Shoulder Complex Examination Flashcards
What is the order of the differential diagnosis process?
- ) Chart Review/ Patient Interview
- ) Visual Inspection
- ) Systems Review
- ) Elimination Tests
- ) Structural Stress Testing
- ) Palpation and Joint Mobility Tests
- ) Confirmation Tests
PATIENT INTERVIEW
PATIENT INTERVIEW
What are some screening questions to ask for the shoulder complex?
- UE Trauma; specify mechanism
- Hx neck pain/trauma
- Hx shoulder dislocation
- DM
- Hx frozen shoulder
- Pain referral from cardiopulmonary systems
- UE paresthesia/anesthesia/weakness
What are some common functional limitations of patients with shoulder issues?
- lifting/carrying objects
- pushing/pulling
- reaching behind back/overhead/away from body
- prolonged positioning
- sleeping
What are some outcome measures used to assess shoulder involvement?
- PSFS
- DASH and QuickDASH (Disabilities of the Arm, Shoulder, and Hand)
- SPADI (Shoulder Pain and Disability Index)
- WOSI (Western Ontario Shoulder Instability Index)
- PSS (Penn Shoulder Score)
VISUAL INSPECTION
VISUAL INSPECTION
What are we looking for during a visual inspection of the shoulder?
- Gross abnormalities
- Integumentary
- Resting posture vs ability to correct
- Posture Assessment
- Scapulohumeral rhythm during elevation
What are some gross abnormalities we might see at the shoulder?
- step-off deformity at ACJ
- deformity of clavicle
- deformity at SCJ
- bulging posterior shoulder
- self-supporting the UE
With a postural assessment, what structures are we looking at?
- head on neck
- mandible on cranium
- neck on trunk
- scapulae on thorax (“winging” or “hiking”)
- upper arms on scapulae (resting ER)
What comes after the visual inspection?
Systems Review
ELIMINATION TESTS
ELIMINATION TESTS
What screening tests are performed both at the neck and shoulder?
- UQ screen
- Neuro screen
- Special tests w/ -LR
What elimination tests are used to rule out radiculopathy?
ULTT
What elimination tests are used to rule out fracture/bony abnormality?
- Bony Apprehension Test
- Olecranon-Manubrium Percussion Test
What elemination test is used to rule out SLAP lesion/ Labral tear?
Active Compression Test (O Brien Test)
What elimination test is used to rule out ACJ dysfunction?
AC Joint Palpation
Why would a ULTT be used when assessing the shoulder?
- Decrease suspicion of c-spine origin for UE symptoms
- Sway focus to further testing to investigate origin of symptoms at neck or locally at the shoulder
- Increase confidence that we can move on from further testing at the neck
Bony Apprehension Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: Anterior instability of shoulder due to bony lesion
- Pt Position: Sitting
- Examiner Position: Grasping proximal forearm and elbow to support, starting in 90 degrees of pt elbow flexion
- Procedure: Abduct the patient’s shoulder to 45 (or less)degrees then externally rotate the shoulder to 45 degrees (or less)
- Positive Test: Apprehension with the test
Olecranon-Manubrium Percussion Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: Fracture/dislocation between elbow and manubrium
- Pt Position: Sitting/standing with arms crossing chest
- Examiner Position: Beside/facing patient
- Procedure: Percuss the olecranon while auscilating the manubrium. Repeat on non-involved side.
- Positive Test: Difference in sound quality between tested sides
Active Compression Test (O’Brien Test):
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: Labral tear or abnormality/ SLAP lesion/ ACJ pathology
- Pt Position: Standing w/ elbow straightened and shoulder at 90° flexion, 10° horizontal adduction, and max IR
- Examiner Position: Standing behind patient
- Procedure: Patient resists isometric extension moment placed on wrist. Pt moves to maximum ER and resists isometric extension moment placed on wrist again.
- Positive Test: Pain and clicking in IR position > pain in ER position
AC Joint Palpation:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: AC joint dysfunction
- Pt Position: Sitting with arm at side
- Examiner Position: Standing behind patient
- Procedure: Palpate ACJ line
- Positive test: concordant pain provocation
STRUCTURAL STRESS TESTING
STRUCTURAL STRESS TESTING
Structural stress testing AROM can be done in _______ or ________. With this we want to observe ____________ and ________ spine motions.
