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Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

00-065752RC939 .T68 2001617.5'72062-dc21

Tovin, Brian J.Evaluation and treatment of the shoulder: an integration of the guide to physical

therapist practice / Brian J. Tovin, Bruce H. Greenfield.p. cm.

Includes bibliographical references and index.ISBN 0-8036-0262-6

1. Shoulder-Diseases-Physical therapy. 2. Shoulder pain-Patients-Rehabilitation. 3.Shoulder pain-Physical therapy. I. Greenfield, Bruce H., 1953- IT. Title.

Library of Congress Cataloging-in-Publication Data

As new scientific information becomes available through basic and clinical research, recom-mended treatments and drug therapies undergo changes. The author(s) and publisher havedone everything possible to make this book accurate, up to date, and in accord with acceptedstandards at the time of publication. The author(s), editors, and publisher are not responsiblefor errors or omissions or for consequences from application of the book, and make nowarranty, expressed or implied, in regard to the contents of the book. Any practice described inthis book should be applied by the reader in accordance with professional standards of careused in regard to the unique circumstances that may apply in each situation. The reader isadvised always to check product information (package inserts) for changes and newinformation regarding dose and contraindications before administering any drug. Caution isespecially urged when using new or infrequently ordered drugs.

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Copyright 2001 by F. A. Davis Company

Copyright 2001 by F. A. Davis Company. All rights reserved. This book is protected bycopyright. No part of it may be reproduced, stored in a retrieval system, or transmitted inany form or by any means, electronic, mechanical, photocopying, recording, or otherwise,without written permission from the publisher.

Publisher: Jean Francois VilainDevelopmental Editor: Sharon LeeCover Designer: Louis J. Forgione

F. A. Davis Company1915 Arch StreetPhiladelphia, PA 19103www.fadavis.com

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Dedication

This book is dedicated to my most significant others: my wife and best friend,Stacey, for makiJ:i.g me a better person and being my b'shert; and my parents,Stefanie and Ian, for their continuous love, support, and guidance.

Brian Tovin

This book is dedicated to my wife Amy, who has provided me with unconditionallove and support, and to my children, Heather, Suzanne, and Eleanor, gifts fromGod.

Bruce Greenfield

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Foreword

As we enter the new millennium, we pause for a moment to recognize thatpublication of Evaluation and Treatment of the Shoulder: An Integration of the Guide toPhysical Therapist Practice marks the 15th anniversary of the Contemporary Perspec-tives in Rehabilitation series. Throughout this time, a consistent and conscientiouseffort has been made to present a variety of topics to rehabilitation specialists,clinicians, and students. Our texts have received recognition for their diversity andcomprehensive informational formats. In all of the volumes in the CPR series, materialis critically and consistently presented using a challenging and problem-solvingapproach, often through the incorporation of case studies, decision trees, andcomprehensive tables.

This approach was undertaken so that we could be "contemporary." Clearly,within the past decade, multiple changes in health-care policy have impacted thecircumstances under which rehabilitation is provided. Opinions about these changeshave varied, with most professionals showing a multitude of emotions, ranging fromambiguity to recalcitrance to anger. Yet, one undeniable fact remains-the concept ofcontemporary has changed, or at least its fabric appears manufactured from a differentfiber and design. What was once labeled clinical decision making has now beentransformed into evidence-based practice; and while empiricism was at one timepermitted to reign as the basis for evaluation and treatment, defined guidelines thatspeak to documentation and evidence are now prevalent.

Against this background, the editors of this text on shoulder evaluation andtreatment have brought together a unique combination of competence, skill,dedication, and friendship to carve a niche in contemporary physical therapy. Thisniche is embedded in the text's application of the Guide to Physical Therapist Practice(Physical Therapy, (ll) 77, 1997) as it pertains to a musculoskeletal problem pervasiveamong clients ranging from young athletes to frail, older adults.

This text is more than a detailed study on evaluation, physical therapy diagnoses,treatment, and reassessment of the shoulder. Tovin and Greenfield have taken acourageous step to offer their interest in the treatment of this body segment as one ofthe first efforts for rethinking the way physical therapists interface and treat patients.To succeed in this task required the contributions of authors whose sense of destiny isredefining how therapists evaluate and treat parallels those of the editors. Indeed,many of the contributors to this book are well known to many orthopedic physicaltherapists and their students. Guccione, Davies, Binkley, McClure, Stralka, McConnell,and Snyder-Mackler can easily be classified as visionaries with the ability to sense thecourse that clinicians must chart to secure further growth and autonomy.

vii

To accomplish the task, the text is divided into three major sections. The firstsection reviews anatomy (Greenfield) and kinesiology (Abelew) while also reviewingthe fundamental constructs underlying the evolution of impairment-based diagnosisby physical therapists (Guccione) and its application to the shoulder girdle (Tovin andGreenfield). The importance of clinical examination (Davies et al.) and integration ofquantified outcome measures (Binkley) complete this section. The second sectionaddresses the preferred practice patterns. To better appreciate the thought that hasmade this section unique, the reader is referred to Chapter 4 of the "Guidelines."Students and clinicians are presented with a discussion of the relationship betweenthe suggested guidelines and specific shoulder joint or girdle pathologies, along withcommentary that challenges their reasoning and thought processes. Lastly, Section IIIdescribes the principles of treatment. In this section, the reader is exposed to clinicalreasoning in the use of manual therapy techniques Oones and Magarey), alternativetreatment modes, such as aquatic therapy (Tovin), and the role of open versus closedkinetic chain exercises as treatment for the shoulder (Livingston). Highlighting thissection is Jenny McConnell's discussion of appropriate neuromuscular re-educationstrategies and a presentation of the rationale underlying the orderly functionalprogression in therapeutic exercise plans (Chmielewski and Snyder-Mackler).

I have served as Editor-in-Chief for all of the volumes in the CPR series, but manyfactors make this book particularly endearing to me. Both Brian Tovin and BruceGreenfield are past students of mine. Perhaps I have contributed a small portion totheir academic accomplishments. Most of their contributors are friends or colleagueswhose work I have respected for many years. As a total team, they have embarked ona venture that may some day be viewed as a model that symbolized a change in how(and why) physical therapy services are provided.

As students and therapists read this book, they should be reminded of theprudent words of the great American humorist, Mark Twain, "A man cannot becomfortable without his own approval." The time has come for us to alter our comfortlevel by not only approving the guidelines, but more importantly, by applying them.This book affords all of us that special opportunity. At the risk of sounding somewhatdramatic, perhaps we might consider the following:

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viii EVALUATION AND TREATMENT OF THE SHOULDER

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The dogmas of the quiet past are inadequate to the stormy present. The occasion ispiled high with difficulty, and we must rise to the occasion. As our case is new, sowe must think anew and act anew. We must disenthrall ourselves.

This thought is as true for the physical therapist pondering changing practice patternsas it was for Abraham Lincoln more than 140 years ago as he pondered the fate of anation.

Steven L. Wolf, PhD, FAPTASeries Editor

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ix

In November 1997, the American Physical Therapy Association published the Guide toPhysical Therapist Practice. "The Guide," as it came to be known, provided the physicaltherapy and medical community with a comprehensive document that outlined thenature and scope of physical therapy practice. The Guide is divided into two parts:part one discusses patient/client management and explains the tests and measuresthat are used in patient management; part two discusses patterns of practice forselected diagnostic categories. The patterns of practice describe the components ofpatient management that a panel of expert clinicians deemed reasonable for adiagnostic group and include examination techniques, evaluation, diagnosis, progno-sis, and intervention. The items in each diagnostic group share common impairmentsand functional losses that distinguish them from other groups. Diagnostic groupsencompass the major body systems and include musculoskeletal, neuromuscular,cardiopulmonary, and integumentary. Up to this point, there is limited documentationthat the guidelines included in the patterns of practice are superior to others. Thechallenge to the profession is to apply the guidelines to the treatment of patients anddetermine their effectiveness by gauging outcomes.

Evaluation and Treatment of the Shoulder: An Integration of the Guide to PhysicalTherapist Practice provides physical therapists, as well as occupational therapists,athletic trainers, and others, with a resource that integrates the musculoskeletalpractice patterns in the Guide with the rehabilitation of the shoulder. This textintroduces orthopedic conditions based on clustering impairments and in so doingembraces the Guide's philosophy that physical therapists and other rehabilitationspecialists diagnose the consequences of disease, pathology, injury, or surgery on themusculoskeletal system. These consequences include related impairments, functionallosses, and disabilities that have been and continue to be the purview of physicaltherapy practice.

The purpose of Evaluation and Treatment of the Shoulder is twofold: to serve as amodel that presents shoulder conditions from an impairment-based perspective sothat the Guide's preferred practice patterns outlining treatment strategies can be usedand assessed for their feasibility and effectiveness. Second, the text is an excellentbasic resource for the entry-level clinician for all aspects of shoulder rehabilitation.Whether or not practicing clinicians embrace the guidelines contained in the Guide,this text provides them with an excellent updated resource on the care andmanagement of selected shoulder conditions.

Evaluation and Treatment of the Shoulder is divided into three parts. Part I discussesshoulder anatomy and kinesiology, reviews the historical basis of impairment-based

Preface

Brian TovinBruce Greenfield

practice, and extrapolates and operationally defines the impairment-based categoriesof the shoulder from the Guide that serve as the organizing construct for the rest ofthe text. Part I concludes with a review of the examination of the shoulder andfunctional outcome measures.

Part II presents the main body of the text-selected shoulder conditions. Inkeeping with a philosophy that we believe to be unique to this text, conditions areintroduced based on their primary impairments, rather than on the traditional medicaldiagnoses. The medical diagnoses are presented as secondary concerns that guide thepace and nature of treatment, rather than direct the primary approach to evaluatingand ameliorating impairments and functional losses. An example is Chapter 7,"Musculoskeletal Pattern D: Impaired Joint Mobility, Motor Function, MusclePerformance, and Range of Motion Associated with Capsular Restriction." Therehabilitation of a painful and stiff shoulder that is the result of primary adhesivecapsulitis or secondary to post-surgical shoulder immobilization is consistently basedon identifying, assessing, and correcting the impairments that affect function. Whatvaries is the pace of treatment dictated by soft tissue healing and the individual'sfunctional goals.

