Shoulder Complex: Anatomy, Kinesiology and Beyond

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Shoulder Complex:
Anatomy, Kinesiology
and Beyond

The shoulder is interesting. Here are some fun facts. (» Shoulder Fun Facts
(nmpm.com))

1. There’s no socket!
Joints like the hip have a really great, deep socket. The shoulder has no such
socket. The ball of the arm bone instead moves against a basically flat surface onthe
shoulder blade. What a curious design!

2. The whole thing barely has any bony connection to the rest of the skeleton.
Think about the arm, the shoulder joint, the whole shoulder blade and all the
surrounding tissue. That’s a heavy bunch of stuff. Well, how does it connect to
therest of the skeleton? It barely connects. The only bony connection is where it
connects to the collarbone. That’s a curious, tenuous, minimal bony connection
tothe rest of the skeleton.

3. It goes all over the place.
At least when it is healthy, your shoulder allows your arm to go all over the place.
Your knee can’t go in so many directions, nor can your finger joints or ankle, nor can
your hip.

4. Muscles matter even more for your shoulder.
Muscles are used around every joint in the body, but the shoulder is more dependent
on muscles than any other joint. The relative lack of bony connection to the rest of
theskeleton, the lack of a bony cup or socket, and the many directions of its
movement mean that muscles have more critical jobs in this region.

1

What we worked Page |2
so hard to learn
OT School
was good
enough…

What we worked OT School
so hard to learn

was good
enough…

Right?

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We learned anatomy and
kinesiology on ‘normal’
subjects that looked,
moved and acted like you!

How did that work out for you??

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How did that work out for you??

The prevalence of shoulder dysfunction in various patient populations have
been reported to be 34% of people 65 and older, 64% of patients with
stroke, and 78% of patients with spinal cord injury.
Additionally, some occupational activities, such as polishing, sanding, and
grinding, and certain recreational activities, such as overhead sports and
wheelchair athletics, have been found to result in or to increase shoulder
dysfunction. Shoulder dysfunction can affect an individual’s ability to
function independently, consequently decreasing quality of life.

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TH E SH OULDER

Where do the upper
extrem ity bones

articulate with the
axial skeleton?

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TH E SH OULDER

I’ll give you a moment
to think about this….

Th e Ste rn o clavicu lar Jo in t

Where the entire upper extremity articulates
here alone. The sternoclavicular joint has a
large degree of mobility. There are several
movements that require SC joint involvement:

• Elevation of the shoulders
o shrugging the shoulders or abducting the
arm above 90º

• Depression of the shoulders
o drooping shoulders or extending the arm at
the shoulder behind the body

• Protraction of the shoulders
o moving the shoulder girdle anteriorly

• Retraction of the shoulders
o moving the shoulder girdle posteriorly

The scapula, along with the clavicle and the manubrium of the sternum, make up
the pectoral (shoulder) girdle which connects the upper limb of the appendicular
skeleton to the axial skeleton.
It allows for elevation, depression, protraction and retraction. What other joint in
the body has that kind of play? (CMC joint)
The SC joint can also be damaged over time, as the protective tissue that covers the
ends of the bones gradually wears away.

• This type of degenerative change in the joint can lead to pain, stiffness, and
reducedmotion in the shoulder and arm.

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Re ally?
So, what holds the
s h o u lde r in place ? Th at
little sternoclavicular
jo in t can ’t d o all th e

work!

This is where it gets
interesting!

It’s called the Shoulder
Complex for a reason

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The Shoulder is Complex!

The shoulder is one of the most complex joint of the body formed by the articulation
of three bones – the Humerus, the Clavicle and the Scapula.
• The scapula is an important bone as each scapula provides a point of attachment

for a number of muscles that make up the arm and shoulder.
• It also articulates with the humerus and clavicle, forming the

glenohumeral (shoulder) joint and acromioclavicular joint
respectively.
• However, because the medial aspect of the scapula is not directly attached to
the axial skeleton but is rather held in place and connected to
the thorax and vertebral column by muscles, the scapula can move freely across
the posterior thoracic wall (scapulothoracic joint).
• This allows the arm to move with the scapula, providing a wide range of
movement and mobility for the upper limb compared to the lower limb.
Along with the spine, there are two more processes: the coracoid and acromion
process. The coracoid process is a beak-like bent that projects anterolaterally from
the superior border.

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So Much to Remember!! Page |9

Bones are covered by many layers of muscles.
• These muscles individually, or on groups:
• coordinate movements of the upper extremity,
• provide assistance to the primary movers,
• provide fixation to stabilize movement in one place to allow movement
inanother plane, or
• neutralizes the effects of an antagonistic muscle(s).

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Function of Muscles of the
Shoulder Complex

• Passive stabilizers
• Sternoclavicular and acromioclavicular
joints rely on ligaments for support.
• GH and scapulothoracic joint rely on
muscles for support.
• At rest, humeral head suspended by:
• Ligaments—superior GH;
coracohumeral
• Negative Intra-articular pressure
• Clavicle and scapula rest on thorax.

• Shoulder instability is a vague, nonspecific term which actually represents a
wide spectrum of clinicalpathologies, ranging from gross instability to subtle
subluxation.
• The shoulder joint sacrifices stability formobility.

• Although the glenohumeral joint exhibits significantphysiologic motion, only a
few millimeters of humeral head displacement occur during these movements
in the normal individual stabilization of the humeral head within the glenoid is
accomplishedthrough the combined efforts of the ligamentous structures and
the surrounding shoulder musculature.

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Ok a y.
So what m otions are
produced by which

m uscles

Glenohumeral Joint

• Ball and socket; three degrees
of freedom

• Inherently unstable
• Humeral head more than twice

the size of glenoid
• Labrum deepens socket
• Large capsule; redundant

inferiorly

The shoulder joint is also called the glenohumeral joint and is classified as a ball and
socketjoint.

• Allows for more movement than any other joint: flexion, extension, abduction,
adduction, external rotation, internal rotation, horizontal abduction, horizontal
adduction, Scaption, and any combination of these movements.

The shoulder joint is the most moveable joint in the body. In order to have wide ranging
mobility, a joint must sacrifice stability.

• Compare the shoulder joint to the hip joint.
• Shoulder disorders can be a result of injuries such as shoulder impingement,

jointinstability, rotator cuff strains, rotator cuff ruptures, and joint dislocations.

