Shoulder Ax and Rx

Question 1

SQs

Answer 1

• Clicking/clunking or any mechanical sounds – labral tears
• Referral patterns- ACJ pain is localised, rotator cuff pain can refer down the lateral aspect of the shoulder, C5 pain can also refer down the lateral aspect of the shoulder from GHJ.
• Pain pattern - Night pain (RC pathology eg. tears), Arc of pain 60-100 (impingement), Arc of pain > 100 & pain on HF (AC joint), EOR pain (OA / instability), Global pain (early frozen shoulder)
• Age - Rotator cuff degeneration > 35 years, Secondary impingement > 25 years, Frozen shoulder 45 –60 years, OA >60 years, Atraumatic instability 10 –35 years
• Diabetes – capsulitis, systemic conditions
• Steroid use - OP, #
• Red flags for pancoast tumour (loss of external rotation, history of cancer, feeling unwell, unexplained weight loss, non-mechanical pain)
• Previous capsulitis/dislocation/instability
• Trauma – fracture, cuff tear
• FOOSH, fall onto elbow point, fall onto shoulder – dislocations, fractures etc;
• Insidious (frozen shoulder), Repetitive (degenerative)
• Giving way – instability
• Neck pain
• Altered sensation
• Hand dominance – overuse injury
• Aggs - LR- ant. dislocation; HF-A/C; Overhead activities – primary impingement; Cx- ext/SF/R
• Eases - Support elbow – instability / acute shoulder disorder, Hand on head – Cx

Question 2

Observation

Answer 2

• Posture-kyphosis, flat back or Scoliosis,
• Position of bony landmarks:
  
  • scapula- is it winging, is it moving normally
  • HOH
  • Cervical position
  • Thoracic spine
• Quality of movement.
• Adaptive postures/movements
• Colour/autonomic changes-localised
• Muscle tone

Question 3

AROM & PROM

Answer 3

• Flex 0-165deg
• Abd 0-170deg (look at in scapular position as more functional),
• External and internal rotation- if external rotation is limited then it is a good indication of capsular tightness. Can be measured in standing with arm by side, standing with arm abducted to 90 degrees or in lying with arm abducted to 90 degrees.
  
  • Internal 0-70deg
  • External 0- 80deg
• Extension 0-60deg
• MR Hand behind back – touch opposite scapula
• Horizontal flexion
• Horizontal extension
• Elevation
• Depression
• Protraction
• Retraction

AROM:

• Look for quality, pain at different levels eg painful arc. Apply OP and assess end-feel

PROM:

• Patient comfort, therapist position, bed height, handling skills, explore end feel
• Capsular pattern: LR, ABD, MR

Question 4

Muscle tests

Answer 4

Strength:

• Oxford grades 1 to 5
• Isometric:
  
  • Rotator cuff tear = Weak and painful or just painful/weak
  • Secondary instability = NAD, painful or/& weak, Apprehension
  • OA = NAD, weak
  • Primary impingement = +/-weakness and +/-pain:

Control:

• control and recruitment of muscles.
• Compensation tactics eg. Hitching of shoulder by upper traps to compensate for lack of abduction

Length:

• Pec major = Supine Lying, Stabilise thorax
  
  • Clavicular fibres- Abd 90° and ext rotn
  • Sternal fibres- Adb 150° and ext rotn
• Pec minor = Supine lying view from head down. Assess the height of the shoulder from the bed then stabilise sternum and push down on coracoid
  
  • >2 cm is normal
• Lat dorsi = Crook Lying, Maintain lumbar neutral, Full flexion of shoulder, Should reach treatment couch if not tight
  
  • Shoulder pathology may limit causing false positive

Question 5

Accessory movements

Answer 5

• GHJ AP,PA,Distraction,Longituidinal Caud
• ACJ AP, Cephalocaudal Glides
• SCJ AP, Cephalocaudal Glides