Finally, Part III reviews principles of rehabilitation for the shoulder. Historically,the treatment strategies and techniques for shoulder conditions have varied both intheir scope and effectiveness. The challenge was to sift through the large number oftreatments, tossing the irrelevant ones and exposing the "nuggets." In meeting thischallenge, we were guided by our commitment and that of the ContemporaryPerspectives of Rehabilitation series to present, whenever possible, evidence-basedoutcome treatments. Chapters on manual therapy strategies, neuromuscular educationtechniques, aquatic therapy, functional progression exercises, and closed kinetic chainexercises, all contain information rich in detail but scrupulous in scientific rigor.

Contributors were selected for their expertise, academic credentials, and profes-sional integrity. The selection criteria are reflected in the quality of the text and theattention paid to pedagogy. Every chapter includes pedagogy designed to enhance thecontent. Chapter outlines give readers a quick overview of the content. Chapterintroductions explain all relevant principles and operational definitions. Specific casestudies within the chapters allow the reader to learn how the information is integratedinto patient care.

In using this text, we anticipate that readers will apply the process method andthe content to formulate treatments for their patients. We feel confident we areoffering cutting-edge material aimed at influencing the future practice of physicaltherapy and rehabilitation in general. Since this venture is directed toward theprofession's growth, we invite the reader's feedback to see if our predictions areaccurate. Future editions will reflect that feedback and the dynamic changes in healthcare policy to effect even better and more relevant treatment assessments andapproaches.

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EVALUATION AND TREATMENT OF THE SHOULDERx

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Acknowledgtnents

A professional career is not only guided by the amount of knowledge, perseverance,and motivation of that individual, but equally by the surrounding cast of peoplewho have helped to shape, direct, and influence that individual along the way.I would like to thank those individuals who have done all of these things for meand helped contribute, both directly and indirectly, to the development of this text.To Pam Levangie for taking a chance on me by admitting me to physical therapyschool at Boston University. To Lynn Snyder-Mackler, who guided me on the righttrack early in my career and taught me to strive for excellence. She continues to be asource of inspiration and motivation in my career. To Steve Wolf, who has patientlytaught me the finer points of research, writing, and editing. Both Lynn and Steve havebeen friends and mentors, serving as my "professional parents" and teaching me thatbalancing academics and clinical practice is possible. To Geoff Maitland and KeithKleven for teaching me that being an expert clinician not only requires advancedclinical skills, but compassion for the patient as well. They taught me that no patientcares how much you know until they know how m4ch you care. To Mark Jones andSteve Kraus for motivating me to continually challenge myself and for helping merefine my clinical reasoning process and manual therapy skills. To Jay Shoop, who hasgiven me the opportunity to have my "dream" job and who has taught me that "oldschool" is sometimes better than "new school." To my brothers Cory and Todd Tovin,and sisters-in-law Melissa and Renee Tovin, who have taught me that a family ofphysical therapists. does not necessarily make for boring dinner conversation. To mycolleagues Catherine Duncan, David Pasion, and Gina Boomershine for all that theydo for our clinics. To Grace Jones for being the backbone of our office. lowe a greatdeal of gratitude to Dr. Angelo Galante, Dr. John Xerogeanes, and Dr. "Chip"Pendleton for their friendship and confidence in me. I would also like to thank JoelleSzendel for assisting with typing and Kelly Ramsdell, Adria Gravely, and AdamSnyder for serving as models. To Jean-Francois Vilain, Sharon Lee, and the staff atF.A. Davis for making this challenging task an unforgettable experience. Finally, toBruce Greenfield, without whose assistance, support, patience, and friendship thisbook would never have happened.

Brian J. Tovin

As human beings, we have good and bad traits that result from the confluence of anumber of factors, not the least of which is the influence of individuals during ourpersonal and professional development. Hopefully, the good traits outweigh the bad,and we are able to accomplish things that make life meaningful.

xi

Bruce Greenfield

EVALUATION AND TREATMENT OF THE SHOULDERxii

The following individuals have helped to identify and nurture the attitudes,values, and habits that constitute the good in me. My greatest debt of gratitude isowed to my late mother, Eleanore Greenfield, my father, Seymour Greenfield, and mysister, Meryl Jacobs. I would like to thank my in-laws, Edward and Florence Schuman,and my brother-in-law, Andrew Jacobs, for their love and support. I would like tothank my colleagues and friends on the faculty of the Division of Physical Therapy atEmory University for their unfailing support and friendship. In particular, I wouldlike to express my gratitude to Dr. Pamela Catlin, who allowed me to "carve out" myown professional time to work on this book. I would like to thank Steve Wolf, a friend,colleague, and role model who impressed upon me the value of rigorous scholarship.I would like to thank Marie Johanson for her friendship and support. I would also liketo thank some of my colleagues who still toil in the clinic and to me are the true heroesof the profession of physical therapy: Michael Wooden, Tim McMahon, RobertDonatelli, Mark Albert, Steve Kraus, Zita Gonzales, and Greg Bennett. These peopledid it right in the beginning, and they continue to do it right.

All the contributors and lowe a great deal to the reviewers whose constructivecriticisms were instrumental in shaping this text. My thanks to EA. Davis for itssupport, particularly to Jean-Francois Vilain and Sharon Lee, both of whom helped toguide the entire project, and in the case of Sharon, she did it with a soft but steadyvoice.

Finally, I would like to thank Brian Tovin, friend, colleague, and co-editor, fortaking on this task with me; his determination and energy provided the impetus tocomplete this project.

COl1.tributors

Thomas Abelew, PhDAssistant ProfessorDepartment of Rehabilitation MedicineDivision of Physical TherapyEmory University School of MedicineAtlanta, Georgia

Jill Binkley, PT, MCISc, FCAMT,FAAOMPT

Assistant ProfessorSchool of PhysiotherapyMcMaster UniversityHamilton, Ontario, Canada

Lori Thein Brody, MS, PT, SCS, ATCSenior Clinical SpecialistUniversity of Wisconsin Clinics

Research ParkSports Medicine and Spine CenterMadison, WIProgram DirectorRocky Mountain University of Physical

TherapyProvo, Utah

Kevin Cappel, MS, PT, SCS, ATC,CSCS

Director of Sports MedicineGunderson Lutheran Sports MedicineWinona, Minnesota

Terese L. Chmielewski, MA, PT, SCSDoctoral Student, Biomechanics and

Movement Sciences ProgramDepartment of Physical TherapyUniversity of DelawareNewark, Delaware

Michael A. Clark, MS, PT, CSCSSports Physical Therapy and

Performance SpecialistPhysiotherapy Associates Tempe Sport

ClinicDirector of Sports ScienceAthletic InstituteFranklin, Pennsylvania

George J. Davies Med, PT, SCS, ATC,CSCS

Professor, Graduate Physical TherapyProgram

University of Wisconsin-LacrosseDirector, Clinical and Research ServicesGunderson Lutheran Sports MedicineLacrosse, Wisconsin

Todd S. Ellenbecker, MS, PT, SCS,CSCS

Clinic DirectorPhysiotherapy AssociatesScottsdale Sports ClinicScottsdale, Arizona

Bruce H. Greenfield, MMSc, PT, OCSInstructorDepartment of Rehabilitation MedicineDivision of Physical TherapyEmory University School of MedicineAtlanta, Georgia

Andrew A. Guccione, PhD, PT, FAPTASenior Vice PresidentDivision of Practice and ResearchAmerican Physical Therapy AssociationAlexandria, Virginia

xiii

xiv EVALUATION AND TREATMENT OF THE SHOULDER

Penny 1. Head, PT, SCS, ATCDirector of Physical TherapyThe Campbell ClinicMemphis, Tennessee

Mark A. Jones, BS, PT, MAppScSenior Lecturer, Centre for Allied

Health ResearchCoordinator, Postgraduate Programs in

Manipulative PhysiotherapySchool of Physiotherapy, Division of

Health SciencesUniversity of South AustraliaAdelaide, South Australia

Beven P. Livingston, MS, PT, ATCGraduate Student, PhD Program in

NeuroscienceEmory UniversityAtlanta, Georgia

Mary M. Magarey, PhD, Grad DipMan Ther

Senior Lecturer, Centre for AlliedHealth Research

Coordinator, Postgraduate Programs inSports Physiotherapy

School of Physiotherapy, Division ofHealth Sciences .

University of South AustraliaAdelaide, South Australia

Phil McClure, PhD, PT, OCSAssociate ProfessorDepartment of Physical TherapyBeaver CollegeGlenside, Pennsylvania

Jenny McConnell, BAppSci (Phty),Grad Dip Man Ther, MBiomedE

Director, McConnell & ClementsPhysiotherapy

New South Wales, Australia

Karen J. Mohr, PT, SCSResearch DirectorKerlan-Jobe Orthopaedic ClinicHermosa Beach, California

Diane Radovich Schwab, MSPTChampion RehabilitationSan Diego, California

Lynn Snyder-Mackler, SeD, PT, ATC,SCS

Associate ProfessorDepartment of Physical TherapyUniversity of DelawareNewark, Delaware

Susan W. Stralka, MS, PTDirector, Outpatient Rehabilitation

ServicesDirector, The Orthopaedic and Sports

Medicine InstituteBaptist Memorial HealthcareMemphis, Tennessee

Brian J. Tovin, MMSe, PT, SCS, ATC,FAAOMPT

Clinic DirectorThe Sports Rehabilitation Center at

Georgia TechDirector of RehabilitationGeorgia Tech Sports MedicineAtlanta, Georgia

Reviewers

Charles D. Ciccone, PhD, PTProfessorDepartment of Physical TherapyIthaca CollegeIthaca, New York

Gary Lentell, MS, PTProfessorDepartment of Physical TherapyCalifornia State University, FresnoFresno, California

Mark R. Wiegand, PhD, PTAssociate ProfessorDepartment of Physical Therapy

ProgramUniversity of Louisville Health Sciences

CenterLouisville, Kentucky

xv

Contents

SECTION I: IntroductionChapter 1 Anatomy of the Shoulder 3

Bruce H. Greenfield, MMSc, PT, oesIntroduction 3Components of the Shoulder 3

Scapulothoracic Joint 4Sternoclavicular Joint 6Acromioclavicular Joint.. 8Glenohumeral Joint 10

