OULD£R
prereqmSlte to any treatment of a patient with in the of freedom. The resting position of the glenohumeral joint is
shoulder region is a precise and compre-_ive picture
of the signs and symptoms as they ent during the
assessment and as they existed until time. This knowledge
ensures that the techniques will be suited to the
condition and that the de-of success will be estimated
against this back-undo Shoulder pain can be caused
by intrinsic dis-
~ of the shoulder joints or pathology in the articular
structures, or it may originate from the ical spine, chest,
or visceral structures. Pathology is
~only related to the level of activity and age can a
significant role. The shoulder complex is difficult ess
because of its many structures (most of which located in
a small area), its many movements, and many lesions that
can occur either inside or out-
the joints. Influences such as referred pain from
cervical spine and the possibility of more than one on
being present at one time, as well as the diffi-ty in
deciding what weight to give to each response, -e the
examination even more difficult to under-
d. Assessment of the shoulder region often necessi--es an
evaluation of the cervical spine (see Chapter 3) rule out
referred symptoms, and the examiner must prepared to
include the cervical spine and its scan-
ng examination in any shoulder assessment.
Applied Anatomy
e glenohumeral joint is a multiaxial, ball-and-ket,
synovial joint that depends primarily on the
uscles and ligaments rather than bones for its sup-rt,
stability, and integrity.l Thus, assessment of the uscles and
ligaments/capsule can playa major role in
- e assessment of the shoulder. The labrum, which is :he ring
of fibrocartilage, surrounds and deepens the ;Ienoid cavity of
the scapula about 50%.2 Only part of the humeral head is in
contact with the glenoid at any one time. This joint has three
axes and three degrees
55° of abduction and 30° of horizontal adduc-tion. The close
packed position of the joint is full abduction and lateral
rotation. When relaxed, the hu-merus sits centered in the
glenoid cavity; with contrac-tion of the rotator cuff muscles,
it is pushed or trans-lated anteriorly, posteriorly, inferiorly,
superiorly, or in any combination of these movements. This
movement is very small, but if it does not occur, full
movement is impossible. The glenoid in the resting position
has a 5° superior tilt or inclination and a r retroversion (slight
medial rotation). The angle between the humeral neck and
shaft is about 130°, and the humeral head is re-troverted 30°
to 40° relative to the line joining the epicondyle. 3
The rotator cuff muscles play an integral role in shoulder
movement. Their positioning on the humerus may be
visualized by "cupping" the shoulder with the thumb
anteriorly, as shown in Figure 5 -1. The biceps tendon runs
between the thumb and index finger just anterior to the index
finger. The primary ligaments of the glenohumeral joint-the
superior, middle, and in-ferior glenohumeral ligaments-play
an important role in stabilizing the shoulder. 3,4 The superior
glenohu-meral ligament's primary role is limiting inferior
trans-lation in adduction. It also acts as a restraint to .ante-rior
translation and to lateral rotation up to 45° abduction. The
middle glenohumeral ligament, which is absent in 30% of the
population, limits lateral rota-tion between 45° and 90°
abduction. The inferior glenohumeral ligament is the most
important of the three ligaments. It has an anterior and
posterior band with a thin "pouch" in between so it acts much
like a hammock or sling. It supports the humeral head above
90° abduction limiting inferior translation while the anterior
band tightens on lateral rotation and the pos-terior band
tightens on medial rotation. 5 The coraco-humeral ligament
primarily limits inferior translation and helps limit lateral
rotation below 60° abduction. This ligament is found in the
rotator interval between the anterior border of the
supraspinatus tendon and
207
 208 CHAPTER 5 • Shoulder
Figure 5-1
Positioning of the rotator cuff with thumb over subscapularis, index
finger over supraspinatus, middle finger over infraspinatus, and ring
finger over teres minor.
the superior border of the subscapularis tendon, thus the
ligament "unites" the two tendons anteriorly (Fig. 5-2).6,7
See Table 5-1 for structures limiting move-ment in different
degrees of abduction. 5,8 The coraco-acromial ligament forms
an arch over the humeral head acting as a block to superior
translation. The transverse humeral ligament forms a roof
over the bi-cipital groove to hold the long head of biceps
tendon within the groove. The capsular pattern of the gleno-
humeral joint is lateral rotation most limited, followed by
abduction and medial rotation. Branches of the posterior cord
of the brachial plexus and the supra-scapular, axillary, and
lateral pectoral nerves innervate the joint.
Glenohumeral Joint
Resting position: 55° abduction, 30° horizontal
adduction (scapular plane)
Close packed position: Full abduction, lateral rotation
Capsular pattern: Lateral rotation, abduction,
medial rotation
The acromioclavicular joint is a plane synovial joint that
augments the range of motion (ROM) of the humerus in the
glenoid. The bones making up this joint are the acromion
process of the scapula and the
lateral end of the clavicle. The joint has three degrees of
freedom. The capsule, which is fibrous, surrounds the joint. An
articular disc may be found within the joint. Rarely does the
disc separate the acromion and clavicular articular surfaces.
This joint depends on liga-ments for its strength. The
acromioclavicular ligaments surround the joint and are
commonly the first liga-ments injured when the joint is
stressed. The coraco-clavicular ligament is the primary support
of the acro-mioclavicular joint. It has two portions-the conoid
and trapezoid parts. If a step deformity occurs, this ligament
has been torn. In the resting position of the joint, the arm rests
by the side in the normal standing position. In the close packed
position of the acromio-clavicular joint, the arm is abducted to
90°. The indi-cation of a capsular pattern in the joint is pain at
the extreme ROM, especially in horizontal adduction (cross-
flexion) and nUl elevation. This joint is inner-vated by
branches of the suprascapular and lateral pec-toral nerve.
Acromioclavicular Joint
Resting position: Arm by side
Close packed position: 90° abduction
Capsular pattern: Pain at extremes of range of
motion, especially horizontal
adduction and full elevation
The sternoclavicular joint, along with the acromio-
clavicular joint, enables the humerus in the glenoid to move
through a fi.ill 180° of abduction. It is a saddle-shaped
synovial joint "vith three degrees of freedom and is made up
of the medial end of the clavicle, the manubrium sternum, and
the cartilage of the first rib. There is a substantial disc
between the two bony joint surfaces, and the capsule is
thicker anteriorly than pos-
Biceps tendon -
Figure 5-2
Rotator interval showing the relationship between the supraspinatus
tendon, subscapularis tendon, and the coracohumeral ligament.
 CHAPTER 5 • Shoulder 209

