Chapter 4
Shoulder Girdle:
Bones: scapula, clavicle, sternum, acromion
Joints: sternoclavicular (SC), acromioclavicular (AC), scapulothoracic “joint”, glenohumeral joint
Ligaments: interclavicular ligament, costoclavicular ligament, sternoclavicular ligament
Key Bony Landmarks: (anterior) manubrium, clavicle, coracoid process, acromion process, glenoid
fossa, lateral border, inferior angle, medial border (posterior) acromion process, glenoid fossa, lateral
border, inferior angle, medial border, superior angle, spine of the scapula
Muscles of the Scapula: (anterior) supraspinatus, subscapularis, teres minor (posterior) supraspinatus,
infraspinatus, teres minor
Clavicle: s shaped for shock absorption; has a sternal end (costal facet) and a acromial end (acromial
facet); anterior surface is convex medially and concave laterally
Arthrokinematics of the Clavicle: (retraction) roll and slide in the same direction, (depression) roll and
slide in the same direction (??)
Sternoclavicular Joint:
Multiaxial: moves anteriorly 15 degrees with protraction, posteriorly 15 degrees with retraction (roll and
slide), superiorly 45 degrees with elevation, inferiorly 5 degrees with depression
Ligamentous support: strong, anteriorly by the anterior SC ligament, posteriorly by the posterior SC
ligament, stability against superior/inferior displacement by costoclavicular (1st rib to costal tuberosity,
firm stabilizer - limits extremes of clavicular motion strongest - superior) and interclavicular ligaments -
inferior
Articulation: of upper extremity with trunk; synovial joint with fibrocartilaginous disc
Sprain: incidence is low (5%), large medially directed force through clavicle - contact sports and road
traffic accidents; anterior or posterior (depends on where the clavicle goes, not where it get hits (pain with
horizontal abduction)
Acromioclavicular Joint:
Classification: multiaxial arthrodial (protraction/retraction), 20 to 30 degrees total gliding and rotational
motion accompanying other shoulder girdle and shoulder joint motions
Synovial Joint: with fibrocartilaginous disc (commonly worn away)
Ligamentous Support: superior acromioclavicular, inferior acromioclavicular, coracoclavicular
ligaments (provides additional stability, consists of - trapezoid/conoid ligaments), lateral forces causing
severe medial displacement)
Commonly Injured: lot of blunt trauma and landing
AC Joint Sprain:
Shoulder Separation (can occur)
Results: from forces that displace the scapular acromion process from the distal end of the clavicle
MOI: direct force applied to shoulder with arm in adducted position, impact from falling or constant with
external object
Subject: to overuse injuries
,Scapulothoracic:
NOT: a true synovial joint (2 bone surfaces), does not have regular synovial features - NO CONVEX ON
CONCAVE
Movement: depends on sternoclavicular and acromioclavicular joints, which allows the scapula to move
- 25 degrees abduction/adduction (protraction/retraction) - transverse plane
- 60 degrees upward/downward rotation - lateral plane
- 55 degrees elevation/depression - frontal plane
Supported: dynamically by its muscles, NO ligamentous support
Coracoacromial Ligament:
Impinges: during upward rotation and GH abduction (POSSIBLY externally rotated), causes a lot of
trauma
Labral Repair: very common in overhead athletes
Capsular Ligament:
GH Pouch, humerus sits in glenoid fossa
Movements:
Abduction (protraction): scapula moves laterally away from the spinal column
Adduction (retraction): scapula moves medially toward the spinal column
Downward Rotation: returning inferior angle inferomedially toward spinal column & glenoid fossa to
normal position
Upward Rotation: turning glenoid fossa upward & moving inferior angle superolaterally away from
spinal column - frontal plane
Depression: downward or inferior movement, returning to normal position
Elevation: upward or superior movement, as in shrugging shoulders - frontal
Shoulder Joint & Shoulder Girdle: work togetheir in carrying out upper extremity activities
- Scapular stabilizing effect so shoulder joint can create more power
