Outline for Shoulder Reading

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The Shoulder
Labelled Structures

Acromion Orientations and Shoulder Impingements
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The types of acromion orientations indicated above are known as Flat, Curved, Hooked and Convex. According to Magee (257), Type 1 exhibits has an acromion is parallel to the humeral head. Type 2 has a concave undersurface. It is considered the common type. In type 3, the most anterior portion of the acromion has a hooked shape. It is related to increased shoulder impingement. For type 4, the underside of the acromion is convex near the end. Here the impingement syndrome already exists.
Causes of Shoulder Impingement
Primary Causes: Impingement syndrome is a pain brought about by rubbing the rotor cuff tendon or biceps tendon against the acromion and being born with a smaller sub-acromial space. Conditions like osteoarthritis translate to the growth of sub-abdominal spurs which narrow the acromion space. Impingement occurs when one has a dynamically unstable shoulder. This is because of weak serratus anterior muscle, tight pectoralis minor muscles, and weak rotor cut-off tendons.
Secondary Causes: Secondary or indirect causes are related to physical activity and posture. Impingement can be caused by poor posture involving the neck shoulder or spine, repetitive overhead activities, forwarded shoulder position and excessive loading. The process of aging also causes degeneration of the rotor cuff (Magee, 260).
Mechanism of Injury
Fall onto the Acromion: Here the humerus moves up into the acromion and presses on the tendons.

