1. Osteopathic Concepts of the Shoulder PPC/OMM Lab Christina Bertolami, DO

2. Objectives Review relevant anatomy of the shoulder
Demonstrate a shoulder exam: Inspection, Palpation, Rom, strength, and instability testing
Discuss physical exam findings including osteopathic diagnosis of scapula, clavicle, AC, and SC joints
Know common shoulder osteopathic treatment techniques

3. Physical Examination Use history to understand where the pain is & what the mechanism of injury is…
General appearance
Inspection
Palpation
ROM
Strength
Stability
Special Testing
Neurovascular Status

4. Inspection Inspection
Patient must be exposed so that both shoulders can be viewed and compared
General appearance
Look for asymmetry, muscle atrophy, ecchymosis, swelling
Below is “Sulcus” sign indicates multidirectional instability

5. Palpation Overview of Anatomy
Bony structures – humerus, clavicle, scapula
Muscles - Deltoid and
”SITS”- Rotator cuff-
Supraspinatus, Infraspinatus,
Teres Minor,
Subscapularis

6. Palpation Overview of Anatomy
Acromioclavicular,
Sternoclavicular,
and
Glenohumeral joints

7. Range of Motion
External and Internal Rotation
Flexion and Extension

8. Range of Motion
ADduction
ABduction

9. Physical Examination start with the neck
Don’t forget to examine the proximal and distal joints to the shoulder
(c-spine and the elbow)
Shoulder pain may come from the neck
Radiculopathy
Origin of trapezius, levator scapulae
Spurling’s maneuver
reproduction of shoulder/arm pain is a positive test and indicates a cervical nerve root diorder
Spurling's test: The examiner passively hyperextends and laterally flexes the patient's neck toward the involved side. The test is positive if axial loading by the examiner's hands reproduces symptoms.
Motion of the scapula controls the location of the glenohumeral joint. If the scapular stabilizers are not equal due to cervical diagnosis, then shoulder function may be altered and pain result.

10. PRACTICE Spurlings Maneuver Inspection & Palpation of Shoulder
ROM-compare both sides, look for restriction

11. Strength Testing of Rotator Cuff Supraspinatus-abduction initiator
Test done in “scaption”
“Full can” or “Empty can”
Doctor pushes down
Positive test-when patient has pain or weakness- indicates supraspinatus tendinitis or muscle or tendon tear
Supraspinatus
Scaption – is the position where the arm is approximately the same plane as the scapula. 45 degrees abduction and 45 degrees to 90 degrees forward flexion.
Thumb up or “the full can” test moves the greater tuberosity of the humerus away from the acromion, lessening the contribution of impingement to pain or weakness during the exam. The empty can test or “thumbs down” position places the greater tuberosity closer to the acromion and increases the contribution of imp[ingement to the test. Avoiding impingement is important because you are performing this exam to detect weakness; painful impingement may cause a patient to make less of an effort due to pain, which you would mistakenly interpret as weakness.

12. Strength Testing of Rotator Cuff Infraspinatus and teres minor-ext rot
difficult to separately test
Tests external rotation strength
Stabilize the arm at the elbow to prevent abduction
Pt externally rotates, doctor internally rotates
If pain-positive test-
Patient externally rotates
Examiner internally rotates
Infraspinatus/Teres

13. Strength Testing of Rotator Cuff Subscapularis – allows for internal rotation
“Lift-off test”
Best Test for subscapularis
Elbow at 90o; patient lifts arm off of waist line against resistance.
Hard for patients with impingement
Testing Against Belly
Close; less precise than “lift off”
Patient holds arm against abdomen as shown; resists examiner attempt to externally rotate arm off of abdomen
Left Off Test
Subscapularis Testing

14. Instability Testing Anterior Instability
Anterior apprehension test
Arm in external rotation
Abduction places pressure on anterior shoulder capsule
Note examiner right hand position which keeps the shoulder from dislocating
Relocation test
Anterior to posterior pressure is place by the examiners right hand to “relocate” shoulder – if symptoms are relieved test is positive
Anterior Release Test

15. Impingement Testing Hawkins Test Neer’s Test
Examiner exerts internal rotation of humerus (blue arrow) with 90º of forward flexion and 90º of elbow flexion; a positive test is reproduction of pain
In this test, the arm is placed thumb down (internal rotation of humerus) in scaption. Examiner stabilizes the scapula border to prevent rotation. The arm is raised in forward flexion in scaption. A positive test is if pain is reproduced.