Structural Relationships and Interdependence of Upper QuarterFunction 20

Functional Anatomy .20Brachial Plexus ' 22

Chapter Summary 22

Chapter 2 Kinesiology of the Shoulder 25Thomas Abelew, PhD

Introduction 25Kinematics 25

Shoulder Complex Kinematics 25Segmental Kinematics 27

Arthrokinematics 31Sternoclavicular Joint 32Acromioclavicular Joint 32Glenohumeral Joint 32

Kinetics 34Joint Reaction Forces 34Joint Moments 35

Muscle Function 36Muscle Synergy 36Muscle Function in 3D 38Scapular Force Couple 39Muscle Activity 39

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xviii EVALUATION AND TREATMENT OF THE SHOULDER

Rotator Cuff. .40Individual Muscle Moments 41

Chapter Sulnmary 43

Chapter 3 Diagnosis by Physical Therapists: Impairment-BasedModel Versus Medical Model .. .45Andrew A. Guccione, PhD, PT, FAPTA

Introduction 45The Evolution of Diagnosis by Physical Therapists ..45

The Process of Disablement 47Disease or Active Pathology .. .. .48IInpairn1ents 48Functional Limitations .49Disability 51

Physical Therapist and Patient/Client Management 52Chapter Summary .. 54

Chapter 4 Impairment-Based Diagnosis for the Shoulder Girdle ..........55Brian J. TOJ,in, MMSc, PT, SCS, ATC, FAAOMPTBruce H. Greenfield, MMSc, PT, OCS

Introduction 55Historical Development of the Impairment-Based Treatment

of the Shoulder 55Early Work 55Later Work 56Current Work 59Evolution of Diagnosis by Physical Therapy 60

Process of Disablement 62Guide to Physical Therapist Practice 63Classification of Shoulder Conditions 65

Pattern D 65Pattern E 67Pattern F 68Referred Pain Syndromes: Integration of Musculoskeletal

Patterns Band G, and Neuromuscular Pattern D 70Pattern H 71Patterns I and ;. 72

Chapter Sun1n1ary . 72

Chapter 5 Clinical Examination of the Shoulder. .75KeJiin Cappel, MS, PT, SCS, ATC, CSCSMichael A. Clark, MS, PT, CSCSGeoweJ. DaJiies, Med, PT, SCS, ATC, CSCSTodd S. Ellmbeclzer, MS, PT, SCS, CSCS

Introduction 75Examination and Evaluation Procedures 76

History 76Physical Tests and Measures .. .. .. ..79

CONTENTS xix

Integration of Evaluative Findings With Preferred PracticePatterns 110

Pattern D: Impaired Joint Mobility, Motor Function, MusclePerformance, and Range of Motion Associated With CapsularRestriction 110

Pattern E: Impaired Joint Mobility, Muscle Performance, andRange of Motion Associated With Ligament of OtherConnective Tissue Disorders 111

Pattern F: Impaired Joint Mobility, Motor Function, MusclePerformance, and Range of Motion Associated WithLocalized Inflammation 113

Pattern G: Impaired Joint Mobility, Motor Function, MusclePerformance, Range of Motion, or Reflex IntegritySecondary to Spinal Disorders 114

Patterns H, I, and J: Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of Motion Associated WithFractures, Joint Arthroplasty, and Soft-Tissue SurgicalProcedures 116

Chapter Sumn1ary .. .117Appendix SA: Isokinetic Assessment 121Appendix SB: Clinical Biomechanical Assessment.. 126

Chapter 6 Functional Outcome Measures for the Shoulder 132Jill Binkley, PT, MCISe, FCAMT, FAAOMPT

Introduction 132Using Functional Outcome Measures in Clinical Practice 133Methods of Measuring Function for Patients With Shoulder

Conditions 133Types of Self-Report Functional Status Outcome Measures 133Criteria for Selecting a Functional Status Outcome Measure 134

Using Self-Report Functional Scales 136Patient Group Comparisons 136Individual Patient Measurement and Goal Setting 137

Using Patient-Specific and Condition-Specific Functional Scales forIndividual Patient Function, Progress, and Goal Setting 140

Incorporating Functional Scales into Clinical Practice 141Case Study 6-1: Incorporation of Functional Status Outcome

Measures in Clinical Practice 143Using Functional Scale Scores to Communicate With Referral

Sources and Payers 143Chapter Summary .144Appendix 6A: Functional Outcome Measurement Scales 146

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xx EVALUATION AND TREATMENT OF THE SHOULDER

SECTION II: Musculoskeletal Patterns of the Shoulder

Chapter 7 Musculoskeletal Pattern D: Impaired Joint Mobility,Motor Function, Muscle Performance, and Rangeof Motion Associated with Capsular Restriction 157Phil McClure, PhD, PT

Introduction 157Classification and Terminology 157

Origins and Pathology of Structural Changes 159Treatment 163

Medical/Surgical Treatment 163Conservative Treatment: Nonstructural Limitation 165Conservative Treatment: Structural Limitation 165

Determining the Proper Dose of Stress: Hierarchy of Tensile StressDelivery and a Clinical Decision Making Algorithm 167

Methods of Stress Delivery for the Stiff Shoulder 170Case Study 7-1 175Chapter SUITIlTIary 178

Chapter 8 Musculoskeletal Pattern E: Impaired Joint Mobility,Muscle Performance, and Range of Motion Associatedwith Ligament or Other Connective Tissue Disorders 181Todd S. Ellenbec!ler, MS, PT, SCS, CSCS

Introduction 181Definitions 182Classification of Instability 182

Macrotraumatic Versus Microtraumatic Instability 182AJ.\1BRlI Versus TUBS 182Additional Factors 183

Clinical Assessment ofImpairments Associated with Instability 183Objective Evaluation 184

Role of Glenohumeral Joint Instability in Rotator CuffInjury 187Role ofHypermobility on the Glenoid Labrum 189Static and Dynamic Glenohumeral Joint Stabilizers 190

Static Stabilizers 190Dynamic Stabilizers 191

Nonoperative Treatment of the Unstable Shoulder 192Submaximal Exercise 192Progressive Exercises 195

Case Study 8-1: Rehabilitation of the Shoulder in an Elite JuniorTennis Player 201

Chapter Summary 206

xxi

Chapter 10 Referred Pain Syndromes of the Shoulder: An Integrationof Musculoskeletal Patterns D and G and NeuromuscularPattern D 23'1Susan W Stralka, MS, PTBrianJ Tovin, MMSc, PT, SCS, ATC, FAAOMPT

Introduction 231Cervical Spine Referred Pain 232

Examination , 233Intervention 235

Myofascial Pain Syndromes 236Examination 239Intervention 240

Thoracic Outlet Syndrome ,.240Etiology 241Examination 242Intervention 244

Other Peripheral Entrapment Neuropathies 245Suprascapular Nerve Entrapment.. 245Dorsal Scapular Nerve Entrapment 245

Chapter 9 Musculoskeletal Pattern F: Impaired Joint Mobility,Motor Function, Muscle Performance, and Rangeof Motion Associated with Localized Inflammation 210Karen J Moh~ PT, SCSDiane Radovich Schwab, MSPTBrian J Tovin, MMSc, PI, SCS, ATC, FAAOMPT

Introduction .21 0Connective Tissue Healing .211

Acute and Chronic Inflammation 211Summary of Connective Tissue Healing 212

Classification of Impingement 213Primary Impingement 213Secondary Impingement 216

Examination 219History 219Observation and Active Range of Motion 219Posture 219Passive Range ofMotion 219Palpation 220Resisted Muscle Testing 221Special Tests 221

Progression ofImpingement Syndrome 222Intervention 222

Eliminating Inflammation 222Improving Range of Motion and Joint Mobilization 223Promoting Flexibility 223Implementing Exercises 224

Case Study 9-1 227Chapter Summary 229

CONTENTS

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Chapter 12 Musculoskeletal Pattern J: Impaired Joint Mobility,Motor Function, Muscle Performance, and Rangeof Motion Associated with Bony or Soft TissueSurgical Procedures 292Lori Thein Brody, MS, PT, SCS, ATC

Introduction 292Soft Tissue Healing 293

Phase I: Inflammatory Response 293Phase II: Repair-Regeneration 293Phase III: Remodeling-Maulration 293

Chapter 11 Musculoskeletal Pattern I: Impaired Joint Mobility,Motor Function, Muscle Performance, and Rangeof Motion Associated with Joint Arthroplasty 264Susan W Stralka, MS, PTPenny L. Head, PT, SCS, ATC

Introduction 264Historical Development of Total Shoulder Arthroplasty 265Prosthetic Design of the Total Shoulder Component.. 267Shoulder Arthroplasty 268

Specific Indications for TSA 269Preoperative Planning and Evaluation 270Surgery 272Complications of Total Shoulder Replacement Arthroplasty 272

Total Shoulder Arthroplasty Rehabilitation 273Examination and Evaluation 273Prognosis 274Interventions 274

Case Study 11-1: Hemiarthroplasty 283Case Study 11-2: Total Shoulder Arthroplasty 286Chapter Summary 289

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xxii EVALUATION AND TREATMENT OF THE SHOULDER

Examination 245Intervention 246

Adverse Neural Tension 247Examination 247Intervention '" 248

Complex Regional Pain Syndromes (CRPS) 248Clinical Course of the Syndrome 249Examination 250Intervention 253CRPS Summary 258

Referred Pain 258Cardiac Induced Pain .258Pulmonary Induced Pain 258Gastrointestinal System Disease Induced Pain 259Tumor Induced Pain .259


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CONTENTS xxiii

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Stabilization Procedures 294Anterior Instability: The Bankart Repair 294Anterior or Multidirectional Instability: Capsulorrhaphy 296Rehabilitation Considerations for Anterior Stabilization 297Posterior Stabilization 299Management of Impaired Joint Mobility Following

Stabilization Procedures 300Subacromial Decompression 302

Rehabilitation Considerations and Management of ImpairedJoint Mobility 303

Rotator Cuff Repair 304Rehabilitation Considerations 306

Other Labral Procedures 306Rehabilitation Considerations 307


SECTION III Treatment StrategiesChapter 13 Clinical Reasoning in the Use of Manual Therapy

Techniques for the Shoulder Girdle 317Mark A. Jones, BS, PT, MAppSciMary M. Magarey, PhD, Grad Dip Man Ther

