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Speed's test Tests for bicipital groove tenderness
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Shoulder Examination
(Shoulder Exam Power Point Presentation)
Anatomy
3 Bone Structures
These bones together make up 6 basic articulations or joints
Functional stability is almost completely dependent upon the synergism of the musculotendinous units. The shoulder is very unstable from a bony standpoint. The only true attachment to the thorax is the junction of the clavicle with the sternum.
15 Muscles move and stabilize the scapula. 9 Muscles provide for Gleno humeral motion and 6 support the scapula on the thorax.
The combinations of these muscles and joints allow for maximal rotation with minimal rotational stress on the proximal fixation point. [ The s\c joint ]
The anterior capsular mechanism is comprised of 4 interrelated structures;
The ligaments are likened to pleated horizontal folds in a fan shaped arrangement. An opening may exist between the superior and middle ligaments. This opening may be covered by a thin capsular layer. This recessed hole may have a predisposing significance in the occurrence of anterior glenohumeral dislocations.
The superior capsular ligament is damaged by external rotation and mid abduction. (ie: reaching into the back seat of a car)
Acromioclavicular joint
The a\c joint is formed by the junction of the clavicle and the acromion process off of the scapula. An articular disk may be present in a percentage of the population. The joint stability is maintained by the ligaments rather than the strength of the interlocking joint surfaces. The primary ligaments are the acromioclavicular and the coracoclavicular ligaments. The coraco clavicular ligament has two distinct ligament portions, the coronoid and the trapezoid. This joint is frequently injured by falling on an outstretched arm or onto the point of the shoulder. A fall on an outstretched arm drives the acromion process up and away from the clavicle while a fall on the shoulder can either drive the clavicle away from the acromion or visa versa. Injuries to the A/C joint may not fully manifest themselves for 3-4 weeks post injury due to the delay in onset of impingement syndromes and degeneration of the A/C joint or meniscus.
Sternoclavicular joint
This joint is the junction of the clavicle with the sternum and is classified as a saddle joint. It has very little motion except for approx. 25 deg. of clavicular rotation and 40 deg. of elevation. This joint serves as the only true bony connection for the shoulder to the thorax. Thus this complete structure is called the clavicular strut and functions much like the front suspension of a car. The joint is supported by the sternoclavicular and costoclavicular ligaments.
This is not a joint that is frequently injured in the athletic setting. However, with more athletes playing on artificial surfaces, this injury has become more prevalent. The most frequent etiology is to have another person fall on the point of the shoulder while the body is perpendicular to the surface with the opposite shoulder fixed into the playing surface. When the axial load on the clavicle is aligned correctly, the force is transmitted through the clavicle and the S/C joint is disrupted. This injury in adolescents might result in a fractured clavicle instead of a separated S/C joint.
Rotator cuff muscles
The rotator cuff is an interactive coupling of muscular components and a tendinous envelope with neuromuscular and visco elastic properties. The rotator cuff muscles stabilize the glenohumeral joint and aid in abduction and rotation of the GH joint. These muscles are:
The primary functions of the cuff are:
The cuff muscles are the fine tuners or stabilizers of the GH joint. They also maintain
the joint contact areas. The latissimus dorsi, deltoid, and the pectoralis major are the
more powerful rotators, abductors and adductors. The rotator cuff muscles lie deep within
the shoulder musculature but they can be palpated with careful knowledge of their
locations and actions. Only the subscapularis which lies on the anterior portion of the
scapula can not be palpated. If the arm is abducted to 110 and externally rotated, the
edge of the subscapularis can be felt along the border
of the scapula under the axilla.
The posterior cuff muscles spell S.I.T. Because of their locations.
[ Supraspinatus, infraspinatus, and teres minor ] The supraspinatus initiates abduction until the shoulder reaches 30-60 degrees of abduction. Then the deltoid takes over. However, if the deltoid was to work alone, it would only shrug the humerus.
The internal rotators are more powerful and longer than the external rotators. However, the anterior group is also slower in action than are the posterior muscles.
If the shoulder were positioned in neutral, with 45 deg. of abduction, and the strength of the adductors is set at 100 %, the abductors are 50% as strong, the internal rotators are 45% and the external rotators are 30%. The external rotators are 70% as strong as the internal rotators. The ratio of adduction to abduction is 2:1.
