2022 Shoulder Complex Kinesiology

Slide 1

Shoulder
Complex:
Anatomy,
Kinesiology
and Beyond

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

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 on the
shoulder blade. What a curious design!

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.

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.

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 the
skeleton, 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.

Slide 2

What we worked
so hard to learn

was good
enough…

OT School

Slide 3

What we worked OT School
so hard to learn

was good
enough…

Right?

Slide 4

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

Slide 5

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.

Slide 6

How did that work out for you??

Shoulder dysfunction can affect an individual’s ability to
function independently, consequently decreasing quality of
life.
Slide 7

Slide 8

TH E SH OULDER

Where do the upper
extrem ity bones

articulate with the
axial skeleton?

Slide 9

TH E SH OULDER

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

Slide 10

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.

Slide 11

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!

Slide 12

This is where it gets
interesting!

It’s called the Shoulder
Complex for a reason

The shoulder must be mobile enough for the wide range actions of
the arms and hands, but also stable enough to allow for actions
such as lifting, pushing and pulling.

The compromise between mobility and stability results in many
shoulder problems not faced by other similar joints, such as the hip.

Slide 13

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.

So Much to Remember!!Slide 14

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 in another plane, or neutralizes the effects of an
antagonistic muscle(s).

Slide 15

Function of Muscles of the
Shoulder Complex

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

Muscles and bones are not equipped to stabilize the glenohumeral joint.

Ligaments hold the
• clavicle to the sternum and scapula,
• scapula to humerus, and
• merge together to form the glenohumeral joint.

Slide 16

Glenohumeral Joint

• Ball and socket joint with 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 socket joint.
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.
• However, this also means that it is unstable, which can result in
injuries such as shoulder impingement, joint instability, rotator cuff
strains, rotator cuff ruptures, joint dislocations.
• It is also susceptible to decreased functional range and
coordinated movements after CVA.

Slide 17

Xray Views of the Normal Shoulder

Slide 18

Glenohumeral joint

• Capsular reinforcements
• Superior/middle/inferior
GH ligaments
• Coracohumeral ligament
• Long head of biceps/
triceps
• Rotator cuff tendons
blend with capsule

The glenohumeral joint ranks as the most mobile joint of the human body.
Static stabilizing structures include:

• the osseous articular anatomy and joint congruity,

• the glenoid labrum,
• the glenohumeral ligaments,
• joint capsule, and
• negative intraarticular pressure

The static and dynamic stabilizing structures allow for extreme degrees of
motion in multiple planes of the body that predisposes the joint to
instability events.

Slide 19

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 the top of your shoulder called the subacromial space.

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

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

Good posture is key to improving this condition.

Slide 20

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
actually 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..

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 tear effect on the long head of the biceps tendon.

Repetitive microtrauma (commonly seen in overhead, repetitive
movements) can also lead to inflammation of the tendon.

Slide 21

Scapulothoracic Joint

• Subscapular bursa/ serratus
anterior

• Functions include:

• Maintains length-tension
relationship of rotator cuff/deltoid

• Positions glenoid to receive
humeral head

• Absorbs shock
• Permits elevation of body (via

scapular depression)
• Enhances shoulder ROM

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 concave surface of the
anterior scapula.

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 and bursa 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.

Since it is not a true joint, the scapulothoracic junction doesn’t have
the capsular pattern nor the close-packed position. The joint takes
the loose-packed position when the arm is resting by the side of the
body.

Slide 22

Scapulohumeral Rhythm

• The actions of the shoulder https://youtu.be/H4nfQEeJmFo
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.

The scapulothoracic articulation allows increased shoulder elevation.
• For every 2º of glenohumeral elevation, there is 1º of
scapulothoracic elevation/rotation.

For 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.

Slide 23

Ok, so what are som e
conditions referred to
Occu patio n al Th e rapy?

Slide 24

Shoulder Conditions Commonly Referred to OT

• Frozen shoulder: Inflammation develops in • Shoulder impingement: The acromion (edge
the shoulder that causes pain and stiffness. As of the scapula) presses on the rotator cuff as
a frozen shoulder progresses, movement in the the arm islifted. If inflammation or an injury in
shoulder can be severely limited. the rotator cuff ispresent, this impingement
causes pain.
• Osteoarthritis: The common "wear-and-tear"
arthritis that occurswith aging. The shoulder is • Shoulder tendonitis: Inflammation of one of
less often affected by osteoarthritis than the the tendons in the shoulder's rotator cuff.
knee.
• Shoulder bursitis: Inflammation of the bursa,
• Rheumatoid arthritis: Aform of arthritis in the small sac of fluid that rests over the rotator
which the immune system attacks the joints, cuff tendons. Pain with overhead activities or
causing inflammation and pain. Rheumatoid pressure on the upper, outer arm are
arthritis can affect any joint, including the symptoms.
shoulder.

