Shoulder practical manual

Question 1

How do you palpate the inferior angle of the scapula?

Answer 1

Model → Sitting edge of plinth with feet supported on a stool - arm medially rotated behind back.

Technique →Identify the prominence of the angle by palpating the tip and the lower medial and lateral borders of the scapula.

Question 2

How do you palpate the spine of the scapula?

Answer 2

Model → Edge of plinth w/feet on stool - arm held by side

Technique → Identify the crest of the spine of the scapula and palpate along the spine towards medial border (starting point). Now palpate along full extent of spine moving laterally to finish your palpation at the angle where the acromion process commences.

Question 3

How do you palpate the acromion process?

Answer 3

Model → Edge of plinth w/feet on stool - arm by side

Techniqiue → Identify angle btween lateral end of spin and acromion process (starting point) - now palpate along the lateral border of the acromion to finish your palpation at the anterior tip. - then palpate superior surface.

Question 4

How do you palpate the clavicle?

Answer 4

Model → same

Technique → Jugular notch and identify bony prominence lateral to it - medial end of clav. Now palpate along the length of the clavicle moving from anterior to the superior aspect as you move your fingers laterally. Finish palpation at point where clavicle dips down (AC joint).

Question 5

How do you palpate the coracoid process?

Answer 5

Model → same

Technique → Cup hand over the superior aspect of the model’s shoulder. Using the pad of your 4th digit, palpate under the the lateral one-third of the clavicle for a bony point which may cause slight discomfort to the model (this is the cp).

Question 6

How do you palpate the greater tubercle of humerus?

Answer 6

Model → same

Technique → Identify lateral border of acromion process. Palpate below this body prominence to identify a further bony point.

Question 7

How do you palpate the lesser tubercle of humerus?

Answer 7

Model → same

Technique → Cup hand over superior aspect of model’s shoulder. Use the pad of your 4th digit to identify the coracoid process. The Pad of 2nd digit should rest over the lesser tubercle.

→→To help confirm this, passively medially rotate the model’s arm and the bony point should move under your finger tip.

Question 8

What is important to consider regarding palpation?

Answer 8

Explain to the model what you are planning to do and make them aware of the process for adequately and appropriately undressing → informed consent before proceeding.

Question 9

What is the classification of the acromioclavicular joint?

Answer 9

Synovial, complex, plane, multi-axial

Question 10

How to palpate the AC joint?

Answer 10

Palpate along length of clavicle moving from anterior to superior aspect as fingers move laterally.

The joint line is indicated at the point where the clavicle dips down.

To confirm the accuracy of this, ask model to shrug shoulder gently to help identify movement occuring at the joint.

Question 11

What is the classification of the sternoclavicular joint?

Answer 11

Synovial, complex, saddle - functionally a ball and socket, multi axial

Question 12

How to palpate the SC joint?

Answer 12

Commence palpation at jugular notch and identify medial end of clav. with one finger.

To confirm the accuracy of this, ask model to shrug shoulder gently to help identify movement opccurring at the joint.

Question 13

What is the classification of the glenohumeral joint?

Answer 13

Synovial, simple, ball and socket, multi-axial

Question 14

How to palpate the GH joint?

Answer 14

𝗔𝗻𝘁𝗲𝗿𝗶𝗼𝗿 𝘀𝘂𝗿𝗳𝗮𝗰𝗲 𝗺𝗮𝗿𝗸𝗶𝗻𝗴
Cup hand over sup. aspect of model’s shoulder. Identify coracoid process and lesser tubercle of humerus as normal. Where the middle finger rests will be the position of the shoulder joint line . (concave laterally).

𝗣𝗼𝘀𝘁𝗲𝗿𝗶𝗼𝗿 𝘀𝘂𝗿𝗳𝗮𝗰𝗲 𝗺𝗮𝗿𝗸𝗶𝗻𝗴
Identify the angle merking the junction between the lateral end of the spine and beginning of acromion process. Move 2cm inferiorly and 2cm medially and indicate the size and direction of the joint line.