This leads to the tearing of the rotor cut-off tendon.
Going Dead. The shoulder capsule of the front becomes overstretched because of a throwing action. The individual mostly players becomes incapable of throwing.
Unidirectional Instability: In this mechanism, the instability is due to tension acting in a single direction, anterior or posterior. It is mostly related to focal failure where a shoulder falls and dislocates. The tension causes ligaments or labrum to tear from the skeleton.
Multidirectional instability: This is a common problem associated with overhead movements. It is specific to the glenohumeral joint of the shoulder. This mechanism of injury leads to general laxity of the glenohumeral capsule. The instability pattern is simply in multiple directions, anterior, posterior and inferior.
Importance of Asking a Patient Which Movement invoke Their Pain
Information on pain allows the examiner to explore the dysfunction. The pain gives an insight into the bearable range of movement. A sharp pain upon movement may suggest a neuropathic cause whereas a deep ache may be due to a torn muscle or a dislocated joint. Radiating pain below the elbow is an indicator of the cervical spine and unstable shoulder pressing onto nerves (Magee, 267).
Scapular Dyskinesia/Scapular Dysfunction
This is a condition in which the normal position or motion of the scapula is altered. This happens during coupled scapula-humeral movements. It occurs following injuries involving the shoulder joint. In most of the cases result in loss of muscular coordination. Causes include intense overhead activity, overuse fatigue, and muscle strain.
Primary Scapula Winging
This form of scapula winging occurs when main muscles holding the scapula stop functioning. Usually, the nerve controlling the scapular muscular. This form of winging is due to neurologic injury, periscapular soft-tissue injuries and pathological changes in the bone.
Secondary Scapula Winging
It is caused by complications around the shoulder complex. It is associated with razor cut-of tear, shoulder dislocation, shoulder bursitis and a frozen shoulder. Bone tumors can also cause secondary winging. This is a condition which originates from disorders of the glenohumeral joint which produce abnormal scapulothoracic changes.
Dynamic Scapula Winging
This condition occurs due to a neuromuscular disorder. Here, the oxalate becomes more prominent upon movement. There are no pathological indications at rest. Another prototype of dynamic winging is the scapula alata caused by serratus anterior palsy. This is exhibited by the insufficiency of the retaining the oxalate to the thorax.
Painful Arc
It occurs on the lateral side of the upper arm and within the deltoid muscle at its point of insertion. The pain is felt at rest and more at night. According to Magee(273) the pain is experienced at a certain arc of movement. A painful arc between 60 and 120 degrees indicates a disorder in the subacromial region. Pain at a full elevation with arm movement through 180 degrees is an indicator of an acromioclavicular joint disorder.
Scapulohumeral Rhythm and Phases
The scapulohumeral rhythm involves two key motion components. The first one is the abduction of the glenohumeral joint which is initiated by the deltoid muscle and supraspinatus muscles. The other rhythm is the scapulothoracic rhythm which is characterized by upward movement of the scapula. This is caused by trapezius fibers, both upper and lower. It is also initiated by the serratus anterior muscle. The scapulohumeral rhythm occurs in three phases. In phase 1, the humerus exhibits a 30-degree abduction, the scapula shows minimum rotation and the clavicle is elevated to a maximum of 5 degrees. Phase 2 exhibits abduction of the humerus at 40 degrees a 40-degrees, upward rotation of the scapula at 20 degrees and 15 degrees elevation of the clavicle. In Phase 3, the humerus is elevated at 60 degrees, the scapula is rotated upward by 30 degrees and the clavicle exhibits 30 to 50 degree of post rotation and up to 15 degrees of elevation.
Shoulder Motion Range for “eating” and “combing” hair
In the shoulder, people need a range of 100, 89 and 205 degrees. Maximum angles of abduction and rotation are reached with combing hair.
Shoulder Instability: This refers to the inability to maintain the humeral head in the glenoid fossa. Ligaments and muscle structures around the glenohumeral joint create a balanced net reaction force(Magee, 290)
Primary Impingement: This form of impingement is considered a structural or morphological issue. These conditions one has no control over. They include osteoarthritis which causes structural narrowing of the acromion.
Secondary Impingement: It’s caused by lifestyle and posture. The scapula becomes too elevated, too abducted or too depressed thus affecting upward and downward rotation. It is also caused by poor T-spine mobility and poor exercise techniques.
Internal Impingement: This is a case where the shoulder joint points towards the back of the shoulder. It is very common among people who play overhead sports. The shoulder hurts when there is an excessive internal rotation.
Specialty Test Viability Based On Anatomy, Potential Pathology And Symptoms For A Positive Test
a. Instability
Andrew’s Anterior Instability Test. The patient lies supine with the shoulder abducted at 130 degrees and externally rotated at 90 degrees. The examiner stabilizes the elbow and the distal humerus. Here, the anterior deltoid, rotor cuff muscles, and glenoid labrum are engaged. Pain is an indicator of shoulder instability.
Inferior Shoulder Instability Test. The examiner applies downward force at the elbow while the arm is at a neutral position. This test examines the glenohumeral joint for hints of inferior instability. This is due to laxity of the glenohumeral ligament and coracohumeral ligament (Magee, 301).
b. Impingement
Hawkins-Kennedy Impingement Test: In this test, the scapula is stabilized to prevent upward rotation during a performance of the internal rotation. Passive internal rotation is performed until the pain occurs. Anatomically, the supraspinatus tendon is forced by the tuberculum majus against the coracoacromial ligament. Pain confirms supraspinatus tendon ,coracoacromial arch impingement.
Neer Impingement Test: Here, the patient has their scapula ipsilateral to prevent protraction. The arm is elevated passively forward. Here the tuberculum majus presses on the supraspinatus and subacromial bursa on the acromion. Pain indicates rotator-cuff impingement and inflammation (Magee, 315).
c. Tests of Labral Tears
Bankart Lesion: It’s an injured glenoid labrum of the shoulder, anterior or exterior due to shoulder dislocation.
SLAP lesion: This is an injury on the glenoid labrum in form of superior lateral tear from anterior to superior.
O’Brien Active Compression Test: The patient’s arm is placed at 90 degrees forward flexion, 15 degrees abduction and full internal rotation. The examiner puts their hand on the forearm of the patient. The downward force is applied to the lower arm as the patient resists. Anatomically, this test causes the acromion to be pushed by the tuberculum majus while compressing the acromioclavicular joint. Pain indicates AC joint pathology (Magee, 318).
d.Acromio-clavicular Tests
Acromioclavicular Crossover, Crossbody, or Y-axis Adduction Test: During the crossover test, the examiner passively places their arm in 90 degrees of forwarding flexion. They then abduct the arm horizontally while attempting to fully cross the chest. Pain over the acromioclavicular joint indicates AC pathology. The shear test involves cupping the hands together and applying a compressive force to the AC joint to create a shear. Abnormal movements confirm a disorder.
e. Muscle Tests
Infraspinatus Test: The elbow is placed at 90 degrees as the humerus is medially rotated at 45 degrees as the patient resists the force. Pain or inability to resist motion indicates Infraspinatus strain.
Speed’s Test: According to Magee (319), the elbow is at full extension and the arm is supinated. The examiner secures the arm from forwarding movement. A disorder is shown by a tender bicipital groove. This may be an indicator of SLAP lesion due to the interaction between the biceps and the labrum.
Supraspinatus or Empty Can test: Here, the arm of the patient is abducted at 90 degrees as the arm is rotated thumb down along the scapular plane of 30 degrees. Resistance is applied to the arm by the examiner while looking for pain or weakness. Their presence reveals supraspinatus tendon or muscle tear.
Yergason’s Test: The elbow is flexed at 90 degrees as the examiner stabilizes the elbow with one hand. The shoulder is rotated externally and the forearm supinated against resistance. Pain or tenderness in the bicipital tendon indicates tendon inflammation. Laxity is confirmed when the tendon pops out of the groove.
f. Shoulder Neurological Specialty Tests
Adson Maneuver: The examiner rotates the patients head towards the shoulder as the patients extend their head. The patient takes a deep breath and holds it. Neural pathology is confirmed in the absence of a pulse.
Works Cited
Magee, David J. Orthopedic physical assessment-E-Book. Elsevier Health Sciences, 2014.