Shoulder Functional/Special Tests Flashcards
DDx of Shoulder Pain
-Impingement/RC
-Adhesive Capsulitis
-GH instability (Labral/Slap)
-Post op
-Serious Cause
-Scapular Instability
-AC/SC Joint
Shoulder Pain DDx: Rotator Cuff/Impingement
(+):
-impingement signs
-painful arc
-pain w/ iso resistance (tendinopathy) (mid range)
-weakenss
-atrophy
(-):
-significant loss of motion
-instability signs
Shoulder Pain DDx: Frozen shoulder
(+):
-spontaneous progressive pain
-loss of motion in multiple planes
-pain at end range
(-):
-normal motion
-<40 yrs
Shoulder Pain DDx: GH Instability
(+):
-<40 year
-Hx of dislocations
-Apprehension
-Laxity
(-):
-No hx of dislocations
-No apprehension
Observations
-Posture
-Willingness to move
-Shoulders level: atrophy, flattening of deltoid (ant dislocation)
-Scapula: winging or deformities
-Dominant arm: lower shoulder
-Muscle spasms, wasting
Contraindications for Manual Therapy
-infection
-Fever
-Cancer
-Acute Circulatory Condition
-Open Wound
-Fracture
-Hematoma
-Advanced DM
-Hypersensitivity
-Abnormal Endfeel
-RA
-Cellulitis
-Constant, Severe pain
-Extensive radiation of pain
-Condition not evaluated
UQ Scan
- Vitals (HR and BP)
- CNs (optional)
- Observation: posture, plumb line, head, face, neck, mouth
- Gait: look for gross abnormalities
- Clear the spine
- UE ROM: All 6 w/ overpressure
- Dermatomes (C4-T2)
- Myotomes (C5-T1)
- DTR: bicep, brachioradialis, tricep
- UMN Testing: Hoffman’s, Babinski, Lhermitte
- Upper Limb Tension Testing (Median)
- Pulses (carotid, axillary, brachial, radial, ulnar) (optional)
- Thyroid (optional)
- Lymph Nodes (neck, and axilla) (optional)
Median Nerve ULTT 1
- Use elbow to depress scap
- Abduct
- Extend wrist and fingers
- ER
- Elbow extension
- Lat sidebending
+ Findings: differences btw sides, distant component, reproduction of s/s
Contraindications for Neurodynamic Mobilizations
-Recent repair
-Malignancy
-Active Inflammatory Disorders
-Acute Inflammatory Demyelinating Disorders
Radial Nerve ULTT 2
- Use hand to depress scap
- GH IR
- Flexion wrist and fingers
- Forearm pronation
- Elbow extension
- GH ABD
- Lat sidebending
+ Findings: differences btw sides, distant component, reproduction of s/s
Ulnar Nerve ULTT 3
- Use hand to depress scap
- Abduct
- GH ER
- Forearm pronation
- Extend wrist and fingers
- Elbow flexion
- Lat side bending
+ Findings: differences btw sides, distant component, reproduction of s/s
Shoulder AROM Exam
-Flexion/IR and ER @0/ABD for everyone
-Ext/Horizontal (cross arms)
overpressure if pain-free
Resisted test in mid-range EVEN if painful
Shoulder Resisted ROM
-hold for 5s
Flx: at wrist
ABD: elbows bent
IR/ER: bent elbows and push at wrist
Strong; painless
Strong; painful
Weak; painless
Weak; painful
Painful Arc Sign
-RC pathology indicator
-impingement test
-Pain in mid-range
GH: 60-120 pain
-max stress on subacromial space
AC: end range pain
-max stress on AC
Scapular Dyskinesis Test
-altered scapular position and motion
-only check if seen during ROM
-changes GH loads
- Pt raises and lowers BIL 3-5x
-if needed inc reps or weight
(+) obvious deformity
SICK Scapula: Malposition of scap, inferior medial boarder, coracoid pain and malposition, scapular dykinesia
GH Distraction Mobilization/Assessment
-all parts of joint
- Pt in supine
- Pt arm to side with elbow above shoulder in OP
- Provide distraction (sustained or oscillatory)
GH Inferior Glide Mobilization/Assessment
-abduction
- Pt in supine
- Pt arm to side with elbow above shoulder in OP
- Use arm crotch on superior humeral head (sustained or oscillatory)
GH Anterior Glide Mobilization/Assessment
-Extension and external rotation, horizontal ABD
- Pt in prone w/ arm off side
- Pt elbow below shoulder
- Provide anterior force to humerus
GH Posterior Glide Mobilization/Assessment
-Flexion and Internal rotation, horizontal ADD (FIADD)
- Pt in supine
- Pt arm to side with elbow above shoulder in OP
- Use hypothenars to push posteriorly while supporting elbow
AC Joint Mobilization/Assessment
-only if they have pain at end range OR pain at AC joint
-Superior glide: adduction/ext
-Inferior glide: Abduction/flx
- Pt in supine
- Grab clavicle closest to acromion
- Superior and Inferior glide
- Can Assess in GH elevation
