Shoulder Complex Evaluation Flashcards
Red flags for shoulder complex in the history
- no incident or accident
- glove like numbness
- are the symptoms constant/unrelenting
- radiating symptoms across multiple dermatomes
- sudden onset of severe pain
- interrupting sleep/worse at night
- symptoms are constant
Patient history that would make you think impingement
- Stage 1: intermittent mild pain with overhead activities
- Stage 2: mild to moderate pain with overhead activities
- Stage 3: pain at rest or activities, night pain, & weakness
Patient history that would make you think rotator cuff tear (RCT)
- night pain
- weakness in abduction & external rotation
- loss of AROM
Patient history that would make you think frozen shoulder
- inability to perform ADLs due to loss of motion
Patient history that would make you think instability
- apprehension with abduction & external rotation
- popping
Patient history that would make you think labral tear
- clonking with overhead motion
Patient history that would make you think AC separation or arthritis
- localized pain
- swelling/deformity over AC joint
Patient history that would make you think cervical spine
- pain/numbness below elbow in dermatomal distribution
Self assessments for shoulder injuries
- DASH (disabilities of the arm, shoulder, and hand)
- Oxford shoulder score (catches the more active patient)
What might you see in a scapular assessment
- bilateral with 1-3 lb weights to bring out impairments better
- Normal
- Subtle dyskinesia
- Obvious dyskinesia
- look for winging, hitching (on the way up one scapula stops & quickly catches up), & dumping (on the way down one scapula stops & quickly catches up)
Describe scapular reposition test (McClure)
- manually reposition scapula with elevation
- look for decreased pain, improved motion, or improved strength
Describe scapular assist test
- assist with upward rotation through facilitation of lower trapezius (try to cue lower trap)
Describe scapular flip test
- resist glenohumeral external rotation while feeling for medial scapular border to wing
Describe scapulohumeral rhythm
- 0-30 degrees elevation is GH motion
- 30-90 degrees elevation 2:1 ratio of GH movement (60 degrees & snap protraction and 30 degrees external rotation)
- 90-170 degrees elevation is a 1:1 ratio
- 170-180 degrees is TS extension
Common painful ranges
- pain & limited between 70-110 degrees scaption: rotator cuff impingement, RCT, subacromial bursitis
- painful arc between 70-110 degrees scaption with full ROM: subacromial bursitis, impingement
General guidelines for resisted movements
- IR is stronger than ER 3:2 ratio
- adduction is stronger than abduction 2:1 ratio
- extension is stronger than flexion 5:4 ratio
- increasing weakness with reps = cervical nerve injury
- consistent weakness with reps = muscular
Peripheral nerve tests
- Spinal accessory nerve (SCM & upper traps): inability to abduct arm greater than 90 degrees
- Musculocutaneous nerve (biceps, brachialis, & coracobrachialis): weak elbow flexion with forearm supination
- Long thoracic nerve (serratus anterior): inability to flex fully extended arm (scapular winging)
- Suprascapular nerve (supraspinatus & infraspinatus): pain with shoulder flexion and/or abduction
- Axillary nerve (teres minor & deltoid): inability to abduct arm
Open pack & closed pack position for shoulder joint mobilizations
- Open pack: 55 degrees abduction with 30 degrees horizontal ABD & slight ER (scaption plane)
- Closed pack: max abduction & ER
What is the capsular pattern of the shoulder
- more ER than ABD and more ABD than IR
- ER > ABD > IR
What motions do the different glenohumeral joint mobilizations improve
- Lateral distraction: all motions
- Inferior glide: abduction
- Anterior glide: ER and horizontal abduction
- Posterior glide: flexion and horizontal adduction
What motions do the the different SC joint (sternoclavicular) mobilizations improve
- Posterior glide: retraction
- Anterior glide: protraction
- Inferior glide: elevation
- Superior glide: depression
History for instability
- multiple recurrent subluxations
- injury to the shoulder
- dislocation
- sensation of something slipping/unstable or anxiety in certain positions
Special tests for instability
- Sulcus sign
- Palpation of subacromial space
- Load and shift
- Apprehension/Relocation/Release
History for labral tear
- FOOSH
- brace oneself with an outstretched arm in MVA
- lifting heavy objects repeatedly
- overhead activities
Symptoms of a labral tear
- popping, clicking, or catching in the shoulder
- pain when you move your arm over your head or throw a ball
- a feeling of weakness or instability in the shoulder
- aching pain of vague location
Special tests for labral tear
- Anterior slide test
- Crank test
- Compression rotation test
- Active compression test
- Bicep load test
- Kim test
History & symptoms for subacromial impingement
- overhead activities
- difficulty reaching up behind the back
- pain with overhead use of the arm
- weakness of shoulder muscles
Test item cluster for subacromial impingement
- Hawkins and Kennedy impingement sign
- Painful arc sign
- Infraspinatus muscle test
History and symptoms for rotator cuff pathology
- age >40
- overhead sports
- overhead occupations
- dull ache deep in the shoulder
- disturb sleep, particularly win lay on affected side
- painful to reach behind back
- weakness
Test item cluster for full thickness RCT (rotator cuff tear)
- Drop arm test
- Painful arc sign
- Infraspinatus muscle test
Special tests for supraspinatus tear
- Drop arm test
- Drop sign
- Full can
- Empty can
- Scapular retraction test
- ER lag sign
- Subacromial grind test
Special test for infraspinatus tear
- Dropping sign
Special test for teres minor tear
- passively place patient in 90 degrees scaption and have them ER against resistance
- Hornblowers
Special tests for subscapularis tear
- IR lag sign
- Napoleon test
History for AC joint separation
- FOOSH
- cradling arm decreases pain
- pain directly over AC joint
- horizontal adduction painful
- positive active compression test
3 types of AC joint separation
- Type I: AC ligament disruption but coracoclavicular ligaments intact
- Type II: AC joint ligaments torn and coraocclavicular ligaments disrupted
- Type III: all ligaments torn and complete AC joint separation
History for adhesive capsulitis (AKA frozen shoulder)
- gradual onset of loss of ROM in a capsular pattern (ER>ABD>IR)
- may be accompanied with a history of shoulder pain however generally idiopathic
- pain with movement
- pain when sleeping on involved side
- difficulty with ADLs
- Freezing, Frozen, and Thawing (18 months to 2 years for natural progression to self resolve)
