TOS + Shoulder Flashcards
TOS is the complex of signs and symptoms that result from the compression of the _______
Neurovascular Bundle
What structures is the neurovascular bundle made of?
- brachial plexus
- subclavian vein
- subclavian artery
The brachial plexus originates at ___ to ___, enters between _____ & _____, under the ____, over the ____, under the _____ posterior to ______
- C5 - T1
- Anterior and middle scalenes
- clavicle
- 1st rib
Coracoid process - pectoralis minor
What are possible causes of TOS
- cervical rib
- reduced inter scalene triangle
- decreased costoclavicular space
- decreased costocoracoid space
- decreased space caused by shoulder droop
- callus formation resulting from a clavicular fracture
What are the rule outs for TOS?
- cervical spine
- shoulder
- thoracic spine (verbalize)
- elbow
There are no specific functional tests for TOS use cervical or shoulder ROM depending on what is their primary concern
How do you perform Adson’s maneuver? What does it test for? What are the positives?
- palpate the radial pulse on the side being tested
- slightly extend the shoulder and apply a downward traction
- ask px to take a deep breath and hold for 1 min while extending and ipsilaterally rotating the neck
This test for scalene compression causing TOS
Positive: a diminished pulse and reproduction of signs & symptoms
How do you perform Travell’s variation/Halstead Maneuver? What does it test for? What are the positives?
- palpate the radial pulse on the side being tested
- slightly extend the shoulder and apply a downward traction
- ask px to take a deep breath and hold for 1 min while extending and contralaterally rotating neck
Scalenes and pec minor compression causing TOS symptoms
Positive: diminished pulse and reproduction of signs and symptoms
How do you perform the costoclavicular syndrome test/Military stance?
- palpate the radial pulse on the side being tested
- ask your px to stand w/ the shoulders down and back in exaggerated military stance
- get px to take a deep breath and hold 1 min
Test for pec major and minor compression causing TOS symptoms
Positive: diminished pulse & reproduction of signs and symptoms
How to perform wright’s hyperabduction Test? What is it testing for? What are the positives?
- palpate the radial pulse on the side being tested
- ask px to take a deep breath and hold it for 1 min
- passively fully abduct px arm w/o elevation
This test for shoulder triangle compression (scalenes, upper traps, pec minor) causing TOS symptoms
Positive: diminished pulse and reproduction of signs and symptoms
How do you perform Roos test/Elevated Arm Stress Test? What are the positives?
- px is seated or standing
- both arms are at 90 degrees of shoulder abduction and ext rot
- px actively brings both elbows to 90 degrees of flexion
- Px slowly opens and closes the hand for 3 mins
Testing to see if the vasculature is being impacted
Positive sign: the inability to maintain the upper limb position, ishchemic pain, numbness or paresthesia of the limb, or heaviness of the arm
How do you perform allen’s test for the shoulder? What are the positives?
- px shoulder is abducted 90 degrees w/ elbow flexed 90 degrees
- therapist palpates the radial pulse as px contralaterally rotates their head
Shoulder triangle (scalene, upper trap, pec minor) stretch to see if this is the source of the TOS symptoms
Positive: radial pulse weakens or disappears
How do you perform the nerve tension maneuver for median nerve/ULNT1?
- patient is supine, apply shoulder depression & slight abduction of the shoulder
- apply elbow ext, slight ext rot of shoulder
- apply supination of the forearm
- apply wrist, finger & thumb ext
- apply greater abduction
How do you perform nerve tension maneuvers for the median nerve, musculocutaneous nerve, axillary nerve/ULNT2?
- patient is supine
- apply shoulder depression & slight abduction
- apply elbow extension with full ext rotation of shoulder
- apply supination of forearm
- apply wrist, finger and thumb ext
- apply greater abduction
How do you perform the nerve tension maneuver for the radial nerve/ULNT3?
- patient is supine
- apply shoulder depression & slight abduction of shoulder
- apply elbow ext w/ int rot.
- apply pronation of the forearm
- apply wrist, finger, and thumb flexion alongside wrist ulnar deviation
- get px to contralaterally side flex their cervical spine
How do you perform nerve tension test of Ulnar nerve/ULNT4?
- patient is supine
- apply wrist ext & forearm supination
- apply elbow flexion
- apply shoulder depression
- maintain these positions and add lateral rotation and abduction
- get px to contralaterally side flex c-spine
What are the rule outs for the shoulder?