Introduction 317Hypothesis Categories 319Patient and Therapist Roles 322

Factors Assisting in the Choice ofTreatrnent byPassive Movement 322

Pain 324Stiffness 324Pain and Stiffness 325

, Movement Diagrams 325Grades of Movement.. 326

Case Study 13-1: Patient 1 328Case Study 13-2: Patient 2 335Other Factors Influencing the Execution and Success

of a Technique 339Patient Understanding 340Patient Comfort and Pain-Relieving Techniques 341Techniques to Treat Tissue Resistance 343

Chapter Summary 344

Chapter 14 Neuromuscular Re-education Strategiesfor the Shoulder Girdle 347Jenny McConnell, BAppSci (Phty), Grad Dip Man Ther, MBiomedE

Introduction 347Specificity of Training 348

External Feedback 349

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Chapter 15 Aquatic Rehabilitation of the Shoulder 366Brian J. Tovin, MMSe, PT, SCS, ATC, FAAOMPT

Introduction 366History ofAquatic Rehabilitation 366Physical Properties ofWater and Clinical Implications 368

Hydrostatic Pressure 368Buoyancy 368Fluid Dynamics 370Thermodynamics 371Clinical Applications 371


Chapter 16 Therapeutic Exercise and Functional Progressionof the Shoulder 379Terese L. Chmielewski) MA) PT, SCSLynn Snyder-MacHer, SeD, PT, ATC, SCS

Introduction 379Developing Goals for the Rehabilitation Program 380Treatment Protocols 381

Individualizing Protocols 381Progressing Between Protocol Phases 383Using Strength as a Criterion for Progression 384Progressing Within a Protocol Phase 384Progressing the Difficulty ofTherapeutic Exercise 385Using Interval Sport Programs 391Progressing Rehabilitation for In-Season Athletes 391

Measuring Shoulder Function 392Key Factors for Choosing a Shoulder Index 392Generic Questionnaires Versus Site-Specific Questionnaires 394An Integrated Approach to Measuring Function 394


"

r,Ii~i!

xxiv EVALUATION AND TREATMENT OF THE SHOULDER

Internal Feedback 349Feed-Forward System 350Adaptive Servo-Assist Theory 350

Taping the Glenohumeral Joint 351Anterior Translation of the Humeral Head 351Multidirectional Instability 352

Muscle Training 354Training for Multidirectional Instability 354Rehabilitation of the Anteriorly Translated Humeral Head 356

Case Study 14-1 360Case SUldy 14-2 361Chapter Summary 364

Index 417

Chapter 17 Open and Closed Chain Exercises for the Shoulder 399Beven P LiJlingston, MS, PT, ATe

Introduction '" , 399Kinematic and Kinetic Chain Terminology 399

Open and Closed Kinetic Chain Activities 400Characteristics of Open and Closed Kinetic Chain Exercises 401Rationale for Use of Closed Kinetic Chain Exercises 403Closed Kinetic Chain Research .404

Suggested Shoulder Program Design 408Acute Phase 408Recovery Phase 409Functional Phase .412


xxvCONTENTS

y-..,

SECTION IIntroduction

CHAPTER 1

CO~ONENTSOFTHESHOULDER

Bruce H. Greenfield, MMSc, PT, OCSt

Physical therapists provide services to patients experiencing impairments,functional limitations, disabilities, or changes in physical function resulting frominjury or disease.1 To be successful, physical therapists combine a clear understandingof the theories of movement science that includes a strong foundation in the basicsciences of anatomy, physiology, kinesiology, and neuroscience with clinical manage-ment skills of patient examination, evaluation, diagnosis, and prognosis and treatmentintervention. For example, the ability to identify structural and physiologicalimpairments at the shoulder for treatment planning is predicated on knowledge andunderstanding of n,ormal shoulder structure and function. Therefore, functionalanatomy of the shoulder provides the basis from which physical therapists begin tounderstand abnormal function.

This chapter reviews the anatomy of the shoulder complex and illustrates areas ofparticular clinical concern and significance in injury, surgery, and rehabilitation. Theinterrelationship and interdependency of the upper quarter of the body with theshoulder is reviewed to establish the importance of cervical and thoracic spine andrelated tissue impairment in shoulder pain referral and secondary areas of dysfunc-tion contributing to shoulder movement dysfunction. This chapter serves to compli-ment the next chapter, which reviews the kinesiology of the shoulder complex.

INTRODUCTION

AnatofilY of the Shoulder

The shoulder girdle is a multijoint complex that functions to produce movementof the upper extremity and, ultimately, to position the hand in space. Because theupper extremity literally can move in many thousands of spatial planes, with eachseparated by approximately 10 of motion, the shoulder is an extremely mobilestructure.2 The shoulder, particularly the glenohumeral (GH) joint, is inherentlymobile. The muscles and joint proprioceptors around the shoulder must maintain

tAcknowledgment: The author thanks Robert Donatelli for the use of the fresh cadaver illustrations.

3

STRUCTURE

KINETICS AND THE AXIOSCAPULAR MUSCLES

EVALUATION AND TREATMENT OF THE SHOULDER

Various muscles attach to both the thorax and scapula, maintaining contactbetween these surfaces while producing movement of the scapula. Saha13 classifies

4

stability of its various segments for normal function. This precarious relationship ofmobility and stability during normal shoulder function is a primary reason that manyshoulder injuries occur during overhead shoulder activities and sports.3

The shoulder is described as an integrated series of links functioning harmoni- .ously during movement of the upper extrernity.4 This concept is similar to Steindler'sdescription of the shoulder and upper extremity as a kinematic chain.s Thecomponents that constitute the links or kinematic chain of the shoulder include thescapulothoracic (ST) joint or junction, the sternoclavicular (SC) and acromioclavicular(AC) joints, and the GH joint.6 The entire arrangement is supported by the upperquarter of the body, including the occiput, cervical, and thoracic spines and relatedneural and soft tissue connections.6 Thus, normal shoulder function includes stabilityand mobility of the upper quarter.

Mechanical analysis of the shoulder indicates two competing demands: stabilitybetween the scapula and thorax and mobility between the humerus and scapula.Stability between the scapula and thorax is satisfied through a closed kinematic chainmechanism between the scapula, the SC joint, and the AC joint, and balance andcontrol of the various muscles that atta~h to the scapula? Aclosed kinematic chain ispresent when segmental movement is interrelated so that isolated movement of onesegment around a joint cannot occur.s During normal function, isolated scapularmovement is impossible to achieve without concomitant movement at either the SCjoint or the AC joint. Descriptive movement of the shoulder complex is described inthe following chapter.

B~usejt20~~ not con...!ain '!..S~psule. qr.. sYl1(wial tissue, th~ STjon:~ is classifiedas ~~X~~!?g~

5~jl

FIGURE 1-2. Resting posmon of thescapula on the thorax. Changes from thenormal resting position could indicate anunderlying impairment in the structuralarrangements around the scapula. (FromNorkin, CC, and Levangie, PK: JointStructure and Function: A Comprehen-sive Analysis, ed 2. FA Davis, Philadelphia,1992, p 210, with permission.)

FIGURE 1-1. Fresh cadaver specimen showing the scapula from an inferior view with the broadattachment of the serratus anterior muscle. Manual distraction of the scapula indicates the firm softtissue attachments to the scapula.

CHAPTER 1 ANATOMY OF THE SHOULDER1I

FUNCTION OF SCAPULA

Sternoclavicular Joint

DeltoidTriceps BrachiiBiceps BrachiiSubscapularisInfraspinatusTeres MinorTeres MajorLatissmus DorsiPectoralis Major

Upper, Middle, and Lower TrapeziusLevator Scapul!!: J.1usetes .

Rhomboid (major and minor)-Muscles' .. '-'-,

Serratus Anteri9rPectoralis MinorOmohyoidSubclavius


TABLE 1-1 Classification of Shoulder Muscles

------...................

Scapulohu11'l:.Yf!:L#JtscleJ

STRUCTURE

The SC joint is des5:!.ib~~_..as_.~ .!lodifi:ed ~yn

7"i)1ft!'~-

Articular surfacemanubrium

FIGURE 1-4. The SC joint shown with the clavicle elevated to view the articulation of themanubrium, the medial clavicle, and the interposed SC disc. (From Norkin, CC, and Levangie, PK:Joint Structure and Function: A Comprehensive Analysis, ed 2. FA Davis, Philadelphia, 1992, p 213,with permission.)

Sternoclavicular disc

FIGURE 1-3. The sternoclavicular articulation. Note the incongruency of the sternal end of theclavicle overriding the corresponding articulating surface of the sternal notch of the manubrium.(From Norkin, CC, and Levangie, PK: Joint Structure and Function: A Comprehensive Analysis,ed 2. FA Davis, Philadelphia, 1992, p 211, with permission.)

over the sternal notch to produce an unstable osseous joint (Fig. 1-3). A fibrocartilagedisc enhances stability of th~~jQint. The ueEer_R-Q[t.!.ol!QiJhgdi.scjsatt~ched.lQ_lhe

sUR~rJorcJ.'!Yi!e; the JQw~!, I2Qrtionjs attache~:L.!Q.~~h~)Jlanubriurnal19 first cost~lcartilage (Fig. 1-4). In this way, the disc actually divides the SC joint into two jointcavrnes ana--acfs-as- a hinge during clavicular movementY The

STRUCTURE

ARTICULAR NEUROLOGY AND VASCULAR SUPPLY

IIIL'----r--rtlIIiI'--- Costoclavicularligament

Interclavicular ligament


Manubrium\''\\},

'-~Anterior sternoclavicular ~.:-=ligament ~

---------~'-~ -~

Acromioclavicular Joint

Inn~rvation is supplied by spinal nervesC5 and CQ.Yl.'l-.,.,t!t~.~l:lEra

CHAPTER 1 ANATOMY OF THE SHOULDER 9

Clavicle

FIGURE 1-7. The AC liga-ment. (From Norkin, CC, andLevangie, PK: Joint Structureand Function: A Comprehen-sive Analysis, ed 2. FA Davis,Philadelphia, 1992, p 217, withpermission. )

~ Coracoid/ process

Trapezoid ---, Coracoclavicular__-...........J_ Conoid ..J ligament

II,

Acromioclavicularligaments '"

FIGURE 1-6. The AC joint.Articulation between the acro-mion of the scapula and thelateral clavicle is shown. (FromNorkin, CC, and Levangie, PK:Joint Structure and Function: AComprehensive Analysis, ed 2.FA Davis, Philadelphia, 1992,p 215, with permission.)