- Need healthy scapular muscles so shoulder can move at good speed
Shoulder Girdle Muscles:
- Stabilize scapula so the shoulder joint muscles will have a stable base from which to exert force
for moving the humerus
- Contract to maintain scapula in a relatively static position during shoulder joint actions
- Contract to move shoulder girdle & to enhance movement of upper extremity when shoulder goes
through extreme ranges of motion
For some movements, scapula must rotate or tilt on its axis: EXTREMES
Lateral tilt (outward): during abduction (horizontal adduction OF GH), scapula rotates about its vertical
axis resulting in posterior movement of medial border & anterior movement of lateral border
Medial Tilt (inward, return from lateral): during extreme adduction (horizontal abduction OF GH),
scapula rotates about its vertical axis resulting in anterior movement of medial border & posterior
movement of lateral border
,Anterior Tilt (upward): rotational movement of scapula about frontal axis occurring during
glenohumeral hyperextension; superior border moving anteroinferiorly & inferior angle moving
posterosuperiorly
Posterior Tilt (downward): rotational movement of scapula about frontal axis occurring during
glenohumeral hyperflexion; superior border moving posteroinferiorly & inferior angle moving
anterosuperiorly
Synergy:
When Shoulder Joint Goes to Extreme ROM: scapular muscles contract to move shoulder girdle so
that it’s glenoid fossa will be in a better position, from which the humerus can move
Without: the scapula movement, humerus can only be raised to 90 degrees
Works By: muscles of both joints working together, ex. Raising out hand out to the side laterally as high
as possible - serratus anterior and trap (lower and middle) muscles upwardly rotate scapula as
supraspinatus and deltoid initiate glenohumeral abduction
Scap/Humeral Rhythm: Force Couple
Multiple Muscles: working in different directions, but causing one movement
Muscles: serratus anterior, upper trapezius, lower trapezius causing scapular upward rotation (some
contribution from other muscles)
Glenohumeral (GH): 120, Scapula Upward Rotation: 60
2:1 ratio, 25:35 (sc:ac)
Downward Rotation: levator scapula, rhomboids, pectoralis minor causing downward rotation
Special Tests:
Hawkin’s Test: test of AC joint impingement and supraspinatus tendon weakness/tear (same as
impingement sign with thumb pronated - more supraspinatus) - arm straight out, thumb down to the
ground
Sulcus Sign: test of ligamentous laxity; humerus is pulled inferiorly, looking for a inferior subluxation or
dislocation gap
Cross-Arm Test: cross arm, grab at bicep and pull; test of AC arthrosis
O’Brien(OBrien) Test: test for SLAP lesion (glenoid labral and biceps tendon tear); shoulder in 90
degrees of forward flexion, 30 degrees of adduction; patient resists forward flexion while the thumbs are
pointed downward, rotates to full supination and resists forward flexion again; positive = painful thumb
when pointed downward and a shoulder click with supination
Yergason Test: tests long head of bicep, flex elbow to 90, grasp forearm and ask patient to supinate,
palpate bicipital groove to see if popping or pain is present
Speed’s Test: fully extend the elbow, forearm in supination then flex the shoulder to 90, patient attempts
to flex the elbow; tests for bicipital pathology (long head)
Kocher Maneuver: elevation with external rotation
Clunk/Crank Test: test for labral tear, flex the shoulder to 90, hold the arm near the wrist, apply a
downward force and internally and externally rotate, looking for a clunk or popping
Lift Off Test: tests subscapularis, patient reaches behind the back for the scapula (anterior capsule ROM),
ability to lift the hand off the back indicates an intact subscapularis - best for activation
, Scapular Winging Test: tests the stability of biceps tendon in the groove, positive result is pain ***what
is movement??? - speed’s test is similar but adds forward elevation
Milker’s Test: tests MCL, patient grasps the examiner’s thumb and pulls downward, reveals weakness or
pain - used for elbow pain in overhead throwing athletes