- all movements of c-spine w/ overpressure except extension
- t-spine all movements (just verbalize for now)
- elbow all movement w/ overpressure
- TOS (adson’s, costoclavicar, wright’s)
- TMJ (3 knuckle test)
Make sure to add shoulder complex movements to AF testing of shoulder. These are done BL…
- elevation
- depression
- protraction
- retraction
What other movements should also be tested with AR testing of the shoulder?
- Elbow: flexion, ext
- Shoulder complex: elevation
What are the tests for anterior instability?
Apprehension Test, Anterior drawer test of the shoulder
What are the tests for inferior instability?
Sulcus sign
What are the tests for posterior instability?
Jerk test
What are the tests for anterior impingement?
- Hawkins-Kennedy impingement test
- Neer impingement test
What are the tests for labral tear?
Clunk test
What are the tests for AC pathology?
- Horizontal Adduction
- Acromioclavicular shear Test
- Ellman’s compression Rotation test
What are the Muscle pathology tests for the shoulder?
- Biceps Brachii (yergason’s, speed’s)
- supraspinatus (drop arm test, empty can test)
How do you perform the Apprehension test for the shoulder. What is this testing for? What are the positives?
- px supine
- abduct px arm to 90 degrees, laterally rotate the shoulder
Positive: px is apprehensive and resists further motion
This test is for anterior instability
Px could also feel pain or pinching in post shoulder. This can be a positive for a posterior impingement.
How do you perform the Anterior drawer test of the shoulder? What are the positives?
- px is supine, therapist places hand under axilla, other hand stabilizes
- distract and move humeral head anteriorly
Positive: click and or apprehension, excessive movement
How do you perform the inferior instability test of the shoulder? What are the positives?
- px stands w/ arm at their side (in neutral)
- therapist grasps the px’s forearm and pulls distally
- repeat test at 20 degrees - 50 degrees of abduction
Positive: presence of a sulcus sign
How do you perform the Posterior instability test of the shoulder (Jerk test) ? What are the positives?
- px is high seated, with arm medially rotated & flexed to 90 degrees
- therapist grasps px’s elbow & applies axial load
- while maintaining axial load px horizontally adducts the arm
- return arm to starting position
Positive: sudden clunk/jerk of the arm as it subluxes. There may be a second clunk when the arm is returned to starting position.
How do you perform the Hawkins-kennedy impingement test? What is it test for? What are the positives?
- therapist flexes px’s arm to 90 degrees then forcibly internally rotates the shoulder while horizontally adducting
This tests for anterior impingement
Positive: local pain which indicates a supraspinatus tendinosis or impingement
How do you perform the Neer impingement test? What is the test for? What are the positives?
- therapist medially rotates the px’s arm then fully elevates the arm in scaption
This is to test for anterior impingement
Positive: local pain (which indicates a supraspinatus overuse injury) [or sometimes biceps]
How do you perform the Clunk test for the shoulder? What is it testing for? What are the positives?
- therapist places fist under px’s humeral head
- therapist’s other hand holds the humerus above the elbow, fully abducts then push anteriorly on the humeral head while extending rot the arm
This test is for Labral Tear/SLAP lesion
Positive: a clunk or grinding sound (indicates a torn labrum)
How do you perform the Horizontal adduction test for the shoulder ? What is this testing for? What are the positives?
- using the affected arm, the px reaches across their body to the opposite shoulder
- passively, the therapist can flex the shoulder and then horizontally adduct the arm
This is to test for Acromioclavicular jt pathology
Positive: pain localized to the AC jt
(Sc jt pain is also possible)
How do you perform the Acromioclavicular Shear test? What is this testing for? What are the positives?
- px is high seated, therapist cups hand over the anterior deltoid with the heel of the hand on the clavicle
- therapist’s other hand cups of the scapula with heel of the hand on the scapular spine
- therapist squeezes the heels of their hand together
This test is for Acromioclavicular jt pathology
Positive: excessive movement at the AC jt (pain localized to the AC jt is also possible)
How do you perform ellman’s compression rotation test? What is this test for? What are the positives?
- px is sidelying, affected side up
- therapist compresses the humeral head into the glenoid fossa while the px internally & externally rotates the shoulder
This tests for arthritic changes/problems in the GH jt
Positive: reproduction of symptoms
How do you perform yergason’s test? What is this test for? What are the positives?
- px’s elbow is flexed to 90 degrees, arm stabilized against the body, forearm pronated
- therapist palpates the bicipital groove
- therapist resists supination while px laterally rotates against resistance (like brandishing a sword)
This is a muscle pathology test for Biceps Brachii
Positive: the biceps tendon pops out during resisted motions
( this indicates a torn transverse humeral ligament)
(Localized pain w/o tendon popping out suggests biceps tenosynovitis)
How do you perform Speed’s test? What is this test for? What are the positives?
