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Chapter 26
The Shoulder Girdle
Copyright 2005 Lippincott Williams & Wilkins
Anatomy and Kinesiology


Composed of four distinct articulations.
Each joint works interdependently and in
concert.
1.
2.
3.
4.
Sternoclavicular (SC)
Acromioclavicular (AC)
Scapulothoracic (ST)
Glenohumeral (GH
Copyright 2005 Lippincott Williams & Wilkins
Sternoclavicular Joint
Synovial joint that
articulates with 1st rib
and sternal notch.
Movements
Elevation (4–60°)
Depression (5–15°)
Protraction/retraction
(15°) from resting
position
Rotation (30–50°
posteriorly about
horizontal axis)
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SC Articulation
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Acromioclavicular Joint
Formed by
articulation of
acromion process of
scapula with acriomial
end of clavicle
Joint Motions
Upward/downward
rotation
Medial (winging)/
lateral rotation)
Anterior/posterior
tilting (tipping)
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Axes of Motion – AC Joint
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Scapulothoracic Joint
Functional, not
“true” joint.
Articulates with
convex rib cage.
Motions of Scapula
Elevation/depression
Abduction/adduction
Medial/lateral rotation
Upward/downward
rotation
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Glenohumeral Joint
Synovial joint
Head of humerus
articulates with
glenoid fossa of
scapula
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AC/GH Ligaments
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Scapulohumeral Rhythm
Initially believed to be 2:1.
More recent proposal of three distinct
patterns (each with different ratio).
Middle phase (80–140 degrees
abduction) – Scapular rotation
provides greater contribution to arm
elevation than GH motion.
Copyright 2005 Lippincott Williams & Wilkins
Myology
Scapulohumeral Group
 Supraspinatus
 Infraspinatus
 Teres minor
 Subscapularis
 Deltoid (anterior fibers)
 Deltoid (middle fibers)
 Deltoid (posterior fibers)
 Teres major
 Coracobrachialis
Function
 Humeral abduction
 Lateral rotation (LR)
 LR
 Medial rotation (MR)
 Flexion and MR
 Abduction
 Extension and LR
 MR
 Flexion and MR
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Myology (cont.)
Axioscapular Group
 Upper trapezius
 Middle trapezius
 Lower trapezius
 Serratus anterior
 Rhomboid major/minor
 Levator scapula
 Pectoralis minor anterior
Scapular Function
 Elevation
 Elevation/adduction
 Depression/adduction
 Abduction
 Elevation/adduction
 Elevation
 Depression and tilting
Copyright 2005 Lippincott Williams & Wilkins
Myology (cont.)
Axiohumeral Group
Function
 Pectoralis major
 MR extension and
adduction, clavicular
fibers flex to 90 degrees.
 Latissimus dorsi
 MR and extension
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Rotator Cuff – Deltoid Force Couple
Deltoid functions to elevate the arm
and produces superior translation of
humeral head.
Inferior and medial forces of rotator
cuff (RC) offset superior translation of
deltoid (specifically the INF, TM,
subscap).
RC also assists in limiting
anterior/posterior translation of
humeral head.
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Scapular Force Couple
Rotation of scapula is
provided by trapezius
force couple (upper,
mid, lower) and and
serratus anterior.
PICR migrates from
root of scapula toward
AC joint.
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EMG and Scapular Force Couple
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Integrated RC – Deltoid and Scapular
Force Couples
 Scapular rotation during arm elevation adds to total
ROM.
 Lack of scapular rotation = impingement.
 Scapular rotation is necessary to keep acromion moving
away from deltoid insertion.
 Lack of scapular rotation – Head of humerus translates
superiorly.
 Failure of scapular adduction – Head of humerus
translates anteriorly.
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Lack of Scapular Rotation
During Arm Elevation
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Examination and Evaluation
“Includes, but not limited to…..”




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



Patient/client history
Clearing examinations
Motor function (motor control and learning)
Muscle performance
Pain
Peripheral nerve injury
Posture
ROM, muscle length, joint mobility/integrity
Work, community, and leisure integration or
reintegration (including ADLs)
Copyright 2005 Lippincott Williams & Wilkins
Patient Client/History
General patient data + functional limitation
related to shoulder dysfunction.
Clearing Exams
Routine cervicothoracic spine screening.
Though rare, elbow-wrist-hand – as a “source.”
Visceral referral of symptoms.
Copyright 2005 Lippincott Williams & Wilkins
Motor Function (Motor Control
and Learning)
Visual observation, palpation of PICR of ST
and GH joints.