The muscles of the shoulder girdle are among the largest and strongest muscles in the body. However, because of their complexity, they should always be examined bilaterally for symmetry. They have to function both concentrically and eccentrically at very rapid speeds, because of this, they are easily weakened and can become dysfunctional quite rapidly. The mobility of the shoulder is instantaneous dependent upon the muscle function and arthokinematics of the clavicular strut.
Movements of the Shoulder
Flexion
Extension
Abduction
Phase One:
0-60° - Very dependent upon the arthrokinematics The supraspinatus, upper trapezius and deltoid work together to help bring the humerus outward and upward. The scapula upwardly protracts and the clavicle externally rotates.
Phase Two:
60-120° - The clavicle elevates to the extreme, the capsule tightens superiorly, then to the middle, and finally interiorly as the humerus is abducted. The cuff is maximally active while the serratus is functioning isometrically. The teres major muscle is the most active when the arm is in abduction and is being used overhead for extended periods of time.
Phase Three:
120-160° - The functional range of motion for most (180 max) athletes is 70-110°. The rotator cuff becomes inactive at 160. The A/C joint is also restricted in the extremes of abduction.
Adduction
External Rotation
Internal Rotation
Scapular elevation ( Scaption ) shoulder shrugs
Retraction [ position of attention ]
Protraction [ reaching ]
The synergy of the shoulder motions should be integrated and harmonious with associated functions. Any dysfunction, will alter the smoothness of the muscular synergy.
Reflex Testing
Dermatomes
Special Shoulder Tests
Apley's Scratch Test
This tests for limited range of motion or asymmetry of movements when comparing the affected and un affected shoulders. The patient is seated or standing and they are instructed to simply touch the opposite side shoulder with their hand. Any difference in the inability to touch the opposite shoulder shall be considered a positive finding.
A. Have the patient touch the other A/C joint.
B. Have them place their thumb from a shoulder abducted position (with the elbow bent 90 degrees) between the scapula.
C. Have them place their thumb between the scapulae from a base position from behind the back.
Yergason Test 1
This tests for an unstable biceps tendon in the bicipital groove the examiner should externally rotate the arm while pulling down on the humerus. The tendon if unstable will rock out of the groove and cause pain.
Yergason Test 2
This test is also for biceps tendon irritation and subluxation in the bicipital groove. The patient is asked to flex the elbow to 90 and pronate the forearm. Because the biceps is also a supinator, a positive test will elicit pain.
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Speed's test Tests for bicipital groove tenderness
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O’Brien Test
This tests for the presence of a SLAP lesion in the shoulder. While it is considered by some to be the most accurate test for assessment of SLAP lesions, the accuracy of this test and others is questionable.
The patient is sitting or standing. The shoulder is flexed to 90 degrees with 45 degrees of horizontal adduction. The examiner stabilizes the elbow and wrist while the patient attempts to adduct the arm across the body.
Pain and or popping should be indicative of a lesion to the labrum / biceps junction. (SLAP lesion)
Transverse humeral ligament test
Tests the ligament that holds the biceps tendon in place
Drop arm test
This tests for lesions in the rotator cuff. The arm should be fully abducted against gravity and then slowly lowered. A tear in the cuff will cause the arm to drop abruptly to the side. The practitioner may wish to apply slight downward pressure to the arm to overcome any accessory stabilization.
Apprehension test
This test evaluates the shoulder for chronic anterior dislocations. The shoulder is externally rotated with the elbow flexed to 90 at in an abducted position. The patient will feel extreme discomfort and express apprehension as the head of the humerus rocks to the edge of the glenoid. This test can be performed for both anterior apprehension with the arm in an abducted, externally rotated position and for posterior apprehension with the elbow flexed to 90 degrees, the shoulder flexed to 90 degrees, pressure is applied to the elbow forcing the humeral head posteriorly against the posterior edge of the glenoid labrum.
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Relocation test - Fowler's Test
This test is done in conjunction with the Apprehension test. With the shoulder abducted and externally rotated, push the head of the humerus from anterior to posterior, if this relocates or relieves the patients discomfort, they have a GH joint that has subluxated anteriorly. This test is best when performed in a supine position.