16. PRACTICE
1. Muscle Strength Testing Supraspinatus, Infraspinatus/Teres Minor Subscapularis 2. Instability Testing 3. Impingement Testing

17. Spencer Technique
Series of proprioceptive neuromuscular facilitation techniques
Can be expanded to include ME treatment
Physician stabilizes scapula
Physician engages barrier of joint
Patient pushes against (away from barrier)
Repeat 3-5 times
Taking up slack and engaging new barrier each time
Engages all of the muscles around the GH joint
Both diagnostic & therapeutic
Kimberly Manual, pp , direct articulatory/ME
Dx findings: Tissue texture changes, passive GH glides may be normal, range of motion is reduced in one or more directions by muscular restrictions, pain with specific shoulder motions or aching at rest, tenderness to palpation. Tender points and trigger points may be present.

18. Spencer Technique The seven stages of motions are:
1. Engage GH extension barrier with elbow flexed
2. Engage GH flexion barrier with the elbow flexed
3. Circumduction with compression
Start small circles, then gradually increase size
Clockwise and counterclockwise
May also do ME of IR/ER barriers 1 2
Kimberly Manual, p
Direct articulatory/ME 3

19. 4. Circumduction with traction on straight arm
Start small circles, then gradually increase size
Clockwise and counterclockwise
5. Engage abduction barrier
6. Adduction/IR with elbow flexed
7. GH pump with distraction and compression along straight arm 4 5 6 7

20. Practice
Spencer technique

22. Humeral Head Anterior and Superior
Both seated.
DO monitors humeral head with posterior hand.
Palm of ant hand and fingers on medial aspect of humerus as high in axilla as possible.
Patient lays the hand of dysfunctional arm across chest and grasps elbow with opposite
hand to pull the elbow across the chest against traction counterforce of
physician’s hand.
Patient needs to relax shoulder muscles at same time.
Patient may be instructed to “lift elbow” slightly to glide humeral head superiorly.
Position humerus into internal rotation by lifting patient’s elbow OR
Ext rotation by depressing elbow to obtain BLT
Test resp phase.
Recheck.

23. Scapulothoracic Dysfunctions
Physician can assess for static/dynamic asymmetry
Physician can physically take scapula through ROM, assessing for ease/restriction
Scapula can glide superiorly/inferiorly, medially/laterally. It can tilt anteriorly/posteriorly through AC horizontal axis. It can rotate upwards/downwards around AC AP axis. Scapula can “wing” (rotate externally/internally) around AC vertical axis.

24. Scapular Release
Patient in lateral recumbent position with physician at side of table
Hook fingers of cephalad hand over superior angle of scapula. Grasp elbow with opposite hand, resting patient’s arm on physician’s cephalad forearm (1)
Carry scapula inferiorly and laterally to muscular restrictive barrier
Apply sufficient force to feel muscles relax
Force is slowly relaxed
Stretching repeated rhythmically until max response obtained
Move fingers to medial scapular margin (2)
Carry scapula laterally and repeat #4-#6
Move fingers to inferior angle (3)
Carry scapula superiorly and laterally, repeating #4-#6 1 2 3
Kimberly Manual p , direct soft tissue method

25. Sternoclavicular Dysfunctions
Sternoclavicular joint motions:
Superior/Inferior glide
Movement in the frontal (coronal) plane
Also called ADduction/ABduction
Anterior/Posterior glide
Movement in a horizontal (transverse) plane
Also called horizontal extension/horizontal flexion
Rotation on its long mechanical axis
Anterior (internal)/Posterior (external)
Joint motions are coupled
ABduction (IG) is coupled with posterior (external) rotation
ADduction (SG) is coupled with anterior (internal) rotation
Frame of reference for ABd/ADd, horizontal flex/ext is lateral end of clavicle
Frame of reference for sup/inf glide, ant/post glide is medial (sternal) end of clavicle
Frame of reference for rotation is the superior surface of clavicle

26. A P A P Posterior Rotation External Rotation Horizontal Flexion
MEDIAL A P
LATERAL
LATERAL
MEDIAL A P
Posterior Rotation
External Rotation
Horizontal Flexion
Posterior Glide
ABduction
Inferior Glide
MEDIAL A P
LATERAL
LATERAL
MEDIAL A P
As the clavicle ABducts laterally, there is a downward (inferior) glide at sternal end
As the clavicle ADducts laterally, there is an upward (superior) glide at the sternal end
ABduction/inferior glide and posterior/external rotation are linked
ADduction/superior glide and anterior/internal rotation are linked
ADduction
Superior Glide
Anterior Rotation
Internal Rotation
Horizontal Extension
Anterior Glide

