, this may lead to...
Definition
shoulder separation, possibly the clavicle can override the acromion.
Term
What other test may indicate an AC joint shoulder separation?
Definition
The Cross Body maneuver
Term
What is the Cross Body Maneuver?
Definition
Injured arm is brought across the body anteriorly to touch opposite shoulder. If there's pain in the AC joint region, then test is +
Term
What do you palpate for on the Coracoid process?
Definition
1) Pectoralis minor m.
2) Short head of Biceps brachii m.
3) Coracobrachialis m.
Term
What do you palpate for on the Lesser Tubercle?
Definition
Subscapularis muscle
Term
What do you palpate for on the Greater Tubercle?
Definition
SIT (Supra-infra-spinatus m.m., Teres minor)
Note: NOT THE Subscapularis m., that's the Lesser Tubercle!
Term
There are 3 spaces that are associated with the Intertubercular (Bicipital) groove. What are they?
Definition
Lateral lip, Medial lip, and the Floor of the bicipital groove
Term
What do you palpate for on the bicipital groove?
Definition
Tendon of the Long head of the bicep
Term
What do you palpate for on the Lateral lip of the bicipital groove?
Definition
Pectoralis Major
Term
What do you palpate for on the Medial Lip?
Definition
Teres Major
Term
What do you palpate for on the Floor of the bicipital groove?
Definition
Latissimus Dorsi
Term
What do you palpate for superior and inferior borders of the scapular spine?
Definition
supraspinatus and infraspinatus, respectively
Term
What muscles are not involved in the bicipital groove palpation?
Definition
The rotator cuff muscles!
SITS, recall they attach to the tubercles!
Term
What comes after Palpation?
Definition
Testing Range of Motion (ROM) - can patient make motions about the shoulder joint? Full/partial motion? etc
Term
What is the first step of ROM?
Definition
Test for ACTIVE rom first!
Make sure to always compare each side!
Term
1) Define Active rom
2) What does a decrease in Active rom mean?
Definition
1) Use of OWN energy w/o assistance involving CONTRACTILE elements
2)Muscles and nerves are malfunctional
Term
What ROM do you assess after Active rom?
Definition
Passive rom
Term
What is Passive rom?
Definition
Movement that occurs w/o muscle action (examiner moves a joint).
Term
What elements are assessed in Passive rom?
Definition
NON-CONTRACTILE elements!
Term
What are Non-Contractile elements?
Definition
Capsule, Ligaments, Cartilage
(things that don't contract)
Notice that Muscle is not a non-contractile element!
Term
Full STRENGTH can only be assessed with which ROM?
Definition
Resisted ROM
Term
How is resisted motion performed?
Definition
Patient uses muscles to produce movement against resistance provided by examiner
Term
See page 190 of Dr. Berg's Notes for examples of Resisted and Passive ROM's
Part (B) will be discussed though
Definition
Left intentionally blank
Term
Compressions to what nerve root(s)/trunk(s) often results in shoulder and neck pain?
Definition
C5 and C6 roots and/or upper trunk of brachial plexus.
Term
How do we "clear the neck"? (eliminate the neck as the source of a problem)
Definition
Move neck (stand upright) in 4 ways: 1) Flexion (head forward) 2) Extension (head back) 3) Rotation (tilt head to look right and left) 4) Lateral flexion (side bending to each side)
Term
What is the false joint of the shoulder girdle?
Definition
The Scapulothoracic joint
Term
What are the PRIME MOVERS of the ST joint?
Definition

STLRLP --> Serratus Anterior, Trapezius, Levator Scapula, Rhomboids, Latissimus Dorsi, Pectoralis Minor

 

---------------------------------------------------------------------

NOT PEC MAJOR b/c that attaches to the lateral groove of the bicipital groove of the HUMERUS