Question 15

Limiting factors to elevation?

Answer 15

Sternoclavicular joint: Tension in costoclavicular ligs. and subclavius muscle

Acromioclavicular joint: Coracoclavicular lig (both bands)

Question 16

Limiting factors to depression?

Answer 16

Sternoclavicular joint: Interclavicular lig. and intra-articular disc

Question 17

Limiting factors to protraction?

Answer 17

Sternoclavicular joint: Sternoclavicular lig. and costoclavicular ligament

Acromioclavicular joint: Coracoclavicular ligament and fibrous capsule

Question 18

Limiting factors to retraction?

Answer 18

Sternoclavicular joint: Sternoclavicular ligament and costoclavicular ligament

Acromioclavicular joint: Coracoclavicular ligament and fibrous capsule

Question 19

How is the model positioned at the start of flexion, extension and abduction goniometry ?

Answer 19

Sitting on stool - arm held by the side

Can stand up if smaller/same height as the model

Question 20

What is normal ROM for shoulder flexion?

Answer 20

0-180 degrees

Question 21

What is normal ROM for shoulder extension?

Answer 21

0-70 degrees

Question 22

What is normal ROM for abduction?

Answer 22

0-170 degrees

Question 23

Command to patient for shoulder flexion?

Answer 23

Keep your elbow straight and lead with your thumb. move your arm as far upwards in front of you as you can.

Question 24

Command for shoulder extension?

Answer 24

Keep your elbow straight and lead with your little finger. Move your arm as far backwards behind you as you can.

Question 25

Command for shoulder abduction?

Answer 25

Keep your elbow straight and lead with your thumb.

Move your arm as upwards towards your ear as you can.

Look for unwanted Cx spine lateral flexion

Question 26

Limiting factors to shoulder flexion?

Answer 26

• Tension in capsular structures
• Surrounding opposing musculature : shoulder extensors

Question 27

Limiting factors to shoulder extension?

Answer 27

• Tension in capsular structures
• Opposing musculature - flexors

Question 28

Limiting factors to shoulder abduction?

Answer 28

Glenohumeral ligs. (middle and inferior bands) and inferior part of the fibrous capsule

Question 29

Limiting factors to shoulder medial rotation?

Answer 29

• Extent of articular surfaces
• Tension in lateral rotators

Question 30

Limiting factors to shoulder lateral rotation?

Answer 30

• Extent of articular surfaces
• Anterior capsule
• GHJ ligaments (all)
• Tension in medial rotators

Question 31

What is SAPS?

Answer 31

Subacromial pain syndrome → a type of non-traumatic shoulder pathology characterised by pain generated by structures within the subacromial space.

→ If all 3 tests are positive, there is a high likelihood of SAPS.
→ 2 positive tests returns a moderate likelihood of SAPS

Question 32

What are 3 SAPS tests?

Answer 32

Hawkins kennedy test
Infraspinatus muscle test
Painful arc - in scapular plane

Question 33

Positive for hawkins kennedy test?

Answer 33

Test is positive if the model experiences their familiar pain

(should be left until the end of the assessment so it is not repeated more than once)

Question 34

Positive for infraspinatus muscle test?

Answer 34

(pushing arms in)

Test is positive if the model experiences familiar pain and/or weakness

Question 35

Positive for painful arc test?

Answer 35

Instruct to report pain as soon as it is felt.

The test is considered positive if the model experiences an onset of pain between ~40 and ~120 degrees of shoulder abduction which eases <~40 degrees and >~120 degrees of abduction.

Question 36

What is a rotator cuff tear?

Answer 36

→ Rotator Cuff tears are muscle injuries sustained to one or more members of the rotator cuff unit.
→ Can be partial or full thickness and occur at various locations within the muscle.
→ Can be traumatic or non-traumatic
→ Caused by an accumulation od degeneration and frequent injury/trauma

Question 37

What are the 3 tests for rotator cuff tears?

Answer 37

Painful arc
Infraspinatus muscle test
Drop arm test

Question 38

What is the drop arm test and what is a positive result?

