Shoulder region Flashcards
Drop arm Test (rotator cuff dysfunction)
- mainly supraspinatus test
Patient is instructed to actively abduct their arm to 90 degrees.
The patient is then instructed to slowly adduct the arm whilst the practitioner applies gentle caudal pressure.
Test is positive if arm ‘drops’ at around 30 degrees abduction.
Tests for Rotator Cuff Dysfunction
Drop Arm Test
Painful arc sign
Weak external rotation of glenohumeral joint
Painful arc test
(rotator cuff dysfunction)
Patient is instructed to actively abduct shoulder and arm.
Pain in the shoulder between 60 – 120 degrees abduction is considered a positive result.
Possible causes - rotator cuff dysfunction, calcified deposits on greater tubercle, bursitis, etc.
Weak external rotation of Glenohumeral joint
(rotator cuff dysfunction)
Patient stands with arm at side, elbow flexed to 90 degrees.
Patient externally rotates arm (and therefore shoulder) against practitioner’s resistance.
Weakness or inability to perform this test is considered positive.
This test is more specific for Infraspinatus pathology, as this muscle is the primary external rotator of the rotator cuff group.
Tests for external (sub-acromial) impingement (3)
Hawkins-Kennedy test
Empty can/ full can test
painful arc and weak external rotation
Hawkins-Kennedy test
(external impingement)
Practitioner stands at patient’s side and stabilizes scapula.
Practitioner then flexes shoulder to 90 degrees, flexes elbow to 90 degrees and passively internally rotates GH joint by applying caudal pressure to posterior aspect of the wrist.
Pain in the shoulder on internal GH rotation is considered positive for this test.
Empty Can/Full can Test
supraspinatus tear test, or suprascapular nerve (c4-c6)
Resisted abduction to 90 degrees with GH internally rotated then repeated with GH in external rotated. ie patient puts thumb down (empty can) and then thumb up (full can).
Pain on internal rotation is considered a positive result for sub-acromial impingement . External rotation may, in fact, relieve pain. Pain during ‘full can’ test (external rotation) would be more specific for Infraspinatus tendonitis.
Painful arc and weak external rotation
(external impingement)
see previous notes
Tests for Internal impingement (2)
Internal rotation resisted strength test (IRRST)
Neers test
Internal rotation resisted strength test (IRRST)
- internal impingement
Patient abducts shoulder to 90 degrees and flexes elbow to 90 degrees.
Practitioner applies resisted external rotation then internal rotation up to the physiological barrier.
Test is +ve if internal rotation is weak and painful compared to external rotation.
Good sensitivity and specificity. Used to distinguish internal versus external impingement (Meister et al 2004)
Neers test
(n.b. also seen this combined with internal rotation)
(internal impingement)
Practitioner stabilizes the shoulder.
Patient’s arm is medially rotated and passively taken into full forward flexion
This may be +ve where internal impingement is causing posterior shoulder pain.
Tests for Subscapularis dysfunction (3)
Bear hug test
Lift off test
The Napoleon or Belly press test
Bear Hug Test
(subscapularis dysfunction)
Patient places palmar surface of hand on contralateral shoulder with arm at 90 degrees horizontal flexion. Patient actively resists cephalic pressure exerted by practitioner on patient’s elbow (ie. resisted internal GH rotation).
Pain and/or weakness in internal rotation is +ve.
Recent research shows increased sensitivity and specificity over other subscapularis tests. (Burkhart & De Beer 2006)
Lift off test
(subscapularis dysfunction)
Patient standing.
Instruct patient to place hand behind back with dorsal surface of the hand against mid lumbar spine, and then to actively lift hand posteriorly away from spine.
Failure to lift off hand is +ve test. (Note: abandon test if pain is felt whilst placing hand behind the back.)
The Napoleon or Belly press test
(subscapularis dysfunction)
Patient flexes elbow and pushes palmar surface of hand against epigastrium or umbilicus – this is a gentle version of the previous test and is less provocative if there are sub-acromial or GH complications.
Pain in the shoulder is considered positive for this test.
Acromioclavicular joint tests (2)
Scarf Test
Paxinos Test
Scarf Test
(acromioclavicular dysfunction)
Patient’s hand is placed on contralateral shoulder and forcibly adducted whilst scapula is stabilized.
Pain locally at the AC joint is a +ve test.
Paxinos Test
(acromioclavicular dysfunction)
Practitioner’s thumb is placed on posterior acromion with the 2nd or 3rd fingers of the same hand placed o the distal portion of the clavicle.
Practitioner’s thumb compresses in an antero-superior direction whilst the fingers compress the clavicle posteriorly.
Pain at the AC joint is a +ve test.
Good specificity and sensitivity. (Walton et al 2004 )
Yergason’s test
- Test for long head of Biceps Brachii Tendinopathy
What other test can be used to diagnose tendinopathy of the bicep’s tendon?