ARTICULAR NEUROLOGY AND VASCULAR SUPPLY

BONY ANATOMY


FIGURE 1-8. Cadaver specimen showing the relative size difference between the humeral head andthe glenoid.

The GH joint is formed by the articulation between the head of the humerus andthe glenoid fossa. Because the humeral head can move freely and to some extent inisolation of the scapula, the GH joint is considered by some as an open kinetic chain.5,?The humeral head is a spherical, or convex, structure that articulates with a concaveor relatively flat glenoid fossa. The articulating surface of the humeral head isapproximately 3 to 4 times the size of the glenoid fossa, resulting in an osseousunstable joint1? (Fig. 1-8). The humeral head is oriented in a superior, medial position

Glenohwneral Joint

The innervation to the AC joint is primarily from the anterior primary ramus ofspinal nerve C4 supplied by the suprascapular and lateral pectoral nerves. 6 Therefore,unlike the SC joint, injury or disease of the AC joint does not commonly refer painaround the shoulder girdle. The arterial supply to the AC joint includes thesuprascapular and thoracoacromial arteries.

10

ligaments (Fig. 1-7). Both ligaments, which attach to the undersurface of the distalclavicle, provide a passive tensile or tractive force to the distal clavicle after 100of humeral elevation. In addition, tension in these ligaments during outward rotationof the scapula produces additional clavicular rotation necessary for full overheadhumeral elevation (see Chap. 2).7,11 Therefore, no muscles act directly on the ACjoint; motion is produced in passive response to active scapula motion.

11

b

Condyles of humerus

Humeralhead

a

The GH joint capsule is a thin structure that attaches around the surgical neck ofthe humerus.6 The capsule is lax and allows approximately 1 cm of distraction withmanual force between the articulating surface of the glenoid and humeral head. Thecapsule forms a vacuum and provides a negative pressure between the articulating

FIGURE 1-9. The humeral head in the transverse plane is commonly angled posteriorly withrespect to an axis through the humeral epicondyles (retroversion). (From Norkin, CC, and Levangie,PK: Joint Structure and Function: A Comprehensive Analysis, ed 2. FA Davis, Philadelphia, 1992,p 219, with permission.)

and is slightly retroverted, whereas the glenoid fossa is superior, lateral, and slightlyretroverted7,n (Fig. 1-9). The retroversion of both the humeral head and glenoid fossais thought by some to offer some anterior osseous stability to the jointY A labrumattaches around the rim of the glenoid and is composed of both fibrous andfibrocartilage tissue. The inner fibrocartilage surface of the labrum is attached to theglenoid rim, and the outer surface of fibrous tissue is continuous with the capsule ofthe GH joint, including the glenohumeral ligaments. The tendons of the long head ofthe biceps brachii and the triceps brachii contribute to the structure and reinforcementof the labrum. IS The labrum is better developed along the anterior and inferior aspectsof the glenoid as compared to the posterior portion, but the entire labrum is designedto deepen the glenoid socket (Fig. 1-10).

CAPSULE STRUCTURE

CHAPTER 1 ANATOMY OF THE SHOULDER

:/--

BURSAE

surfaces.19 The negative pressure provides a suction effect to help hold the humeralhead to the glenoid.

The anterior aspect of the capsule contains a small cleft or opening thinly veiledwith fibrofatty, synovial tissue. This cleft is known anatomically as the rotator cuffinterval because it is present between the tendons of the supraspinatus andsubscapularis.2o,21 The rotator cuff interval is significant because surgeons often enterthe shoulder capsule through it to minimize tissue damage. Additionally, and in somecases, if larger than normal, this interval is a source of instability requiring plication tostabilize the GH joint?l

FIGURE 1-10. The glenoid la-brum.


Numerous bursae are present around the GH joint.6 The subacromial bursa islocated between the deltoid muscle and the joint capsule. The bursa extends under theacromion and coracoacromialligament (Fig. 1-11) and over the supraspinatus muscle,and may communicate with the joint in the presence of a rotator cuff tear. 19 Thesubscapularis bursa is located between the subscapularis tendon and the neck of thescapula and may communicate with the GH joint cavity between the superior andmiddle glenohumeral ligament in the rotator cuff interval (Fig. 1-12).

The bursae, which allow free gliding of tissues, are particularly susceptible toinflammation (bursitis) with repetitive friction. Other bursae associated with the GHjoint structures, but of less clinical significance, are located between the infraspinatusmuscles and the capsule, on the superior surface of the acromion, between the coracoidprocess and the capsule, under the coracobrachialis muscle, between the teres major andthe long head of the triceps, and in front and behind the tendon of the latissimus dorsimuscles.6

12

FIGURE I-II. Subacromial bursa is contiguous and allows smooth gliding of the supraspinatusmuscle and the humeral head under the deltoid muscle and the acromion. (From Norkin, CC, andLevangie, PK: Joint Structure and Function: A Comprehensive Analysis, ed 2. FA Davis, Philadelphia,1992, p 221, with permission.)

13

CORACQACROMIAL LIGAMENT

-"\\

Glenoidfossa

1 --.::::r----:- SUBCORACOIDbe ,.' SUBSCAPULARIS'\.. '

\

X-sectiona:;;;Z~-

Subacromial I --l-4ttrlsubdeltoidbursa

Synovial_capsuleTRANtY8~~NHrERAr-_.~

BICEPS TENDONINVACINAnONBICEPS TENOON--+--{ I

LIGAMENT STRUCTURE AND FUNCTION

The intrinsic ligaments of the GH joint, which include the superior, middle, andinferior glenohumeral ligaments, are described as thickening of the capsule.2223 Thesuperior glenohumeral ligament is a small, thin ligament that covers the long head ofthe biceps muscle. It attaches from the labrum of the glenoid to the inferior tuberosityof the humeral head. The middle glenohumeral ligament has a wide attachment andlies under the subscapularis tendon. The points of attaclunent include the middlelabrum and along the inferior facet of the inferior tuberosity of the humerus. Both thesuperior and middle glenohumeral ligaments form the floor of the rotator cuffinterval. The inferior glenohumeral ligament, also known as the axillary pouch, hasrecently been investigated by O'Brien24 and found to have three distinct portions:anterior, posterior, and inferior bands (see Fig. 8-4). The inferior glenohumeralligament complex (IGHLC) functions like a hammock during overhead elevation. Forexample, the anterior band of the IGHLC becomes taut with humeral abduction and

FIGURE 1-12. The subscapu-laris bursa. (From Calliet, R:Shoulder Pain, ed 3. FA Davis,Philadelphia, 1991, p 13, withpermission. )

CHAPTER I ANATOMY OF THE SHOULDER

, .

,

tt;

FIGURE 1-13. The glenohumeral ligaments make a Z configuration in approximately 88% ofshoulders. Note the position of the coracohumeral ligament above the superior glenohumeralligament. (Adapted from Ferrari, DA: Capsular ligament of the shoulder: anatomical and functionalstudy of the anterior superior capsule. Am J Sports Med 18:20,1990, p 21, with permission.)

external rotation, while the posterior band relaxes. Conversely, the posterior bandbecomes taut with humeral internal rotation and adduction, while the anterior bandrelaxes. The inferior band of the IGHLC helps support the humeral head within theglenoid and prevents inferior subluxation. Laxity in this ligament leads to instabilityof the GH joint. Tearing of the ligament occurs with traumatic anterior dislocation.Because the anterior band attaches to the inferior labrum and glenoid, a tear of theanterior band of the IGHLC results in a concomitant tear of this area of the labrumand is known as a Bankhart lesion.24

The glenohumeral ligaments form a distinct Z pattern (Fig. 1-13) in 88% of thepopulation.25 The coracohumeral ligament attaches from the coracoid process into thegreater and lesser tuberosities of the humerus. lO The ligament creates a tunnel throughwhich the biceps tendon passes.

Twelve percent of the population exhibits variability in the shape and presence ofthe middle glenohumeral ligament (Fig. 1-14A and B). This group is particularlypredisposed to anterior subluxations and dislocations. The functions of the glenohu-meral ligaments are listed in Table 1-2.

Ligament

Superior glenohumeral ligament; coracohumeral ligament andsubscapularis muscle

Middle glenohumeral ligamentAnterior band of inferior glenohumeral ligament


TABLE 1-2 Anterior Restraints to External Rotation

Position

Neutral or Adducted Position

Approximately 45 abduction90 abduction

14

DER CHAPTER 1 ANATOMY OF THE SHOULDER 15

MUSCLE ATTACHMENTS

J:]ijJ.,jJII11

(';fs~~rr-- SUBSCAPULARIS

SUPRASPINATUS -----.~"I-f--,,~INFRASPINATUS

TER ES MI NOR-

Rotator CuffA distinguishing feature of the scapulohumeral muscles and to a lesser extent the

axiohurneral muscles (Table 1-1) are their intimate connection to the glenohumeralcapsule. The blending of the rotator cuff muscles to the capsule provides a dynamiccapsuloligamentous struchlre that serves to alter the stiffness in the joint duringcontraction of the muscles.26 In cadaver studies, Cain found that experimentaltightening of the infraspinatus and teres minor muscle resulted in reduced anteriorhumeral translation.27

Figure 1-15 and Figure 1-16 illustrate the primary rotator cuff muscles andattachments at the GH joint. The specific functions of the muscles are reviewed in thefollowing chapter. The subscapularis attaches along the anterior capsule into the lessertuberosity. The supraspinatus, infraspinatus, and teres minor muscles attach along

FIGpRE 1-14. (A) Schematic shows the absence of the middle glenohumeral ligament. (FromFerrari, DA: Capsular ligament of the shoulder: anatomical and fi.mctional study of the anteriorsuperior capsule. Am JSports Med 18:20, 1990, p 22, with permission.) (B) Fresh cadaver dissectionshows the absence of the middle glenohumeral Ligament. Note the humeral head and glenoid fossathat are visible within the capsular opening.

FIGURE 1-15. The attachment sites of the rotator cuff muscles. (From Calliet, R: Shoulder Pain,ed 3. FA Davis~ Philadelphia, 1991, p 24, with permission.)

16 EVALUATION AND TREATMENT OF THE SHOULDER

:~' ,:if .