SC Joint Mobilization/Assessment
-only if they have pain at SC joint
-Superior glide: ext
-Inferior glide: flx
- Pt in supine with arms at side
- Grab patients clavicle as close to sternum
- Inferior or superior glide
ST Joint Mobilization/Assessment
- Pt in sidelying
- Pt arm on PT forearm
- PT holding top and bottom of scapula
- Distraction; lift up medial boarder
-Superior/inferior/medial/lateral
Palpation
-muscles
-AC joint
-SC joint
-Clavicle
-Coracoid
-sternum
-Scap
Shoulder Impingement Tests
-provocative, 1 side only
-Neer
-Hawkins-Kennedy
-Cross-Body Adduction
-Painful Arc
Muscle/Tendon Pathology Tests
-BIL assessment
-look for weakness and pain
-Speed’s Test
-Full can
-Empty Can
-ER Lag sign
-Infraspinatus Strength
-Belly press
-Lift off Sign
-IR lag sign
-Drop Arm
Neer Test
-jam greater tuberosity hits acromion
-overuse or injury to supraspinatus and possible biceps tendon
- Pt in sitting
- PT passively IR and FLX arm
- Repeat with ER
(+): pain with IR relieved with ER
Hawkins-Kennedy Test
-supraspinatus tendinopathy
-press supra into coracoid or coraco-acromial lig
- Pt in sitting
- Arm flexed to 90 (slight H ADD) with elbow bent
- PT forces into IR
(+): pain
Cross-Body Adduction Test
-AC joint pathology
- Pt in sitting
- PT elevates to 90 and Horizontally ADD to end range
(+): subacromial pain
Speed’s Test
-long head of bicep tendinopathy
- Pt flexion at shoulder level, elbow extended, forearm supinated
- PT push on wrist
(+): pain in bicipital groove
Full Can Test
-done first, less provocative, then Empty Can
-Supraspinatus tendinopathy
- Pt sitting
- Arms scaption, ER, thumbs up
- PT pushes on wrists
(+): weakness and reproduction of s/s
Empty Can test
-done 2nd after positive Full Can
-Supraspinatus tendinopathy
- Pt sitting
- Arms scaption, IR, thumbs down
- PT pushes on wrists
(+): weakness and reproduction of s/s
Infraspinatus Strength test
-infraspinatus strength
- Pt holds arm out 45 deg in scapular plane
- PT holds elbow and pushes into ER witht resistance
(+): Pt cannot resist due to pain or weakness
ER Lag Sign
-infraspinatus tear
- Pt holds arm out 45 deg in scapular plane
- PT holds elbow and puts them in ER and ask to hold positTion before releasing
(+): Pt cannot hold position; infra tear
Belly Press Test (Napoleon Sign)
-subscapularis tendinopathy or tear
- Pt sits with hand across belly
- PT grabs Pt wrist and ttries to pull away from belly
(+): Pt hands moves away or elbow moves posteriorly to compensate
Lift-Off Test
-subscapular pathology
- Pt places hand on belt line and a lift away
- If capable, resist on wrist
(+): inability to do so; subscap
IR Lag Sign
-subscapular pathology
- PT places Pt hand on belt line and a lift away
- Ask Pt to hold
(+): inability to do so; large RC/subscap tear
Drop Arm Test
- PT passively lifts arm to 90 deg of ABD and ER
- Ask Pt to hold in space and let go
(+): Pt unable to maintain arm; significant RC pathology
Shoulder Hx: Subjective
-Pain (duration, quality and behavior/other pain)
-Neck/back issues
-Movement issues
-MOI (traumatic/overuse/change in activities)
-Work
-Handedness
-Aggs/Eases
-Duration
-Age
Shoulder Hx: Age
Children: Cancer or epiphysis
10-20s: instability then secondary imingement
20:40: calcium depositis
40-60: RC or frozen shoulder
Shoulder Hx: MOI
Overheard Exertion/Repetitive:
-Subacromiial
-RC tear
-Biceps tendinopathy
FOOSH:
-Fx
-AC Joint separation
-GH Dislocations
Fall on Tip of Shoulder:
-AC Joint separation
-C-spine
Forced Horizontal ABD/est/ER
-anterior dislocation
Swimmers:
-Fatigue of muscles
-impaired stability
Shoulder Hx: Pain Relief
W/ Elevation:
-C-spine
W/ Elbow Supported:
-AC joint separation
-RC tears
Circumduction w/ click:
-GH instability
W/ Arm Distraction:
-Bursitis
-RC
Arm in dependent position:
-TOS
General Rehab Principles for Shoulder
- Pt Education:
-posture
-ergonomics
-activities to avoid - Proximal to Distal Tx
-T spine
-C soine
- Shoulder
Specific Rehab Tools for Shoulder
- Joint mobs
- Mobility
- Strengthening
- Endurance
- Closed Kinetic chain
- Plyometrics
GH Progressive Inferior Mobilization
-lacking ABD
- Pt supine w/ arm abd 45-90 deg
- PT provides long axis distraction AND inferior glide
- Repeat by increasing ABD
