Chapter 4 The shoulder joint

Anatomy

1. The shoulder joint is a synovial ball and socket joint.

2. It is the articulation between the head of the humerus (ball) and the glenoid fossa (socket) of the scapula.

3. It has a loose capsule surrounding the joint, allowing for the large range of movement and multiple degrees of freedom associated with this joint. There is an increased laxity in the capsule inferiorly, to allow for abduction at the joint.

4. The joint is strengthened anteriorly by capsular ligaments (superior, middle and inferior glenohumeral ligaments).

5. The joint is also strengthened by the rotator cuff muscles – supraspinatus, infraspinatus, teres minor and subscapularis.

6. The glenoid fossa is deepened by the glenoid labrum, a thick wedge of cartilage that surrounds the articular margins, increasing the congruency of the joint.

7. The movements that take place at the shoulder joint are: flexion, extension, abduction, adduction, lateral (external) rotation and medial (internal) rotation.

Bony Landmarks to be Palpated

The scapula – acromion process, acromion angle, spine of the scapula, coracoid process, inferior angle and medial border.

The humerus – greater tubercle, lesser tubercle and the intertubercular groove.

Ligaments

Table 4.1 The ligaments of the shoulder

Muscles

Measurement

Range of Movement

Extension

Fig 4.1 Goniometric measurement of shoulder extension.

Starting position:

The patient is positioned in prone lying on the plinth (or sitting), their arm resting at the side, palm facing medially.

Goniometer axis:

The axis of the goniometer is placed over the lateral aspect of the centre of the humeral head, approximately 2.5 cm inferior to the lateral aspect of acromial process.

Stationary arm:

This is parallel to lateral mid-line of the trunk.

Moveable arm:

This is parallel to longitudinal axis of the humerus, pointing towards the lateral epicondyle of the humerus.

Command to patient:

‘Keeping your elbow straight, move your arm backwards, as far as you can.’

End position:

The humerus moves posteriorly, to the limit of motion.

Trick movements:

Scapular anterior tilting, elevation and shoulder abduction. The patient may also flex the trunk.

NB: It may be necessary to reposition the stationary and moveable arms of the goniometer prior to taking the reading, as they may have moved when the patient extended their shoulder.

Flexion

Fig 4.2 Goniometric measurement of shoulder flexion.

Starting position:

The patient is positioned in half lying on the plinth or sitting, their arm at their side, palm facing medially.

Goniometer axis:

The axis of the goniometer is placed over the lateral aspect of the centre of the humeral head, approximately 2.5 cm inferior to the lateral aspect of acromial process.

Stationary arm:

This is parallel to the mid-line of the trunk.

Moveable arm:

This is parallel to the longitudinal axis of the humerus, pointing towards the lateral epicondyle of the humerus.

Command to patient:

‘Keeping your elbow straight, move your arm forwards and upwards as far as you can.’

End position:

The humerus moves in an anterior direction to the limit of motion.

NB: It may be necessary to reposition the stationary and moveable arms of the goniometer prior to taking the reading, as they may have moved when the patient flexed their shoulder.

Abduction

Fig 4.3 Goniometric measurement of shoulder abduction.

Starting position:

The patient is positioned in supine lying on the plinth or sitting, their arm at their side, palm facing medially.

Goniometer axis:

The axis of the goniometer is placed over the mid-point of the anterior aspect of the glenohumeral joint, approximately 1.5 cm inferior and lateral to the coracoid process of the scapula.

Stationary arm:

This is parallel to the mid-sternal line.

Moveable arm:

This is parallel to the longitudinal axis of the humerus, pointing towards the lateral epicondyle of the humerus.

Command to patient:

‘Move your arm outwards and upwards towards your head as far as you can, keeping your palm facing the same way.’

End position:

The humerus moves laterally to the limit of motion.

Trick movements:

Contralateral trunk side flexion, scapular elevation, and shoulder flexion.

Adduction

Fig 4.4 Goniometric measurement of shoulder adduction.

Starting position:

The patient is positioned in supine lying on the plinth or sitting, their arm at their side, palm facing medially.