Observation can be augmented by SEMG.
SEMG assesses timing, magnitude, and
patterns of recruitment.
SEMG can be useful in determining faulty
motor control patterns.
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Muscle Performance
Specific MMTs
Can be done in conjunction
with SEMG or dynamometer
Positional strength testing
Selective tension tests
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Pain
 Choose tests that will determine pathomechanical
cause of pain
 Palpation of selected tissues to evaluate tissue
tension, temperature, swelling, and provocation of pain
 Subjective report of pain (VAS, etc.)
Peripheral Nerve Integrity
 Thoracic outlet and neural tissue provocation testing
 Patterns of weakness indicate peripheral nerve, nerve
root involvement, or forms of myopathy
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Posture
 Total body alignment (related to symmetry in limb
length)
 Head, thoracic, and lumbar spine alignment.
 Pelvic position (all three planes)
 Analysis of alignment of scapula, clavicle, and
humerus (all three planes)
 Do not underestimate the role of the lower quadrant
on function of the shoulder girdle
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ROM, Muscle Length, Joint
Mobility/Integrity – Tests
A/PROM ST, GH, CSP, TSP
Passive arthrokinematic mobility of SC, AC, GH,
ST, and cervicothoracic joints
Capsuloligamentous integrity
Glenoid labrum integrity tests
Rotator cuff integrity
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ROM, Muscle Length, Joint
Mobility/Integrity – Tests (cont.)
Subacromial impingement tests
Muscle length testing for SH, axioscapular, and
axiohumeral muscle groups
Functional movements including reaching
behind the back, touching back of the head and
neck, and reaching across to the opposite
shoulder
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Work, Community, and Leisure
Integration or Reintegration (including
ADLs)
Functional testing in the form of performance
testing or subjective grading
For example, shoulder pain and disability index
(SPADI)
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Therapeutic Exercise Intervention for
Common Physiologic Impairments – Pain
Differential diagnosis of pain in the shoulder girdle
is difficult due to interdependence of anatomy of
shoulder, elbow, wrist, hand, and cervicothoracic
spine.
 Treatment can be directed toward the source of the pain
(i.e., rotator cuff tendinopathy)
 Treatment must be directed toward the cause of the
pain (i.e., scapula downward syndrome)
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ROM and Joint Mobility Impairments
Hypomobility
Often coexists with hypermobility
Treatment
Manual stretching with concurrent strengthening
of weakened antagonist.
For example, stretch rhomboids while
strengthening scapular upward rotators.
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Stretching of Rhomboids/Upward
Rotator Strengthening
FIGURE 26-11. Transitional rotator cuff exercises. (A) The
patient places the ulnar aspects of the hands on the wall
and slides the hands up the wall in the sagittal or scapular
plane, depending on whether the focus is on the serratus
anterior or lower trapezius, respectively.
Copyright 2005 Lippincott Williams & Wilkins
Hypermobility
To treat effectively – Hypomobile segment(s)
must be identified.
 Improve muscle performance, length-tension
relationships, motor control of dynamic stabilizers
 For example, anterior GH hypermobility due to inefficient
properties of medial rotators (subscapularis)
 Goal – Train subscapularis to limit anterior GH
movement
 Include functional activities
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Subscapularis Isometric Exercise
Strengthen in Shortened Range
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Impaired Muscle Performance
Neurologic pathology
Muscle strain
Disuse, deconditioning, and
reduced conditioning
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Neurologic Pathology
Supraspinatus, axillary, long thoracic, spinal
accessory, and brachial plexus nerves are
vulnerable to injury.
 Resolve pathomechanics relating to injury (postures and
body mechanics).
 Early stages – NMES and level I exercises can be used
to prevent atrophy.
 PROM and joint mobility exercises to prevent loss of
mobility.
 Progress exercise positions from gravity-assisted to
gravity-lessened to against gravity.
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Muscle Strain
Can result from sudden and excessive tension or from
gradual and continuous tension imposed on muscle.
 Initially – Isometric contractions in pain-free shortened
range
 Concentric-eccentric dynamic exercise can be slowly
introduced
 Low-load muscle contractions in regeneration phase
 Final phase of healing should include activity-specific
exercises
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Disuse, Deconditioning, and Reduced
Conditioning
Combined program aimed at restoring muscle
force, endurance, and coordination.
Conditioning program should include exercises
for all major muscle groups.
Posture and movement technique should be
closely monitored.
