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Chapter 6: The Shoulder
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy, Function, and Dysfunction of
the Shoulder Complex
• General Overview
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Bones: scapula, clavicle, sternum, humerus, ribs
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Joints
• Typical: glenohumeral, sternoclavicular, acromioclavicular,
scapulothoracic
• Functional: coracoacromial arch
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Shoulder facts
• Most mobile joint in body & most frequently injured
• Function depends on many joints
• Most shoulder disorders affect several structures in region
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy, Function, and Dysfunction of
the Shoulder Complex (cont’d)
• Anterior view of the bones and joints of the shoulder
complex
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy, Function, and Dysfunction of
the Shoulder Complex (cont’d)
• Bones and Joints of Shoulder Girdle
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Bones
• Scapula
• Clavicle
• Sternum
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Joints
• Sternoclavicular
• Acromioclavicular
• Scapulothoracic
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy, Function, and Dysfunction of
the Shoulder Complex (cont’d)
• Glenohumeral Joint
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Structure
• Ball-and-socket synovial joint
• Joins glenoid fossa of scapula & head of humerus
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Function
• Greatest ROM of any joint in body
• Six basic motions: flexion, extension, abduction, adduction,
medial & lateral rotation
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy, Function, and Dysfunction of
the Shoulder Complex (cont’d)
• Glenohumeral Joint
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy, Function, and Dysfunction of
the Shoulder Complex (cont’d)
• Glenohumeral Joint
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Dysfunction & injury
• Susceptible to dislocation & subluxation (partial dislocation)
• Instability due to traumatic dislocation, rotator cuff injury or
weakness, or acquired or congenital joint laxity
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Treatment implications
• For instability: contract-relax (CR) muscle energy technique
(MET) in rotator cuff & muscles stabilizing scapula
• For muscle dysfunction and injury: soft tissue
mobilization, joint mobilization, MET
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy, Function, and Dysfunction of
the Shoulder Complex (cont’d)
• Bones and Soft Tissue of Glenohumeral Joint
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Humerus
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Joint capsule
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Labrum
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Ligaments
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Coracoacromial arch
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Bursae
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Nerves
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy, Function, and Dysfunction of
the Shoulder Complex (cont’d)
• Bones and Soft Tissue of Glenohumeral Joint
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Muscles of the shoulder region
• Muscles that stabilize the scapula: rhomboids, trapezius,
levator scapula, serratus anterior
• Muscles of the rotator cuff: supraspinatus, infraspinatus,
teres minor, subscapularis
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Function of rotator cuff muscles: dynamic stabilization
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Two common conditions that decrease stability of joint:
• Thoracic kyphosis
• Weakness in scapular stabilizing muscles
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy, Function, and Dysfunction of
the Shoulder Complex (cont’d)
• Muscles of the posterior shoulder region
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy, Function, and Dysfunction of
the Shoulder Complex (cont’d)
• Muscles of the anterior shoulder region
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Shoulder Dysfunction and Injury
• Factors Predisposing to Shoulder Pain
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Instability of glenohumeral joint
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Weakness in scapular stabilizing muscles
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Previous injury (dislocation of glenohumeral joint, separation of
AC joint)
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Hypomobility of cervical or thoracic spine
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Postural dysfunction
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Muscle imbalances
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Shoulder Dysfunction and Injury (cont’d)
• Differentiation of Shoulder Pain
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Active inflammation: pain that occurs or increases at night
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Irritation of a sensory nerve root: sharp pain, numbing, &
tingling in a dermatome
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Rotator cuff injury: pain at lateral portion of upper arm, painful
limitation when elevating arm overhead
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Bicipital tendinitis: well-localized pain at anterior portion of
head of humerus & aggravation with Speed’s test
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Adhesive capsulitis: stiffness in shoulder, dramatic loss of arm
motion (especially external rotation)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Shoulder Dysfunction and Injury (cont’d)
• Differentiation of Shoulder Pain
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Impingement: pain over anterior humerus, loss of internal
rotation, & painful Neer’s test
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Instability: clunking in shoulder with active circumduction &
excessive joint play in passive motion test for glenohumeral joint
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Pain originating in glenohumeral joint: rarely felt at joint,
but over lateral brachial region
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Shoulder Dysfunction and Injury (cont’d)
• Characteristics of Shoulder Pain (vs. neck pain)
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Elicited or increased from active shoulder motion & relieved by
rest
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Isometric challenge will be painful with localized lesion
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Painless weakness in arm & shoulder muscles from motor nerve
root problem in cervical spine
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Shoulder Dysfunction and Injury (cont’d)
• Common Dysfunctions and Injuries of the Shoulder
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Rotator cuff tendinitis (supraspinatus tendinitis)
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Infraspinatus tendinitis
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Subscapularis tendinitis
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Adhesive capsulitis (frozen shoulder)
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Impingement syndrome
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Instability syndrome of the glenohumeral joint
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Shoulder Dysfunction and Injury (cont’d)
• Common Dysfunctions and Injuries of the
Shoulder
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Bicipital tendinitis
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Subacromial (subdeltoid) bursitis
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Acromioclavicular ligament sprain
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Suprascapular nerve entrapment
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Costoclavicular syndrome (part of thoracic outlet syndrome)
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Pectoralis minor syndrome (part of thoracic outlet syndrome)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Shoulder Assessment
• History Questions Specific to Shoulder Pain
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Where is the pain? What is the quality of the pain?
