This is a power point presentation on the basic concepts of Shoulder Joint- Introduction, Bones present, Movements of shoulder joint, Muscles, Examination, Frozen shoulder, Diseases of shoulder jont. The shoulder joint is a complex ball-and-socket joint that allows for a wide range of motion in the arm. It is formed by the articulation of the head of the humerus (the upper arm bone) with the glenoid cavity of the scapula (shoulder blade). This joint is surrounded by a group of muscles, tendons, ligaments, and other structures that contribute to its stability and function. The shoulder joint provides flexibility, enabling movements such as flexion, extension, abduction, adduction, internal rotation, and external rotation. However, due to its extensive range of motion, the shoulder joint is also susceptible to injuries, such as dislocations, rotator cuff tears, and other conditions. Proper shoulder function is crucial for various daily activities, and maintaining shoulder health often involves exercises, stretching, and proper care to prevent injuries and promote overall joint well-being. he exact cause of frozen shoulder is not always clear, but certain factors may contribute to its development. These factors include: Inflammation: Inflammation of the shoulder joint capsule can lead to the development of adhesions, causing the joint capsule to thicken and tighten. Immobilization: Lack of movement in the shoulder joint, which can occur after an injury, surgery, or prolonged periods of inactivity, may contribute to the development of frozen shoulder. Diabetes: Individuals with diabetes are at a higher risk of developing frozen shoulder. Other Health Conditions: Certain medical conditions such as heart disease, thyroid disorders, and Parkinson's disease may be associated with an increased risk of frozen shoulder. The symptoms of frozen shoulder include pain, stiffness, and a gradual loss of range of motion in the shoulder. The condition typically progresses through stages, including a painful stage, a frozen stage characterized by stiffness, and a thawing stage where symptoms gradually improve. #shoulderjoint #jointsof thebody #examination #testsofshoulderjoint#frozenshoulder#shoulder#scapula#clavicle#humerus#bones#bonesofshoulderjoint#Muscles

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AMRITA SCHOOL OF AYURVEDA
Seminar On;
SHOULDER JOINT PAIN-
DIFFRENTIAL DIAGONOSIS
Presented by,
Sholly Elizabeth
Final Year BAMS
Amrita school of ayurveda

3. Introduction
Shoulder joint is a ball and socket joint between
glenoid cavity of scapula and upper end of
humerus.It is the most freely movable joint.
Shoulder girdle connects the upper limb to axial
skeleton.
Shoulder joint pain is the second most commonest
musculoskeletal pain and responsible for 4-16% of
musculoskeletal complaints.
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4. Anatomy Of Shoulder Joint…

5. Shoulder joint
comprises of:
• 3 bones
• 3 joints
• 3 groups of muscles
• other structures

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3 Bones are:
• Clavicle
• Humerus
• Scapula

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8. 3 Joints are:
Acromoiclavicular Joint
Sternoclavicular Joint
Glenohumeral Joint
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9. 3 Groups of Muscles:
1.Scapulohumeral Group:
• Supraspinatus
• Infraspinatus
• Teres Minor
• Subscapularis
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10. 3 Groups of Muscles:
cont:-
2.Axioscapular group:
• Rhomboids
• Trapezius
• Serratus anterior
• Levator scapulae
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11. 3 Groups of Muscles:
cont:-
3.Axiohumeral group:
• Pectoralis major
• pectoralis minor
• Lattissimus dorsi
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12. 3 Groups of Muscles:
cont:-
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13. Other Structures:
• Bursa
• Labrum
• capsule
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15. Blood Supply
• Anterior Circumflex Humeral Vessels
• Posterioir Circumflex Humeral Vessels
• Suprascapular Vessels
• Subscapular Vessels
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16. Nerve Supply
• Axillary Nerve
• Musculocutaneous Nerve
• Subscapular Nerve
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17. Movements Of Shoulder Joint:
7 Movements
• Flexion
• Extension
• Abduction
• Adduction
• Medial Rotation
• Lateral Rotation
• Circumduction
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20. Movements And Muscles
Flexion:
• Pectoralis major
• Deltoid
• Coracobrachilais
• Assisted by biceps
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21. Movements And Muscles
Cont:-
Extension
• Deltoid
• Teres Major
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22. Movements And Muscles
Cont:-
Abduction
• Deltoid
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23. Movements And Muscles
Cont:-
Adduction
• Lattismus Dorsi
• Pectoralis Major
• Coracobrachialis
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24. Movements And Muscles
Cont:-
Medial Rotation:
• Pectoralis Major
• Deltoid
• Lattissimus Dorsi
• Teres Major
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25. Movements And Muscles
Cont:-
Lateral Rotation:
• Infraspinatus
• Deltoid
• Teres Major
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26. Shoulder Pain
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27. Shoulder pain can be of two types,
1.True /Intrinsic pain
Pain due to any pathologies of shoulder joint.
2.False/Extrinsic/Reffered pain
Pain due to any other structures which are not related to
shoulder.
Eg:Pathologies with:
• Cervical spine
• Intrathoracic lesion(Eg:Pancoast tumor)
• Gallbladder
• Hepatic disesase
• Diaphragmatic disease
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28. History Taking
H/O:Trauma
Fibromyalgia
Infection
Inflammation
Occupational Hazards
Previous Cervical Disease
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29. Cont:-
The patient with affected shoulder joint presents
with one or more of the complaints :
a)Pain
b)Swelling
c)Stiffness
d)Deformity and loss of contour
e)Restriction or loss of movements
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30. Cont:-
CHARACTERISTICS OF PAIN (DD)
a) Bone pain-Penetrating,deep ,dull,worsens at night.
b) Muscular pain-stiffness,aching,agrevated by use of affected
muscles.
c) Tendon pain-Burning pain,not necessarily radiating.
d) Fracture pain-Sharp,stabbing,aggrevated on movements and
releived on rest and splintage.
e) Nerve pain- Shooting,sharp,burning,radiating.
f) Vascular pain-Diffused aching pain,localised,easily definable.
g) Localised pain-Suggests tumor,osteomyelitis,osteonecrosis.
h) Progressive joint pain-Commomly caused by osteoarthritis.
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31. Inspection
Observe the way the patient moves and carries the shoulder.
The upper part of the body should be undressed to inspect the
following from the front,behind,above and from the sides.
• Position of the clavicle.
• Position of scapula.
• Presence of absenlavicce of
swelling or scars.
• Presence or absence of asymmetery.
• Drooping.
• Loss of contour.
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32. Cont:-
Clinical findings
Winging of scapula:
• Instability of Serratus
anterior Or Trapezius
• Dysfunction.
Squaring of shoulder:
• Anterior Dislocation.
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33. Cont:-
Fracture of Clavicle:
• Swelling on the line of clavicle.
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34. Palpation
GHJ Involvement:
a) Place the thumb
over GHJ joint.
b) Apply pressure over it.
c) Make the patient to rotate the humerus internally
and externally.
Pain localised in this region is indicative of
Glenohumeral pathology.
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35. Cont:-
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Palpation of GHJ joint.