Training depends on performance level (e.g.,
high-level athletes, strenuous workers).
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Shoulder Girdle Conditioning Program
Bench press (flat, incline, decline)
Prone middle and lower trapezius
Latissimus pulldown
Lateral deltoid raise – Frontal or scapular
plane (through full ROM) or military press
Front deltoid raise (through full ROM)
Biceps curl
Triceps extension
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Posture and Movement Impairment
Posture Treatment
 Education of habitual postures (cervical, thoracic,
lumbar, and pelvic) standing, sitting, and sleeping.
 Ergonomic/workstation education and modification.
 Support via bracing, taping, etc. to reduce strain on
lengthened muscles.
Movement
 Restore optimal PICR during active motion.
 Use of SEMG and cinematography can be helpful
Copyright 2005 Lippincott Williams & Wilkins
Therapeutic Exercise Interventions for
Common Diagnoses
Rotator cuff disorders include
medical diagnsoses such as:
Impingement syndrome
Rotator cuff/glenoid labral tears
Posterior shoulder pain
GH hypermobility/instability
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Stages of Pathology
 Stage I – Edema
and hemorrage
 Stage II – Fibrosis
and tendonitis
 Stage III – Tendon
degeneration and
rupture
May involve:
Supraspinatus
Biceps tendon
Subacromial bursa
AC joint
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Therapeutic Exercise Intervention of
Rotator Cuff Disorders
Secondary disorders should consider impairments
related to hypermobility and instability related to
impingement.
Serratus anterior and trapezius (all portions)
strengthening is essential while monitoring GH
movement!
Attention to “level” (difficulty) of intervention is
important for dosage and success.
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Treatment for Primary Rotator Cuff
Disorders
 Early stages – Medications, rest, resting position, ice
 Physical agents (IFC, etc.) for pain and inflammation
 ROM, muscle length, joint mobility exercises, and joint
mobilization
 Muscle performance exercises
 Posture and movement training
 Surgery – If conservative treatment fails
 Prevention – Educate early recognition
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Specific Therapeutic Exercise
Intervention for Rotator Cuff Disorder
 Pain and inflammation – Provide exercise for
impairments contributing to cause of symptoms.
 Muscle length – Passive manual stretch of rhomboids.
Self-stretch to GH lateral rotators.
 Muscle performance – Strengthen middle/lower
trapezius, serratus anterior in short range. Strengthen
rotator cuff.
 Posture and movement – Ergonomic modifications.
SEMG training for temporal relationships in scapular
rotators. Functional training.
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Scapular Upward Rotator Exercises
Upper Trapezius
 Shoulder shrug from armelevated postion
Middle Trapezius
 Prone arm lift with arm
overhead
 Prone horizontal
extension with lateral
rotation
Lower Trapezius
 Prone arm lift with arm
overhead
 Prone lateral rotation at
90° abduction
 Prone horizontal
extension with lateral
rotation
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Middle and Lower Trapezius Strengthening – Levels I/II/III
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Serratus Anterior Progressions – Levels I/II/III
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Hypermobility/Instability of GH Joint
GH stability involves articular geometry, the static
capsuloligamentous complex, dynamic muscular
stabilizers, and NM control.
Most common abnormal GH Motions
 Excessive anterior translation during lateral rotation and
abduction
 Excessive anterior translation during medial rotation
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Continuum of Shoulder Stability
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Contribution of Shoulder Musculature
to Joint Stability
 Passive muscle tension from bulk effect of rotator cuff.
 Rotator cuff contraction – Compression of articular
surfaces.
 Joint motion that secondarily tightens passive
ligamentous restraints.
 Barrier or restrain effect of contracted rotator cuff
muscle.
 Redirection of joint force to center of glenoid surface by
coordination of forces from GH and ST joints.
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Scapulothoracic Muscle Balance
Efficient forces depend on stability of origins
on scapula.
Scapular position affects length-tension
properties of rotator cuff.
Scapular upward rotation, posterior tilt, lateral
rotation – necessary to maximize subacromial
space.
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Treatment for GH
Instability/Hypermobility
 Specific joint mobilization (posterior capsule).
 Immobilization (max. 3 weeks) IF subluxation is
diagnosed.
 AROM against gravity as patient regains strength and
motor control.
 Main target muscle tends to be subscapularis as well as
gradually resisted exercises for pectoralis major,
latissimus, teres major.
 Infraspinatous and teres minor are also often targeted.
Must have stable scapula for rotator
cuff function to be effective!
