W3 physical exam of shoulder Flashcards
• Shoulder pain key points
o Common complaint – second to knee pain
o Most commonly due to subacromial impingement syndrome and rotator cuff problems
o 8-13% of athletic injuries
o History and exam are keys to diagnosis
• Physical exam steps
o Inspection o Palpation o ROM o Strength testing o Special tests
• Inspection
o Swelling, asymmetry, scars, ecchymosis/bruising o Posture o Deformities (atrophy, scapular winging)
o Acromioclavicular joint palpation
Patient’s arm at side
Note swelling, pain, gapping
Indicates joint separation or pathology
o Bicipital groove palpation
Patient sitting with arm straight
Patient flexes biceps muscle while examiner provides supination and external rotation
Examiner palpates bicipital groove for pain
Indicates pathology associated with long head of biceps tendon
• Range of motion
o Evaluate active ROM
o If movement is limited by pain, weakness, or tightness, assist passively
o Lack of full ROM with active and passive exam is common with shoulder pathology
o Evaluate bilaterally
• ROM normal ranges
o Forward flexion – 160-180 degrees
o Extension – 40 degrees
o Abduction – 170-180 degrees (palms up)
o Adduction – 0 degrees
o External rotation – 45 degrees (arms at side, elbow flexed)
o Internal rotation – 55 degrees (arm at side, elbow flexed)
• Forward flexion evaluation
o Arm straight and brought upward through frontal plane
o Move as far as patient can go above head
o 0 degrees is defined as straight down at patient’s side, 180 degrees is straight up
• Abduction evaluation
o Arm straight
o Palm up, arm supinated
o ROM measure in degrees as for forward flexion
o Normal is 180
• External and internal rotation evaluation
o Arm at side, elbow flexed at 90 and held at waist
o Examiner internally and externally rotates arm
o Normal ER is 45
o Normal IR is 55
• Apley scratch test for ER
o External rotation and abduction
o Reach for upper scapula
o Compare bilaterally and note level of reach
• Apley scratch test for IR
o Internal rotation and adduction
o Reach for lower scapula
o Compare bilaterally and note level of reach
• Strength tests flexion and extension
o Compared bilaterally and graded on a 5 point scale and presence or absence of pain
o 5 ROM against gravity with full resistance of examiner
o 1 is no joint motion
• Strength test for ER and IR
o Sitting, arms at sides with elbows at 90
o Maintain elbow position at sides while external or internal rotations is attempted by patient against resistance
o ER tests infraspinatus and teres minor
o IR tests subscapularis
• Empty can test
o Supraspinatus
o Patient sitting with arms out straight, elbows locked, thumbs down and arm at 30 degrees in scapular plane
o Patient should attempt to abduct arms against examiner’s resistance
• Lift off test
o Subscapularis
o Patient rests dorsum of hand on back in lumbar area
o Patient attempts to push examiner’s hand of their hand
o Note weakness or pain
o Modify by putting hand on abdomen and resisting ER by examiner
• Drop arm test
o Rotator cuff
o Primarily supraspinatus
o Patient abducts arm and slowly lowers it, arm will drop if cuff is injured
o Positive test: patient unable to lower arm further without control
o Can compensate to 90 degrees with deltoid
o Can hold at 90 with wrist but then will drop
• Neer’s sign
o Impingement
o Rotator cuff
o Patient seated with arm at side, palm down
o Examiner stabilizes scapular and raises arm (between flexion and abduction)
o Positive test: pain
o Occurs when rotator cuff tendons are pinched under coracoacromial arch
• Hawkin’s test
o Impingement
o Rotator cuff
o Patient is standing
o Examiner flexes shoulder to 90 and then forcibly IRs
o Positive test: pain in area of superior glenohumeral or AC joint
o Pain with this suggests subacromial impingement or rotator cuff tendonitis
o May be more sensitive than Neer’s test
• Speed’s test
o Biceps tendon
o Forward flex shoulder against resistance while maintaining elbow in extension and forearm in supination
o Positive test: tender in bicipital groove (bicipital tendonitis)
• O’Brien’s active compression test
o Labral tear (SLAP lesion)
o Patient standing
o Arm forward flexed 90 degrees, adducted to 15 or 20 with elbow straight
o Full IR so thumb is down
o Examiner applies downward force on arm and patient resists
o Patient ER are so thumb is up
o Examiner applies downward force
o Positive: pain or painful clicking elicited with thumb down and decreased with thumb up
• Crank test
o Labral tear (SLAP lesion)
o Shoulder elevated to 160 in scapular plane
o Gentle axial load is applied through glenohumeral joint with one hand will other does IR and ER
o Positive: pain, catching, or clicking in shoulder
• Apprehension test – sitting
o Glenohumeral joint stability
o 90 degrees of abduction
o Examiner applies slight anterior pressure to humerus and ERs
o Positive: patient expresses apprehension (concern that it will dislocated)
o May indicate a loose capsule and or ligaments
• Apprehension test – supine
o Glenohumeral joint stability
o Patient in supine with affected shoulder at edge of table, arm abducted 90 degrees
o Examiner ERs by pushing forearm posteriorly
o Positive: patient expression apprehension