Answer 38

1.Instruct to report any pain during test as soon as it is felt.
2. Instruct model to abduct arm in scapular plane of movement to 90 degrees.
3. Model then instructed to slowly lower the arm back to the side.

The test is considered positive if the model experiences either pain or weakness on the returning the arm to the side which causes the arm to ‘drop’ suddenly.

Question 39

If the rotator cuff tears are positive, further rotator cuff tests can be undertaken for specific muscles.
What are these muscle tests?

Answer 39

Infraspinatus muscle test → infraspinatus
Drop arm test → supraspinatus
Bear hug test → subscapularis
Hornblower’s sign (Patte test) → teres minor

Question 40

How to carry out bear hug test and positive result?

Answer 40

1. The model is instructed to report any pain experienced during the test as soon as it’s felt.
2. Palm of hand on patient’s affected side is placed on opposite hsoulder with fingers extended and elbow positioned ant. to body.
3. Patient is asked to hold that position as the examiner tries to pull the patient’s hand from the shoulder with an external rotation force applied perpendicular to the forearm.

The test is positive if the patient is unable to resst the examiners external rotation power - either due to pain or weakness - and if affected arm exhibits weakness compared w/contralateral side.

Question 41

How to carry out hornblower test and positive result?

Answer 41

1. Instruct model to report any pain experienced during test as soon as it is felt
2. The model’s shoulder is flexed to 90 degrees with the elbow flexed to 90 degrees
3. Model instructed to maintain this position

The test is considered positive if the patient is unable to maintain this position - either through pain or weakness.

Question 42

What is the test for ACJ dysfyunction?

Answer 42

Scarf test

1. Report any pain as soon as it is felt
2. Ask to reach horizontally across their body towards their opposite shoulder.
3. Apply pressure on arm (pushing it further back)

Positive test if pain reproduced in region of the ACJ → this test compresses the joint surfaces of the ACJ together and may indicate ACJ dysfunction.

Question 43

What are the accessory movements of the shoulder region?

Answer 43

𝐒𝐭𝐞𝐫𝐧𝐨𝐜𝐥𝐚𝐯𝐢𝐜𝐮𝐥𝐚𝐫 𝐣𝐨𝐢𝐧𝐭
→Medial end of clavicle
→ Supine lying, pillow under humerus
→ Thumbs adjacent to SCJ , fan out fingers for stability, AP glide

𝐀𝐜𝐫𝐨𝐦𝐢𝐨𝐜𝐥𝐚𝐯𝐢𝐜𝐮𝐥𝐚𝐫 𝐉𝐨𝐢𝐧𝐭
→ Lateral end of clavicle
→ Supine lying, pillow under the humerus
→ Locate lat. end of clav, thumb tip technique in AP

On females don’t splay the fingers!!

𝐆𝐥𝐞𝐧𝐨𝐡𝐮𝐦𝐞𝐫𝐚𝐥 𝐉𝐨𝐢𝐧𝐭
→ Movement of head of humerus in AP
→ Supine with pillow under humerus, hand on stomach
→ Stabalise scapula, glide head in AP with “heel” of other hand

𝐋𝐨𝐧𝐠𝐢𝐭𝐮𝐝𝐢𝐧𝐚𝐥 𝐂𝐚𝐮𝐝𝐚𝐝 𝐦𝐨𝐯𝐞𝐦𝐞𝐧𝐭 (𝐇𝐮𝐦𝐞𝐫𝐮𝐬)
→Pillow under humerus, bed high
→ Stand at the side, with patient’s elbow in 90 degrees flexion, hold patient’s wrist with one hand and grasp.
→ Grasp around anterior surface of the patient’s upper arm with your other hand
→ Direct pressure in longitudinal caudad direction

Question 44

What AP movement mimicks shoulder flexion and why?

Answer 44

AP Humerus

The head of humerus is a convex surface articulating with the concave glenoid fossa.

Question 45

What accessory movement mimicks shoulder abduction?

Answer 45

Longitudinal caudad of humerus