All about shoulder Joint ..

All about shoulder joint , Anatomy ,Examination, Special tests and radiology.

1. Shoulder joint By: Aya Reyad Rheumatology resident at Aswan University Hospital

2. c ontents Anatomy 01 Examination 02 DD of shoulder pain 03 Radiology 04

3. ANATOMY

4. The shoulder complex composed of Three bones , the clavicle , scapula and humerus. Four joints, the Glenohumeral (GH) Joint the Acromioclavicular (AC) Joint the Sternoclavicular (SC) Joint the Scapulothoracic (ST) joint { false floating joint } The shoulder allows for a large range of motion due to the spheroid shape of the glenohumeral joint but this (i.e. a large ball in a small socket) renders it prone to dislocation and other injuries. BONES | JOINTS

5. The glenohumeral joint movements : Flexion (110°) - extension (60°) Abduction (120°) - adduction (0°) Internal rotation (90°) - external rotation (90°) Combination of these movements gives circumduction Together with acromioclavicular, sternoclavicular and scapulothoracic articulations : a greater range of motion is available : Flexion (180°) - extension (90°) Abduction (180°) - adduction (30°) Internal rotation (90°) - External rotation (90°) Movements

6. The glenohumeral joint seen from a lateral view . Green | The capsule

7. The glenohumeral joint is innervated by,, T he subscapular nerve (C5-C6), a branch of the posterior cord of brachial plexus. The joint capsule is supplied from several sources,, Suprascapular nerve supplies the posterior and superior aspects Axillary nerve innervates the anteroinferior part of the capsule Lateral pectoral nerve supplies the anterosuperior part and the rotator capsule INNERVATION

8. Green suprascapular nerve

9. Green Axillary nerve

10. Green Lateral pectoral nerve

11. Blood supply to the shoulder joint comes from : The anterior and posterior circumflex humeral. circumflex scapular. suprascapular arteries. BLOOD SUPPLY

12. Green Circumflex scapular artery

13. Glenohumeral Ligaments 1 . Superior 2.Middle 3.Inferior Coracoacromial Ligament Coracohumeral Ligament Coracoclavicular Ligament Acromioclavicular Ligaments LIGAMENTS

14. Muscles acting on the shoulder joint Flexion Pectoralis major, deltoid, coracobrachialis, long head of biceps brachii Extension Latissimus dorsi, teres major, pectoralis major, deltoid, long head of triceps brachii Adduction Coracobrachialis, pectoralis major, latissimus dorsi, teres major Abduction Supraspinatus, deltoid Internal rotation Subscapularis, teres major, latissimus dorsi, pectoralis major, deltoid External rotation Teres minor, infraspinatus, deltoid

15. Muscles around the shoulder joint include: 1-The rotator cuff muscles { infraspinatus, teres minor, supraspinatus and subscapularis } 2-The deltoid muscles { anterior , middle , posterior} 3- secondary movers * Triceps (3 heads) * Biceps brachii (long head / short head) 4 - Extrinsic muscles * Teres major * Pectoralis minor * Pectoralis major * Latissimus dorsi 5- The other muscles * Subclavius * Coracobrachialis * Sternocleidomastoid * Levator scapulae * Rhomboid major * Rhomboid minor * Trapezius (upper / middle / lower) MUSCLES

16. Function of Bursae ??? BURSAE

17. The bursae have both a nerve supply and mechanoreceptors which aid proprioceptive information of shoulder joint position. This shows that bursae don’t only function as a lubricator between tissues.

18. 1=Subacromial-subdeltoid (SASD) bursa 2=Subscapular recess 3=Subcoracoid bursa 4=Coracoclavicular bursa 5=Supra-acromial bursa 6=Medial extension of subacromial-subdeltoid bursa

19. https://www.youtube.com/watch?v=D3GVKjeY1FM&t=19s youtube video

20. Examination

21. 01 02 03 04 Inspection Screening exam Palpation Range of motion then SPECIAL TESTS

22. Inspection • Skin : redness, scars, rashes. • Muscles : wasting, atrophy of deltoid (squaring sign). • Bones and joints: _ swelling particularly anteriorly obscuring the coracoid process area; this is in case of glenohumeral joint effusion. _ deformities (acromioclavicular (AC) joint, clavicle). _ scapula elevation (back), and asymmetry posteriorly. (look at back exam for asymmetry)

23. Screening Exam The aim is to screen for gross pathology. • It is basically the active ROM testing • Ask the patient to abduct (ABD) shoulders to 90°, then supinate forearms , continue abduction to 180°, do painful arc by bringing both shoulders to zero position again { if the patient develops pain, it indicates positive painful arc test suggestive rotator cuff tendinitis } • Ask patient to bring his hands behind the neck (ER + ABD), and then move hands backward over the back internal rotation (IR) and adduction (ADD) (IR + ADD). • Then try bringing your thumbs on your back as high as possible. • Ask the patient to do forward flexion and extension. • Shoulder elevation, protraction, retraction, and circumduction.

