KEY ANATOMICAL AREAS WHEN ASSESSING THE

SHOULDER

MIKE GRICE: OSTEOPATH, CLINICAL ANATOMIST

Mike Grice – Osteopath, Clinical Anatomist,
Sports Therapist
Mike.Grice@MTE.Education

IOC World Conference

for Injury Prevention

Chapter 2 –
Subjective History

Movement Therapy
@BhamMovement @MovementTherapyEducation
Education
IMPINGEMENT
IMPINGEMENT?

• Debated whether the term impingement should still be

used
• Will patients get scared if they are told their problem is
coming from an impingement

Lift your arm up above your head

Subacromial Pain Syndrome?

 SUB ACROMIAL PAIN SYNDROME
(SAPS)

External & Internal

Primary and Secondary

We’ll focus on External – Primary & Secondary

SUB ACROMIAL PAIN SYNDROME
(SAPS)

External – Primary
 EXTERNAL SHOULDER IMPINGEMENT (SAPS)
• Primary External Impingement
related to structural changes, either
congenital or acquired, that
mechanically narrow the subacromial
space such as

• Bony narrowing or osteophyte

formation
• Bony malposition after a fracture
• An increase in the volume of the
subacromial soft tissues.
• The shape of the acromion or
shoulder blade may play an
important role in recovery and
treatment from primary impingement.
SUBACROMIAL
ARCH – BONY
ROOF
 CORACOACROMIAL
ARCH – LIGAMENT ROOF

Strong triangular band which

joins the coracoid process with
the acromion process

Creates an arch for

the subacromial
space

Gives anterosuperior stability

to the GH joint
ACROMION Flat:10-43%

Curved: 25-89.8%

Hooked 0-40%
Bergman, R., Tubbs, R., Shoja, M.,
Loukas, M. and Bergman, R.,
n.d. Bergman's comprehensive Inferiorly Convex: 1.6-2.6%
encyclopedia of human anatomic
variation.
 ACROMION

Bergman, R., Tubbs, R., Shoja, M., Loukas, M. and

Bergman, R., n.d. Bergman's comprehensive
encyclopedia of human anatomic variation.
WHAT CAN GET COMPRESSED UNDER
THE ARCH SUB ACROMION ARCH?

• Supraspinatus
• Infraspinatus
• Sub acromion Bursa
SUPRASPINATUS
 SUPRASPINATUS
O I A N Ar
Abduct Upper and Subscapular,
Greater
shoulder lower Suprascapular
Supraspinous tubercle
joint, subscapular and lateral
Fossa of
Stabilise nerves C5- thoracic
humerus
humerus C7 atreries

Supraspinatus – prone, resist initial abduction

Tendon – sitting, hand behind back

INFRASPINATUS
 INFRASPINATUS
O I A N Ar
Laterally
rotates
shoulder,
adducts Suprascapular
Greater
Infraspinous shoulder, Suprascapular and circumflex
tubercle of
Fossa Extends nerve scapular
humerus
shoulder, atreries
horizontally
extends

One of the most powerful external rotators.

Recruited eccentrically to slow down in follow through.
Infraspinatus – prone, abduction, resist lateral rotation or
horizontal extension

Tendon – supine, flexion, adduction, lateral rotation

SUB ACROMION BURSA
 SUPRA-ACROMIAL RIGHT SHOULDER

BURSAE
BURSA ANTERIOR VIEW

Sacs of fluid
MIAL-
that prevent SUB
O
ACR TOID
UBDEL
friction S
BUR
SA CORACO-
CLAVICULAR
between BURSA

surfaces
May become
inflamed SU SUBCORACOID
BS
causing a C
BU AP
BURSA
RS ULA
bursitis A R

(Hirji, Hunjun and Choudur, 2011)

WHAT CAN GET COMPRESSED UNDER
THE SUBCORACOACROMIAL ARCH?