Finkelstein Test: indicates tenosynovitis; patient makes a fist with the thumb tucked in and ulnar flexes
the wrist, positive test is pain reduction in tunnel 1 - indicating DeQuervain’s disease, carpal tunnel
Elson’s Test: sudden flexion injuries; patient rests finger at the PIP joint at the edge of table, patient
extends the finger while it is immobilized on the table, a positive test is extension at the PIP joint; if
extension is compromised, middle slip is ruptured - if the middle slip is intact but the lateral bands are
ruptured, the DIP is nonfunctional, boutonnieres deformity; pain is DIP or PIP rupture
Watson Test: indicates a scapholunate interosseous ligament tear, palpate the volar aspect of the
scaphoid; begin with dorsiflexion and ulnar deviation, then radially deviate the volar wrist flex; if this
produces a clunk as the lunate moves past the scaphoid, then the patient has pathology (palpating on
scaphoid side, ulnar deviate then radially deviate and look for clicking)
Phalen’s Sign: indicates carpal tunnel syndrome, bilateral volar wrist flexion for 30 to 60 seconds to
elicit pain and or paresthesia in sensory distribution
Tinel’s Sign: indicates carpal tunnel syndrome; tap directly over the median or other peripheral nerve to
elicit pain and or paresthesia in sensory distribution
Retinacular Test: distinguishes between retinacular tightness and capsule contracture; flex the DIP while
holding the PIP, positive test is no flexion at the DIP; then flex the PIP and try again - if flexion now
occurs, then the patient has retinacular tightness, if flexion does not occur then the patient has contracture
Dugas Test: tests shoulder instability - subluxations and dislocations; place hand on opposite shoulder,
look for ability to touch, look for pain or inability
Drop Arm: assess the functionality of the rotator cuff, patient fully abducts shoulder to 90 degrees,
slowly lower arm back to side, pain and weakness may suggest a tear
Apprehension: assesses shoulder instability, lie on the back, flex shoulder to 90, elbow bent to 90,
externally rotates arm away from body, gently pull and push; heightened risk of anterior shoulder
instability
Protraction/Abduction: serratus anterior, pectoralis minor
Retractors/Adduction: rhomboids, lower trapezius, middle trapezius, levator scapulae
Elevator: rhomboids (with retraction), middle trapezius, upper trapezius, levator scapulae
Depressor: lower trapezius, pectoralis minor, lower serratus anterior
Upward Rotator: lower trapezius, middle trapezius, serratus anterior
Downward Rotator: rhomboids, pectoralis minor, levator scapulae
Trapezius:
Upper Trapezius Actions: elevation and upward rotation of the scapula, extension and rotation of head
Middle Trapezius Actions: elevation, upward rotation, and adduction
Lower Trapezius Actions: depression, adduction, and upward rotation
Origins: base of skull, occipital protuberance, posterior ligaments of neck, spinous processes of C7 and
all thoracic vertebrae (T1-12)
Insertion: posterior aspect of lateral third of clavicle, medial border of acromion process and upper
border of scapular spine, triangular space at base of scapular spine
Shoulder Girdle:
Bones: scapula, clavicle, sternum, acromion
Joints: sternoclavicular (SC), acromioclavicular (AC), scapulothoracic “joint”, glenohumeral joint
Ligaments: interclavicular ligament, costoclavicular ligament, sternoclavicular ligament
Key Bony Landmarks: (anterior) manubrium, clavicle, coracoid process, acromion process, glenoid
fossa, lateral border, inferior angle, medial border (posterior) acromion process, glenoid fossa, lateral
border, inferior angle, medial border, superior angle, spine of the scapula
Muscles of the Scapula: (anterior) supraspinatus, subscapularis, teres minor (posterior) supraspinatus,
infraspinatus, teres minor
Clavicle: s shaped for shock absorption; has a sternal end (costal facet) and a acromial end (acromial
facet); anterior surface is convex medially and concave laterally
Arthrokinematics of the Clavicle: (retraction) roll and slide in the same direction, (depression) roll and
slide in the same direction (??)
