Shoulder LAB

Question 1

Quick Test: GH

Answer 1

1. Flexion: bring your arms up overhead and go down
2. Abduction: brings arms up over head to side and go down
3. Hand behind head: reach behind neck and go down
4. Hand behind back: reach behind back (how far they go) and go down
   a. Compare how high up in sides, which spinous process, compare between sessions
5. Rotator cuff:

Question 2

Painful Arc

45-60-120 degrees

170-180 degrees

Answer 2

GH: 45-120

AC: 170-180

Question 3

Active Movement Testing

Answer 3

i. Cervical spine : look over right shoulder, look over left shoulder, look up, side tilt [also can do thoracic]—find out if this hurts and is the reason they are here—finding cardinal sign, it may not be from shoulder
ii. Scapular elevation/depression
iii. Scapular upward and downward rotation
iv. Scapular adduction/abduction
v. Glenohumeral physiological motions
vi. Elbow flexion/extension

Question 4

When do we apply overpressure?

Answer 4

f. OVERPRESSURE: stabilize ST joint (hand over shoulder) and bring the arc into extreme of the motion using short lever (my hands close to each other, going into the end feel)—short lever and not a longer lever because forces at the joint wont be as much with a shorter lever
i. Do not overpressure if there is pain even if there is normal range
ii. Example, go to end range, stabilize scapula, take a short lever, and overpressure for a little capsular end feel (flexion, abduction, behind neck…)
iii. Clear on overpressure, pain on overpressure…

Question 5

Resistive Testing

Answer 5

Isometric

We want strong and painless

GH Flexion:

1. Pillow under head, pillow to hold 55 abduction and 30 horizontal adduction, neutral ER/IR
2. Punch up to ceiling and I block her and match resistance for a contraction, see if it created cardinal sign

GH Abduction:
1. Come out to side and push into my hand

GH Adduction: pecs and lats
1. Come out to side and push into my hand

GH extension :
1. Come from behind and push into my hand through elbow

GH IR:

GH ER:

Scapula: protraction/retraction, ab/adduction etc

Question 6

In the passive physiological and joint mobility testing, what 3 things must we look for?

Answer 6

1. Endfeel –normal for that joint
   GH expect capsular endfeel
   Elbow expect hard endfeel
   Boggy: squish:
   Empty: limited by pain, patient says stop
   Muscular endfeel: limited by muscle tightness (we document where in the range we get the endfeel)
2. Arc of motion (ROM)–full ROM, hypermobile or hypomobile
3. Quality of movement: grinding, clicking, crepitus, muscle spasm

Question 7

Passive GH Flexion

Answer 7

Pt position: Pillow under the head, Supine, close to the edge of the table, Stabilize the scapula against the thorax (top of scapula, heel of hand on acromion)

PT: face patient, arm in neutral, grab distal humerus and cradle forearm against mine, stabilize the scapula, squat down and stand up for range of motion, switch hands on humerus and use other hand under scapula against the thorax, feel for scapular motion and that is the end of the GH motion

Note which is GH movement (about 90 degrees) and when the scapula starts to move, put goniometer to read which is GH and which is the full arc after that to 120

Question 8

Passive GH Abduction

Answer 8

Pt position: Pillow under the head, stabilize the scapula against the thorax

Arm at the side, edge of table. I have wide base of support, I am slightly angled, I push scapula against thorax and cradle forearm with forarm and take her to the beginning of the motion, then I switch hands and grab the distal forearm with my other hand and cradle the forearm against my forearm and I need a forwards backwards stance and stablize scapula and do abduction

Note which is GH movement (about 90 degrees) and when the scapula starts to move, [then we want the arm to externally rotate so I switch around, my arm elbow to her elbow] put goniometer to read which is GH and which is the full arc after that to 120
i. Pivot point at AC, the Static arm at sternum, Moving arm at humerus

Question 9

Passive GH Internal Rotation:

Answer 9

Pillow under the head

Stabilize the scapula against the thorax, Her hand on my elbow, Create bridge, my right on her right: her wrist at my elbow with my right hand pushing scapula down, my left hand at the distal humerus

As I turn I squat down and allow for the full range

Goniometer

Question 10

5. Passive GH External Rotation:

Answer 10

Pillow under the head, arm off side of table

Stabilize the scapula against the thorax (scoop underneath), Her hand on my elbow, As I turn I squat down and allow for the full range

Side to side stance, hand on distal humerus allow to fall with gravity or I will turn it, take the other hand to stabilize ST joint by pressing acromion down and in, grab hold of distal humerus which should be parallel to floor, do WS with top leg and let gravity bring arm down to external rotation

Goniometer:

i. Pivot:
ii. Static arm: table
iii. Moving arm: ulna
iv. Give a range: ie 0-45, 0-90, 10-45

Question 11

GH Glides

Patient position

Answer 11

Patient position: Supine, near edge of table, relaxed neck and back, Thorax can be stabilized wit belt, Shoulder at approximatly 55 degrees abduction and 30 degrees horizontal adduction

Therapist supports the arm at the elbow, Can reverse with my hand at their elbow and their elbow at my wrist

Therapist other hand is free to apply the joint mobilization force

Question 12

GH: Inferior Glide

Answer 12

in order to engage any movement, need to drop head of humerus down into ball/belly of glenoid

Supine, shoulder at approximatly 55 degrees abduction and 30 degrees horizontal adduction. Have arm resting on me so I can feel the play, not pulling on the humerus

Heel of therapist mobilizing hand on the greater tuberosity of the patient’s shoulder/humerus [can use web space on top of humerus and glide using web space]. Forearm should be in line of the force. Side to side stance for using the weight shift.