- sitting or supine
- scapulothoracic and thoracic spine
What movements are performed during AROM and PROM assessment?
- flexion/extension
- abduction/adduction
- IR/ER
Muscle length testing of what can be performed during structural stress testing?
- Lats
- Pec Minor
- Levator Scap/ posterior scalene/ splenius cervicis
- Upper trap/ SCM
With AROM/PROM and Resistive testing, what 4 things are we assessing for?
- Quality
- Quantity
- Provocation
- Willingness to move
What scapular MMT tests can be assessed during structural stress testing?
- Abduction and upward rotation
- Elevation
- Adduction
- Depression and adduction
What shoulder MMT tests can be assessed during structural stress testing?
- flexion/extension
- abduction
- horizontal ab/adduction
- IR/ER
PALPATION AND JOINT MOBILITY TESTS
PALPATION AND JOINT MOBILITY TESTS
List the palpable bone and joint structures of the shoulder.
- Clavicle
- SC joint line
- AC joint line
- Coracoid process
- Humerus (greater/lesser tuberosity, head)
- Spine of scapula
- Acromion
- Sternum
- Ribs/Costal cartilage
List the palpable soft tissue structures of the shoulder.
- Sub-Acromial Space
- Supraspinatus tendon and muscle belly
- Subscapularis tendon and muscle belly
- Infraspinatus tendon and muscle belly
- Supraspinatus tendon and muscle belly
- Long head of biceps tendon
- Deltoid muscle belly
- Trapezius
- Pec major/minor
What joints can we apply joint mobilizations to in the shoulder?
- GH
- Scapulothoracic
- SC
- AC
Joint Mobility:
- The GH joint has a ______, ______, and ______ glide.
- The SC joint has a _______, ______, and ______ glide.
- The AC joint has a _______ glide.
- caudal, dorsal, and ventral
- caudal, dorsal, and ventral
- anterior
Describe the scapulothoracic glides.
- Patient Position?
- Examiner Position?
- Procedure?
Patient Position
-side-lying, 90° elbow flexion
Examiner Position
-facing patient’s anterior trunk
-caudal UE: reaching medial to upper arm, support inferior angle of scapula
-Cranial UE: superior scapula
Procedure
-passively bring scapula through depression, elevation, retraction, upward rotation, and downward rotation
-move scapula and humerus as a unit
-ensure shoulder girdle musculature is relaxed
- For the dorsal (posterior) glide of the SC joint we push on the _______.
- For the ventral (anterior) glide of the SC joint we push on the _______.
- For the caudal glide of the SC joint we apply a caudal force on the medial _______ in a slight _______ and _______ direction.
- clavicle
- manubrium
- clavicle, anterior and lateral
For the ventral (anterior) glide of the AC joint we apply a ventral force on the ________ while the patient is sitting.
clavicle
CONFIRMATION TESTS
CONFIRMATION TESTS
What confirmation tests are used for rotator cuff tear?
- External Rotation Lag Sign
- Lift-Off Test
- Internal Rotation Lag Sign
- Empty can Test
- Belly Press Test
- Drop Arm Test
- Infraspinatus Test
External Rotation Lag Sign:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: Rotator Cuff Tear
- Pt Position: Sitting
- Examiner Position: Behind patient with medial hand stabilizing patient UE at elbow, and lateral hand grasping patients wrist
- Procedure: Passively places elbow in 90° flexion and shoulder in 20° scaption, passively externally rotate shoulder to near-end-range and ask patient to maintain position
- Positive test: Inability to maintain shoulder in externally rotated position
Lift Off Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: Rotator Cuff Tear
- Pt Position: sitting, tested UE behind pt’s back with dorsum of wrist/hand contacting posterior trunk
- Examiner Position: posterior for observation
- Procedure: pt instructed to lift arm off back
- Positive test: inability to lift arm off of the back
Internal Rotation Lag Sign:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: Rotator Cuff Tear
- Pt Position: sitting, tested UE behind pt’s back
- Examiner Position: behind stabilizing patient’s elbow wth more lateral UE, grasping patient’s wrist with more medial UE
- Procedure: pt’s UE lifted away from back (passive IR), pt instructed to maintain position
- Positive test: inability to maintain position
Empty Can Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: Rotator Cuff Tear
- Pt Position: sitting, edge/corner of table
- Examiner Position: behind pt
- Procedure: pt elevates shoulder to 90° scaption, isometric extension moment placed at wrists in thumbs-up and thumbs down position
- Positive test: weakness and/or pain in thumbs-down position (relative to thumbs-up)
Belly Press Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: Rotator Cuff Tear
- Pt Position: sitting, elbow flexed 90°, palm on abdomen
- Examiner Position: standing in front of patient
- Procedure: patient internally rotates shoulder to press hand into abdomen
- Positive test: elbow drops into extension
Drop Arm Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: Rotator Cuff Tear
- Pt Position: sitting
- Examiner Position: behind pt on symptomatic side
- Procedure: grasping at the wrist, examiner passively abducts the shoulder to 90°, examiner then releases the UE with instruction to slowly lower the UE
- Positive test: inability to lower the arm
Infraspinatus Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: Rotator Cuff Tear
- Pt Position: standing, elbow flexed to 90° and neutral rotation
- Examiner Position: behind on symptomatic side
- Procedure- supporting the pt elbow, examiner applies an internal rotation force at the wrist
- Positive test- pain or weakness with resistance
What are the 4 components of the Rotator Cuff Tear Diagnostic Cluster?
