1. Shoulder

2. 2 Shoulder Movements 1 Gleno-humeral joint 50% of abduction 2 Further abduction after 90 º is stopped when greater tubercle impinges on the 3 Glenoid rim 4 This range can be increased when the arm is externally rotated

3. 3 Role of Deltoid Muscle in Shoulder Abduction  Supraspinatus initiates the abduction, then deltoid takesover  Deltoid has 3 divisions-  Anterior division: from the anterior border and upper surface of the lateral third of the clavicle. abduction, horizontal flexion and medial rotation of humerus  Medial division: from the lateral margin and upper surface of the acromion. Abduction of the humerus at the shoulder  Posterior division: from the lower lip of the posterior border of the spine of the scapula. abduction, horizontal extension & lateral rotation (hyperextensor)

4. 4 Causes of shoulder pain  Cervical Spondylitis  Impingement syndrome-subacromial bursitis may be present. Causes pain when shoulder moves 70 º -120 º (ball throwing)  Rotator Cuff tears- trauma, degenerative disease. Supraspinatus most commonly inovlved-(trouble in initiating abduction) may lead to ‘frozen’ shoulder

5. 5 Frozen shoulder  Shoulder-gross restriction of movements, thickening of joint capsule.  Common in 40+ age group  Previous trauma, pain disturbs sleep  L>R  Diabetics  Gentle graded exercises/ manipulation

6. 6 Califying supraspinatus tendinitis  May be silent, can result in sudden severe incapacitating pain  May affect sub-deltoid bursa  Warm tender shoulder  X-ray shows calcified tendon  Shortwave diathermy helps

7. 7 Shoulder-Elbow issues

8. 8 1 Hawkins' Impingement Test.  Forward flex the arm to 90 degrees with the elbow bent to 90 degrees. The arm is then internally rotated. A positive test, noted by pain on internal rotation, may signify subacromial impingement including rotator cuff tendinopathy or tear.

9. 9 2 Drop-Arm Rotator Cuff Test.  The arm is passively raised to 160 degrees. The patient is then asked to slowly lower the arm to the side. A positive test, noted by an inability to control the lowering phase and a dropping or giving way of the arm, may indicate a large rotator cuff tear.

10. 10 3 Empty-Can Supraspinatus Test.  The arms are abducted to 90 degrees and forward flexed 30 degrees. With the thumbs turned downward, the patient actively resists a downward force applied by the examiner. A positive test is indicated by weakness compared with the contralateral side and may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear.

11. 11 4 Lift-Off Subscapularis Test.  With the arm internally rotated behind the patient's lower back, the patient internally rotates against the examiner's hand. A positive test is indicated by the inability to lift the hand off of the back and may indicate subscapularis tendinopathy or tear.

12. 12 5 External Rotation/ Infraspinatus Strength Test.  The patient's arms are held at their sides with the elbows flexed to 90 degrees. The patient actively externally rotates against resistance. A positive test is indicated by weakness compared with the contralateral side and may be associated with infraspinatus or teres minor tendinopathy or tear.

13. 13 6 Cross-Body Adduction Test.  The arm is passively adducted across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint pathology, including chronic sprain or osteoarthritis.

14. 14 7 Apprehension and Relocation Tests.  With the patient supine, the patient's arm is abducted to 90 degrees and the elbow is flexed to 90 degrees. Pain and a sense of instability with further external rotation may indicate shoulder instability. Relief of these symptoms with a posteriorly directed force on the proximal humerus is a positive relocation test and further supports diagnosis of shoulder instability.

15. 15  Pg 737-738: thoracic outlet syndrome can be vascular or neural. Scalene muscles are the main players – with fibrosis or cervical disc compression can cause, can also be slouching and sagging shoulders. Aging, obesity, or women with big boobs can suffer from this also. Might need breast reduction. Pain, numbness, weakness can be illicited by compressing on the Erb’s point. Vascular sx can be pallor of the nails, disappearance of radial pulse, extreme response to cold with spasms. Can get gangrene of the digits. Venous obstruction is marked by swelling and blueness of the area. Chest Xray will show this syndrome

16. 16  Horner’s Syndrome Symathetic compression of the ganglion by a tumor of the lung. Ipsilateral, pinpoint pupils, myosis, droopy eyelid. Loss of sweating on that half of the face. Hydrosis. Can be mistaken for thoracic outlet syndrome.

17. 17 Low Back Pain From lumbar to sacral. Kyphosis, scoliosis, Trauma, spondylolisthesis can be the prb. So can Systemic illnesses such as ulcerative cholitis which feels like sacroiliitis. Ankylosing spondylosis also, which starts as a stiff back. If sx of bloody diarrhea, suspect the UC. Older people will get OA of the lower spine. Obesity can put strain on the back. Excessive lumbar lordosis – women have it anyhow, but gets worse in preggers.