Direction of force: caudally, towards patient feet

Question 13

GH Posterior Glide

Answer 13

a. Supine
b. Arm positioned in 50-55 degrees abduction
i. not the resting position because the resting position will put head of humerus posteriorly already so we cannot add that component, so we only do the 50-55 degree abduction because we want to assess posterior joint play.
1. Whatever position you apply, need to be documenting it and be consistent
c. Heel of therapist hand on anterior proximal humerus
i. Heel of hand close to joint as possible
ii. Forearm to be vertical for a gravity assisted glide to the floor
iii. (if see acromion go way back probably did too much)
d. Direct force: posteriorly

Question 14

GH lateral glide

Answer 14

a. Resting position
b. Flat surface of palm of therapist hand in axilla, facing laterally (palm faces humerus)
i. Her hand can rest on my forearm of my mobilizing hand, and use my other hand on the distal humerus
ii. I can hold with one hand and mobilize with the other hand by standing in between torso and humerus
c. Direction of force: lateral
i. Lateral to humerus

d. In testing, carry humerus with you, For treatment: Therapist may apply counter-pressure on patient elbow with supporting hand
P

Question 15

GH anterior glide in prone

Answer 15

a. Patient prone, towel roll/wedge under coracoid, arm in resting position
i. Abduct 55 degrees and drop humerus towards the floor to get the resting position.
ii. Heel of hand close to joint to glide.

b. Heel of therapist hand on posterior humerus
c. Direction of force: anterior
d. Imporant to stabilize the scapula—ie towel roll in coracoid process to fill in the gap. Gliding head of humerus towards the floor because the patient is prone

Question 16

GH anterior glide supine

Answer 16

a. Patient supine. Therapist supports the arm in the resting position by holding it between body and arm
i. Both hands hold proximal humerus
ii. Use body to stabilize the distal humerus
iii. Take up the slack
iv. Mobilize to ceiling, try to bring humerus with you

b. Palms of both therapists hands go behind the humerus
c. Direction of force: anterior

d. Therapist may allow distal humerus to follow the anterior glide or may prevent it from moving if needed (this is more for treatment)

Question 17

Passive scapular depression

Answer 17

press from the top hand and guide with the bottom hand, side to side stance

2. Hand placement:
   a. Pillow under patient head for a neutral spine.
   b. Get the scapula into a neutral position. Neutral spine. We don not want him rolling forward.
   c. Grab hold of the inferior angle with one hand and then superior angle and acromion with the other hand.
   i. I can use my web space or the divot between hyperthenar eminence for the inferior angle
   ii. Heel of hand at acromion and web space superior angle
   d. I drape their humerus over my forearm with their elbow bent and allow their hand to fall to the ground to allow the patient to relax. (assuming they have 90 degrees of flexion, otherwise let their arm be at their side)

Question 18

Passive scapular elevation

Answer 18

press more from bottom hand, guide with top hand, side to side stance

2. Hand placement:
   a. Pillow under patient head for a neutral spine.
   b. Get the scapula into a neutral position. Neutral spine. We don not want him rolling forward.
   c. Grab hold of the inferior angle with one hand and then superior angle and acromion with the other hand.
   i. I can use my web space or the divot between hyperthenar eminence for the inferior angle
   ii. Heel of hand at acromion and web space superior angle
   d. I drape their humerus over my forearm with their elbow bent and allow their hand to fall to the ground to allow the patient to relax. (assuming they have 90 degrees of flexion, otherwise let their arm be at their side)

Question 19

passive scapular retraction

Answer 19

forward backwards stance
index finger on vertebral border with same grip
stand from squatting position keeping humerus at 90 degrees of flexion

2. Hand placement:
   a. Pillow under patient head for a neutral spine.
   b. Get the scapula into a neutral position. Neutral spine. We don not want him rolling forward.
   c. Grab hold of the inferior angle with one hand and then superior angle and acromion with the other hand.
   i. I can use my web space or the divot between hyperthenar eminence for the inferior angle
   ii. Heel of hand at acromion and web space superior angle
   d. I drape their humerus over my forearm with their elbow bent and allow their hand to fall to the ground to allow the patient to relax. (assuming they have 90 degrees of flexion, otherwise let their arm be at their side)