Patient actively flexes elbow to 90 degrees and pronates their forearm.
Practitioner resists active forearm supination and flexion.
Pain localised to bicipital groove area is a positive test
Speed’s test
Tests for sub-acromial bursitis (2)
Painful arc test
Neers test
Which are the rotator cuff muscles?
Supraspinatus,
Infraspinatus,
Subscapularis,
Teres minor
What are the types of rotator cuff injury? (3)
Rotator cuff tendonitis
Rotator cuff impingement syndrom (ext. and int.)
Rotator cuff tear
What is external Impingment (also known as Subacromial Impingement)?
Where the rotator cuff is impinged in the sub-acromial space.
What is Internal impingement?
Pinching of the inferior surface of the rotator cuff tendons and the glenoid labrum between the head of the humerus (commonly the greater tuberosity) and the posterior-superior aspect of the glenoid.
diagram showing subscapularis trauma (complete tear of subscapularis tendon)
Diagram showing the long head of the biceps tendon
What is peritendinitis?
inflammation of the tendon sheath, also described as tenosynovitis.
Often caused by impingement of the tendon against a bony surface.
What type of labral tears are there in the shoulder joint? (3)
SLAP Tears – top shoulder where biceps attaches usually seen in overhead throwing athletes.
Bankart Lesion – occurs when shoulder dislocates
Posterior Labral Tears – less common but can cause ‘internal impingement’ where the rotator cuff and labrum are pinched together at back of shoulder .
infraspinatus
insertion - greater tubercle of humerus
innervated by suprascapular nerve (C5,6)
External rotator
teres minor
inserts into greater tubercle of the humerus
innervated by the axillary nerve (C5, 6)
external rotator
Pectoralis minor
inserts into coracoid process of scapula, origin 3-5 ribs
innervated by medial pectoral nerve (C8-T1)
action; elevates the ribs, draws scapula downwards and medially.
teres major
originates from the inferior angle of the scapula and inserts into the intertubercular groove of the humerus.
innervation is lower subscapular nerve (C5,6)
extends, adducts, and is a medial rotator of the humerus
Name some special tests for GHJ (15)
Apley’s scratch
Yeargason’s (for long head of biceps in bicipital groove)
Speed’s test, Drop arm
Empty Can, Belly press and lift off sign
External rotation
Serratus anterior/ long thoracic nerve tests (1 + 2)
Test for GH ant and post instability
Clunk test, Slap lesions, Bankart’s lesion
Painful arc, Neers, Hawkin’s Kennedy test
What does the suprascapular nerve innervate?
Supraspinatus and infraspinatus muscles
Speed’s test
- tendinopathy of the biceps
palpate tendon in bicipital groove. Px flexes arm from extended position against resistance.
May also be performed from 90 degree angle
where does the long head of the biceps tendon insert, and what is the origin?
Inn. and level?
insertion point : supraglenoid tubercle of the scapula
origin point : radial tuberosity and bicipital aponeurosis
inn. musculocutaneous nerve (C05, C06)
What does resisted external rotation test for?
infraspinatus or teres minor tears
tendonitis
Serratus Anterior/ Long thoracic nerve tests (1 + 2)
N.B. rhomboids oppose the serratus and can become shortened in some cases of serratus anterior weakness.
tests the ability of the serratus anterior to stabilise the scapula in a position of abduction and lateral rotationm, with the arm in approx 130 degree flexion. Operator presses caudally, and the other hand tracks movement of the scapula.
Test for GH anterior and posterior instability
stabilise the scapula and clavicle and move humerus in A/P direction
Clunk test
- for glenoid labrum tears
get image for this
arm is abducted above head, operator hand; one under the GHJ, and other pushs posteriorly. Px is supine.
What are SLAP tears
Superior Labrum tears, from Anterior to Posterior
NB long head of biceps tendon becomes fibro-cartilagenous as it attaches in the superior portion of the labrum. It can also be damaged.
What is Bankart’s lesion?
Tear in the antero-inferior portion of the glenoid labrum. Common with recurrent dislocations.
May affect the long head of the triceps
Serratus Anterior muscle
O: upper 8-9 ribs
I: medial border of the scapula
Inn. Long thoracic nerve (C05-07)
Action: protracts scapula, upward rotation of the scapula, holds scapula close to thoracic wall, elevates ribs when scapula is fixed
Latissimus dorsi
NB insertion point is close to teres major
O: Spinous processes of T07-T12 L01-L05 and sacrum, thoracolumbar fascia, third of iliac crest
I: greater tubercle of humerus
Action: adducts and flexes the arm and rotates it medially
What are the actions of teres major?
O: inf. angle of scap.
I: intertubercular groove of humerus
inn. lower subscapular nerve (C05, C06)
Extension
Adduction
Medial rotation of the humerus
What are the medial rotator muscles of the GMJ?
(4)
latissimissi dorsi,
teres major
deltoid,
pectoralis major