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Glenohumeral joint

• Capsular reinforcements

• Superior/middle/inferior GH
ligaments

• Coracohumeral ligament
• Long head of biceps/triceps
• Rotator cuff tendons blend

with capsule

Glenohumeral Joint

• Coracoacromial arch

• Forms “roof” of GH joint
• Subacromial space

between humeral head
and acromion
• Coracoacromial ligament
• Subacromial
impingement syndrome
(SAIS)

Shoulder impingement is a common form of shoulder pain in which structures
in your shoulder joint get squeezed and possibly injured over time.

• There is a rotator cuff tendon and a bursa in the narrow space at thetop
of your shoulder called the subacromial space.

• This space gets reduced if you have poor posture, a rounded upperback,
or forward shoulders.

• When you go to reach with your arm, those structures get impingedand
you feel pain.

Good posture is key to improving this condition.

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Glenohumeral Joint

• Bicipital groove

• Biceps tendon restrained by
coracohumeral and
transverse humeral ligament.

• During shoulder motion,
humerus moves on tendon.

• Tendon subject to wear and
tear as well as impingement.

The long head of biceps tendon travels deep into the shoulder joint and merges with the
lining of the joint.

• The tendon sits in a deep groove in the arm bone called the ‘bicipital groove’ and
it is held in place in that groove by a ligament called the transverse humeral
ligament.

THE DEPTH OF THE BICIPITAL GROOVE: The depth of the bicipital groove varies. A
shallow groove appears to be a contributing factor in dislocations of the biceps tendon
As the long head of the biceps tendon rests encased in its synovial sheath within the
intertubercular sulcus of the humerus, the transverse humeral ligament covering this
sulcus can rupture, causing it to slide back and forth, leading to a wear and teareffect on
the long head of the biceps tendon.
Repetitive microtrauma (commonly seen in overhead-throwing or racquet athletes)can
also lead to inflammation of the tendon. ment called the transverse humeral ligament.

Patient is a 59 y/o male who works in an auto repair shop. His job requires repetitive
overhead arm motion, pulling, or lifting moderately heavy materials. He has had this
pain in his right arm and shoulder for several months and has tried to control it with
NSAIDs. Now complains that this right arm pain is gotten to the pointit interferes with
his work.
Describes it as a deep, throbbing ache in the anterior shoulder. The pain worsens at
night and makes it difficult to sleep on the affected shoulder.

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The scapulothoracic joint is not a true synovial joint. Rather, the scapulothoracic
articulation is formed by the convex surface of the posterior thoracic cage and the
concavesurface of the anterior scapula.
The scapulothoracic articulation allows increased shoulder elevation. For every 2º of
glenohumeral elevation, there is 1º of scapulothoracic elevation.
The surfaces don’t adhere directly to each other. Instead, they are separated by
the subscapularis muscle that fills the subscapular fossa on the anterior surface of
scapula,the serratus anterior muscle which attaches to the thoracic wall, and the
fascial space between these two muscles.
Scapular stability
Since it has no ligaments, the scapulothoracic junction is stabilized by the
synchronized
actions and passive tensions of the three functional muscle units;

•The trapezius muscle
•The serratus anterior muscle
•The medial stabilizers of the scapula; levator scapulae and rhomboid muscles.

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Scapulohumeral Rhythm

• The actions of the shoulder
are paired with actions of the
scapula. This serves to both
increase the range of motion
of the upper extremity and
allows the glenoid fossa to be
positioned in a more stable
position in relation to the
humeral head.

Scapulohumeral rhythm is a common metric for assessing muscle function and
shoulder joint motion.

• There is a three-dimensional scapular kinematic pattern during normal arm
elevation that include upward rotation, posterior tilting and varying
internal/external rotation dependent on the plane and angle of elevation.

• When there is change of the normal position of the scapula related to the
humerus, the scapulohumeral rhythm is disturbed.

Example: shoulder abduction is accompanied by upward rotation – this increases
the amount of glenohumeral abduction available by moving the acromion process
up and out of the way; this positions the glenoid fossa partially under the humeral
head providing mechanical stability to downward force.

This short video demonstrates the importance of scapulohumeral rhythm

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Scapular Protraction

• Prime Mover: Serratus anterior (long thoracic n.)
• Synergist: Pectoralis minor (medial pectoral n.)
• Antagonists: Mid traps, rhomboids
• Neutralizers:

• Upper and lower traps act to prevent downward
rotation

• Lower traps act to prevent elevation, and
downward rotation

• Stabilizers: Serratus anterior, rhomboids, levator
scapulae

• Fixators: Intrinsic stabilization subsystem, rectus
abdominis, obliques, quadratus lumborum,
erector spinae

The serratus anterior is a muscle that originates on the surface of the 1st to 8th ribs at
the side of the chest and inserts along the entire anterior length of the medial border of
the scapula.

• The serratus anterior acts to pull the scapula forward around the thorax.
• Its purpose is to protract or pull around the shoulder blade as we reach forward.
• By protracting the shoulder blade, the bone is in a more supportive position to

allow the rotator cuff to do its job.
When this operates correctly it means the scalenes and upper traps, which attach into
the neck do not have to overcompensate which is a common cause of neck and shoulder
pain.

Serratus anterior pain can be caused by several medical conditions and
lifestyle factors.

• The most common causes of muscle pain include:
o tension
o stress
o overuse
o minor injuries

Functional Deficiency Serratus anterior
Limited ability of scapula to upwardly rotate

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Scapular Retraction A
B
• Prime Mover: Middle trapezius (spinal accessory n.) C
• Synergist: Rhomboids (dorsal scapular n.)
• Antagonists: Serratus anterior, pectoralis

minor
• Neutralizers:

• Upper and lower trapezius acts to prevent ancillary
motion in the frontal plane (elevation and
depression)

• Stabilizers: Serratus anterior, rhomboids,
levator scapulae

• Fixators: Intrinsic stabilization subsystem,
rectus abdominis, obliques, quadratus
lumborum, erector spinae

Stability of the scapulothoracic joint depends on coordinated activity of the surrounding
musculature.

• The scapular muscles must dynamically position the glenoid so that efficient
glenohumeral movement can occur.

• When weakness or dysfunction of the scapular musculature is present, normal
scapular positioning and mechanics may become altered.

• When the scapula fails to perform its stabilization role, shoulder complex
function is inefficient, which can result not only in decreased neuromuscular
performance but also may predispose the individual to injury of the
glenohumeral joint

Trapezius
The trapezius muscle is a postural and active movement muscle, used to tilt and
turn the head and neck, shrug, steady the shoulders, and twist the arms.