36. Cont:-
Subacromial Bursa:
Examiner should apply direct manual pressure over
subacromial bursa that lies laterally and immediately
to acromion.
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37. Cont:-
Bicipital Tendon:
• Lateral to subacromion bursa.
• Best identified by palpating bicipital grove as the
patient rotates the humerus internally and externally.
• Direct pressure over the tendon may reveal pain
indicative of bicipital tendonitis.
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38. • A grinding sensation (crepitus)
during shoulder movement.
FRACTURE
SCAPULA/ARTHRITIS
• When the arm is abducted with pressure
just below the acromion;it will elicit
tenderness.
PAINFULARC
• Swelling and tenderness can be elicited
just beneath acromion;even without
abduction.
SUB ACROMIAL
BURSITIS
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Cont:-

39. • Pain below antero-lateral acromial
rim during palpation
ROTATOR CUFF
TEAR
• Dissappearance of greater
tuberosity of humerus.
DISLOCATION
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Cont:-

40. Examination
Special tests:
1) Crossover test
2) Appleys scratch test
3) Neers impingement test/sign
4) Hawkins Kennedy impingement test/sign
5) Empty can test
6) Speeds test
7) Dugas test
8) Apprehension test
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41. Cont:-
CROSSOVER TEST
1.Forward flexion to 90degree
2.Horizontal adduction of arm
over the chest.
3.Reproductive pain over the joint suggest ACJ
involvment.
Pain during this manoeuver suggests Inflammation or
Arthritis of the acroioclavicular joint.
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42. Cont:-
APPLEYS SCRATCH TEST
3 Steps;
Stand behind the patient
and ask to scratch over the
opposite shoulder.
1. By reaching opposite shoulder.
2. By reaching behind the neck.
3. By reaching behind the back.
Difficulty with these motions suggest a Rotator
cuff disorder or Adhesive capsulitis.
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43. Cont:-
Neers Test
1. Patient’s arm should be in internal rotation.
2. Examiner should stand on the side of the patient and place
on hand on the patient’s scapula and other hand on the
patient’s arm below the elbow.
3. Examiner should passively flex the shoulder
forward.
Pain during this maneuver indicates Shoulder impingement
syndrome or Rotator cuff tear.
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44. Cont:-
Hawkins Kennedy Test/Impingement Sign
1.Flex the patient’s shoulder
and elbow to 90 degrees
with the palm facing down
2.Then with one hand on
the forearm and one on the
opposite arm ,rotate the
arm internally.
Pain during this manoeuver indicates shoulder
impingement syndrome or rotator cuff tear.
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45. Cont:-
Empty Can Test
1.Elevate the patient’s arm to 90 deg.
2.Internally rotate the arms with the
thumbs pointing down,as if emptying a can.
3.Ask the patient to resist as you place downward
pressure on the arms.
Weakness during this manoeuver indicates
possible Rotator cuff tear.
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46. Cont:-
Speeds Test
1.The examiner places the
patient’s arm in forward
flexion.
2.Then manual resistance is applied
by the examiner in the downward direction.
Pain in the Bicipital groove shows positive
speeds test,suggestive of bicipital tendonitis.
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47. Cont:-
Dugas Test
1.The patient is made to sit.
2.The examiner instructs patient
to reach across body,By placing a
hand on opposite shoulder and
pull their elbow against their chest.
If there is an inability to complete test;it indicates
shoulder dislocation.
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48. Cont:-
Apprehension Test
Mainly to asses anterior stability of shoulder.
Stand behind the patient,
1.Abduct
2.Extent
3.Externally rotate the shoulder
While pushing the head of humerus forward with thumb,
patient strongly resist this manoeuver if there is impending
dislocation.
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49. Disease Pain Radiating Swelling
Affected
ROM
Rotator cuff
tendonitis
Present _ Present Abduction
Adhesive
capsulitis
Present - - Flexion
Abduction
Adduction
Impingement
syndrome
Present Present - Internal
rotation
Bicipital
tendonitis
- Tenderness at
bicipital groove
- External
rotation,
Abduction
Bursitis Present - Tenderness at
deltiod
Abduction
Adduction
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50. Adhesive Capsulitis/Frozen
Shoulder
Presents with pain associated with marked