- px actively flexes shoulder w/ forearm supinated to 90 degrees, ask if theres pain
- therapist resists shoulder flexion at 90 degrees, ask if there’s pain
- therapist resists eccentric contraction from 90 degrees back to neutral, ask if there’s pain
This is a muscle pathology test for Biceps brachii
Positive: pain localized to the bicipital groove (esp when forearm is supinated). This indicates bicipital tenosynovitis
This test can also be positive w/ a labral tear - pain would be more localized to prox att of the long head of BB
How do you perform the drop arm test? What is this test for? What are the positives?
- therapist abducts px’s arm to 90 degrees, then asks px to slowly lower the arm to their side
OR
Therapist taps the abducted arm to see if px can control vs surprise resistance
This tests is for muscle pathology of the supraspinatus mm
Positive: px is unable to return the arm to their side slowly or has pain when doing so
How do you perform the empty can test? What is this test for? What are the positives?
- therapist abducts px arm to 90 degrees then applies resistance to abduction
- the shoulder is then medially rotated and moved into scaption, therapist then applies resistance to abduction
This tests for supraspinatus muscle pathology
Positive: weakness w/ pain indicates a supraspinatus tear, weakness w/o pain indicates nerve damage
How do you perform the scapulohumeral rhythm test? What are the positives?
- during slow AF abduction, therapist observes the movement of the scapula
- Normal:
- no/very litttle mvmt of scap during 1st 30 degrees of abduction
- 2:1 mvmt ratio (humerus:scap) during next 60 degrees of abduction
- clavicle elevates and starts to posteriorly rotate
- 2:1 mvmt ratio during last 90 degrees of abduction, scap elevates & clavicle elevates and post rots
Positive:
- early movement of the scapula/greater upward rotation, often seen with capsular tightness
- upward rotation, often seen with impingement rotator cuff problems. GH instability (especially SA)
- Winging often scene with weak SA, Rhomb
- Tipping often seen with short pec minor
- greater clavicular elevation, often scene with excessive UFT activation
How do you perform a muscle length test for pec major clavicular head?
- Patient’s back is flat on the table
- Patients arm is abducted to 90° and laterally rotated
Positive: humourous does not reach the surface/plain of the table
How do you perform a muscle length test for pec major sternal coastal head?
- Patient’s back is flat on the table
- patients arm is abducted to 120° and laterally rotated
Positive: humourous does not reach the surface/plane of the table
How do you perform a muscle length test for pec minor?
- Patient’s back is flat on table
- Therapist observes the patient from the head of the table, comparing the position of the scapula and shoulder
Positive: posterior shoulder is flat on the table (Scapular tipping is observed)
What is the muscle length test for pec minor & lats?
- Patient’s back is flat on the table
- Patient fully flexes the shoulder
Positive: humourous does not reach the plane of the table
(Location of stretch can indicate which muscle is short)
Weakness without pain, suggest a…
Neurological problem
Pain without weakness, suggest a…
Mild muscle strain
Weakness with pain, suggest a…
Moderate to severe muscle strain
How do you perform a muscle strength test for the rhomboids?
- patient is prone abduct the arm to 90° and internally rotate *thumbs down, booo rhomboids (watch for compensatory pronation)
- Therapist applies resistance to push the arm down to the floor
Positive: pain and or weakness
How do you perform the muscle strength test for middle trapezius?
- patient is prone abduct arm to 90° and externally rotate *thumbs up like yaaay traps (watch for compensatory supination)
- Therapist applies resistance to push the arm down to the floor
Positive: Pain & or weakness
What is the muscle strength test for lower trapezius?
- Patient is prone abduct the arm to 130°
- Therapist applies resistance to push arm down towards the floor and out
Positive: pain and or weakness
How do you perform the muscle strength test for serratus anterior
- patient is standing with arms flexed to 90° slightly internally rotate and palms against a wall
- patient pushes against the wall. Therapist observes the scapula for winging.
- Alternatively, the patient arm is flexed to 120°, and the therapist applies a downward forced on the arm, while trying to push the lateral border of the scapula into downward rotation/retraction (observe for winging)
Positive: pain, weakness, winging of scap
How do you perform a muscle strength test for subscapularis?
- Patient prone with shoulder, abducted, and elbow flexed
- Position the arm in about 60° of medium rotation
- Stabilize the humerus, therapist applies resistance into external rotation
Positive: pain and/or weakness
