What - Shoulder Flashcards
Look at the overall appearance of the shoulders with the patient standing (with adequate exposure)
1. What are four things that you look for?
Look for any signs of asymmetry:
a. Contours of the shoulder joint I ACJ, clavicle, deltoid mm position of scapula
b. Swelling over joints and muscles that make up shoulder joint and soft tissue eg bruising/local
infection
c. Muscle wasting (infraspinatus, deltoid and trapezius will be the most obvious ones)
d. Scars from previous shoulder operations or trauma, and skin changes from malignant
lesions/infection
Feel the glenohumeral, acromioclavicular & sternoclavicular joints (at least two)
2. What are four things that you feel for in general?
Feel for:
a. Tenderness
b. Swelling/effusion
c. Bony landmarks
d. Joint spaces
Feel the greater tuberosity (insertion of supraspinatus) & long head of biceps tendon
3. What is the origin and insertion of the long head of biceps? Short head?
The long head of biceps origin is the supraglenoid tubercle and the insertion is the radial tuberosity
The short head of biceps origin is the coracoid process of the scapula and the insertion is the bicipital
aponeurosis to the fascia of the medial side of the arm
Assess range of motion in the shoulders (abduction, internal & external rotation) & scapulo-humeral rhythm
4. What nerve roots innervate the muscles for abduction, internal rotation and external rotation?
Abduction C5/6 – Internal rotation C5-7 – External rotation C5-6
Assess deltoid strength (abduction at 90 degrees)
5. What is the name of the nerve (and its nerve root) that innervates the deltoid muscle?
Deltoid muscle is innervated by the axillary nerve (C5-6)
Assess supraspinatus strength (abduction in scapular plane, thumb down)
6. What does ‘in the scapular plane’ mean?
‘In the scapular plane’ means in the line of 20-30 degrees forward of the coronal plane
Assess infraspinatus & teres minor strength (external rotation) & subscapularis (IR) strength
7. What are the names of the nerves that innervate each of these muscles?
Infraspinatus (ER) is innervated by the suprascapular nerve (C-6)
Teres minor (ER) is innervated by the axillary nerve (C5-6)
Subscapularis (IR) is innervated by the upper and lower scapular nerves (C5-6)
Assess biceps strength and performs tests for pain at the bicipital groove (Speed, Upper Cut)
8. What is the sensitivity and specificity of Speed’s test and Upper cut test
9. What does it mean if the patient says the pain is reproduced with both tests?
Speed’s test sensitivity 90% specificity 14%
Upper cut test sensitivity 77% and specificity 80% (LR+ 3.38)
answer to question 9: The patient may have a biceps tendinopathy
Perform tests for impingement in the subacromial space (Hawkins, painful arc)
10. What are these tests designed to do?
mpingement testing is performed to cause pain to the patient by compressing the contents of the
subacromial space - remember it is to try and reproduce the pain/symptoms that the patient is
experiencing – always ask ‘Is this the pain that is worrying you?’ Eg. subsacromial bursitis.
Perform tests for rotator cuff tear (‘drop arm’, external rotation lag sign and internal rotation lag sign)
11. What is the purpose of the rotator cuff?
The rotator cuff provides much of the stability of the shoulder joint (along with ligaments in the joint
capsule) because the shoulder is inherently unstable (imagine a soccer ball balancing on a golf tee!)
Test stability of glenohumeral joint (sulcus sign; apprehension +/- relocation tests)
12. What does ‘apprehension’ mean in this situation?
13. If a patient has external rotation weakness, a positive Hawkins Kennedy, and weakness of the
supraspinatus, what pathology does the patient likely have?
- ‘Apprehension’ is the worried and fearful look that a patient has on their face when their shoulder is
first abducted then moved into external rotation and a force applied to the posterior aspect of the
humeral head to try and make it disclocate anteriorly - 98% chance of a rotator cuff tear.