Term
STLRP = Prime mover muscles of the ST joint. What's the mnemonic?
Definition
Someone Tried Licking Rolaids Like Penis
Term
For the upcoming Prime Mover muscles, name the type of (1) Movement, (2) nerve supply, and (3) Deficit (observation)
Definition
Left intentionally blank.
Term
Serratus Anterior muscle
Definition
1) Protraction of Scapula
2) Long Thoracic Nerve
3) Winging of Scapula (Medial border protrudes like a wing)
Term
Trapezius muscle
Definition
1) Retraction and Upward Rotation of Scapula
2) Cr. XI - Spinal Accessory Nerve (NOT Brachial Plexus!)
3) Drooping ipsilateral shoulder
Term
Trapezius + Rhomboids
Definition
1) Retraction and elevation (shoulder shrugs)
2) Cr XI and Dorsal Scapular Nerve
3) Not in chart (darn) - I'm guessing droopy shoulders (can't shrug shoulders?)
Term
Levator Scapula
Definition
1) Elevate Scapula
2) C3, C4 (NOT BRACHIAL PLEXUS!)
3) Not in chart (guess - can't lift scapula on affected side)
Term
Serratus Anterior + Upper Trapezius
Definition

1) Phase 3 Shoulder Abduction --> Upward Rotation of Scapula, abduct arm ABOVE shoulder level

 

2) Long Thoracic n. + Cr. XI

 

3) Cannot abduct arm over shoulder level

Term
Pectoralis Minor
Definition
1) Downward Rotation
2) Medial Pectoral Nerve
3) ?
Term
Latissimus Dorsi
Definition
1) Downward Rotation of Scapula (think Lat pulls)
2) Thoracodorsal nerve (Lat is in thorax region and on the back!)
3) Upward displacement of shoulder if weak
Term
What is Scapulohumeral rhythm?
Definition
describes interaction of S & H upon COMPLETE Abduction of shoulder
Term
How can you tell if the scapula is not being upwardly rotated as humerus is abducted?
Definition
Humerus can't go above shoulder level (acromion stops it)
Term
What is upward rotation?
Definition
Acromion moves UPWARD
Inferior angle moves LATERALLY
Palpate inferior angle and have humerus abducted.
Term
How many phases are there in shoulder abduction?
Definition
3 phases
Term
[image]
Definition
Note the r/s b'w each ligament and associated bone. 
(Shoulder abduction phases continued on next flashcard!)
Term
Phase 1 (initial) of ABDUCTION
Definition
SUPRASPINATUS moves the HUMERUS about 15 degrees. Scapula moves very little
Term
Phase 2 of ABDUCTION
Definition
DELTOID MUSCLE moves Humerus to Shoulder level.
Term
In Phase 2, the Scapula is upwardly rotated. How?
Definition
The Serratus anterior and upper trapezius muscles!
Term
Phase 3 (Terminal phase) of Abduction
Definition
Still the DELTOID m. (humerus to head)
Term
In Phase 3, upward rotation is completed of the Scapula. How?
Definition
Again, the Serratus anterior and upper trapezius muscles! Phase 3 abduction cannot occur w/o scapula upward rotation b/c acromion would prevent humerus from going further.
Term
How would you test for a "Painful Arc"?
Definition
Upon full ABDUCTION, patient feels PAIN MIDWAY through (during Phase 2 of Abduction). Not Phase 1 or 3!
Term
What does a painful arc indicate?
Definition
Shoulder impingement (pain)
Term
What are the rotator cuff muscles again?
Definition
SITS - Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis
Term
What muscles are tested in the Appley Scratch test?
Definition
Tests for function of the Subscapularis, Teres Minor, and Infraspinatus muscles
Term
What ROM is (are) tested by the Appley Scratch Test?
Definition

1) External (Lateral) Rotation of shoulder)

 

 2) Internal (Medial) Rotation of shoulder 

Term
[image]
Definition

Appley Scratch Test (I-T-S muscles only!)

 

Left side = External Rotation (Infraspinatus and Teres Minor m.m.)

 

Right Side = Internal Rotation (Subscapularis m)

Term
There are different ways to describe the rotations of the shoulder. What are they?
Definition
Lateral = External = Outward Rotation
AND
Medial = Internal = Inward Rotation
Term
*RANDOM Q* Prime Movers of the Glenohumeral joint are...
Definition

Pectoralis major, Biceps, Supraspinatus, Serratus anterior Deltoid, Latissimus Dorsi, Teres Major, Triceps (long head), upper Trapezius 

 

Mnemonic

P-B-S Showed Dr. Lee and T T T

 

Can't be Pec minor (attaches to Coracoid)
should be Upper Trapezius b/c GH joint is superior 

Term
For the following cards, describe (1) movement and (2) nerve innervation
Definition
left blank
Term
Pectoralis Major - Clavicular Head
Definition
1) Flex shoulder
2) Lateral Pectoral N. (C5,6,7)
Term
Biceps Brachii
Definition