FIGURE 1-16. Fresh cadaver section of the posterior aspccr of the GH joim and showing theposterior ror;uCIr t.:llff muscks induding the supraspinatus, infr.lspin:u:us, and teres minor muscles.

the superior and posterior humeral head onto the facets of the greater tuberosity.Ligaments and muscles on both sides of the glenohumeral joint provide static anddynamic stability so that shoulder stability can be thought of as a dynamic circleconcept28 The circle concept indicates that structures on all sides of the joint provideeither primary or secondary restraint of humeral head movement in anyone direction.For example, for a shoulder to dislocate anteriorly, both the anterior and posteriorstructures must be damaged; that is, the anterior capsule is the primary restraint toanterior dislocation, and the posterior capsule is the secondary restraint.

Tightening or active contraction of the rotator cuff muscles has the additionaleffects of centering the humeral head in the glenoid and providing increased jointcompression during elevation of the limb29~") Poppen and Walker" found that themovement of instantaneolls axis of rotation of the humeral head was limited toapproximately 3 mm in a superior direction along the glenoid during active shoulderelevation. This limited arthrokinematic motion was controlled by the contraction of therotator cuff muscles to offset the strong eleva tory contraction of the deltoid muscles.Saha 17 appropriately refers to the rotator cuff muscles as steerers of the humeral head.interestingly, Poppen and Walker found increased superior humeral head translationgreater than the normal 3 mm in patients with rotator cuff disease. An in-depth reviewof both the kinematics and kinetics of the GH joint is presented in Chapter 2.

Biceps Brachii MechanismThe long head of the biceps runs superiorly from the anterior shaft of the

humerus through the bicipital groove between the greater and lesser tuberosities toattach to the supraglenoid tubercle above the glenoid fossa, and blend in the superiorlabrum6 11 The tendon exits the joint capsule but, within, the capsule remainsextrasynovial. However, a synovial sheath and a transverse bicipital ligament along itscourse within the bicipital groove cover the tendon (Fig. 1-17). The ligament addsadditional support to the rotator cuff muscles to stabilize the GH joint32 This isparticularly evident during. the cocking phase of baseball pitching, when the bicepstendon concentrically contracts to compress the humeral head inferiorly within theglenoid." The attachment of the biceps tendon to the labrum can result in a traction

:':r-':>r;''i:

",

;1

17

I If

Transverse_-/---p,,*,humeralligamentTendon sheath

CHAl'TER 1 ANATOMY OF THE SHOULDER

FIGURE 1-17. The:: long head of the biceps br:H:hii p;\sses through;l I1bro-OSSCOLlS tlIllnd fonm:dby the bicipital groove and the trans\'crsc~hul11cral ligament. It is prodUl:cd within the tullnel by ;ltendon sheath. (From Norkin. CC, ;\Ild LC\'angic, PK: Joint Strlh.:rurc and Function: :\ Compn.::hcn-sive Analysis, cd 2. FA Davis, Philadelphia, 1992, p 228, with permission.)

injury during repetitive overhead throwing with a tendonitis and labrum tear, knownas a SLA.P. (superior labrum anterior and posterior) tear."1

ARTICULAR NEUROLOGYThe innervation of the GH joint is derived from spinal nerves C5 and C6, with a

minor contribution from C4" The AC joint has an isolated innervation from C4. Theperipheral nerves supplying the glenohumeral capsule, ligaments, synovial mem-brane, and rotator cuff tendons are the axillary.. suprascapular, subscapular, andmusculocutaneous.

Afferent receptors from these nerves are listed in Table 1-3. The Ruffini endingsand Golgi tendon organs are slowly adapting receptors and contribute primarily toposition sense and awareness." The Pacinian corpuscles are rapidly adapting receptorsthat sense sudden motion and contribute to awareness of joint motion (kinesthesia).Stimulation can cause muscle contraction (protective reflex) of the rotator cuffmuscles, which are assisted by various afferent muscle spindles.'" The protectivereflex modulating protective reflexes at the shoulder is considered polysynaptic.coStrong evidence exists that illustrates the importance of these joint receptors toprovide stability and position sense to the shoulder. Smith and Brunolli foundkinesthetic deficits in patients with anterior shoulder dislocations when comparedwith healthy-matched subjects."

18 EVALUATiON AND TREATMENT OF THE SHOULDER

TABLE 1-3 Joint Receptor

Type

Ruffini endings

Pacinian corpuscles

Goigi end organs

Free nerve endings

Action

Numt:TOUS in superficial jointsSlowad:lpt3tionLow threshold stimulationNumerous in deep capsuleR:\pid adaptationLow threshold to stimulationIntrinsic and extrinsic ligamentsSlow adaptationHigh threshold to stimulationLocation in most tissuesNo adaptationHigh threshold for stimulation

Function

Provides joint position sense

Provides information concerning rapidch3ngc in motion

Adjusts muscle toneProduces reflex dli:cr on muscle rone

Produces ronil: muscle contraction

VASCULAR SUPPLYThe vascular supply to the rotator cuff comes from the posterior humeral

circumflex and the suprascapular arteries.'6 These arteries prinCipally supply theinfraspinatus and teres minor muscle areas of the tendinous cuff. The anterior aspectof the glenohumeral capsule is supplied by the anterior humeral circumflex artery andthe thoracoacromial, suprahumeral, and subscapularis arteries. Superiorly, the thora-coacromial artery supplies the supraspinature. Of clinical importance, the supraspina-tus tendon has an area of low vascularity approXimately 1 cm proximal to its humeralinsertion on the greater tuberosity." Codman3? referred to this area as the critical zOllein the rotator cuff, because of the high incidence of degeneration. Rothman andParke'" found that this area of vascularity decreased with age. Rathbun and McNabnoted that the critical zone of the rotator cuff had an adequate blood supply when thevessels were injected with the arm in the abducted position. However, this area washypovascular when the injection was given with the arm in the adducted position.'"The authors hypothesize that an area of transient hypovascularity occurs in the criticalzone as a result of vessels being stretched across the humeral head when the upperextremity is fully adducted. This phenomenon is known as the "wringing-out" effectof the rotator cuff tendon blood vessels.37

CORACOACROMITALARCHFigure 1-18 illustrates the coracoacromial arch. The arch, also known as the

supraspinatus outlet, forms the roof for the underlying subacromial tissues includingthe rotator cuff tendon, subacromial bursa, and long head of the biceps brachii]9 Thetough and sharp-edged coracoacromial ligament encloses the arch. The ligament isthought to help prevent superior traumatic dislocation of the humeral head 6

The coracoacromial arch is a significant site for potential dysfunction and injury.The arch space enclosing the subacromial tissues is normally, approximately 9 to 10mm.o This small space allows the subacromial tissues to glide freely during humeralelevation, but leaves very little margin of error for free gliding. In fact, some low-levelimpingement of these tissues invariably occurs during humeral elevation.'9 Duringdysfunction, such as rotator cuff muscle weakness, the subacromial impingementforce increases, resulting in mechanical impingement syndrome and inflammation of

CHAFfER 1 ANATOMY OF THE SHOULDER

Coracoacromialligament

Acromion

19

FIGURE 1-18. Fresh (;J,davcr vicw of [he cO(:l(ohulllcral arch. Note (he (or~H;ohllmcr;ll ligamentand the long head of the biceps tendon.

these tissues. In some cases, the shape of the anterior acromion is slightly hooked orcurved. This results in a less inherent subacromial space, predisposing to impinge-ment syndrome .in the presence of overuse injury:11

SUMMARY OF FACTORS THAT RELATE TO GLENOHUMERALJOINT STABILITY

The factors that influence the normally tenuous stability of the GH joint are listedin Table 1-4. These factors are delineated dynamiC or static stabilizers. The physicaltherapist's identification of the dynamic factors amenable to rehabilitation gUidesdecision making.

Dynamic stabilizers include rotator cuff muscle strength, parascapular musclestrength, and proprioception. Static factors include the shape and size of thearticulating surface, soft tissue configurations including the labrum, the presence andstatus of the middle glenohumeral ligament, the size of the rotator cuff interval, or the

TABLE 1-4 Factors Affecting Glenohumeral Joint Stability

Stability Factors

Adequate gknoid sizePosterior tilt ~fcnoid ;md hUnler:l1 hcadIm;lct c;lpsulc""and labrum

Axi(ls~;lpular musclc control and balance (Sec Chap. 2)Rotator cuff musclc control and balance (Sec Chap. 2)Intact proprioception and neuromuscular (olltrol

Type of Stabilizer

Static stabilizerSutic stabilizerSt;'\tic stabilizerDrnamic stabilizerDynamic stabilizerD)'namic stabilizer

laxity of the JGHLe. These factors are beyond the control of the rehabilitationspecialist. When shoulder symptoms are present, if one or more static factors iscompromised and not accessible to rehabilitation, then additional medical and/orsurgical management is necessary.


STRUCTURAL RELATIONSHIPS AND INTERDEPENDENCEOF UPPER QUARTER FUNCTION

Any discussion of shoulder anatomy should include a review of some of thestructures in the upper one-quarter of the body because of the close relationship infunction between many of these structures (Box 1-1). Many conditions affecting theshoulder can originate in other tissue and structures within the upper quarter. -Forexample, postural changes with muscle imbalances can result in aberrant movementpatterns affecting normal scapulohumeral rhythm (see Chap. 2) subsequently leadingto subacromial impingement and tissue pathology. (See Chap. 9.) Referred pain fromtissues that share the same segmental spinal innervation as the shoulder must be ruledout. (See Chap. 10.) Clearly, a thorough clinical evaluation for shoulder pain andimpairments should include a screening assessment of related structures andknowledge of upper quarter structure and function. (See Chap. 5.)

Functional Anatomy

The informotion thot follows is extrapolated from Donatelli ond Wooden:12 Theupper quarter includes the occiput, the cervicol spine, the shoulder girdle, the upperextremities, associated soft tissues, and related nerves and blood vessels.

The shoulder girdle is attached to the axial skeleton by the SC joint. Numeroussoft tissue and muscular attachments join the occiput, mondible, cervical spine, andshoulder girdle. The superficiol and deep fibers of the cervical fascia join the superiornuchal line of the occipital bone, the mastoid process, ond the bose of the mondibleabove to the acromion, clavicle, ond manubrium sterni below. Muscles partlyresponsible for scopulN movement, namely the upper fibers of the trapezius ond thelevator scapulae, connect the occiput and cervicol spine to the superior lateral andsuperior mediol borders of the scapula, respectively. Anteriorly, the sternocleidomas-toid muscle attaches from the mastoid process of the cronium to the sternum andclavicle (Fig. 1-19).