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Hand position is very important, the hand should be placed over the proximal humeral shaft, just beyond the edge of the pectoralis insertion and not directly over the humeral head. |
Relocation Video, move the mouse over the picture or click on the picture to operate.
Throwers Test
This test is performed with the arm at 90 of abduction, the patient then pushes against the examiners hand. If there is anterior instability, the patient will experience posterior shoulder pain as a result of the posterior cuff being stretched as the head slides anteriorly.
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Rowe Test
Have the patient bend forward at the waist approximately 300, the apply downward pressure on the arm which will distract the joint. A positive test involves the humerus being distracted inferiorly.
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Sulcus Sign or Test
The patient is seated, the practitioner pulls inferiorly on the humerus and attempts to distract the joint. The Rowe test is more accurate due to POS positioning.
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Note the depression just below the acromion in the right picture |
Anterior Drawer – Glide Test
The patient is supine, the practitioner flexes the shoulder to 90 degrees, places the arm into the correct POS (plane of scapula) positioning and moves the humeral head up and down in the glenoid fossa.
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Empty can test
Tests the integrity of the supraspinatus tendon and muscle.
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Impingement tests
Overuse injury to the supraspinatus tendon and sub acromial bursae.
Primary impingement - arm is abducted and flexed horizontally then is brought into an adducted and internally rotated position. (Cross Over Impingement Test)
The Neer Impingement test is when the patient is seated and the arm is forwarded flexed and remains in the same plane.
Secondary impingement test - arm is abducted, elbow flexed, and the arm is rotated back and forth under the acromial arch. (Hawkins – Kennedy Impingement Test)
Allen maneuver
Thoracic outlet syndrome, neurovascular test
Stress test
This tests for both A/C joint laxity and GH joint sulcus signs via standard X-Rays. The X-rays should be taken where both shoulders are seen on the same film and should be taken both with and without weight. Approximately 20 lbs or more should be used for athletes. The weight should be hung from the wrist and not grasped in the hand. Grasping the weight will likely tighten the muscular and skew the exam.
The Piano Key Exam may also be used to test the integrity of the A/C joint. If the distal end of the clavicle can be moved up and down like a piano key, then disruption of the coraco-clavicular ligament is likely.
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Move the arm in all planes while feeling the top of the A/C joint. Any crepitus is indicative of some acute ligament disruption or advancing DJD. |
CT-Scan, Arthrogram This computerized X-Ray and arthrogram is the best indicator at this time for labrum or capsular lesions. The CT scan is more specific for bony lesions than is the MRI Scan. This is seldom used now because of advances in the MRI.
MRI Scan
This magnetic scan is used for looking a small muscle tears or lesions of the musculotendinous system. This may best be done with a saline injection which provides contrast for the scan.
Evaluation Principles
Always follow a standard evaluation progression when examining a patient's shoulder.
Determine the target tissue. What area is injured ?
History, biomechanical evaluation
Assessment
Plan
You have to be able to reproduce the patient's pain.
Try to effect that pain on the first visit.
DO NOT overlook some other pathology that may be the cause of their discomfort. Observe the patient take off their shirt or coat. Have them raise their arm overhead, do not tell them how or where to raise it, simply tell them to raise it. Patients with pain will work in a bad plane or will be dysfunctional in their actions.
Follow a Cyriax Progression of Movement
Assess the Range of Motion
Sulcus Sign
This is the dimple that results from the humerus being pulled down from the glenoid. The dimple will show in the sub acromial space above the head of the humerus.
Isokinetics (never perform an isokinetic test on the patients first visit, the patient must be used to the machine to get good testing results) Always follow the same protocol when testing a patient. Perform an isotonic warm up using the U.B.E. or stationary bike. 5 reps per setting, with 30 seconds of rest between each set. The patient must also do a 5 rep maximal warm-up set prior to testing. Rest 1 minute after the warm-up set before testing. Do not encourage the patient during the testing procedure. Be consistent.
You should wait at least 12 weeks post surgery before performing an isokinetic test. If the patient can not perform a maximal muscle contraction, do not test them.
The data interpretation should be based on the peak torque, work, power, and total work performed by the patient. You should also look at the data in a specific point in the range of motion. Do not always just look at the generalized or average data.