able 5-1
tructures Limiting Movement in Different Degrees of Abduction
Angle of Abduction Lateral Rotation Neutral Medial Rotation

Superior G- H ligament Coracohumeral ligament Posterior capsule

Anterior capsule Superior G-H ligament
Capsule (anterior and
posterior)
Supraspinatus
_45° Coracohumeral ligament Middle G- H ligament Posterior capsule
ote 30°-45° abduction in Superior G- H ligament Posterior capsule
capular plane [resting Anterior capsule Subscapularis
position]-maximum looseness Infraspinatus
of shoulder) Teres minor
-=-°_60° Middle G-H ligament Middle G-H ligament Inferior G- H ligament
Coracohumeral ligament Inferior G- H ligament (posterior band)
Inferior G- H ligament (especially anterior Posterior capusle
(anterior band) portion)
Anterior capsule Subscapularis
Infraspinatus
Teres minor
Inferior G- H ligament Inferior G- H ligament Inferior G- H ligament
(anterior band) (especially posterior (posterior band)
Anterior capsule portion) Posterior capsule
Middle G- H ligament
Inferior G- H ligament Inferior G- H ligament Inferior G- H ligament
(anterior band) (posterior band)
Anterior capsule Posterior capsule
Inferior G- H ligament Inferior G- H ligament Inferior G-H ligament
(anterior band) (posterior band)
Anterior capsule Posterior capsule

G-H = Glenohumeral
Data from Curl, L.A., and R.F. Warren: Glenohumeral joint stability-selective cutting studies on the static capsular restraints. Coo. Orthop.
Relat. Res. 330:54-65, 1996; and Peat, M., and E. Culham: Functional anatomy of the shoulder complex. In Andrews, J.R., and KE. Wilk
[eds.]: The Athlete's Shoulder: New York, Churchill Livingstone, 1994.