27. Sternoclavicular Dysfunction Assessment
ABduction (IG)/ADduction (SG)
Physician stands at head of table
Patient is supine
Place tips of your fingers on the superior edges of the medial ends of the patient’s clavicle
Ask your patient to shrug their shoulders. Both clavicles should move into ABduction, and the medial clavicles should move inferiorly (inferior glide)
In the absence of trauma, the dysfunctional (restricted) clavicle stays superior at the SC jointNamed an ADduction somatic dysfunction (superior glide)

28. Sternoclavicular Dysfunction Assessment
Horizontal Flex (PG)/Horizontal Ext (AG)
Physician stands at head of table
Patient is supine
Place tips of your fingers on the anterior edges of the medial ends of the patient’s clavicle
Ask your patient to reach toward the ceiling with their arms. Their scapulae should come off the table. Both clavicles should move into horizontal flexion, and the medial clavicles should move posterior (posterior glide)
In the absence of trauma, the dysfunctional (restricted) clavicle stays anterior at the SC jointNamed a horizontal extension (anterior glide) somatic dysfunction

29. Treat elevated SC Joint
Pt is seated and physician stands behind the patient toward the side to be treated
Use hand closest to Pt. place the second metacarpophalangeal joint over the distil third of the clavicle to be treated
Maintain constant caudad pressure over Pt. clavicle
With other hand grasp pt. arm on side to be treated below the elbow.
Bring pt. arm toward flexion from adduction with a continuous backstroke motion, the arm is circumducted toward extension until it is at the side of the pt. The arm can be brought forward and placed across the chest if this is comfortable for pt.
The release may occur before the barrier is met.
The physician reevaluates the dysfunctional (TART) components

31. Left Clavicle anterior and superior glide (SC Joint)
Both seated.
Thumbs under junction of th medial and middle third of clavicle.
Fingers over each end of clavicle.
Patient rests forearm over D.O.’s forearm.
“Lean forward slightly toward me.”
“Slightly turn your body away from me.” (gaps SC joint!)
D.O. carries sholder posteriorly to gap and balance AC joint.
Medial end of clavicle is elevated by rotating clavicle around pivot point formed by thumbs.
Clavicle is taken to a point of BLT (balanced ligamentous tension).
May need minor movement of the patient’s scapula and clavicle by moving the forearm & body to achieve BLT.
Respiratory phases are tested. Pt holds breath in phase giving best ligamentous balance.
Recheck.
Similar to doing the interosseous membrane in lower leg.
Left Clavicle anterior and superior glide (SC Joint)

32. 2. 1. 3. 4.
Elevated SC joint-Articulatory

33. Acromioclavicular Somatic Dysfunction Assessment
Superior/Inferior Glide
Physician places fingers on distal clavicle at AC joint.
Palpate position of distal clavicle in relation to acromion
Spring inferiorly on distal clavicle to assess for motion
Assess for restriction of gapping at AC joint. A P
External
Rotation
ADduction
AC gapping

34. Treat elevated AC joint
Pt. seated, physician stands behind the pt. toward the side being treated
Physician, using the closest hand to pt., places the second metacarpophalangeal joint over the distal third of clavicle being treated
Physician’s other hand grasps the Pt. arm on side to be treated below elbow
Pt arm is pulled down and then drawn backward into extension with a continuous motion similar to throwing a ball, circumducting the arm until it is once again in front of patient, finishing with arm across chest in adduction
The release may occur before barrier is met
The physician reevaluates the dysfunctional (TART) components

36. Right Clavicle Superior Glide (at Lateral end of clavicle)
Grasp elbow or forearm.
Pad of thumb with other hand applies Ant/Inf pressure to the restrictive barrier.
Flex elbow.
Extend and adduct humerus to gap AC joint.
Extend shoulder further and apply a circulatory sweep
elbow posterior, then superior, and finally anteromedially
must maintain capsular tension through out.
Recheck.
Right Clavicle Superior Glide (at Lateral end of clavicle)
Elevated clavicle on Acromion(elevated AC joint)

37. Right Clavicle Superior Glide (AC)
Thumbs under middle and medial third portion of clavicle.
Patient rests forearm on D.O. forearm.
“Lean slightly forward and toward me.”
Clavicle needs to be supported by D.O.’s thumbs.
“Slightly turn body away from me.” (gaps SC joint.)
Carry shoulder posteriorly to gap and balance the AC joint.
Elevate lateral end of clavicle by rotating the clavicle around the povot point formed by the DO thumbs.
May need minor movement of scapula and body position to obtain BLT.
Test resp phase to get best BLT
Recheck.

38. Practice
1. SC assessment and treatment 2. Treat elevated SC joint 3. AC assessment and treatment 4. Treat elevated AC joint