BOX 1-1 HABITUAL CERVICAL MOTIONAn excellent illustration of the interdependency of fUIKtion. in. the upper quarter is observedduring limb elevation. Unilateral limb de".\tion produccs side-bending of the uppcr tho-racic and mid-cer\'kal spines to thc ipsilatcral sidc and cOllmer romtion of the atlanta-axialjoint to the comralatcral side. Bibreral limb de\'atioll rcsults in flexion of rhe upper thoracicspinc, extension of the mid-cervic,,1 spine .mel the .ulamo-occipital joint:16 These coupledmovemcnts werc termed habiru,,1 cervical motion, in an article by Lec17 and illustrate the im-portance for norm:lI mobility and soft tissue tllllaion in the upper quarter to allow full Overhead shoulder motion.

Multiple soft tissue connections are present behveen the cranium, mandible,hyoid bone, cervical spine.. and shoulder girdle:13 The temporalis and massetermuscles join the cranium and the mandible. The mandible is joined to the hyoid boneby the suprahyoid muscles, including the digastric, stylohyoid, mylohyoid, andgeniohyoid. The infrahyoid muscles connect the hyoid bone to the shoulder girdle,and indirectly, through soft tissue connections to the cervical spine. These musclesinclude the sternohyoid, sternothyroid, thyrohyoid, and omohyoid. Specifically, thehyoid bone is joined to the scapula by the omohyoid muscle and to the sternum andclavicle by the sternohyoid muscle44 (Fig. 1-20).

CHAPTER 1 ANATOMY OF THE SHOULDER 21

FIGURE 1-19. Fresh eadaversection showing the multiple softtissue attachments around thethoracic outlet area of the upperquarter of the body. (AJ Anteriorscalene muscle. (B) Sternocleido-mastoid muscle. (C) Pectoralismajor muscle. (D) Pectoralis mi-nor muscle.

FIGURE 1-20. Fresh cadaverdissection showing the (AJ su-prahyoid muscle; (B) infrahy-oid muscles; (C) course of theomohyoid muscle along theposterior triangle of the neckfrom the hyoid bone to thesuperior bor"dcr of the scapula.Note that the scalene muscleshave been removed.

A B

FIGURE 1-21. Th" Brachialplexus. The br'lChial plexus iscomposed of the anterior pri-mary rami of segments C5through TA. The roots emergefrom the vertebral foraminathrough the scalene muscles.The roOts merge into the[funks in the region of the firstrib. The trunks via divisionsbecome cords that divide imoperpendicular ntrVt;S of the up-per extremities. (From Callier,R: Shoulder Pain, cd 3. FA Da-vis, Philaddphi., 1991, p 170,with permission.)

PERIPHERAL NERVES

FiRST RIB

AXILLA


ULNAR (RADIAL \

MEDIAN

NERVE ROOTS -----1;'/1

NERVE TRU NKS ---\"III!fi(/;

CORDS ---------~

22

Brachial Plexus

I

The brachial plexus (Fig. 1-21) is derived from the anterior primary rami of C4through T1 and supplies the innervation to the tissues and structures in the upperlimb, including the shoulder6 The proximal part of the brachial plexus passes throughthe anterior and medial scalene muscles, the middle portion between the clavicle andfirst ribs, and the distal portion passed under the pectoralis minor tendon attachmentat the coracoid process (Fig. 1-19). The plexus gives rise to the peripheral nerves thatinnervate the shoulder, including the scapula. Specific nerves such as the dorsalscapula nerve, the supraspinatus nerve, and the axillary nerve, are highly prone tosoft tissue impingement or traction injury, particularly in the presence of trauma ofpostural changes."5 Some of these conditions are presented in Chapter 10.

CHAPTER SUMMARY

.~IIIi

IThe study of anatomy of the shoulder presented in this chapter includes all the

relevant joints, soft tissue, and neural stmctures to provide a foundation forunderstanding the kinesiology discussed in Chapter 2 and the clinical information

REFERENCES

presented in the remainder of the text. The microanatomy and histology of certaintissues, such as the labrum, are gaining clinical importance related to potentialpathology and healing/surgical factors. However, this information is not presented.That is not to diminish the importance of such information; this information wasdetermined to be beyond the scope of this chapter. Readers are encouraged to readother sources that present this information..l~ The separation of the anatomy with thesubsequent information of kinesiology was done purposefully to add refinement andscope to both chapters and a logical progression for understanding the relationshipbetween structure and function.

The shoulder presents an anatomically complex series of joints that challenges therehabilitation specialist to understand the individual components and to integrateoverall structure and function. The approach to the study of anatomy and function ofthe shoulder is presented to coincide with the manner of evaluation and treatment,that is, from specific to a general consideration and analysis. An additionalappreciation of the interrelationship of upper quarter structure and function of theshoulder provides the background and functional foundation for Chapter 10,"Referred Pain Syndromes of the Shoulder," and is requisite for a thorough evaluationof shoulder conditions.

23cHAPTER I ANATOMY OF THE SHOULDER

L Guide 10 Physical Therapist Practice: Phys Ther n:ll, 1997.2. Moseley, J6, et al: EMG analysis of the scapular muscles during a shoulder rehabilitation program. Am

J Sport Med 20:128, 1992.3. ]obe, FW, and Pink. M: Classification and treatment of shoulder dysfunction in the overhead .1thlctc.

J Orthop Sports Phys Ther 18'427, 1993.4. Dempster, \NT: Mechanisms of shoulder movement. Arch [,hy:; Med Rehab 146A:49, 1965.5. Steindler, A: Kinesiology of Human Body Under Normal and Pathological Conditions. Charles C.

Thomns, Springfield, IJI.~ 1955.6. WarNick, R, and Williams, P (eds ): Gray's Anatomy, cd 35. WB Saunders, Philadelphia, 1973.7. Calliet. R: Shoulder Pain, ed 3. FA Davis, Philadelphia, J991.8. Culham, E, and Peat, M: Functional anatomy of the shoulder complex. J Orthop Sport Phy!> n,er 18:342,

1993.9. Johnston, TB: Movements of the shoulder joint: "plea for use of plane of the sc.1pula" .15 plane of

reference for movements occurring al humeroscapula joint. Br J Surg 25:232,1937.10. Kondo, M, et al: Changes of the tilting angle of the scapulil following elevation of the arill. (n Gat(.'man,

JE, and Welsh, RP (eds): Surgery of the Shoulder, CV Mosby. Philadelphia, 1984.11. Norkin, ce, and Levangie, PK: Joint Structure and Function: A Comprehensive Anulysis, cd 2. FA O;'lvis,

Philadelphia, 1992.12. Wadsworth, W: Manual Examination and Treatment of the Spine and Extremities. Williams and Wilkins.

Baltimore, 1988.13. Saha, AK: Mechanics of elevation of glenohumer.l1 joint. Acta Scand 44:6688, 1973.14. Inman, vr, et al; Observations of the function of the shoulder join!. J Bon(' Joint Surg 726: 1, 1944.15. Sadr, B, and Swann, M: Spontaneous dislocation of the sterno-clavicular joint. Acta Orthop Scand

50'269, 1979.16. Petersson, CJ: Degeneration of the acromie-c1avicular joint. Acta Grthop Scand 54:43-l, 1983.17. Sc1ha, AK: Dynamic stability of the glenohumeral joint. Acta Orthop Scand 42:491, 1971.18. Moseley, HP, and Overgaard, B: The anterior capsular mechanism in recurrent anterior dislocations of

the shoulder: morphological and clinical studies with special reference to the glenoid labrum andglenohumeral ligaments. J Bone Joint Surg 44B:913, 1962.

19. KummeR 8M: Spectntrn of lesions of the anterior capsular mt.'Chanism of the shoulder. A J Sports Mcd7'111,1979.

20. Nobuhara, K. and Ikeda, H: Rotator interval lesion. elin Orthop 22..1:+-1, 1987.21. Harryman, DT, et al: The role of rotator interval capsule in passive motion and stnbilit}' of the shoulder.

J Bone Joint Surg 74A:53, 1992.22. Turke, S1. et al: StabiliZing mechanism pre\'enting anterior dislocation of the glenohumeral joint. J Bone

Joint Surg 63A:1208, 1981.


23. Warner, Jj, et al: Static capsuloligamentous restraints to superior-inferior translation of the glenohu-meral joint. Am J Sporls Med 20:675, 1992.

24. O'Brien, 51, et al: The anatomy and histology of the inferior glenohumeral ligament complex of theshoulder. Am 1 Sports !\tied 18:449, 1993.

25. Ferrari, DA: C::Ipsular ligament of the shoulder: anatomical and functional study of the anterior superiorcapsule. Am 1Sports Med 18:20, 1990.

26. Guanche, et at: The synergistic action of the capsule and the shoulder muscles. Am J Sports Med 23.1995.

27. Hawkin'i, Rj, et al: The assessment of glenohumeral translation using manual and fluoroscopictechniques. Orthop Trans 12:727, 1988.

28. Cain. PR, et at: Anterior st

CHAPTER 2,J

,, .

I


y

z

,,, ,

",I \

x

FIGURE 2-1. RiglH h3mkd Cam:sian coordin:uc sysn:m widl the origin at rhe gknohumef;ll joinr(enter. Positi\'C fm;ltions established using the right hand rule. \Vith rhe right hand, place the thumbpointing in dtc dircnion ofdlC: axis ofimcn:sL Curl the fingers into a fist. The direction in which theflllgcrs move is positive rotation about (h~H axis. (From OZka}';l. N, and Nordin, i'vt: FundamCfl[;,ls ofBiomcchanil:s: Equilibrium, Motion and Dct

CHAPTER 2 KINESIOLOGY OF THE SHOULDER

TABLE 2-2 Average Active Shoulder Range of Motion

Movement

27

R..tnge (Degrees)

Ji

IFlexionHyperextensionAbductionMedial RotationLateral RotationHorizontal Adduction #'* +Horizontal Abduction #'* +

# also rclcHed to as horizontal ncxion also referred to as horizolltal extension+ movement is initialed from 90~ of abdW':lion(From i\hgcc, OJ: Orthopcdic Physical.A.ssc~mcnt.\VB S:llmdcrs, Phil:lddphia, 1987.)