GH Progressive Flexion/ABD/ER Mobilization
-for Pt who have issues with combined motions
- Pt prone in abd/flx/ER
- PT uses webspace to mobe into arm pit in direction of the elbow as you move
- Increase ABD as you go
GH Progressive Posterior Mobilization
- Start in normal posterior position as close to 90 as possible
- Increase Pt horizontal ADD and scoop out AND down
- Increase ADD as you go
GH Progressive Anterior Mobilization in Prone
-frozen shoulder or significant loss of mobility of volume
- Pt in prone
- Towel under glenoid
- PT distracts and mobs PA on humerus
- Can use stool to increase ER
GH Progressive Anterior Mobilization in Supine
- frozen shoulder or significant loss of mobility
-cannot tolerate prone
- Pt supine with towel under humerus
- PT distracts humerus and AP mobs at GLENOID
- Progressively increase ER
GH Posterior Mobilization w/ Movement
- Pt in sitting
- PT on opposite side with hand on scapula and superior head
- Have pt move with you
GH Inferior Mobilization w/ ER for Adhesive Capsulitis
- Pt in supine
- PT faces feet and holds elbow
- PT ERs wind up of shoulder with long axis distraction
Shoulder Mobility
- Pendulum
- T Bar ER from side to side
- T Bar Elevation
- Wall Pulleys
Capsular Stretching
Anterior:
-Limited ER or EXT
-ER and progress with weights
-don’t give if excessice anterior glide
Posterior:
-limited FLX or IR
- Pt lays on side and brings arm across body
- Progress with towel then pull hand
Lower Trap Strengthening
-check scapular mobility for anterior tightness
- Pt in prone
- PT passively into lower trap set and has Pt hold it
- Progress to lifting past set or add weight
Instability Tests
-Anterior Apprehension
- Jobe Relocation Test
-Sulcus Sign
-Posterior Apprehension Test
SLAP Lesion Tests
-Active Compression/O’Brien’s
-Biceps Load I
-Biceps Load II
Labral Test
-Clunk Test
Scapular Stability Tests
-Scapular Dyskinesis Test
-Scapular Assistance Test
-Wall Push Up
-Pec Minor Tightness
AC Joint Pathology Tests
-Step Deformity
-Palpation
-Cross-Body Adduction
-Active Compression/O’Brien’s Test
Apprehension Test
-Anterior GH instability
- Place Pt into 90/90 with overpressure
- Watch for Apprehension
(+): apprehennsion or guarding
Jobe Relocatioon Test
-anterior GH instability
-Only if Apprehension test (+)
- Provide Overprssure in 90/90 and should get better
(+): dec apprehension or reducttion in s/s; can ER more
Sulcus Sign
-Inferior or multidirectional GH instability
- Pt seated
- ABD arm 20-50 and provide downward force
(+): sulcus sign greater than 1 finger
Grade 1: 1 cm
Grade 2: 1-2cm
Grade 3: >2 cm
Posterior Apprehension Test
-posterior GH instability
- Pt Supine or siting
- PT stabilizes scap, horizontally ADD shoulder and proiides posterior force
(+): pain in post shoulder, aprehension
Active Compression/O’Brien’s Test
-SLAP tear OR AC Joint test
-assess pain from Bicep NOT labrum
- Pt in standing w/ arm flexed, ext, horizontally ADD and IR
- PT aplies resisance for 5s
- Turn to ER and do again
(+): pain w/ IR that dec with ER OR over AC joint
Biceps Load I Test
-SLAP tear
-done 1st
- Pt in supine in 90/90
- PT resists elbow flexion
(+): reproducion of shoulder pain w/ resisted flexion
Biceps Load II Test
-SLAP tear
-done 2nd if Bicep I not positive
- Pt in supine in 90/120 (abd)
- PT resists elbow flexion
(+): reproducion of shoulder pain w/ resisted flexion
Clunk Test
-Labral pathology/ labral fragment caught in joint (=instability)
- Pt in supine
- PT holds humerus and forearm
- PT abd arm fully and ER while pushing humeral head anteriorly
(+): clunk or grindninng sound; may cause apprehension
Scapular Assistance Test
-Scapular stability/dyskinesis
-oppens up subacromial space
- Pt in standing
- PT hands on suerior angle and inferior angle
- Pt activiely elevates while PT helps upwardly rotates
(+): dec of shoulder s/s
Wall/Floor Push Ups
-scapular stability
- Pt performs 3-5 push ups
- Can do on floor or walk outs for stronger
(+): obvious muscle weakness noted (winging)
Pec Minor Tightness Test
-scapular stability/asymmetries (maybe ant tipping)
- Pt supine w/ arms at side
- PT pushes on both coracoids
(+): differnces in shoulder heights
Presense of Step Deformity
-AC joint pathology
- Gapping of AC joint to GH