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Treatment Principles for Postoperative
Rotator Cuff Disorders – Four Phases
Educate patient – Tendinous repair may take
12 months.
 Protective (1–6 wks) – Sling protection/pendulum exercise, selfassisted ROM.
 Early intermediate (6wks–3 mos) – Additional self assisted ROM,
PROM.
 Late intermediate (3–5 mos) – Isometrics and progress to dynamics
if possible. Swimming at 5 mos.
 Advanced rehabilitation (5 mos–1 year) – Submaximal activityspecific training. Progress to maximal training by end of year one.
Copyright 2005 Lippincott Williams & Wilkins
Adhesive Capsulitis
Characterized by a gradual loss of
active and passive ROM.


Primary adhesive capsulitis
Secondary adhesive capsulitis
1.
2.
3.
4.
4 Stages
Stage 1 – Acute (0–3 months)
Stage 2 – Freezing stage (3–9 months)
Stage 3 – Frozen stage (15–24 months)
Stage 4 – Thawing stage
Copyright 2005 Lippincott Williams & Wilkins
Treatment of Adhesive Capsulitis
Type and intensity of exercise depends on patient’s specific
strength, ROM, joint mobility, motor control, and level of
irritability.
Stage 1
 NSAIDs, steroid, and local analgesics can be helpful.
 Postural training to discourage FHP and kyphosis.
 Therapeutic modalities to control pain, inflammation, and
promote relaxation.
Copyright 2005 Lippincott Williams & Wilkins
Treatment of Adhesive Capsulitis
Stage 1 (cont.)
Grade I and II joint mobilizations and
movements within pain-free range.
Closed chain exercises to promote GH
stabilization.
Scapular exercises in pain-free positions.
Taping can be used to augment stability.
Copyright 2005 Lippincott Williams & Wilkins
Treatment of Adhesive Capsulitis
Stage 2
Continue to decrease pain and inflammation.
Passive stretching of posterior capsule (in
pain-free range).
Active exercises against gravity MAY be
introduced.
Careful isolated strengthening of rotator cuff,
serratus anterior, middle and lower trapezius.
Taping of ST joint for stabilization.
Copyright 2005 Lippincott Williams & Wilkins
Treatment of Adhesive Capsulitis
Stages 3 and 4
Improve GH mobility.
Restore SH rhythm.
Aggressive stretching and joint mobilization.
Heat may be used for relaxation of tissues.
Strengthening of rotator cuff and SH
muscles.
Copyright 2005 Lippincott Williams & Wilkins
Adjunctive Interventions: Taping
Scapular taping can improve the resting
alignment of the scapula on the thorax
Goals and Benefits of Taping
 Improve initial alignment.
 Alter length-tension properties.
 Provide support and reduce stress to myofascial
tissues.
 Provides kinesthetic awareness of scapular position
during rest and movement.
 Guide PICR during movement.
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Scapular Correction Possibilities
with Tape
 Correction of scapular depression and improving
scapular elevation.
 Correction of scapular downward rotation and
improving scapular upward rotation.
 Correction of scapular abduction and improving
scapular adduction.
 Correction of scapular winging.
 Correction of scapular anterior tilt.
 Correction of scapular elevation.
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Taping Scapula into Upward Rotation
C
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Taping Scapula into Elevation
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Summary
 Management of the shoulder complex requires an
understanding of the anatomy and kinesiology of the four
articulations that make up the complex.
 Precise PICRs at each articulation and integration of
each with respect to joint function, force couples, precise
motor control are required for optimal function of the
shoulder complex.
 Function of shoulder girdle affects and is affected by
other regions of upper and lower quadrant.
Copyright 2005 Lippincott Williams & Wilkins
Summary (cont.)
 Treatment of impairments should be complemented by
functional retraining modified to the level of ability at a
given time in the rehab process.
 Ideal total body posture is a prerequisite for optimal
movement in shoulder girdle complex.
 Understanding the integrated approach to therapeutic
exercise in the shoulder girdle is key to successful
outcomes of shoulder girdle conditions.
Copyright 2005 Lippincott Williams & Wilkins
Summary (cont.)
 Rotator cuff disorders include impingement
syndrome, rotator cuff/glenoid labral tears, posterior
shoulder pain, GH hypermobility, and instability.
 Treatment of adhesive capsulitis is individually
based on the stage of disease.
 Early intervention is key to successful outcomes of
adhesive capsulitis.
 Scapular taping can improve resting posture and
thereby affect movement of the shoulder girdle
complex.
Copyright 2005 Lippincott Williams & Wilkins