The trapezius elevates, depresses, rotates, and retracts the scapula, or shoulder
blade. Innervation of the trapezius is derived from the spinal accessory nerve.

A. The descending part of the trapezius muscle supports the arms.
B. The transverse part retracts the scapulae, and
C. the ascending part medially rotates or depresses the scapulae.

Functional Deficiency Applications

The causes of trapezius muscle pain include:

• Body posture: If bad posture is not corrected early, it may become permanent.
Sitting or standing improperly may lead to trapezius muscle pain that may even
radiate to the spine (spinal vertebrae) and support muscles. Maintaining
awkward standing or sitting positions can lead to muscle pain that is felt in the
trapezius muscle. This may also be referred to as a repetitive stress injury.

• Pressure: Heavy or tight pressure on the trapezius causing pressure on the
muscle can lead to pain. This can be induced by wearing heavy backpacks,
shoulder bags, or even tight bra straps.

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• Overuse: Repetitive activities, such as lifting heavy objects or swimming can
lead to trapezius pain. People who perform monotonous work with the neck and
shoulder muscles are at a high risk of trapezius pain.
• Examples include nurses who lift and turn patients, construction workers
who carry heavy objects, and retail workers who lift heavy boxes and bags.

The rhomboids (major and minor) function to stabilize the medial border of the
scapula. Therhomboids are very active in scapular adduction or retraction, which
can be defined as backward rotation of the scapula toward the vertebral column.
What happens when scapular adductors are weak?

• If the scapular adductors are weak, fatigued, or injured, the muscular tension
created by the pectoralis minor will tilt the scapulae forward and
down, resulting in kyphosis.

• Strengthening this muscle group should be emphasized when rehabilitating
patients with anterior instability

Strengthening this muscle group should be emphasized when rehabilitating
patients withanterior instability

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Scapular Upward Rotation

• Prime Mover: Serratus anterior (long thoracic n.)
• Synergists: Middle and lower trapezius (spinal

accessory n.)

• Antagonists: Pectoralis minor, rhomboids,
levator scapulae

• Neutralizers:

• Lower traps act to prevent elevation caused by
upper traps

• Stabilizers: Serratus anterior, rhomboids,
levator scapulae

• Fixators: Intrinsic stabilization subsystem,
rectus abdominis, obliques, quadratus
lumborum, erector spinae

The serratus anterior is a muscle that originates on the surface of the 1st to 8th ribs at
the side of the chest and inserts along the entire anterior length of the medial border of
the scapula.

• The serratus anterior acts to pull the scapula forward around the thorax.
• Its purpose is to protract or pull around the shoulder blade as we reach forward.
• By protracting the shoulder blade, the bone is in a more supportive position to

allow the rotator cuff to do its job.
When this operates correctly it means the scalenes and upper traps, which attach into
the neck do not have to overcompensate which is a common cause of neck and shoulder
pain.

Serratus anterior pain can be caused by several medical conditions and
lifestyle factors.

• The most common causes of muscle pain include:
o tension
o stress
o overuse
o minor injuries

Functional Deficiency Serratus anterior
Limited ability of scapula to upwardly rotate

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Scapular Downward Rotation

• Prime Mover: Pectoralis minor (medial pectoral n.)
• Synergists: Rhomboids (dorsal scapular n.), levator

scapulae (3d & 4th cervical spinal n.)
• Antagonists: Serratus anterior, upper & lower

traps
• Neutralizers:

• Lower traps acts to prevent elevation force
created by synergists and the anterior tipping
force created by the pectoralis minor.

• Stabilizers: Serratus anterior, rhomboids, levator
scapulae

• Fixators: Intrinsic stabilization subsystem, rectus
abdominis, obliques, quadratus lumborum,
erector spinae

When pectoralis minor is weak, the strength of arm is diminished.
• Moreover, weakness of this muscle will increase respiratory difficulty in
patientsalready experience fatigue and/or compromise of the respiratory
muscles.

An overactive pec minor can have a significant effect on the function of the shoulder
joint,which in turn can lead to injuries.
• Probably the most common injury to occur as a direct result of a short pec

minor issubacromial impingement.
• In this condition, a lack of space below the subacromial arch causes the
underlying tendons (typically supraspinatus, and also the subacromial
bursa) tobe impinged or "pinched" with arm movements above shoulder
height and especially with a rotation element.
• This lack of space below the subacromial arch can be directly linked to an
overactive pec minor protracting, anteriorly tilting and downwardly
rotating thescapula, effectively lowering the subacromial arch.

• Along with the increased impingement risk, a tight pec minor and subsequently
inhibitedserratus anterior causes the glenoid fossa to become more vertical in its
alignment, resulting in increased abduction, rotation and winging of the scapula.
• An overactive pectoralis minor and underactive serratus anterior leads to
winging of the scapula

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Scapular Elevation

• Prime Mover: Upper trapezius (spinal accessory n.)
• Synergists: Levator scapulae (3d & 4th cervical spinal n.),

rhomboids (dorsal scapular n.)
• Antagonists: Lower traps, pectoralis minor
• Neutralizers:

• Serratus anterior and rhomboids must carefully
balance upward and downward rotation to prevent
excessive motion in either directions caused by the
prime mover and synergists

• Stabilizers: Serratus anterior, rhomboids, levator
scapulae

• Fixators: Intrinsic stabilization subsystem, rectus
abdominis, obliques, quadratus lumborum, erector
spinae

Scapular elevation refers to the cranial motion of the scapula (scapulothoracic
joint), commonly described as “shrugging the shoulders”.

• This movement is facilitated by several muscles and it is useful to
distinguish these as primary movers and stabilizers.

• It is important to note that no one movement of the scapula occurs
inisolation and no individual muscle exerts a singular action on the
scapula.

• In addition, movement of the clavicle also aids scapular motion by
virtue of its articulation with the scapula as part of the pectoral
girdle.

The opposite movement is scapular depression.

Primary movers

• trapezius – generates elevation through its upper fibers by virtue of its
attachment to the acromion and spine of the scapula, and the lateral
clavicle

• levator scapulae - works with trapezius to elevate the scapula
(specifically, it elevates the superior angle of the scapula). Also
prevents lateral rotation of scapula (i.e. a medial rotator)

• rhomboideus major and minor – minor action through elevation of
themedial border of the scapula. They also prevent lateral rotation of
scapula.