1) Flex shoulder 2) Musculocutaneous N. (C5,C6, C7)

 

 

 

Recall Mnemonic for brachial plexus Branches:

My Aunt Raped My Uncle

 

MC, Ax, Rad, Median, Ulnar

Term
Anterior Deltoid
Definition
1) Flex Shoulder
2) Axillary n (C5, C6)
Term
Posterior Deltoid
Definition
1) Extend shoulder
2) Axillary n. (C5, C6)
Term
Long head of Triceps brachii
Definition
1) Extend shoulder
2) Radial n. (C5,6,7,8, sometimes T1)
Term
Pectoralis Major (sternocostal head)
Definition

1) Adduction (fly exercise) medially rotates the humerus Actively.

 

 

It also Passively protracts Scapula anteriorly and inferiorly (push-ups).

 


2) Medial Pectoral n (C8, T1)

Term
Latissimus Dorsi
Definition
1) Adduction (lat pulldown)
2) Thoracodorsal n (C7, C8)
Term
Teres Major
Definition
1) Adduction
2) Lower Subscapular n. (C5, C6)
Term
Supraspinatus m. 
Definition
1) Starts Abduction 2) Suprascapular n. (C5, C6) 3) If lesioned --> inability to move arm AWAY from SIDE.
Term

Serratus Anterior m.

(with trapezius m.)

Definition
1) Lateral Thoracic n. (C5, C6, C7) 2) Abduction of humerus
Term
Subscapularis m.
Definition
1) Upper and Lower Subscapular nerves (Both are C5, C6)
2) Internal Rotation
3) Test: Appley Scratch, resisted internal rotation, Lift test (hand behind back, inwardly rotate against resistance)
Term
Test for Supraspinatus m.
Definition
1) Resist initial abduction
2) Drop Arm Test for tears (Start at 90 deg abduction, and lower arm smoothly, if difficult and feels pain, then + test for tear in supraspinatus)
Term
Infraspinatus m.
Definition

1) Action: Outward (External) rotation 2) Tests: i) Appley Scratch ii) Resist External Rotation

3) Suprascapular nerve (C5,C6)

Term
Teres Minor m.
Definition

1) Outward (external) rotation 2) Appley Scratch and resist external rotation

3) Axillary n. (C5,C6)

 

Term
Last Part: Neurovascular Testing
Definition
Dermatomes, Myotomes, Common Nerve Lesions
Term
Shoulder Dermatomes
Definition
Top --> C3, C4
Lateral: C5
Medial -> T1
Term
If pain from a test is NOT reproduceble, what may be going on?
Definition
If pain is reproduced after resistance, for example, then the pain is likely a DIRECT PAIN. If NOT reproduced, then it may be REFERRED PAIN. Why --> Referred pain is not affected by joint/muscle movement. True joint pain can be reproduced through palpation or resisted muscle testing.
Term
What nerve is derived from C3,C4?
Definition
Phrenic nerve!
Term
Phrenic nerve Referred pain
Definition
1)Pleura (mediastinal and diaphragmatic)
2)Peritoneum under diaphragm (right -gall bladder, left - spleen)
3) Pericardium
Term
Myotomes of shoulder
Definition
C5 and C6
Term
C5 myotome => muscle?
Definition
Deltoid Muscle (Axillary n => C5,C6)
If C6 is damaged, deltoid m. still weak, but not as weak if C5 was damaged. No other myotome affects the deltoid
Term
What nerve may be lesioned from an ANTERIOR shoulder dislocation?
Definition
Axillary nerve (C5 and C6)
Term
Result of Axillary nerve lesion?
Definition
Flaccid Paralysis Deltoid and teres minor
Visible acromion
Term
Too much Abduction and Lateral (External) Rotation may lead to lesion of...
Definition
Suprascapular nerve (C5, C6)
Term
Result of too much javelin throwing can damage the....nerve and affect which muscles?
Definition
Suprascapular nerve (C5, C6).

Supraspinatus and infraspinatus muscles
Term
Signs of damages suprascapular nerve are?
Definition
1) hard to START abduction (supraspinatus)
2) + Empty Can test (arms internally rotated and resist downward force; supraspinatus)
3) Weak external rotation of humerus (infraspinatus m)
4) hollow impression above and below scapular spine
Term
Check vascular integrity how?
Definition
Axillary and brachial pulses
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