24. Palpation • Palpate for bony and soft tissue structures : start with sternoclavicular joint , then move to feel clavicle , AC joint, Acromion , Subacromial bursae (a lateral structure just below the acromion) (tenderness indicates RCT ) Greater trochanter (rotator cuff inserts here ) medially feel bicipital groove (long head of biceps) Coracoid process where the short head of biceps inserts . • Palpate for crepitus by simply feeling over the joints while moving the shoulder joint.

25. Range of Motion • The aim is to differentiate between intra articular and extra-articular pathology. • In intra-articular pathology (arthritis), active and passive ROM are limited due to infammation of the synovial membrane that moves during both active and passive ranges causes pain . • In extra-articular pathology (periarthritis), the active range only is limited . there is pathology in structures around the joint like in RCT or subacromial (subdeltoid) bursitis ,Here the active ROM will be limited but the passive is not.

26. • Active ROM was assessed during the screening exam. • For passive ROM: watch the location of your hands! _ Place your right hand on the right shoulder over AC joint frmly. This is to stabilize the scapula in order to do isolated GH joint movement without scapular elevation. The other hand should hold the proximal forearm. • Do shoulder abduction up to 90°. This is a pure GH joint movement. Then do ER and IR, while the shoulder is abducted at 90°. Then adduct the shoulder back to zero position . Then do extension. Then do forward fexion. • You can assess ER + IR while at zero abduction with arms on the sides ,and elbows flexed

27. RCT • Isometric resisted abduction while the arm is in zero degree. If there is pain developing, this could be due supraspinatus tendinitis . • Empty can sign: ( Shoulder abducted 90° + forward fexion 30° + thumb down (IR) — supraspinatus tendinitis ). • Infraspinatus test Isometric resisted ER (elbow fexed 90° with the arm at the side) , In the same position, you can assess isometric resisted IR for subscapularis tendinitis • Left off Test This test is performed with isometric resisted IR while the patient adducting his shoulder and internally rotating it. Presence of pain while resistance may indicate subscapularis tendinitis Special tests

28. Empty can sign Left off Test

29. subacromial impingement syndrome • Hawkins Sign Shoulder horizontal adduction in 90° of fexion then adduct shoulder more with passive IR; this should reproduce symptoms if subacromial impingement syndrome. • Neer test stabilize the patient's scapula with one hand, while passively flexing the arm while it is internally rotated. the patient reports pain if subacromial impingement syndrome. • Painful arc : from 60 to 120 so subacromial impingement syndrome

30. Hawkins sign Neer test

31. • Drop Arm Test This is to test for complete supraspinatus tear Stand behind the seated patient and passively abduct the patient's extended arm to 900 and full external rotation, while supporting the arm at the elbow Release the elbow support and ask patient to slowly lower the arm back to neutral.

32. • For bicipital tendinitis: 1– Speed’s test : resisted shoulder fexion at 90° with elbow extended and forearm supinated. 2– Yergason’s sign : resisted supination of the forearm with elbow 90° fexion. It has to be noted that rupture of the long head of biceps is rarely associated with signifcant weakness in elbow fexion. This is probably due to the fact that 85% of elbow flexion is from brachioradialis and short head of biceps .

33. For AC joint : • Painful arc : when it produces pain from 180 to 120. It is usually due to AC joint pathology rather than RCT. • There is another test called cross-body adduction test . The patient simply performs horizontal adduction with the shoulder in fexion. This might reproduce pain due AC joint pathology. For glenohumeral joint instability : • Anterior apprehension test (supine, 90 ABD and 90 ER, apply gentle forward pressure to posterior aspect of humeral head).

34. Anterior apprehension test cross-body adduction test

35. Surface anatomy

36. shoulder pain

37. Radiology

38. 1. anatomical neck of humerus 2. greater tuberosity 3. lesser tuberosity 4. surgical neck of humerus 5. humeral shaft 6. humeral head 7. glenoid fossa 8. acromion 9. acromioclavicular joint 10. coracoid process 11. clavicle 12. superior angle of scapula 13. medial border of scapula 14. inferior angle of scapula 15. lateral border of scapula 16. scapula

39. Thank you ..