Stabilizers

• pectoralis minor – prevents lateral rotation exerted by trapezius

• subclavius – exerts stabilizing action by preventing rotation of
theclavicle

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Scapular Depression

• Prime Mover: Lower trapezius (spinal accessory n.)
• Synergists: Pectoralis minor (medial pectoral n.)
• Antagonists: Upper traps, levator scapulae,

rhomboids
• Neutralizers:

• The lower traps and stabilizers of the scapula neutralize
the anterior tipping force created by the pectoralis
minor

• Stabilizers: Serratus anterior, rhomboids, levator
scapulae

• Fixators: Intrinsic stabilization subsystem, rectus
abdominis, obliques, quadratus lumborum,
erector spinae

Scapular depression refers to the caudal motion of the scapula (scapulothoracic joint).
• In most instances, depression of the scapula is a passive process (dueto
gravity) that is facilitated by movement at the acromioclavicular joint.
• Occasionally some muscular attachments serve as active depressors,the
most commonly described being the inferior fibers of serratus anterior
and pectoralis minor .
• Other minor depressors of the scapula include:
• latissimus dorsi
• pectoralis major (secondarily through its action on the clavicle
and humerus)
• Trapezius (generates depression through its upper fibers by virtue
of its attachment to the acromion and spine of the scapula, and
the lateral clavicle)

•It is important to note that no one movement of the scapula occurs in isolation
and no individual muscle exerts a singular action on the scapula. The opposite
movement is scapular elevation.

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Shoulder Flexion

• Prime Mover: Anterior deltoid (axillary n.)
• Synergists: Pectoralis major (clavicular head) (medial &

lateral pectoral n.), coracobrachialis (musculocutaneous n.),
biceps brachii (musculocutaneous n.)
• Antagonists: Latissimus dorsi, posterior deltoid, teres
major, biceps brachii
• Neutralizers:

• Posterior deltoid, infraspinatus & teres minor neutralize internal
rotation force created by the prime mover and synergists

• Middle deltoid may contribute to flexion if arm is internally
rotated or it may act to neutralize adduction forces created by
the primo mover and synergists if arm is in neutral position

• Stabilizers: Rotator cuff (SITS)
• Fixators: scapular muscles, intrinsic stabilization

subsystem, rectus abdominis, obliques, quadratus
lumborum, erector spinae

Front shoulder pain or anterior pain is one of the most common types of shoulder
pain that people encounter.

• There are various factors that can contribute to shoulder pain in general,
but nearly all of them stem from various factors that cause injury and
inflammation to the rotator cuff and tendons.

• These conditions can greatly affect your normal functioning including your
ability to lift even lightweight objects with the affected arm, or even raise
that arm or rotate your shoulder due to the ongoing pain, swelling,
discomfort, or stiffness.

• Note that anterior shoulder pain can also be the result of preexisting
chronic illness or other conditions.

Some of the common symptoms of this type of shoulder pain are:
• swelling, tenderness, and pain in front shoulder joint,
• severe pain and stiffness in the shoulder,
• a continuous or ongoing feeling of discomfort, decreased strength, and
• limited mobility of the affected shoulder, including the inability to lift
heavier objects or difficulty lowering that arm.

Common types of anterior shoulder pain include:
• Acromioclavicular Joint Injury – Localized pain in the clavicle caused by the
overuse of the shoulder.
• Adhesive Capsulitis – Stiffness in the shoulder joint that can lead to the loss
of movement during abduction and external rotation.
• Biceps Tendonitis – When the tendons and muscles are damaged by lifting
up and carrying heavy objects.
• Shoulder Impingement Syndrome – When the tendons on your shoulder
blade rub together, causing pain in the front of the shoulder.
• Labral Tear – Torn cartilage in the shoulder region, causing deep, severe
pain.
• Rotator Cuff Tear or Tendinopathy – An injury causing severe pain when
you rotate your shoulder and the general weakening of the tendons in your

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shoulder joints.
• Shoulder Arthritis – This progressive condition causes pain in the shoulder

and surrounding areas and can be at least partially treated by removing the
loose fragments of bone cartilage, and other tissue from the shoulder joint.

EFFECTS OF WEAKNESS OF THE ANTERIOR DELTOID
Shoulder flexion weakness
May decrease strength in medial rotation, abduction, and horizontal adduction
of the shoulder

EFFECTS OF TIGHTNESS OF THE ANTERIOR DELTOID
Limited data but believed to limit extension and lateral rotation ROM of the
shoulder

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Shoulder Extension

• Prime Mover: Latissimus dorsi (thoracodorsal n.) Posterior

• Synergists: Posterior deltoid (axillary n.), teres major

(lower subscapular n.), long head of triceps (radial n.)

• Antagonists: Anterior deltoid, pectoralis major
(clavicular head), coracobrachialis, biceps brachii

• Neutralizers:

• Posterior deltoid, infraspinatus & teres minor neutralize
internal rotation force created by the prime mover

• Middle deltoid may neutralize adduction force created by
prime mover

• Stabilizers: Rotator cuff (SITS)

• Fixators: Scapular muscles, intrinsic stabilization
subsystem, rectus abdominis, obliques, quadratus
lumborum, erector spinae

The latissimus dorsi is a large, flat muscle covering the width of the middle and
lower back. It connects the bone of the upper arm to the spine and the hip.

• This muscle is often referred to as the lats.
• You use your lat muscle every single day, while standing, walking,

sitting, or doing any movement with the upper body—as well
as stabilizing your core, which include your abdominal muscles

When flexed, the muscle works at extending, adducting and rotating the arm.
• It’s an important stabilizer for the spine and arm function, and it
provides balance for the pectoralis, the large muscle of the front of the
body, the chest

Once aggravated pain might show up at the back of the shoulder, the backof the
armpit, or the mid to low back area.

• Here’s what could cause latissimus dorsi pain.
• Muscle or tendon tear
• Muscle strain or tendonitis
• Osteoarthritis
• Pinched nerve
• Rotator Cuff injuries

ACTIONS OF THE LATISSIMUS DORSI MUSCLE
Extends, adducts, medially rotates, and depresses shoulder; also active in
forcedinspiration and expiration.

EFFECTS OF WEAKNESS OF THE LATISSIMUS DORSI
Weakness in actions listed above.

EFFECTS OF TIGHTNESS OF THE LATISSIMUS DORSI
Limited ROM in lateral rotation, flexion, and abduction of
shoulderMay contribute to increased thoracic kyphosis

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Shoulder Abduction

• Prime Mover: Anterior & middle deltoid (axillary n.)

• Synergists: supraspinatus (subscapular n.)