eriorly. The disc separates the articular surfaces of the

Sternoclavicular Joint
-lavicle and sternum and adds significant strength to the
joint because of attachments, thereby preventing medial Resting position: Arm at side
displacement of the clavicle. Like the acromio--lavicular
joint, the joint depends on ligaments for its trength. The Close packed position: Full elevation
ligaments of the sternoclavicular joint include the anterior Capsular pattern: Pain at extremes of range of
and posterior sternoclavicular liga-ments, which support the motion, especially horizontal
joint anteriorly and posteri-orly, the interclavicular ligament, adduction and full elevation
and the costoclavicu-lar ligament running from the clavicle
to the first rib and its costal cartilage. This is the main
ligament main-taining the integrity of the sternoclavicular
joint. The movements possible at this joint and at the joint is innervated by branches of the anterior supracla-vicular
acromiocla-vicular joint are elevation, depression, nerve and the nerve to the subclavius muscle.
protrusion, re-traction, and rotation. The close packed Although the scapulothoracic joint is not a true joint, it
position of the sternoclavicular joint is full or maximum functions as an integral part of the shoulder complex and must
rotation of the clavicle, which occurs when the upper arm is in be considered in any assessment because a stable scapula
full elevation. The resting position and capsular pattern are enables the rest of the shoul-der to function correctly. Some
the same as with the acromioclavicular joint. The texts call this structure the scapulocostal joint. This "joint"
consists of the
210 CHAPTER 5 • Shoulder

body of the scapula and the muscles covering the pos-terior
chest wall. The muscles acting on the scapula help to
control its movements. The medial border of the scapula is
not parallel with the spinous processes but is angled about
3° away (top to bottom), and the scapula lies 20° to 30°
forward relative to the sagittal plane. 3 Because it is not a
true joint, it does not have a capsular pattern nor a close
packed position. The rest-ing position of this joint is the
same as for the acro-mioclavicular joint. The scapula
extends from the level of T2 spinous process to T7 or T9
spinous process, depending on the size of the scapula.
Because the scapula acts as a "stable base" for the rotator
cuff muscles, the muscles controlling its movements must
be stroQ.g and balanced because the joint acts to funnel the
forces of the trunk and legs into the arm. 9
.. Patient History
In addition to the questions listed under Patient His-tory in
Chapter 1, the examiner should obtain the
following information from the patient. IO Most com-
monly, the patient complains of pain, especially on
movement, restricted motion, and/or shoulder insta-bility.
1. What is the patient's age? Many problems of the
shoulder can be age related. For example, rotator cuff
degeneration usually occurs in patients who are be-tween
40 and 60 years of age. Primary impingement due to
degeneration and weakness is usually seen in patients older
than 35, whereas secondary impinge-ment due to instability
caused by weakness in the scap-ular or humeral control
muscles is more common in people in their late teens or
20s especially those in-volved in vigorous overhead
activities such as swim-mers or pitchers in baseball. I I
Calcium deposits may occur between the ages of 20 and
40. 12 Chondrosarco-mas may be seen in those older than
30 years of age, whereas frozen shoulder is seen in persons
between the ages of 45 and 60 years if it results from
causes other than trauma (Tables 5-2 and 5-3). Frozen
shoulder due to trauma can occur at any age but is more
com-mon with increased age.

Table 5-2
Differential Diagnosis ot Rotator Cuft Degeneration, Frozen Shoulder, Atraumatic Instability, and Cervical Spondylosis

Rotator Cuff Lesions Frozen Shoulder Atraumatic Instability Cervical Spondylosis

History Age 30-50 years Age 45+ Age 10-35 years Age 50+ years
Pain and weakness after (insidious type) Pain and instability with Acute or chronic
eccentric load Insidious onset or activity
after trauma or No history of trauma
surgery
Functional
restriction of
lateral rotation,
abduction, and
medial rotation
Observation Normal bone and soft ormal bone and Normal bone and soft- Minimal or no cervical
tissue outlines soft-tissue tissue outlines spine movement
Protective shoulder hike outlines Torticollis may be
may be seen present
Active Weakness of abduction or Restricted ROM Full or excessive ROM Limited ROM with
movement rotation, or both Shoulder hiking pain
Crepitus may be present
Passive Pain if impingement occurs Limited ROM, Normal or excessive Limited ROM
movement especially in ROM (symptoms may be
lateral, rotation, exacerbated)
abduction, and
medial rotation
(capsular
pattern)
Resisted Pain and weakness on Normal, when Normal Normal, except if
isometric abduction and lateral arm by side nerve root
movement rotation compressed
Myotome may be
affected