• Rotator cuff tear: Atear in one of the muscles
or tendons surrounding the top of the
humerus. Arotator cuff tear may be a sudden
injury or result from steady overuse.

Slide 25
Ok a y.

So what m otions are
produced by which

m uscles

Slide 26

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

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
• Decreased strength in above motions

EFFECTS OF TIGHTNESS OF THE PECTORALIS MAJOR
• Decreased ROM in lateral rotation and horizontal abduction; may
also limit shoulder flexion ROM

Slide 27

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

Serratus anterior pain can be caused by several medical conditions and
lifestyle factors.
The most common causes of muscle pain include:

• tension
• stress
• overuse
• minor injuries

Functional Deficiency Serratus anterior
Limited ability of scapula to upwardly rotate
Possibly long thoracic nerve palsy?

Slide 28

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

Deltoid pain is more common in people who do a lot of strenuous
activities or exercise involving the shoulder.

• You can also strain your deltoid muscle while doing repetitive
activity that puts pressure on the shoulder, including typing with a
keyboard that’s too high.

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.

Slide 29

Scapular Retraction

• Prime Mover: Middle trapezius (spinal

accessory n.)

• 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

The trapezius muscle is a postural and active movement muscle,
• The trapezius elevates, depresses, rotates, and retracts the scapula.
• used to tilt and turn the head and neck, shrug, steady the shoulders,
and twist the arms.
• The descending part of the trapezius muscle supports the arms.
• The transverse part retracts the scapulae, and
• the ascending part medially rotates or depresses the scapulae.

Innervation of the trapezius is derived from the spinal accessory nerve.

Functional Deficiency Applications

Trapezius
Spinal accessory nerve palsy—rare
Extreme limitation of shoulder elevation

Slide 30

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

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

Slide 31

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

Slide 32

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 patients already experience fatigue and/or compromise
of the respiratory muscles.

An overactive pectoralis minor and underactive serratus anterior leads to
winging of the scapula

Slide 33

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

When flexed, the muscle works at extending, adducting and rotating the
arm.

Because of its size and central location, injury to this muscle can be
debilitating.

• Injuries may include rips and tears.
• Once aggravated, the latissimus dorsi muscle is often the source of

chronic shoulder and neck pain, and it can cause tendonitis of the
shoulder joint.

ACTIONS OF THE LATISSIMUS DORSI MUSCLE
Extends, adducts, medially rotates, and depresses shoulder; also
active in forced inspiration 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 shoulder
May contribute to increased thoracic kyphosis

Slide 34

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

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 serratus anterior.

• The supraspinatus is the primary muscle for the abduction of the
arm to 15-30 degrees.

• The deltoid controls abduction from about 30 to 90 degrees.
• The trapezius and serratus anterior coordinate with each other and

the scapula to facilitate 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, teres minor—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 abduction to 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

Slide 35

Scapular Upward Rotation

• Prime Mover: Serratus anterior (long thoracic n.)
• Synergists: Upper and lower traps (spinal accessory n.)
• Antagonists: Pectoralis minor, rhomboids,

levator scapulae
• Neutralizers:

• Lower traps acts to prevent elevation caused by upper
traps

• Stabilizers: Serratus anterior, rhomboids, levator
scapulae

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

CONSEQUENCES OF WEAKNESS OF THE SERRATUS ANTERIOR AND
TRAPEZIUS MUSCLES

• Inability to upwardly rotate scapula can alter mechanics of
glenohumeral joint.

• Tightness of the serratus anterior may occurs with tightness of the
upper trapezius

Slide 36

Scapular Adduction

• Prime Mover: Latissimus dorsi (thoracodorsal n.)
• Synergists: Pectoralis major (sternal head) (medial and

lateral pectoral n.), coracobrachialis (musculocutaneous n), long
head of triceps (radial n.), infraspinatus (suprascapular n.),
teres minor (axillary n.), subscapularis (upper subscapular n.)
• Antagonists: Anterior deltoid, middle deltoid, biceps
brachii
• Neutralizers:

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

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

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

The muscles that protract and retract the scapula are antagonistic, that is,
they have opposed actions.

Used together, they fix the scapula in space to provide a fulcrum from
which to move the (lever) arm.