• Antagonists: Latissimus dorsi, pectoralis major
(sternal head), teres major, coracobrachialis, long
head of triceps, infraspinatus, teres minor,
subscapularis

• Neutralizers:

• Posterior deltoid, infraspinatus & teres minor neutralize
internal rotation force created by the anterior deltoid

• Stabilizers: Rotator cuff (SITS)

• Fixators: Scapular muscles, intrinsic stabilization
subsystem, rectus abdominis, obliques, quadratus
lumborum, erector spinae

While the separate fibers of the deltoid can by synergists in several joint
actions, its principal role as a single unit when all fibers contract
simultaneouslyis shoulder abduction.

• The ability to abduct the arm is a crucial contributor to the full range of
motion of the arm.

Four different muscles control this action: supraspinatus, deltoid, trapezius,
and serratusanterior.

• The supraspinatus is the primary muscle for the abduction of the
arm to 15degrees.

• The deltoid controls abduction from 15 to 90 degrees.
• The trapezius and serratus anterior coordinate with each other and the

scapula tofacilitate abduction of the arm upwards of 90 degrees.

One of the most common reasons for the inability to abduct the arm or pain with the
abduction of the arm is a tear of the rotator cuff.
The rotator cuff is a group of muscles—supraspinatus, infraspinatus,
subscapularis, teresminor—responsible for movement and stabilization of the
shoulder joint.

Of the four muscles found in the rotator cuff, the supraspinatus is the one most
frequently torn or injured.

• As previously mentioned, the supraspinatus is crucial to the initiation of
abductionto 15-30 degrees and assists the deltoid with abduction up to 90
degrees; as
such, injury to it would represent a significant obstacle to one’s ability to
abduct the arm

P a g e | 44

Shoulder Internal Rotation

(Note: shoulder rotation is not strictly paired with a specific movement of the scapula)

• Prime Mover: Subscapularis (upper subscapular n.)
• Synergists: Anterior deltoid (axillary n.), pectoralis major

(medial & lateral pectoral n.), latissimus dorsi (thoracodorsal n.),
teres major (lower subscapularis n.)
• Antagonists: Posterior deltoid, infraspinatus, teres
minor
• Neutralizers:

• Biceps brachii, long head of triceps, middle deltoid &
coracobrachialis neutralize ancillary motion in the sagittal
and frontal plane

• Supraspinatus prevents/neutralizes the adduction force
created by the prime movers

• Stabilizers: Rotator cuff (SITS)
• Fixators: Scapular muscles, intrinsic stabilization

subsystem, rectus abdominis, obliques, quadratus
lumborum, erector spinae

The subscapularis muscle is the most-used muscle in the shoulder.

• The subscapularis, along with the teres major, another intrinsic muscle
that is not part of the rotator cuff, and extrinsic muscles like the pectoralis
major and latissimus dorsi, is responsible for medial, or internal, rotation
of the arm.

• The function of the subscapularis muscle is to stabilize and rotate the
shoulder joint to allow the arm to turn inward.

The subscapularis muscle internally rotates the humerus;

• the upper portion of the muscle influences abduction, while the lower area
influences adduction.

• When the arm is extended, it draws the humerus forward and downward.

• It also prevents the dislocation of the head of the humerus.

P a g e | 45

Shoulder External Rotation

(Note: shoulder rotation is not strictly paired with a specific movement of the scapula)

• Prime Mover: Infraspinatus (suprascapular n.), teres minor

(axillary n.)

• Synergists: Posterior deltoid (axillary n.)
• Antagonists: Subscapularis, anterior deltoid,

pectoralis major, latissimus dorsi, teres major
• Neutralizers:

• Biceps brachii, long head of triceps, middle deltoid &
coracobrachialis neutralize ancillary motion in the sagittal
and frontal plane

• Supraspinatus prevents/neutralizes the adduction force
created by the prime movers

• Stabilizers: Rotator cuff (SITS)
• Fixators: Scapular muscles, intrinsic stabilization

subsystem, rectus abdominis, obliques, quadratus
lumborum, erector spinae

The Infraspinatus originates from the infraspinous fossa of the scapula, located on
thedorsal aspect of the scapula below the scapular spine.

• It inserts on the middle facet of the greater tuberosity.
• Its primary function is the external rotation of the shoulder joint and the

abduction of the scapula.
• Teres minor originates from the posterior part of the scapular, next to the

lateral border.
• It inserts at the greater tubercle of the humerus.
• The teres minor’s function is to externally rotate the upper arm at the

shoulder joint.
• It is an antagonist to internal rotation.

Pain in the infraspinatus is most likely caused by repetitive motion involving the
shoulder.

• Swimmers, tennis players, painters, and carpenters get it more frequently.
• It also becomes more likely as you get older.
• There are several potential causes of infraspinatus pain.

• Some are serious, but none are life threatening.

P a g e | 46

Shoulder Horizontal Adduction

Pectoralis Major • Prime Mover: Pectoralis major (pectoral n.)

• Synergist: Anterior deltoid (axillary n.)

• Antagonist: Posterior deltoid

• Neutralizers:

• Posterior deltoid, infraspinatus, & teres minor
neutralize internal rotation force created by the
anterior deltoid and pectoralis major.

• Middle deltoid, latissimus dorsi, teres major, and
coracobrachialis neutralize ancillary motion in the front
plane.

• Stabilizers: Rotator cuff (SITS)

• Fixators: Scapular muscles, intrinsic stabilization
subsystem, rectus abdominis, obliques, quadratus
lumborum, erector spinae

The pectoralis major is the most superficial muscle in the pectoral region.
• It is large and fan shaped and is composed of a sternal head and aclavicular
head.
• The pectoralis major is active in deep or forced inspiration, but not
expiration.

ACTIONS OF THE PECTORALIS MAJOR
• Medially rotates shoulder but perhaps only against resistance
• depresses, adducts, and provides horizontal adduction
• can be an auxiliary muscle of respiration

EFFECTS OF WEAKNESS OF THE PECTORALIS MAJOR
• Upper part of pectoralis major:
• Decrease the ability to draw the arm in horizontal adduction across
the chest, making it difficult to touch the hand to the opposite
shoulder. Decreases the strength of shoulder flexion and medial
rotation.
• Lower part of pectoralis major:
• Decreases the strength of adduction obliquely toward the opposite
hip (diagonal movement).
• From a supine position, if the subject's arm is placed diagonally
overhead, it will be difficult to lift arm from a table.
• The subject will also have difficulty holding any large or heavy object
in both hands either at or near waist level.

