Examination of the Shoulder & Elbow

Question 1

Knowing the age of the patient helps us start to classify people into different diagnostic categories. If you have a patient below 40 who has shoulder pain or some sort of shoulder dysfunction they are more likely to have (overuse/instability). Patients above 40 are more likely to have (overuse/instability) or rotator cuff pathology. Generally when you get people above 40 or they’re getting into their 50s, 60s, and 70s it is pretty rare to see someone with (overuse/instability) unless it is traumatic (think falling and dislocating their shoulder). Having this little piece of information I can start classifying people into different groups and that can help with my initial hypotheses, questions, and examinations to start getting a ruling on things.

Answer 1

Instability; overuse; instability

Question 2

It may just be getting them to move in different directions and that sort of thing to see if I can change, reproduce, or decrease their pain. This is especially true if you go and start doing your more focused exam on the shoulder or the elbow and you aren’t really finding anything. ROM is normal, strength seems normal, and I do all of these special tests and that seems normal, I can’t really change the pain at all. Instantly then I start thinking that it has to be something else that is going on here and often times the (cervical spine/shoulder instability) is a pretty big culprit.

Answer 2

cervical spine

Question 3

It is extremely rare for people to have shoulder pain that refers itself (above/below) the elbow. If someone comes in with a diagnosis of shoulder pain and they are telling me that they have pain and pins and needles sensations radiating to their hand I am instantly thinking that this is cervical spine or some peripheral nerve issue.

Answer 3

below

Question 4

It is very common for shoulder pain to refer itself to the insertion point of what muscle? That is a very common radicular pattern for shoulder pain.

Answer 4

The deltoid

Question 5

Understanding their hobbies, occupations, daily activities gives an indication to the daily stressors that they put on their shoulder. Or if there has been a change in activity or a new activity that they have been involved in. They’ve done that activity for a while but it has dramatically increased recently, often times those overuse type of injuries and stuff, in the history if you ask those type of questions it can reveal what is going on with their shoulder.

Answer 5

Roger that

Question 6

If the patient can point to when the injury started bothering them when they did a specific thing, it is often times helpful for you to know their mechanism of injury because often times it will help you identify what tissues might have been injured or what joints might be involved which then helps you know exactly where to do your focused examination.

Answer 6

Roger that

Question 7

(Posterior/anterior) dislocations and subluxations are much more common than (posterior/anterior) (95% (posteriorly/anteriorly), 5% (posteriorly/anteriorly).

Answer 7

Anterior; posterior; anteriorly; posteriorly

Question 8

Falling directly on top of your shoulder is a really common mechanism for (SC/AC) separation.

Answer 8

AC

Question 9

If someone can identify something that irritates their shoulder all of the time, that is a perfect time to ask them to show you exactly how they are doing whatever it is that causes them pain and might reveal to you exactly what the mechanism of injury is.

Answer 9

Roger that

Question 10

The most common thing you should be looking for when it comes to posture is what? When thinking of the cervical spine and shoulder, this sustained posture puts abnormal stress on a number of different structures and makes a lot of structures work harder than they have to.

Answer 10

Forward head and rounded shoulders

Question 11

Another thing to look at when assessing posture is whether or not the shoulders are leveled. It isn’t uncommon to see unequal shoulder height especially in right handers. Often times right handers their right shoulder will sit a little bit lower than their left. Right handers tend to use only their right hand so they’ve stretched out that side a little bit more so it has to hang a little bit lower. This is (more/less) common in left handers. Having unleveled shoulders should not throw a red flag immediately when you see that.

Answer 11

less

Question 12

Other things you want to look at in a static position for posture is how the scapulae look relative to one another. Does the medial border look like they are parallel to one another? Does one look rotated differently than the other? Does the inferior angle stick out a little bit in comparison to the other?

Answer 12

Roger that

Question 13

The inferior angle sits at about the level of _. It is a good landmark to know and a good shortcut to know what spinal level you are on.

Answer 13

T7

Question 14

Another thing to look at with posture is the position of the arm, does one arm sit out way further than the other or do they look the same? How level is the pelvis? When you palpate the iliac crest, the ASIS, or the PSIS, do those things look level? If they are not level then they are going to affect things above them.

Answer 14

Roger that

Question 15

The iliac crest lines up with the disk space between L_ and L_.

Answer 15

4 and 5

Question 16

Massive deltoid atrophy could signify an injury to what nerve?

Answer 16

Axillary nerve

Question 17

Sometimes people who have had strokes and that sort of thing (gain/lose) muscle tone and often times they’ll get subluxation of their shoulder. Their shoulder will actually sit down in an inferior position because they do not have the muscle tone to hold the head of the humerus in the glenoid itself.