Sternoclavicular Joint:
Multiaxial: moves anteriorly 15 degrees with protraction, posteriorly 15 degrees with retraction (roll and
slide), superiorly 45 degrees with elevation, inferiorly 5 degrees with depression
Ligamentous support: strong, anteriorly by the anterior SC ligament, posteriorly by the posterior SC
ligament, stability against superior/inferior displacement by costoclavicular (1st rib to costal tuberosity,
firm stabilizer - limits extremes of clavicular motion strongest - superior) and interclavicular ligaments -
inferior
Articulation: of upper extremity with trunk; synovial joint with fibrocartilaginous disc
Sprain: incidence is low (5%), large medially directed force through clavicle - contact sports and road
traffic accidents; anterior or posterior (depends on where the clavicle goes, not where it get hits (pain with
horizontal abduction)
Acromioclavicular Joint:
Classification: multiaxial arthrodial (protraction/retraction), 20 to 30 degrees total gliding and rotational
motion accompanying other shoulder girdle and shoulder joint motions
Synovial Joint: with fibrocartilaginous disc (commonly worn away)
Ligamentous Support: superior acromioclavicular, inferior acromioclavicular, coracoclavicular
ligaments (provides additional stability, consists of - trapezoid/conoid ligaments), lateral forces causing
severe medial displacement)
Commonly Injured: lot of blunt trauma and landing
AC Joint Sprain:
Shoulder Separation (can occur)
Results: from forces that displace the scapular acromion process from the distal end of the clavicle
MOI: direct force applied to shoulder with arm in adducted position, impact from falling or constant with
external object
Subject: to overuse injuries
,Scapulothoracic:
NOT: a true synovial joint (2 bone surfaces), does not have regular synovial features - NO CONVEX ON
CONCAVE
Movement: depends on sternoclavicular and acromioclavicular joints, which allows the scapula to move
- 25 degrees abduction/adduction (protraction/retraction) - transverse plane
- 60 degrees upward/downward rotation - lateral plane
- 55 degrees elevation/depression - frontal plane
Supported: dynamically by its muscles, NO ligamentous support
Coracoacromial Ligament:
Impinges: during upward rotation and GH abduction (POSSIBLY externally rotated), causes a lot of
trauma
Labral Repair: very common in overhead athletes
Capsular Ligament:
GH Pouch, humerus sits in glenoid fossa
Movements:
Abduction (protraction): scapula moves laterally away from the spinal column
Adduction (retraction): scapula moves medially toward the spinal column
Downward Rotation: returning inferior angle inferomedially toward spinal column & glenoid fossa to
normal position
Upward Rotation: turning glenoid fossa upward & moving inferior angle superolaterally away from
spinal column - frontal plane
Depression: downward or inferior movement, returning to normal position
Elevation: upward or superior movement, as in shrugging shoulders - frontal
Shoulder Joint & Shoulder Girdle: work togetheir in carrying out upper extremity activities
- Scapular stabilizing effect so shoulder joint can create more power
- Need healthy scapular muscles so shoulder can move at good speed
Shoulder Girdle Muscles:
- Stabilize scapula so the shoulder joint muscles will have a stable base from which to exert force
for moving the humerus
- Contract to maintain scapula in a relatively static position during shoulder joint actions
- Contract to move shoulder girdle & to enhance movement of upper extremity when shoulder goes
through extreme ranges of motion
For some movements, scapula must rotate or tilt on its axis: EXTREMES
Lateral tilt (outward): during abduction (horizontal adduction OF GH), scapula rotates about its vertical
axis resulting in posterior movement of medial border & anterior movement of lateral border
Medial Tilt (inward, return from lateral): during extreme adduction (horizontal abduction OF GH),
scapula rotates about its vertical axis resulting in anterior movement of medial border & posterior
movement of lateral border
,Anterior Tilt (upward): rotational movement of scapula about frontal axis occurring during
glenohumeral hyperextension; superior border moving anteroinferiorly & inferior angle moving
posterosuperiorly
Posterior Tilt (downward): rotational movement of scapula about frontal axis occurring during
glenohumeral hyperflexion; superior border moving posteroinferiorly & inferior angle moving
anterosuperiorly
Synergy:
When Shoulder Joint Goes to Extreme ROM: scapular muscles contract to move shoulder girdle so
that it’s glenoid fossa will be in a better position, from which the humerus can move
Without: the scapula movement, humerus can only be raised to 90 degrees
Works By: muscles of both joints working together, ex. Raising out hand out to the side laterally as high
as possible - serratus anterior and trap (lower and middle) muscles upwardly rotate scapula as
supraspinatus and deltoid initiate glenohumeral abduction
Scap/Humeral Rhythm: Force Couple
Multiple Muscles: working in different directions, but causing one movement
Muscles: serratus anterior, upper trapezius, lower trapezius causing scapular upward rotation (some
contribution from other muscles)