P a g e | 47

Shoulder Horizontal Abduction

• Prime Mover: Posterior Deltoid (axillary n.)
• Synergist: N/A
• Antagonists: Pectoralis major, anterior deltoid
• Neutralizers:

• Anterior deltoid & subscapularis neutralize external
rotation force created by agonists and synergists

• Middle deltoid, latissimus dorsi, teres major &
coracobrachialis neutralize ancillary motion in
frontal plane

• Stabilizers: Rotator cuff (SITS)
• Fixators: Scapular muscles, intrinsic stabilization

subsystem, rectus abdominis, obliques,
quadratus lumborum, erector spinae

Because of the synergistic dominance that is common with these fibers
(Ant/mid/post deltoid fibers), they have a tendency to become overactive.

• However, this overactivity occurs when other shoulder muscles
become over/underactive, evidenced by imbalanced posture and
shoulder dysfunction.

• Such dysfunction, such as short pec minor/major and lats, will cause
the rear deltoid to rest in a lengthened position.

• That means, stretching the muscle is not a remedy for overactivity.
• Instead, a static manual or self-myofascial release may reduce
signs of overactivity and synergist dominance in these muscle
fibers.

The most common causes of deltoid pain are overuse injuries and strains.
• People who use their shoulders and deltoid muscles repetitively, especially
jobs requiring overhead work, have an increased risk of deltoid injury.
• You can also strain your deltoid muscle while doing repetitive activity
thatputs pressure on the shoulder, including typing with a keyboard
that’s toohigh.
• A strain can suddenly result from heavy lifting or an accident, such as a
trip or fall.
• Most injuries to the deltoid muscle take time to develop

EFFECTS OF WEAKNESS OF THE POSTERIOR DELTOID
At least weakness in shoulder extension

EFFECTS OF TIGHTNESS OF THE POSTERIOR DELTOID
Decreased flexion ROM. Further study is needed to determine any other effects.

P a g e | 48

Scaption

• The term Scaption was first coined in
1991.

• It is a contraction of Scapular Plane
Elevation and refers to lifting the arms
from the sides in a slightly forward
alignment
• abduction in the scapular plane of 30-
45o forward in the horizontal plane

Scaption refers to raising your arms from your sides and slightly forward.
• This position aligns with the normal anatomy of the shoulder joint. We
often useScaption as both an assessment and rehab point. It is
particularly important for assessing the function of the shoulder blade.
• The arms move through the scaption plane with the thumbs on top.
• Sometimes it’s referred to as scapular plane elevation.

During scaption, you draw your shoulder blades toward the center of your spine,
which helps to open your chest.

• The movement builds strength in the shoulders and back.
• Paying attention to your form during scaption can help develop body

awareness.

Scaption works the following muscles:
•trapezius
•serratus anterior
•deltoids
•rotator cuff

Scaption helps promote healthy movement patterns, improve muscle function, and
prevent injuries. It also builds strength in your rotator cuff, which improves shoulder
stability.

Scaption is useful for actions where you need to raise your arms up or to the sides
during daily activities

P a g e | 49

Ok, so now I’ve reviewed my
anatomy and kinesiology. What
can I do with this knowledge?

Start by Developing an Initial
Evaluation for Your Patient

P a g e | 50

SHOULDER EXAMINATION

1. Inspection 3. ROM: Resisted
a. Gait a. C-spine, shoulder, elbow
b. Ability to disrobe b. Note pain, range, and apparent weakness
c. Topical scan
A typical Occupational Therapy (1) Discoloration 4. Neurological examination
(2) Atrophy
Shoulder Examination may (3) Bilateral comparison - symmetry a. DTR's
(4) Indication of present or past
include some or all of these pathology (1) Biceps - C5
d. Osteology (always look at joints
categories. proximal and distal) (2) Brachioradialis - C6
(1) Anterior
• The Correct Evaluation will (a) Clavicle (3) Triceps - C7
depend upon your patient (b) Acromion
(clinical reasoning) (c) Humerus b. Sensory by dermatome
(d) Head and neck posture
• You would approach a CVA (2) Posterior (1) Light touch
shoulder differently than you (a) Scapula
would a rotator cuff injury. (b) Shoulder level (2) Pin prick
(c) Cervical and thoracic spine
c. Segmental Muscle test
2. Active and passive ROM
a. Cervical Spine (1) C2-3-4 Scapular elevation
(1) Flexion
(2) Extension (trapezius and levator scapulae)
(3) Side Bending
(4) Rotation (2) C5 Scapular retraction
b. Shoulder
(1) Flexion (anterior deltoid, (rhomboids)
coracobrachialis)
(2) Extension (posterior deltiod, teres (3) C5-6-7 Scapular protraction
major, latissimus dorsi)
(3) Abduction (deltoid, supraspinatus) (serratus anterior)
(4) Adduction (teres major, latissimus
dorsi, pectoralis major) (4) C5 Deltoid, Biceps
(5) Intrnal rotation (subscapularis, teres
major, latissimus dorsi) (5) C6 Extensor carpi radialis
(6) External rotation (infraspinatus,
teres minor) longus and brevis
c. Elbow
(1) Flexion (6) C7 Triceps
(2) Extension
(3) Pronation (7) C8 Flexor digitorum
(4) Supination
superficialis

(8) T1 Dorsal interossei

5. Palpation
a. Skin
b. Muscle and tendons
c. Subdeltoid bursa
d. Ligaments
e. Bone
f. Joints
(1) acromioclavicular
(2) sternoclavicular
(3) scapulothoracic
(4) glenohumeral

The prerequisite for any treatment in the shoulder region of a patient with pain is a
precise and comprehensive picture of the signs and symptoms as they occur during
the assessmentand as they existed until then.

Because of its many structures (most of which are in a small area), its many
movements,and the many lesions that may occur either inside or outside the joints,
the shoulder complex is difficult to assess.

Having a systematic and structured approach to the shoulder history and
examination ensures that key aspects of the condition are elicited, and important
conditions are notmissed.

• Information gathered in this process can help guide decisions about the need
for specialtests or investigations and ongoing management.

When assessing shoulder pain, take a history and perform an examination with
these questions in mind:

• Is the pain arising from the shoulder, neck or elsewhere?
• Are there any 'red flag' symptoms/signs suggesting a systemic cause?
• Is the pain localized to the acromioclavicular joint: the 'pointing sign’ (where it

hurts the most)?
• If yes, consider acromioclavicular joint disease.