restriction of elevation and external rotation.
Commonly associated with DM
and neck radicular radiations.
May follow Bursitis /Tendonitis of the
shoulder or be associated
with Systemic disorders.
Age group
More common in women after 50yrs.
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51. Cont:-
Pathology:
• Capsule of shoulder thickened
• Mild chronic inflammation
• Fibrosis
Characteristics of Pain
• Pain and stiffness usually develop gradually but progress
rapidly in some patients.
• Night pain is often present in affected shoulder and pain may
interfere with sleep.
• Tender on palpation.
• Both active and passive movement restricted.
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52. Cont:-
Diagnosis
• Radiographs of shoulder show osteopenia.
• Diagnosis is typically made
by physical examination.
• If needed,confirmation can be made by
arthrography-limited amount of contrast
material,usually<15ml can be injected under
pressure in to the shoulder joint
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53. Cont:-
Management
• Physiotherapy provides the foundation of treatment.
• Local injections of glucocorticoids,NSAID’s may also
provide relief of symptoms.
• Slow but forceful injection of contrast material in to the
joint may remove the adhesions and stretch the
capsule,resulting in improving shoulder motion.
• Manipulation under anaesthesia may be helpful in some
patients.
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55. Rotator Cuff Tendonitis And
Impingement Syndrome
• Subacromial bursitis usually accompanies this
syndrome.
• Symptoms usually appear after injury or
overuse,especially with activities involving
elevation of arm with some degree of forward
flexion.
• Impingement syndrome usually occurs in persons
participating in tennis,swimming or occupations
that require repeated elevation of arm.
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58. Cont:-
Etiology
• Tendonitis of the rotator cuff is the major cause.
• Caused by inflammation of tendons.
Evolution of disease-stages
• Oedema and heammorhage of rotator cuff
• Fibrotic thickening
• Rotator cuff degeneration
• Tendon tears
• Bone spurs
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59. Cont:-
Age group
>40yrs
Characteristics of Pain
• Dull aching pain in shoulder.
• May interfere with sleep.
• Severe pain when arm is actively abducted into an overheal
position.
• Arc between 60 and 120 degree is especially painful.
• Tenderness present over lateral aspect of humeral head just
below acromion.
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60. Cont:-
Diagnosis
• Arthrography
• USG
• MRI
Management
• NSAID’s
• Local glococorticoid injection.
• Physical therapy
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61. Subacromial Bursitis
• Bursa-Thin walled sac lined
with synovial tissue.
• Functions of bursa:facilitate
movement of tendons and muscles
over bony prominences
• Sub acromial bursa is located between the
undersurface of acromion and humeral head.
• Most common form of bursitis.
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62. Cont:-
Etiology
• Exesccive frictional force from overuse
• Trauma
• Systemic disease[eg:RA;Gout]
• Infection
• Caused by repeated overhead motion and often accompanies
rotator cuff tendonitis
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63. Cont:-
Age group
40 to 60yrs
Pain
• Pain along the front and side of the
shoulder is the most common symptom.
• Onset of pain may be gradual or sudden.
• May or may be related to trauma.
• Night time pain,especially when sleeping on affected shoulder is
reported.
• May be associated with arthritis, rotator cuff tendoinitis,rotator
cuff tear,cervical radiculopathy etc.
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64. Cont:-
Diagnosis
• Difficult to distinguish
between pain caused by
bursitis or that caused by a rotator cuff injury as both
exhibit similar pain patterns.
• X ray
• MRI
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65. Cont:-
Treatment
• RICE method:
a)Rest
b)Ice
c)Compression
d)Elevation
• Oral administration of non steroidal
antiinflammatory drugs
• Physical therapy
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66. Conclusion:
Almost all pathologies of shoulder are presented
with pain.
Proper history taking and examination is needed
for correct diagnosis ,otherwise may lead to
misdiagnosis.
Shoulder joint disease can be excluded if the
patient can raise both his arms above the head and
bring the two palms together.
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