Answer 17

lose

Question 18

When you start making people move, do we see abnormalities or differences in the way that they move? A pretty common abnormal movement pattern that you will see in the shoulder when a person is asked to lift their arms over their head, they’ll do a sort of shoulder shrug and this could be because of ___ and to substitute for that they start to elevate their arm or they could have ____ and to substitute for that they start to shrug their shoulder.

Answer 18

Restriction in movement at the joint; weakness

Question 19

Sometimes patients can come in with chronic or recurring arm pain and they’ll posture their arm up against their side sort of in this protective posture and they are really reluctant to have people grab it or for them to be able to use it or that sort of thing. You want to observe those things and see if it is part of the condition here.

Answer 19

Roger that

Question 20

In observation of the joints you want to look at the position of the joints. How the AC joint is positioned, how the humeral head is positioned in relation to the glenoid. That can give us clues into what could be going on with the patient. If someone with a previous AC separation came to you with shoulder pain and I looked at his shoulder, one thing to think about is if their AC joint is getting irritated just due to the position that he is in. If someone came in and had a stroke and their shoulder is sitting way down and they complained of shoulder pain as they often do, we gotta figure out a way to build muscle strength so they can support that arm or put them in a sling to support them until they can get their muscle strength back to be able to support their own shoulder.

Answer 20

Roger that

Question 21

Look for cardinal signs of inflammation during observations. Does the shoulder joint itself seem discolored because there is bruising there or does it feel warm to the touch, does it look like it is swelling? If they truly have inflammation you should be able to feel warmth or see swelling and that sort of thing.

Answer 21

Roger that

Question 22

If you have limitations in motion of the shoulder it can come from any of the 4 joints of the shoulder, but the main two joints that are the culprits are the ___ joint and the ____ joint, and between the two it is mainly the ___ joint that is the culprit.

Answer 22

glenohumeral; scapulothoracic; glenohumeral

Question 23

PROM of the scapula is assessed in what position?

Answer 23

Sidelying

Question 24

(AROM/PROM) of the scapula is more important to look at than (AROM/PROM) because you want to see when people are (dynamically/statically) moving, how the scapula acts. Two things to look at when looking at the AROM of the scapula is what?

Answer 24

AROM; PROM; dynamically

The amount of motion and the quality of motion

Question 25

For every _ degree the scapula moves, the humerus moves _ degrees. You want to look for that pattern when we are assessing movement of the scapula.

Answer 25

1; 2

Question 26

One thing that you want to pay attention to when assessing AROM of the scapula is the setting phase. The setting phase is the fist _ degrees of abduction or the first _ degrees of flexion depending on if you are looking at abduction or flexion. This becomes important because as people start to move their scapula can do some funky things but we are much more concerned of how the scapula moves after the setting phase and we are really concerned about how the scapula moves as the person lowers in that (concentric/eccentric) phase. That is where we see most deviations of movement.

Answer 26

30; 60; eccentric;

Question 27

The way to assess the scapula actively is that we need to look at it when performing flexion and abduction and we need to look at it in both a weighted and unweighted scenario. When we assess AROM of the scapula we are going to have our patient stand there in normal position to look at their static alignment first, then we are going to ask the person to lift their arm up over their head into flexion and then coming back down and we are going to ask them to do that repeatedly. A _ second count up and then a _ second count down is a good rate of speed to have the patient go. Don’t have the patient do it once or twice, have them do it 5 or 6 times, sometimes even 10 or 12 times or so until you are satisfied that the way the scapula is moving is normal or you are seeing an abnormal pattern and you are satisfied with what you are seeing. Then add weights (_ lbs for women and _ lbs for men in studies). The same procedure with abduction but have their thumbs pointing (upward/downward) so they are a little bit externally rotated.

Answer 27

4; 4; 3; 5; upward

Question 28

Scapular winging refers to the medial border of the scapula and/or the inferior angle of the scapula pulling (towards/away) from the thoracic wall.

Answer 28

away

Question 29

What two weak muscles are thought to be the cause of scapular winging?

Answer 29

The serratus anterior and the lower trapezius

Question 30

When we see scapula winging or dumping deviations in the sagittal plane we think of the (serratus anterior/lower trapezius) being the primary culprit.
When we see scapula winging or dumping deviations in the frontal plane we think of the (serratus anterior/lower trapezius ) as the primary culprit. MMT helps to determine which is the true cause.

Answer 30

serratus anterior; lower trapezius

Question 31

Scapular dumping refers to an abrupt (upward/downward) rotation of the scapula during (concentric/eccentric) lowering and they can’t control it.

Answer 31

downward; eccentric

Question 32

What are the 5 motions you measure when assessing AROM/PROM of the glenohumeral joint?

Answer 32

Flexion/extension, external/internal rotation, and abduction

Question 33

We don’t tend to measure ___ when assessing the shoulder, we are just content with someone being able to put their hands on their side.