• Is there global pain and restriction of all active and passive movements?
• If yes, this suggests glenohumeral joint disorder (perhaps frozen shoulder
or arthritis).

• Does the patient show a broad area of pain: the 'grasping sign' suggestive of
subacromial pain?

P a g e | 51

Manual Muscle Testing of the
Shoulder Complex

Manual Muscle Test: Shoulder Complex

P a g e | 52

Rotator Cuff Subacromial
Impingement

Apley Scratch Test Sensitivity: 0.84 | Specificity: 0.71 | LR: +2.90/-0.20

To assess simultaneous
movements of the shoulder
girdle (the scapulothoracic
and glenohumeral joints).

• Movements include:

• Shoulder extension and
flexion

• Internal and external
rotation of the humerus

• Scapular abduction and
adduction

The Apley scratch test is another useful maneuver to assess shoulder range of motion.

• In this test, abduction and external rotation are measured by having the
patient reach behind the head and touch the superior aspect of the opposite
scapula.

• Conversely, internal rotation and adduction of the shoulder are tested by
having the patient reach behind the back and touch the inferior aspect of the
opposite scapula.

Tests for limitations in motions of the upper extremity. Each motion is performed bilaterally to
compare.

Action 1: The subject is instructed to touch the opposite shoulder with his/her hand.
• This motion checks Glenohumeral adduction, internal rotation,
horizontal adduction and scapular protraction.

Action 2: The subject is instructed to place his/her arm overhead and reach behind
the neck to touch his/her upper back.

• This motion checks Glenohumeral abduction, external rotation and scapular
upward rotation and elevation.

Action 3: The subject puts his/her hand on the lower back and reaches upward as far
as possible.

• This motion checks glenohumeral adduction, internal rotation and scapular
retraction with downward rotation

Observations:

• Note the client’s ability to touch the medial border of the contralateral scapula or how far
down the spine he or she can reach with shoulder flexion and external rotation.

• Note the client’s ability to touch the opposite inferior angle of the scapula or how
far up the spine he or she can reach with shoulder extension and internal rotation.

• Observe any bilateral differences between the left and right arms in performing both
movements.

P a g e | 53

Provocative Tests

SENSITIVITY is defined as the ability of a test to identify patients with a particular disorder.

• "SnNout" High Sensitivity, Negative test = rule out

SPECIFICITY is the ability of a test to identify patients that do not have the disorder in question

• "SpPin" High Specificity, Positive test = rule in

When searching for a provocative test to use with your clinical practice, look carefully
atthe specificity and sensitivity of the test.

Sensitivity is defined as the ability of a test to identify patients with a particular
disorder. Inother words, it represents the proportion of a population with the target
disorder that has a positive result with the diagnostic test. Tests that are highly
sensitive are most useful for ruling out a disorder, as people who test negative are
more likely not to have the target disorder.

• "SnNout" is an acronym that can be used to remember that a highly sensitive
test and a negative result is good for ruling out the disorder in question.

• For example, if the Neers Test has been reported to have a sensitivity rating of
0.93for detecting subacromial impingement.
• So, if the test is negative, the examiner can be confident that the patient
does not have impingement.

P a g e | 54

Specificity is the ability of a test to identify patients that do not have the disorder in
question. In other words, specificity is the proportion of the population without the
targetdisorder who test negative for the disorder. Therefore, tests that are highly
specific are useful for ruling in a disorder.
• The acronym "SpPin" is commonly used to remember that a test with

high specificity and a positive result is good for ruling in a disorder.

• For example, if the Hawkins-Kennedy test for subacromial impingement was
reported by some to have a specificity of 1.00, or 100%.
• A positive test result is very likely to include those people who have
impingement.

P a g e | 55

Gismervik, et al.. (2017). Physical
examination tests of the shoulder. BMC
musculoskeletal disorders, 18(1), 41.

Likelihood ratios (LR) in medical testing are used to interpret diagnostic tests.
Basically, the LR tells you how likely a patient has a condition.
The likelihood ratio = probability a person with the condition has a certain test result

probability a person without the condition has a certain test result
• The higher the ratio, the more likely they have the disease or condition.
• Conversely, a low ratio means that they very likely do not. Therefore,

these ratios can help a physician rule in or rule out a disease.
.Let’s look at a case study that will use the Likelihood Ratios to determine your
diagnostic workup

P a g e | 56

You have evaluated your patient and find you can elicit a positive pain response by palpating at the area
that extends form the anterior deltoid muscle down toward the insertion of the Deltoid muscle.

• Pain becomes exquisite when you press along the bicipital groove.
• You administer the Yergasen test to validate what you learned from your palpation of the

upper arm and shoulder – results are positive.
You now feel that your patient has bicipital tendonitis.
HOWEVER You begin to think about why you needed to do 2 tests and not just rely on the results of
your palpation eliciting a positive response. Palpation is easier to administer and interpret. How would
you answer this concern?

P a g e | 57

Gismervik, et al.. (2017). Physical
examination tests of the shoulder. BMC
musculoskeletal disorders, 18(1), 41.

Case Study: Patient is a 59 y/o male who works in an auto repair shop. His job
requires repetitive overheadarm motion, pulling, or lifting moderately heavy materials.
He has had this pain in his right arm and shoulder for several months and has tried to
control it with NSAIDs. Now complains that this right arm pain is gotten to the point
it interferes with his work. Describes it as a deep, throbbing ache in the anterior
shoulder. The pain worsens at night and makes if difficult to sleep on the affected
shoulder.
• So, for the Yergason test, we see that a positive result will be 2½ times likely to

correctly identify bicipital tendonitis.
• However, bicipital grove tenderness only has a positive likelihood of 1.0
AND negative likelihood of also 1.0 which means it is probably not going to
be the determining factor in making the diagnosis.

P a g e | 58

P a g e | 59

Supraspinatus Muscle

Hawkins-Kennedy Test
• Position arm in throwing position

and flexed forward 30 degrees.
Examiner internally rotates
humerus.

Sensitivity: 0.72 | Specificity: 0.66 | LR: +1.04/-0.96

www.pthaven.com

A positive Hawkins-Kennedy test is indicative of an impingement of all
structures that are located between the greater tubercle of the humerus
and the coracohumeral ligament.
• The impinged structures include the supraspinatus muscle, teres minor

muscle, and the infraspinatus muscle.

P a g e | 60

Supraspinatus Muscle

Jobe’s Test (Empty Can Test)
• Position arm in scapular plane and
point thumb down as if emptying
out can. Examiner pushes down
on arm.