Slide 37

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

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

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

The subscapularis muscle is the most-used muscle in the shoulder.
• Overuse of the muscle-tendon complex may create a strain response
in the tendon that may not adequately heal.
• As a result, fibrosis and fatty tissue deposition in the tendon may
result.
• Trigger points in the muscle may then develop that tighten and
weaken the muscle.

Slide 38

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

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.
• Infraspinatus tear, tendinopathy, impingement, bursitis

Slide 39

Scapular Elevation and Depression

• Note that scapular elevation and
depression are not strictly paired
with a specific shoulder
movement or other scapular
action.

• They likely function to allow
movement of the glenohumeral
joint in various transverse plane
or to extend movement in the
frontal plane

Scaption refers to raising your arms from your sides and slightly forward.
• 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

Slide 40

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

Impacts shoulder motions above 90 degrees of so.

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.

It elevates, depresses, rotates, and retracts the scapula, or shoulder blade.

The functional scapula motions of upward rotation, posterior tilt, and
external rotation increase the width of the subacromial space during
humeral elevation.

However, a lack of proper scapula function (scapula dyskinesis) increases
the translation of the humeral head, which alters scapula position and
motion in both static and dynamic applications possibly leading to injury

Functional Deficiency Trapezius
Spinal accessory nerve palsy—rare
Extreme limitation of shoulder elevation

Slide 41

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

You can see the influence of the lower traps and pec minor due to its
insertions along the spine of the scapula and the coracoid process.

• When muscles contract together, then tilt the scapula downward

The lower trapezius is one muscle that plays an important role in scapula
movement and positioning, and also dynamic scapula stability.

Slide 42

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

Slide 43

Start by Developing an Initial
Evaluation for Your Patient

Slide 44 SHOULDER EXAMINATION

A typical Occupational Therapy 1. Inspection 3. ROM: Resisted
Shoulder Examination may a. Gait a. C-spine, shoulder, elbow
include some or all of these b. Ability to disrobe b. Note pain, range, and apparent weakness
categories. c. Topical scan
(1) Discoloration 4. Neurological examination
• The Correct Evaluation will (2) Atrophy a. DTR's
depend upon your patient (3) Bilateral comparison - symmetry (1) Biceps - C5
(clinical reasoning) (4) Indication of present or past (2) Brachioradialis - C6
pathology (3) Triceps - C7
• You would approach a CVA d. Osteology (always look at joints b. Sensory by dermatome
shoulder differently than you proximal and distal) (1) Light touch
would a rotator cuff injury. (1) Anterior (2) Pin prick
(a) Clavicle c. Segmental Muscle test
(b) Acromion (1) C2-3-4 Scapular elevation
(c) Humerus (trapezius and levator scapulae)
(d) Head and neck posture (2) C5 Scapular retraction
(2) Posterior (rhomboids)
(a) Scapula (3) C5-6-7 Scapular protraction
(b) Shoulder level (serratus anterior)
(c) Cervical and thoracic spine (4) C5 Deltoid, Biceps
(5) C6 Extensor carpi radialis
2. Active and passive ROM longus and brevis
a. Cervical Spine (6) C7 Triceps
(1) Flexion (7) C8 Flexor digitorum
(2) Extension superficialis
(3) Side Bending (8) T1 Dorsal interossei
(4) Rotation
b. Shoulder 5. Palpation
(1) Flexion (anterior deltoid, a. Skin
coracobrachialis) b. Muscle and tendons
(2) Extension (posterior deltiod, teres c. Subdeltoid bursa
major, latissimus dorsi) d. Ligaments
(3) Abduction (deltoid, supraspinatus) e. Bone
(4) Adduction (teres major, latissimus f. Joints
dorsi, pectoralis major) (1) acromioclavicular
(5) Intrnal rotation (subscapularis, teres (2) sternoclavicular
major, latissimus dorsi) (3) scapulothoracic
(6) External rotation (infraspinatus, (4) glenohumeral
teres minor)
c. Elbow
(1) Flexion
(2) Extension
(3) Pronation
(4) Supination

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 assessment and 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 not missed.

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

Slide 45

MANUAL MUSLCE TESTING OF
THE SHOULDER COMPLEX

Slide 46

Manual Muscle Test: Shoulder Complex

https://youtu.be/_cZmHxI_VeY

This is a quick 9-minute video on how to conduct a MMT of the shoulder.

Slide 47

Rotator Cuff Subacromial
Impingement

Apley Scratch Test

• This test is a useful
maneuver to assess
shoulder range of
motion.

https://youtu.be/oORkZ2gLlbA

2 min Video

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.
o 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.