Goniometer axis:

The axis of the goniometer is placed over the mid-point of the anterior aspect of the glenohumeral joint, approximately 1.5 cm inferior and lateral to the coracoid process.

Stationary arm:

This is parallel to the mid-sternal line.

Moveable arm:

This is parallel to the longitudinal axis of the humerus, pointing towards the lateral epicondyle of the humerus.

Command to patient:

‘Move your arm across your body, as far as you can towards the opposite side of the plinth.’

End position:

The humerus moves medially to the limit of motion.

Clinical tip

The shoulder has to be in some degree of flexion to achieve shoulder adduction.

Medial (internal) rotation

Fig 4.5 Goniometric measurement of shoulder medial (internal) rotation.

Starting position:

The patient is positioned in supine lying on the plinth, their shoulder in 90° of abduction, the elbow flexed to 90° and the forearm in the pronated position. A towel is placed under the humerus to achieve an abducted position.

Goniometer axis:

The axis of the goniometer is placed on the olecranon process of the ulna.

Stationary arm:

This is perpendicular to the floor.

Moveable arm:

This is parallel to the longitudinal axis of the ulna, pointing towards the ulnar styloid process.

Command to patient:

‘Move your palm downwards towards the floor.’

End position:

The palm of the hand is moved towards the floor to the limit of medial rotation.

Trick movements:

Elbow extension, scapular elevation and abduction.

Observational/reflective checklist

Limb Girth

Upper limb

Measurements may need to be taken of the upper limb if, for example, a patient has lymphoedema.

Fig 4.7 Measurement of the girth of the upper limb.

Patient’s position:

The patient is positioned in long sitting or half lying on the plinth, well supported. Their elbow is resting on a pillow, which is on their lap.

Observational/reflective checklist

Muscle Strength: Oxford Muscle Grading

Flexors

Grade 2 – ‘Full ROM with the effects of gravity eliminated’

Patient’s position:

The patient is positioned in side lying on the plinth. The arm is supported in full shoulder extension.

Clinician’s position:

The clinician is standing by the patient, supporting the limb, with one hand under the elbow and the other just above the wrist.

Command to patient:

‘Try and move your arm forwards as far as you can.’

The shoulder has to move through its full range of movement – full extension to full flexion.

Clinical tip:

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Tags: A Physiotherapists Guide to Clinical Measurement

Jun 4, 2016 | Posted by admin in MANUAL THERAPIST | Comments Off

Musculoskeletal Key

Fastest Musculoskeletal Insight Engine

shoulder joint

Anatomy

Bony Landmarks to be Palpated

Ligaments

Muscles

Flexors

Extensors

Adductors

Abductors

Lateral (external) rotators

Medial (internal) rotators

Measurement

Range of Movement

Extension

Starting position:

Goniometer axis:

Stationary arm:

Moveable arm:

Command to patient:

End position:

Trick movements:

Flexion

Starting position:

Goniometer axis:

Stationary arm:

Moveable arm:

Command to patient:

End position:

Abduction

Starting position:

Goniometer axis:

Stationary arm:

Moveable arm:

Command to patient:

End position:

Trick movements:

Adduction

Starting position:

Goniometer axis:

Stationary arm:

Moveable arm:

Command to patient:

End position:

Medial (internal) rotation

Starting position:

Goniometer axis:

Stationary arm:

Moveable arm:

Command to patient:

End position:

Trick movements:

Lateral (external) rotation

Starting position:

Goniometer axis:

Stationary arm:

Moveable arm:

Command to patient:

End position:

Trick movements:

Observational/reflective checklist

Limb Girth

Upper limb

Patient’s position:

Method:

Observational/reflective checklist

Flexors

Grade 0 – ‘No contraction’ and Grade 1 – ‘Flicker of a contraction’

Patient’s position:

Clinician’s position:

Command to patient:

Clinical tip:

Grade 2 – ‘Full ROM with the effects of gravity eliminated’

Patient’s position:

Clinician’s position:

Command to patient:

Clinical tip:

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