Question 20

passive scapular protraction

Answer 20

forwards backwards stance
index finger on vertebral border with same grip
squat down more for protraction (keeping humerus at 90 degrees of flexion)

2. Hand placement:
   a. Pillow under patient head for a neutral spine.
   b. Get the scapula into a neutral position. Neutral spine. We don not want him rolling forward.
   c. Grab hold of the inferior angle with one hand and then superior angle and acromion with the other hand.
   i. I can use my web space or the divot between hyperthenar eminence for the inferior angle
   ii. Heel of hand at acromion and web space superior angle
   d. I drape their humerus over my forearm with their elbow bent and allow their hand to fall to the ground to allow the patient to relax. (assuming they have 90 degrees of flexion, otherwise let their arm be at their side)

Question 21

passive scapular upwards and downwards rotation

Answer 21

diagonal stance, regular grip, move to upwards and downwards rotation comes from my body and not from my arms

2. Hand placement:
   a. Pillow under patient head for a neutral spine.
   b. Get the scapula into a neutral position. Neutral spine. We don not want him rolling forward.
   c. Grab hold of the inferior angle with one hand and then superior angle and acromion with the other hand.
   i. I can use my web space or the divot between hyperthenar eminence for the inferior angle
   ii. Heel of hand at acromion and web space superior angle
   d. I drape their humerus over my forearm with their elbow bent and allow their hand to fall to the ground to allow the patient to relax. (assuming they have 90 degrees of flexion, otherwise let their arm be at their side)

Question 22

SC Joint

rationale for glides

a. Inferior glide to increase c
b. Superior glide to increase
c. A-P glide to increase
d. P-A glide to increase

Answer 22

a. Inferior glide to increase clavicular elevation
b. Superior glide to increase depression
c. A-P glide to increase retraction
d. P-A glide to increase protraction

Question 23

How to Palpate SC

Answer 23

Palpate for the SC joint: start at the interclavicular notch and come laterally. Get as close to the joint as possible. Note that the motion is small.

Question 24

SC Joint Inferior Glide:

Answer 24

Rationale: clavicular elevation

a. Patient supine, area exposed
b. Therapist thumb on the superior surface of the clavicle—avoid stress on airway, monitor joint with one finger (monitor inferior aspect of joint)
i. Thumb to thumb on superior aspect of the clavicle, index finger inferior to clavicle to monitor
ii. Keep arms level with the table for a pure force
iii. Push glide down and out
c. Direction of force: inferior-lateral

Question 25

SC Joint Superior Glide:

Answer 25

rationale: increase clavicle depression
a. Patient supine, area exposed
b. Therapist thumb on the inferior surface of the clavicle— monitor joint with index finger
i. Thumb to thumb on inferior aspect of the clavicle, index finger superior to clavicle to monitor
ii. Keep arms level with the table for a pure force
iii. Push glide up and in
c. Direction of force: superior and slightly medial

Question 26

SC Joint A-P Glide:

Answer 26

rationale: increase clavicle retraction
a. Patient supine, area exposed
b. Therapist thumb on the anterior clavicle
i. Thumb close to the joint
ii. Push down towards the table: glide and return
iii. Keep fingers away from the neck
iv. Keep arm vertical to the force
c. Direction of force: posterior
d. Be relaxed and gentle

Question 27

SC Joint P-A Glide:

Answer 27

rationale: increase clavicle protraction
a. Patient supine, area exposed—or seated with arm supported on pillow or lap [supine so table stabilizes scapula]
b. Therapist gently positions thumb or key grip behind clavicle—index finger can monitor joint
i. Thumb is on the anterior portion of the clavicle close to the joint and index finer on posterior clavicle, take up the soft tissue, we lift the clavicle up and return to neutral this does not require a lot of force
ii. Use index finger to monitor joint play
iii. Use vertical force to lift, pull up towards the ceiling
c. Direction of force: anterior

Question 28

AC: Anterior to Posterior Glide:

Answer 28

a. Patient supine, area exposed
b. Find lateral aspect of clavicle, look for the shelf behind the joint
c. Therapist stabilizes posterior aspect of acromion with one hand—that thumb monitors the joint or assists in applying pressure
d. Therapist’s other thumb on anterior clavicle
e. Stabilize the scapula because we only want AC mobility, Push front to back from anterior clavicle just before the joint towards the floor
i. hand A stabilizes with thumb in front of the acromion and fingers behind the scapula, push up
ii. hand B thumb brings the clavicle from anterior to posterior, pull down
f. Direction of force: posterior

Question 29

AC: Posterior to Anterior Glide:

Answer 29

a. Patient supine, side-lie or seated, area exposed
b. Therapist stabilizes the anterior humerus and acromion with fingers
c. Therapist thumbs on posterior aspect of lateral clavicle push towards the ceiling anterior and slightly laterally
d. (this is the one where I was under the patient to create the force in the same direction as my forearm)
i. find the lateral clavicle, hand on anterior acromion stabilize, thumb on posterior clavicle and push up
e. Direction of force: anterior and slightly lateral