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Is there a loss of motion in the arm?
• Observation Questions
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Anterior view
• Are the clavicles level? Is shoulder height even?
• Is there a smooth contour to the area of the lateral shoulder?
• Is there a sulcus sign from the flattening of the deltoid?
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Posterior view: Is there scapular winging?
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Side view: Are there rounded shoulders and FHP?
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Shoulder Assessment (cont’d)
• Motion Assessment
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Scapular stabilization test
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Abduction
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Medial rotation
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Flexion with internal rotation (Neer’s impingement test)
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Lateral rotation
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Horizontal flexion (adduction)
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Shoulder Assessment (cont’d)
• Scapular stabilization test
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Shoulder Assessment (cont’d)
• Passive Movements
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Abduction
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Lateral rotation
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Circumduction
• Isometric Tests
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Middle deltoid
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Empty-can test
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Resisted lateral rotation
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Long head of biceps (Speed’s test)
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Techniques
• Guidelines to Applying Techniques
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Two underlying assumptions
• 1. An injury or dysfunction in one structure causes
compensations in entire region of injury & elsewhere in body
• 2. An injury or dysfunction localized in one tissue affects
many other tissues in area
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Three techniques
• Muscle energy technique (MET)
• Soft tissue mobilization (STM)
• Joint mobilization
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Techniques (cont’d)
• Guidelines to Applying Techniques
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Intentions of treatment for acute conditions
• To stimulate movement of fluids to reduce edema, increase
oxygenation & nutrition, & eliminate waste products
• To maintain pain-free joint motion, prevent adhesions, &
maintain health of cartilage
• To provide mechanical stimulation to help align healing fibers
& stimulate cellular synthesis
• To provide neurological input to minimize muscular inhibition
& help maintain proprioceptive function
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Techniques (cont’d)
• Guidelines to Applying Techniques
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Intentions of treatment for chronic conditions
• To dissolve adhesions and restore flexibility, length, &
alignment to myofascia
• To dissolve fibrosis in ligaments and capsular tissues
surrounding the joints
• To rehydrate the cartilage & restore mobility & ROM to joints
• To eliminate hypertonicity in short, tight muscles; strengthen
weakened muscles; and reestablish normal firing patterns
• To restore neurological function by increasing sensory
awareness and proprioception
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Techniques (cont’d)
• Muscle Energy Technique (MET)
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Assessment of muscle length & glenohumeral joint passive ROM
• Lateral rotation
• Medial rotation
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Contract-relax & postisometric relaxation techniques
• Medial & lateral rotators of shoulder, pectoralis major & minor,
supraspinatus
• To increase medial rotation, external rotation, & inferior glide
of glenohumeral joint
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Treatment for loss of shoulder motion: external rotation &
elevation
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Techniques (cont’d)
• Soft Tissue Mobilization (STM)
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Wave mobilization: a combination of joint mobilization & STM
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Performed in rhythmic oscillations, 50 to 70 cycles/min
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Level I: for every client; designed to enhance health & bring
body to optimum performance
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Level II: for treating acute conditions; typically applied after
level I strokes
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