- Age >60 years
- Painful Arc
- Drop Arm Test
- Infraspinatus Test
What confirmation tests are used for Torn Labrum/ Instability?
- Biceps Load II Test
- Yeargaon’s Test
- Crank Test
- Speed’s Test
- Modified Relocation Test
Biceps Load II Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: SLAP Lesion
- Pt Position: supine
- Examiner Position: symptomatic side
- Procedure: shoulder passively placed in 120° abduction and end-range ER, elbow 90° flexion, forearm supinated. Examiner resists isometric elbow flexion
- Positive test: concordant pain provocation with resisted elbow flexion
Yergason’s Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: SLAP Lesion/ labral lesion
- Pt Position: sitting or standing, 90° elbow flexion, forearm pronation
- Examiner Position: patients symptomatic side
- Procedure: pt instructed to supinate forearm while examiner resists this motion at the wrist
- Positive test: concordant pain provocation at bicipital groove
Crank Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: Labral Tear
- Pt Position: supine
- Examiner Position: facing patient on symptomatic side
- Procedure: examiner passively abducts shoulder to 160° and flexes elbow 90°, axial compression imposed on upper arm in line with long axis of humerus, repeated IR/ER passively performed (small motions)
- Positive test: concordant pain provocation
Speed’s Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: subacromial impingement, SLAP lesion, labral lesion, biceps pathology
- Pt Position: standing, elbow extended, forearm supinated
- Examiner Position: standing, facing patient
- Procedure: shoulder flexion resisted from 0° to 60° of motion
- Positive test: concordant pain provocation in bicipital groove
Modified Relocation:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications:labral pathology, traumatic anterior instability
- Pt Position: supine
- Examiner Position: standing beside patient
- Procedure: shoulder passively abducted to 120° and full ER, anterior force applied to posterior humeral head. If painful, a posterior force is applied to anterior humeral head
- Positive test: pain and/or apprehension
What confirmation test is used for AC joint dysfunction?
AC Resisted Extension Test
AC Resisted Extension Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: AC Joint Pathology
- Pt Position: sitting
- Examiner Position: standing
- Procedure: patient placed in 90° shoulder flexion and IR, 90° elbow flexion. Examiner resists shoulder horizontal abduction
- Positive test: concordant pain provocation at AC joint line
What confirmation tests are used for impingement/RC tear?
- Hawkins-Kennedy Test
- Neer Test
Hawkins-Kennedy Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: subacromial impingement, RC integrity, superior labral tear
- Pt Position: seated, elbow flexed to 90°
- Examiner Position: standing, anterior to involved shoulder
- Procedure: passively elevate shoulder to 90° of shoulder flexion or abduction (stabilize scapula superiorly with other hand)
- Positive test: concordant shoulder pain provocation
Neer Test:
- Indications?
- Pt Position?
- Examiner Position?
- Procedure?
- Positive test?
- Indications: subacromial impingement
- Pt Position: seated, elbow extended
- Examiner Position: standing to side of patient
- Procedure: passively flex the arm with one hand while stabilizing the scapula with the other hand, apply overpressure for flexion at end-range
- Positive test: concordant shoulder pain provocation