Sensitivity: 0.89 | Specificity: 0.90 | LR: +1.78/-0.63

www.pthaven.com

The Empty Can Test, is a commonly used orthopedic examination test for
supraspinatus impingement or integrity of the supraspinatus muscle and tendon.

• The test is also sometimes called the Empty Beer Can Test.
• The supraspinatus is one of the four rotator cuff muscles.
The Empty Can Test is considered positive if there is significant pain and/or
weakness.
• Pain alone is less accurate than actual weakness, especially when the arm is tested
in full can position as pain can be the result of supraspinatus tendonitis or other
injured or inflamed structures.
• Weakness can be the result of a tear in the supraspinatus muscle or tendon but
can also be the result of pain induced inhibition.
• Pain is usually felt in the subacromial region but can sometimes be feltinto the
upper arm.

P a g e | 61

Supraspinatus Muscle

Drop Arm Test

• Position patient’s arm
fully abducted so hand is
over the head.

• Ask patient to slowly
adduct arm to their side.

• If supraspinatus muscle is
torn, at <90o, the arm
will suddenly drop to
side.

Sensitivity: 0.27 | Specificity: 0.88 | LR: +2.25/-0.83

www.pthaven.com

Drop Arm Test is a test for rotator cuff tears, specifically of the supraspinatus
tendon.

• A positive test is determined by the patient’s inability to smoothly control
the lowering of their arm or the inability to hold the arm in 90 degrees of
abduction.

• In a positive test that starts above 90 degrees of abduction, the patient will
tend to have difficulty controlling the movement around 90 degrees of
abduction.

• There may or may not be pain reported. Pain alone is not a positive test.

P a g e | 62

Infraspinatus Muscle

Infraspinatus Scapular Rotation Test:

• 90% of shoulder external
rotation uses infraspinatus
muscle

• Patient has pain when
externally rotates shoulder
against resistance (with
elbow in 90 degree flexion)

Sensitivity: 0.72 | Specificity: 0.90 | LR: +4.2/-0.65

www.pthaven.com

The infraspinatus muscle is one of the rotator cuff muscles.
• Rotator cuff muscle dysfunction can lead to shoulder impingement as the
head of the humerus superiorly migrates during arm elevation.
• Infraspinatus muscle is often involved in shoulder pathologies as shoulder
impingement and rotator cuff tears.
• The Infraspinatus test is used to test for infraspinatus muscle involvement
in rotator cuff pathologies such as subacromial impingement or rotator
cuff tears.

P a g e | 63

Rotator Cuff Subacromial
Impingement

Lift Off Test
• To test for a lesion of

the subscapularis
muscle and scapular
instability

Sensitivity: 0.75 | Specificity: 0.56 | LR: +0.43/-1.38

The ability to actively lift the dorsum of the hand off the back constitutes a
normal lift-off test.

• Inability to move the dorsum off the back constitutes an abnormal lift-off test
andindicates subscapularis rupture or dysfunction.

• The patient stands and places the dorsum of the hand against mid-lumbar
spine.

• The patient then lifts his hand away from the back.
• An inability to perform this action indicates a lesion of the subscapularis

muscle.
• Abnormal motion of the scapula during the test may indicate scapular

instability.

P a g e | 64

Labral Tear

O’Brien Test

• Position patient’s shoulder in 90 deg
flexion, elbow extended, and 15
degrees adducted (medial to sagittal
plane).

• Point thumb down. Examiner stands
behind patient and applies downward
force.

• Repeat with arm supinated (thumb up).

• If pain is elicited in first maneuver only,
then suggests labral tear (if pain
“inside” shoulder) or AC joint
abnormality (if pain “on top” of
shoulder).

Sensitivity: 0.47 | Specificity: 0.55 | LR: +1.04/-.096

www.pthaven.com

This test, called O’Brien test or compression rotation test, is used to identify glenoid
labral tears and assess an unstable superior labral anterior posterior (SLAP- superior
labrum anterior and posterior) lesions.

• A positive test occurs with pain reproduction or clicking in the
shoulder with the first position and reduced/absent with the
second position.

• Depth of symptoms must also be assessed as superficial pain can
indicate acromioclavicular joint symptoms and deep pain is more often a
sign of a labral lesion.

P a g e | 65

Biceps Muscle

Yergason Test
• Position patient’s elbow

at 90 degrees with the
thumb up. Have the
patient supinate and flex
elbow against
examiner’s resistance
(holding at wrist)

Sensitivity: 0.74 | Specificity: 0.58 | LR: +1.76/-0.45

www.pthaven.com

Yergason's was designed to assess for pathology in the long head ofbiceps
tendon in its sheath.

• Pain located to bicipital groove area suggests pathology in the long
head of biceps in its sheath.

P a g e | 66

Biceps Muscle

Speed’s Test
• Place the patient's arm in shoulder

flexion, external rotation, full
elbow extension, and forearm
supination;
• manual resistance is then applied
by the examiner in a downward
direction.
• The test is considered to be
positive if pain in the bicipital
tendon or bicipital groove is
reproduced.

Sensitivity: 0.90 | Specificity: 0.14 | LR: +1.0/-0.71

www.pthaven.com

Speed's test was originally designed to assess for pathology of the long head of
biceps in its groove but has also been utilized in the assessment for SLAP lesions.

• Positive: Pain located to bicipital groove.
• This is commonly interpreted as suggestive of inflammation or lesions

related to the long head of biceps or biceps/labral complex.

P a g e | 67

Inferior Glenohumeral Capsule Laxity

Sulcus Sign
• Patient sitting or standing;

shoulder in neutral position,
elbow flexed at 90o; muscles
relaxed.
• Downward traction applied
at elbow.
• Positive if dimpling of skin
below acromion or widening
of subacromial space on
palpation of >2cm.

Sensitivity: 0.47 | Specificity: 0.55

Sulcus sign is used to detect inferior instability due to laxity of the superior
glenohumeral and coracohumeral ligaments (multidirectional instability)

Test for the presence of shoulder instability.

Because the head of the humerus is less stable within the glenoid fossa, patients with
an MDI frequently subluxate or dislocate.

• The inferior portion of the glenohumeral capsule is often most lax, and as a
result the head of the humerus can easily shift inferiorly.

• By applying a distal pull on the humerus, a glenohumeral joint that
displays capsular, muscular, or ligamentous laxity will translate inferiorly
greater than an asymptomatic joint.

• This excessive gapping between the acromion and humeral head is
considered a positive sulcus sign.