Answer 33

adduction

Question 34

When you are assessing AROM/PROM of the shoulder, often times you get people who have what we refer to as a painful arc. There are two painful arcs that we think about. The most common one is the one in the (mid range/ end range) of motion and we think about that being as all of the structures are trying to clear the acromion, that if someone has pain in that range it is often times due to the fact that they have inflammation of the cuff or the bursa that sits in there and they are getting compression of the tissues in there and that causes them pain. Sometimes for them they won’t be able to get through that painful arc and some of those people can go ow ow that hurts and then as they continue through that arc they’ll be good. The other arc is at that (mid range/end range) of motion when they have pain. Often times they say they have pain at the AC joint and it is thought that in terminal flexion you get a lot of compressive forces on the AC joint and sometimes that will cause them pain.

Answer 34

mid range; end range

Question 35

The mid range painful arc for the shoulder is between _ and _ degrees

Answer 35

45 and 120

Question 36

The end range painful arc for the shoulder is between _ and _ degrees

Answer 36

170 and 180

Question 37

There is a diagnostic tool that is used for any joint called resisted motion. The idea here is to not try and quantify strength. We aren’t using this tool to say how strong somebody is. We are using this as a tool to figure out what might be going on with the musculotendinous unit. So as the muscle attaches to the tendon itself, you are going to put stress on that by actively having the person “crack?” that and depending on how strong they are with that contraction and what they feel with that contraction, that is going to indicate to us what the integrity of that tissue is.

Answer 37

Roger that

Question 38

We want to put stress on the musculotendinous unit and we normally do that in a neutral position. So for the shoulder we will have someone in anatomical position and we would make them resist isometrically into flexion, extension, abduction, adduction, external, & internal rotation. We may want to test all of those motions or only one depends on what you think is going on with the patient. We are having them do an isometric contraction in that neutral position and we are assessing two things: what are those two things?

Answer 38

Does it hurt and does it feel strong or weak?

Question 39

For the resisted motion grading scale, what is the combination for normal?

Answer 39

Strong/painless

Question 40

For the resisted motion grading scale, what is the combination for a minor lesion?

Answer 40

Strong/painful

Question 41

What are two diagnoses you could see in someone who has a minor lesion?

Answer 41

Tendinitis or a muscle strain

Question 42

For the resisted motion grading scale, what are the two combinations for a major lesion?

Answer 42

Weak/painful and weak/painless

Question 43

What are two diagnoses you could see in someone who has a major lesion?

Answer 43

Incomplete tear and a complete tear

Question 44

Resisted motions:
Weak/painless:

The theory is, if they are really weak and have no pain then those are typically indicative of a complete tear of that tissue. If you think about it, it makes sense. If the tissue is no longer connected to each other then you are not pulling on these nerves anymore.

Answer 44

Roger that

Question 45

Resisted motions is used as a diagnostic tool within our examinations to help to try to categorize people into different levels especially if we think it is an issue with the musculotendinous unit around that joint.

Answer 45

Roger that

Question 46

Sometimes in post op individuals where you may not be able to do full MMT because you are worried about putting too much stress on healing structures, sometimes you can use the resisted motions positions and that sort of thing just to ensure that the person can contract the muscles around the joint. So it can be used as an alternative to MMT.

Answer 46

Roger that

Question 47

The most common type of injury to get at the elbow is (repetitive stress/traumatic) injuries. Think of overhead throwers, tennis elbow, golfers elbow, that repetitive swinging motion. So in your history it goes back to asking the patient what activities they have been performing and if they have had changes in those activities or the intensity of those activities and that type of thing.

Answer 47

repetitive stress

Question 48

With the (shoulder/elbow), pain can refer itself to the forearm and the hand. Patients can come in complaining about their hand but in reality the (shoulder/elbow) is generating that discomfort.

Answer 48

elbow; elbow

Question 49

What are the three most common MOI for elbow pain? This relates back to history and having a better head start on diagnosing and treating the patient if you know the MOI.

Answer 49

Varus stress, valgus stress, hyperextension

Question 50

If my forearm is put in a valgus position that is putting all sorts of tensile stress on the (medial/lateral) aspect of the elbow and compressive forces on the (medial/lateral) side of the elbow. If my forearm is in a varus position that is putting tensile stress on the (medial/lateral) aspect of the elbow and compressive forces on the (medial/lateral) aspect of the elbow.

Answer 50

medial; lateral; lateral; medial

Question 51

The motion that is most limited at the elbow and is the hardest to get back is what?

Answer 51

Elbow extension

Question 52

Often times if people flex their elbow and you see that they have a golf ball size bicep muscle that is a classic sign that someone ruptured their distal or proximal ___ tendon.

Answer 52

biceps

Question 53

What are the 4motions you measure when assessing AROM/PROM of the elbow joint?

Answer 53

Flexion/extension and pronation/supination