• Supraspinatus
• Subscapularis
• Sub acromion Bursa
• Biceps Tendon (Long Head)?
SUBSCAPULARIS
 SUBSCAPULARIS
O I A N Ar
Lesser Medially Upper and Subscapular,
Subscapular tubercle rotates Lower suprascapular
fossa of shoulder, subscapular & lateral
humerus stabilizes nerves C5-7 thoracic artery

Largest rotator cuff

Stabilizes during majority of powerful movements

Subscapularis – side lying, flexion, resist medial rotation

Tendon – supine, no movement

LONG HEAD OF BICEPS
 BICEPS BRACHII
O I A N Ar
SH –
Coracoid Flexion of
process elbow, Anterior
Radial supination of Musculocutaneous Circumflex,
LH – tuberosity radio-ulnar joint, C5,6 Brachial
Supraglen flexion of Artery
oid shoulder
tubercle

Biceps – 90° flexion, supination, shake

hand + resist flexion
SUMMARY: EXTERNAL PRIMARY

BONY ANATOMY OR CALCIFIC

TENDON
SUB ACROMIAL PAIN SYNDROME
(SAPS)

External – Secondary
• Secondary External Impingement
• Functional Limitations
• Generally thought to be caused by
weakness of the Rotator Cuff Muscles
(functional instability)
• Glenohumeral joint capsule and
ligaments that are to loose (micro-
instability).
• Lack of centration of the humeral head on
the glenoid
• Impingement generally occurs at the
coracoacromial space secondary to
anterior (forward) translation of the
humeral head as opposed to the
Subacromial space that is seen in
primary impingement.
• Altered Biomechanics another possible
cause
BIOMECHANICAL TESTS
 PECTORALIS MINOR
O I A N Ar
Protraction
&
depression Medial
of scapula and Thoracoacromial,
3rd
to 5th Coracoid lateral superior and
process Pectoral lateral thoracic
rib Elevates
Nerves arteries
ribs during
C5-T1
forced
inhalation

Increased tone can lead to protracted shoulder girdle

and affect overhead shoulder joint movements

Pec Minor – supine, abduction + depression

 PEC MINOR – SOURCE OF "IMPINGEMENT"?
Why test it?
• A tight pectoralis minor limits scapular upward rotation,
external rotation, and posterior tilt, thereby reducing sub
acromial space. (Page, 2011)
• An adaptively short pectoralis minor may influence
scapular kinematics and is therefore a potential
mechanism for subacromial impingement. Borstad (2005)

Test:
• Lie supine.
• Compare distance of both posterior borders of acromion
processes from couch.

Pass:
• Symmetrical height and less than 2.5cms (1”)
NB: NOT a clinical test and lots of
Positive: anatomical variance
• Anterior shoulder girdle
PEC MINOR LENGTH TEST

Test: Supine Pec minor

length test

Conclusions drawn:
‘Tightness’ of the pec
minor causing a (Saxena, 2017)
protracted shoulder
girdle
Other muscles that attach
Something to consider: to the coracoid
Variations in pec minor
attachment, Rib cage
orientation, clavicle
(Tubbs, 2016)
shape
THORACIC The influence of thoracic mobility on shoulder pain

ROTATION requires further investigation

 GIRD & GERD
What is it?
•Glenohumeral Internal & External
Rotation Deficit
Causes?
•Overactive external/Internal rotators
•Capsule tightness
Signs and Symptoms?
•Altered biomechanics – reduced IR/ER
and associated ‘wind up’
•‘Impingement’ symptoms
Clinical Test?
•GIRD/GERD Test (Functional rather than
clinical)
DON’T FORGET ‘TROM’ THOUGH…
CLINICAL TESTS
 CLUSTER OF TESTS FOR SAPS
Dutch Orthopaedic Association Guidelines:

3 Tests: Hawkins Kennedy, Painful Arc, Infraspinatus Test

Positive Tests Likelihood Ratio Meaning?

3 tests are positive 10.56 High Likelihood

2 tests are positive 5.03 Moderate Likelihood

1 test is positive 0.9 Low Likelihood

0 tests are positive 0.17 Very Low Likelihood

(Park, 2005)
 CONCLUSION

IT’S DIFFICULT TO BE PRECISE

WITH STRUCTURE – RULE OUT
BONY CHANGES/CALCIFICATION
EARLY ON
Mike Grice – Osteopath, Clinical Anatomist,
Sports Therapist
Mike.Grice@MTE.Education

IOC World Conference

for Injury Prevention

MULȚUMESC Chapter 2 –
Subjective History

Movement Therapy
@BhamMovement @MovementTherapyEducation
Education