Question 6

Special tests

Answer 6

• Empty/full can
  
  • Tests: Rotator cuff- specifically Supraspinatus
  • Positive Sign: Pain or Weakness
  • Procedure: Patient holds out the affected arm (abducts) with elbow extended and wrist pronated. The examiner then pushes down on the extended arm and the patient tries to resist.
  • Consider: flex/abd, search for symptoms, will cause compression in either SA or CA
• Gerbers Push Test
  
  • Tests: Rotator cuff-specifically subscapularis- In standing
  • Positive Sign : Inability to move the dorsum off the back.
  • Procedure: Patient places their hand behind their back with the dorsum of the hand resting in the region of the mid- lumbar spine. Hand is raised off the back by maintaining or increasing internal rotation of the humerus and extension at the shoulder.
• Hawkins Kennedy
  
  • Tests: rotator cuff impingement
  • Positive Sign: Pain located to the sub-acromial space
  • Procedure: Patients arm at 90° and their elbow flexed to 90°, supported by the examiner. Stabilise proximal to the elbow with their outside hand and with the other holds just proximal to the patient’s wrist. Quickly move the arm into internal rotation
  • Consider: flex/abd, search for symptoms, will cause compression in either SA or CA
• Neers
  
  • Tests: For rotator cuff impingement
  • Positive: Pain located to the sub-acromial space or anterior edge of acromion
  • Procedure: Examiner performs maximal passive abduction in the scapula plane, with internal rotation, whilst stabilising the scapula.
• Speeds
  
  • Tests: Long head of Biceps tendinopathy
  • Positive: pain along long head of biceps in anterior shoulder/ weakness.
  • Procedure: Resisted flexion with elbow slightly bent and arm externally rotated.
• Scarf
  
  • Tests: ACJ
  • Positive Sign: pain localised to ACJ
  • Procedure: Lift the arm to 90 degrees and the flexed arm is forcibly adducted across the chest.
• Clunk Test
  
  • Tests: Labrum tears
  • Positive Sign: A clunk or grinding noise or sensation indicates a positive test
  • Procedure: Patient in supine with the glenohumeral joint slightly over the edge of the table and the shoulder relaxed. Shoulder in full abduction above the patient’s head with the elbow slightly flexed.Passively abduct and externally rotate the subject’s arm overhead and apply an anterior force to the humerus. Internally and externally rotate the humerus and then circumduct the humeral head about the glenoid labrum.

Instability tests: Normally will only test one direction at a time, Several tests may be positive with multidirectional instability (primary), Test passive structures

• Anterior apprehension:
  
  • Tests: GHJ Anterior Instability
  • Positive Sign: Patient gets increasingly apprehensive during external rotation
  • Procedure: Patient in supine with the scapula supported on table. The arm is positioned in 90 °abduction and external rotation. With increasing external rotation the examiner watches for apprehension from patient. Often done with the examiner exerting an anterior/posterior force during external rotation and then lifting off this force while looking for apprehension.
• Load and Shift
  
  • Tests: GHJ Instability
  • Positive Sign: Grading system utilised to quantify amount of translation: 0/Normal (25% HOH diameter), I/Mild (0-lcm translation; <50% HOH diameter), II/Moderate (1-2 cm or translates to glenoid rim; >50% HOH diameter), III/Severe (>2cm translation or over the rim of the glenoid)
  • Procedure: Place one hand over the shoulder and scapula to stabilise the shoulder girdle. Use the other hand to grasp the humeral head. Create a loading force to relocate the humeral head centrally in the glenoid. The humerus is loaded into the glenoid and then translated anteriorly and posteriorly. As the stress applied is increased the humeral head may be felt to ride up the glenoid rim. Compare both shoulders for similarities/differences in translation.
• Sulcus sign
  
  • Tests: Inferior stability
  • Positive: Palpation reveals widening of the subacromial space between the acromion and the humeral head, which is a positive for this test.
  • Procedure: In sitting or standing and shoulder in a neutral position. With the arm grasped above the elbow - inferior traction is applied. The examiner watches for dimpling of the skin below the acromion.

Question 7

Functional assessment

Answer 7

• Reaching,
• picking something up from the floor
• getting on and off the bed,
• Lying on shoulder/ back
• Dressing/putting on bra
• Driving-gear change
• Seatbelt