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

Slide 48

Provocative Tests

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

• "SnNout" High Sensitivity, Negative results = rule out the disorder in question

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

• "SpPin" High Specificity, Positive results = rule in the disorder in question

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

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

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

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 target disorder 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, the Hawkins-Kennedy test for subacromial
impingement has been reported by some to have a specificty of
1.00, or 100%. A positive test result is very likely to include those
people who have impingement.

Slide 49

Supraspinatus Muscle

Hawkin’s Test
• Position arm in throwing position

and flexed forward 30 degrees.
Examiner internally rotates
humerus.

Sensitivity: 0.92 | Specificity: 1.00
https://youtu.be/X9YiuvQJVJc

2 min 15 sec video

Originally described in the 1980's the Hawkins and Kennedy test was
interpreted as indicative of impingement between the greater tuberosity of
the humerus against the coraco- humeral ligament trapping all those
structures which intervene.

The patient stands while the examiner forward flexes the arm to 90 degrees
and then forcibly medially rotates the shoulder.

The test may be performed in different degrees of forward flexion or
horizontal adduction.”

Slide 50

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

https://youtu.be/DeO50UTxwoo

2 min video

The Empty Can Test (ECT) was originally described by Jobe and
Moynes to test integrity of the supraspinatus tendon.

Patient is seated or standing with arm raised in the scapular plane to 45-90
degrees with shoulder externally rotated.

• The therapist applies a downward force just proximal to the
patient’s wrist while the patient resists.

• Test is positive if it elicits pain and/or weakness.

Slide 51

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: 0.48 | Specificity: 0.97

https://youtu.be/JXgRBeqToik

90 sec video

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

“Patient is seated with examiner to the front.
• Examiner grasps the patient’s wrist and passively abducts the
patient’s shoulder to 90 degrees.
• Examiner releases the patient’s arm with instructions to slowly
lower the arm.
• Test is positive if the patient is unable to lower his or her arm in a
smooth, controlled fashion.”

Glenohumeral subluxation

Glenohumeral subluxation was defined as a
palpable gap between the inferior aspect of
the acromion and the superior aspect of the
humeral head that is ½ fingerbreadth or
more.

0–5 grading scheme
• 0 = no subluxation,
• 1 = ½ fingerbreadth gap,
• 2 = 1 fingerbreadth gap,
• 3 = 1½ fingerbreadth gap,
• 4 = 2 fingerbreadth gap, and
• 5 = 2½ fingerbreadth gap.

Glenohumeral subluxation was defined as a palpable gap between
the inferior aspect of the acromion and the superior aspect of the
humeral head that is ½ fingerbreadth or more.

A 0–5 grading scheme
0 = no subluxation,
1 = ½ fingerbreadth gap,
2 = 1 fingerbreadth gap,
3 = 1½ fingerbreadth gap,
4 = 2 fingerbreadth gap, and
5 = 2½ fingerbreadth gap.

Slide 52

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: 0.41 | Specificity: 0.90

https://youtu.be/R67cIKM3EAM

1 min 44 sec video

“The patient stands with the arm at the side with the elbow at 90 degrees
and the humerus medially rotated to 45 degrees.

• The therapist applies a medial rotation force that the patient resists.
• Pain or the inability to resist medial rotation indicates a positive test

for an infraspinatus strain.

Slide 53

Rotator Cuff Subacromial
Impingement

Lift-Off Test Sensitivity: 0.89 | Specificity: 0.31
• With the arm fully
https://youtu.be/t9dSDVRbjn0
pronated, the examiner
raises the arm above the
patient’s head in
forward flexion
movement. Stabilize
scapula to prevent
scapulothoracic motion.

1 min 44 sec video

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.

Slide 54

Labral Tear

Crank Test

• Position patient’s
arm in 90 deg
abduction and elbow
flexion. Examiner
pushes humerus into
glenohumeral joint
while internally and
externally rotating
arm.

Sensitivity: 1.00 | Specificity: 0.98

https://youtu.be/HTpejI3FGG4

1 min 50 sec video

This test is used to evaluate the different glenohumeral ligaments or for
anterior shoulder instability. This test may also be used to assess a labral
tear.

“With the subject standing, the examiner places the distal hand on the
subject’s elbow and the proximal hand on the subject’s proximal humerus
and then passively elevates the subject's shoulder to 160 degrees in the
scapular plane.

• With the distal hand, the examiner applies a load along the long
axis of the humerus while the proximal hand externally and
internally rotates the humerus.

• The Crank Test is considered positive if the patient’s pain is
reproduced.

• The test may also produce an audible or palpable clicking in the
glenohumeral joint.
• This clicking should be repeatable.