Glenohumeral (GH): 120, Scapula Upward Rotation: 60
2:1 ratio, 25:35 (sc:ac)
Downward Rotation: levator scapula, rhomboids, pectoralis minor causing downward rotation
Special Tests:
Hawkin’s Test: test of AC joint impingement and supraspinatus tendon weakness/tear (same as
impingement sign with thumb pronated - more supraspinatus) - arm straight out, thumb down to the
ground
Sulcus Sign: test of ligamentous laxity; humerus is pulled inferiorly, looking for a inferior subluxation or
dislocation gap
Cross-Arm Test: cross arm, grab at bicep and pull; test of AC arthrosis
O’Brien(OBrien) Test: test for SLAP lesion (glenoid labral and biceps tendon tear); shoulder in 90
degrees of forward flexion, 30 degrees of adduction; patient resists forward flexion while the thumbs are
pointed downward, rotates to full supination and resists forward flexion again; positive = painful thumb
when pointed downward and a shoulder click with supination
Yergason Test: tests long head of bicep, flex elbow to 90, grasp forearm and ask patient to supinate,
palpate bicipital groove to see if popping or pain is present
Speed’s Test: fully extend the elbow, forearm in supination then flex the shoulder to 90, patient attempts
to flex the elbow; tests for bicipital pathology (long head)
Kocher Maneuver: elevation with external rotation
Clunk/Crank Test: test for labral tear, flex the shoulder to 90, hold the arm near the wrist, apply a
downward force and internally and externally rotate, looking for a clunk or popping
Lift Off Test: tests subscapularis, patient reaches behind the back for the scapula (anterior capsule ROM),
ability to lift the hand off the back indicates an intact subscapularis - best for activation
, Scapular Winging Test: tests the stability of biceps tendon in the groove, positive result is pain ***what
is movement??? - speed’s test is similar but adds forward elevation
Milker’s Test: tests MCL, patient grasps the examiner’s thumb and pulls downward, reveals weakness or
pain - used for elbow pain in overhead throwing athletes
Finkelstein Test: indicates tenosynovitis; patient makes a fist with the thumb tucked in and ulnar flexes
the wrist, positive test is pain reduction in tunnel 1 - indicating DeQuervain’s disease, carpal tunnel
Elson’s Test: sudden flexion injuries; patient rests finger at the PIP joint at the edge of table, patient
extends the finger while it is immobilized on the table, a positive test is extension at the PIP joint; if
extension is compromised, middle slip is ruptured - if the middle slip is intact but the lateral bands are
ruptured, the DIP is nonfunctional, boutonnieres deformity; pain is DIP or PIP rupture
Watson Test: indicates a scapholunate interosseous ligament tear, palpate the volar aspect of the
scaphoid; begin with dorsiflexion and ulnar deviation, then radially deviate the volar wrist flex; if this
produces a clunk as the lunate moves past the scaphoid, then the patient has pathology (palpating on
scaphoid side, ulnar deviate then radially deviate and look for clicking)
Phalen’s Sign: indicates carpal tunnel syndrome, bilateral volar wrist flexion for 30 to 60 seconds to
elicit pain and or paresthesia in sensory distribution
Tinel’s Sign: indicates carpal tunnel syndrome; tap directly over the median or other peripheral nerve to
elicit pain and or paresthesia in sensory distribution
Retinacular Test: distinguishes between retinacular tightness and capsule contracture; flex the DIP while
holding the PIP, positive test is no flexion at the DIP; then flex the PIP and try again - if flexion now
occurs, then the patient has retinacular tightness, if flexion does not occur then the patient has contracture
Dugas Test: tests shoulder instability - subluxations and dislocations; place hand on opposite shoulder,
look for ability to touch, look for pain or inability
Drop Arm: assess the functionality of the rotator cuff, patient fully abducts shoulder to 90 degrees,
slowly lower arm back to side, pain and weakness may suggest a tear
Apprehension: assesses shoulder instability, lie on the back, flex shoulder to 90, elbow bent to 90,
externally rotates arm away from body, gently pull and push; heightened risk of anterior shoulder
instability
Protraction/Abduction: serratus anterior, pectoralis minor
Retractors/Adduction: rhomboids, lower trapezius, middle trapezius, levator scapulae
Elevator: rhomboids (with retraction), middle trapezius, upper trapezius, levator scapulae
Depressor: lower trapezius, pectoralis minor, lower serratus anterior
Upward Rotator: lower trapezius, middle trapezius, serratus anterior
Downward Rotator: rhomboids, pectoralis minor, levator scapulae
Trapezius:
Upper Trapezius Actions: elevation and upward rotation of the scapula, extension and rotation of head
Middle Trapezius Actions: elevation, upward rotation, and adduction
Lower Trapezius Actions: depression, adduction, and upward rotation
Origins: base of skull, occipital protuberance, posterior ligaments of neck, spinous processes of C7 and
all thoracic vertebrae (T1-12)
Insertion: posterior aspect of lateral third of clavicle, medial border of acromion process and upper
border of scapular spine, triangular space at base of scapular spine