Segmental Kinematics

SCAPULA

1601805060

170180601008()9013045

The scapula, which is partially responsible for maintaining the connectionbetween the humerus and the thorax, serves as the site of attachment of numerousmuscles. Normal scapular motion, critical for normal shoulder function, requiressimultaneous movement at the scapulothoracic (ST), sternoclavicular (SC), andacromioclavicular (AC) joints.

Scapular motion consists of two translations and three rotations. (See Fig. 2-2/\.)Vertical translation superiorly (elevation) and inferiorly (depression) occur along withmedial and lateral translation, commonly known as retraction (adduction) andprotraction (abduction), respectively. The rotational motion with the greatest rangeoccurs around an axis of rotation projecting anteriorly and posteriorly through thebody of the scapula. (The location of the axis of rotation varies throughout shouldermovement and will be discussed later.) Displacement of the inferior angle of thescapula laterally and superiorly is described as upward rotation, whereas the reversemotion is downward rotation. The normal range of scapular rotation is 60, whereasranges of elevation-depression and protraction-retraction have not been reported:'.56

The two remaining rotational motions of the scapula are winging and tipping.7.5(Winging is used to refer to a pathological condition involving excessive rotationabout a vertical axis of rotation, although some rotation in this plane is considerednormal and essential to proper shoulder motion.) Both of these motions, resultingfrom the geometry of the scapula and thorax, will occur in conjunction withelevation-depression, protraction-retraction, and upward-downward rotation as thescapula maintains its connection to the thorax. Winging is a rotation of the scapulaabout a vertical axis of rotation that pierces the AC joint. Tipping is a rotation abouta horizontal (medial to lateral) axis of rotation that extends through the AC joint.Normal ranges of winging and tipping during humeral elevation have been reportedas 40 and 20, respectively.s

CLAVICLE

The clavicle connects the scapula to the sternum and has three rotational degreesof freedom due to the combined movement at the AC and SC joints (Fig. 2-28).Protraction, anterior movement of the acromial end of the clavicle, and retraction,


Upwardrotation

OCprcuion

Aj 45 superiorl ~ 15 posterior~ ~~OO-500rotation posteriorly

15 anterior ~ ~--:---.~5 inferior V'l';.~( ,v

\ )B ~H

FIGURE 2-2. (A) Scapular motions occurring at the scapulothor.u:ic and acromiodavicuLtr joints(From Norkin, ee, ;md Lc\'angic, PK: Joint Struaurc and Function. A Comprehensive Approach.FA Davis, Philaddphia, 1992, with permission.) (R) Ctwicular motions occurring at the srcrnoclavicular and acromioclavicular joims (From Soderberg, GL: Kinesiology. Application to pathologkalmorion. \Nilliams and Wilkins, Baltimore, 1997.)

CHAPTER 2 KINESIOLOGY OF THE SHOULDER 29

posterior motion of the acromial end, occur around a vertical axis of rotation throughthe costoclavicular ligament. Anterior and posterior axial rotation occur about alongitudinal axis of rotation extending laterally along the long axis of the clavicle andprojecting through the AC and SC joints. With anterior rotation, the superior surfaceof the clavicle rotates to face anteriorly. Posterior rotation is the reverse motion.Elevation and depression occur around an axis with an anterior-posterior orientation.Superior movement of the acromial end of the clavicle is called elevation, whereasinferior movement is clavicular depression. Figure 2-28 illustrates the motions of theclavicle and the generally accepted range of motion.'

MOTION COUPLING BETWEEN SCAPULA AND CLAVICLE

Because of the mechanical connections that exist between the clavicle andscapula, all movements of one bone will be coupled to movements of the other.Elevation and depression of the clavicle, for example, must be coupled to elevationand depression of the scapula, respectively. Scapular upward rotation will also occurduring clavicular elevation. Protraction of the clavicle is coupled to scapularprotraction and some winging, 'whereas clavicular retraction is coupled to scapularretraction. The function of this shoulder "girdle" allows the opposing needs ofstability and mobility to be met and, in turn, allows for normal shoulder complexmotion.'ttl

Whereas the shoulder complex has been described as a closed chain, Dvir andBerme"1 suggested an alternative view. The complex as a whole can be viewed as anopen chain if one considers a free distal endpoint (that is, the hand). Theinterdependence of motion is seen, however, when the relationship between thescapula and clavicle is examined. These bones are mechanically coupled and cannotmove independently. Dvir and Berme;' therefore, classified the shoulder complex as acombination of both a closed chain mechanism (scapula, clavicle, and thorax) and anopen chain mechanism (scapula and humerus) working together to achieve normalupper limb motion. The concept of tl,e "continuous controlled skid bed," introducedby Dvir and Berme: refers to the interaction between the glenoid fossa and humeralhead. The glenoid surface serves as a "skid bed" that, while it moves, allows thehumeral head to roll and translate on its articular surface. The moving "bed" allowsthe required changes in articular geometry to help maintain a more optimum musclelength and velocity necessary for full range of motion, while simultaneouslymaintaining glenohumeral (GH) joint surface congruency. Through this mechanism,both requirements of mobility and stability of the shoulder complex can be achieved.

HUMERUS

The humerus is the primary segment in the shoulder complex because upper limbmotion is defined by the humeral connections to the forearm and hand. The humerusalso has the largest range of motion when compared to that of the scapula andclavicle, Humeral kinematics are centered on the area where the GH joint connects thehumerus to the scapula (Fig. 2-1). The movements of the humerus at the GH joint arequalitatively the same as those defined as shoulder complex movements (thnt is,flexion-extension, abduction-adduction, and axial rotation medially and laterally)However, the range of humeral motion is considerably less when the AC, SC, and STjoints are constrained,s

~\l1i~tf0l~~'E;;:?2~f~~f~f4::~~;~~~:~~TE::;~~f~:;;.lP~~:'~:i};;-'-~~~1:2"'-~'l:':;~,"lil-'1ii"~~~-W~~~I!!:&'fiMi!IW!!.I1'ii'1liw~"\l!~!!iiW:!1i[!#i':1lE~-


I!

SCAPULOHUMERAL RHYTHM

During elevation of the humerus (for example, frontal plane abduction), a patternof scapular upwnrd rotation with concurrent clavicular elevation and axial rotation areconsistently observed.'-l.6 In the initial phases of humeral flexion o~ abduction, little tono scapular or clavicular motion occurs. At approximately 200 of humeral elevation,however, upward rotation of the scapula with concurrent clavicular elevation begins.6At approximately 900 of humeral elevation, clavicular elevation stops due to tension inthe costoclavicular ligament.5 Continued elevation of the humerus requires continuedupward rotation of the scapula, which has rotated through a range of approximately 30(for humeral elevation to 90)_ The axis of rotation for the scapular rotation is located atthe base of the scapular spine and extends anteriorly through the SC joint:'

For additional scapular motion to take place, posterior axial rotation of theclavicle Inust occur. The trapezius and serratus anterior muscles will continue togenerate forces that tend to upwardly rotate the scapula. These muscular forcesapplied to the scapula are transferred to the clavicle through the coracoclavicularligaments. As a result, the clavicle rotates posteriorly to allow the scapula to continueto rotate upward another 300S A resultant shift in the location of the axis for scapularupward rotation from the base of the scapular spine to the AC joint occurs:' The rangeof clavicular elevation is approximately 30-36 and the posterior rotation is approxi-mately 30-40,6

This quantitative kinematic relationship between the humerus and scapula variesthroughout the normal range of humeral elevation and is dependent on shoulder loadand the level of fatiguey,lo The average ratio for humeral elevation to scapularupward rotation across the entire range of elevation has been reported as 2:1.5,3,8Freedman and Monro I , found that although the relationship between the humerusand scapula was linearly related, the ratio of humeral to scapular motion was 3:2.Poppen and Walker7 suggested that the ratio was not linear, finding that during theinitial phases of abduction (up to 30) the humerus to scapula ratio was 4.3:1, afterwhich it dropped to 1.25:1. Investigations examining the scapulohumeral relationshiphave employed different methodologies and different subject populations_ Differentranges of motion, different movements (passive or active), different methods forcalculation of the scapulohumeral ratios, and the lIse of live subjects as opposed tocadavers may all have influenced the results.

Most of the studies performed have suggested that the scapular contribution toshoulder elevation increased with the increasing elevation angle (that is, decreasingthe ratio). McQuade and Smith9 measured scapulohumeral rhythm using a magnetictracking device in human subjects performing scapular plane elevation. ComparingpClssive humeral elevation, elevation under light loads, and elevation under heavyloads, tests indicated that scapulohumeral rhythm was nonlinear and varied withactivity, load, and the degree of humeral elevation. During passive conditions, forexample, the contribution of the scapula increased with increasing humeral elevation.In both loaded conditions, however, the scapular contribution decreased as thehumeral angle increased. This finding is consistent with data reported by Doodyet al. 12 Studying 25 women, Doody et al.l! found that scapulohumeral rhythm wasnonlinear and varied Significantly between individual subjects_ The scapular contribu-tion to humeral elevation was observed to peak between 90 and 140 and thendecrease as the humerus was elevated beyond 140. Under loaded conditions, thescapular contribution began earlier and decreased in overall magnitude.

Whereas variations in the nlagnitude of scapulohumeral rhythm have beenreported, it is likely that the relationship between scapular and humeral motion is notconstant throughout the full range of humeral elevation:1,7.ILI~ Therefore, from aclinical standpoint, closely considering the plane of motion, the activity level (active orpassive), and the load applied to the upper limb are important when assessing thestatus of scapulohumeral rhythm in a patient.

CHAPTER 2 KINESIOLOGY OF THE SHOULDER 31

;,

ARTHROKINEMATICS

Segmental motions of the scapula, clavicle, and humerus occur as a result of aspecific joint structure that includes the bony configuration of the articular surfacesand the ligamentous and capsular restraints. Patterns of motion of the articularsurfaces have been described as nrtllrokil1cmatic patterns.5 In general, these motions area combination of rolling, sliding (translation), and spinning. The degree to which eachoccurs is based on the articular anatomy (Fig. 2-3). These motions result in the

A

B

Surface-on-surfacemotion

Rolling

Bone-vs.-bonemotion

Translation androtation

FIGURE 2-3. B:.sic :lnhrokim;l11;ltic p;'lUcrns that C~\Il (ake pbCl.; :It :\ joim. (A) Diagram of jointsurfaces. (B) Rolling consisting of translation and rotation. (e) Primarily sliding (translati

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