Conducting the “Nonshoulder” Shoulder Examination

AARON SCIASCIA W. BEN KIBLER, MD

Alterations in the kinetic chain are found in a high percentage of patients Conducting the “nonshoulder” shoulder examination

ABSTRACT: Optimal shoulder function is achieved with the kinetic chain. Alterations in this sequenced activation of body segments often are associated with shoulder injury. A screening examination of areas proximal to the shoulder where these alterations often are found can help physicians make the diagnosis. Core stability provides proximal stability for the distal mobility and function of the limbs. Excessive scapular protraction alters the roles of the scapula in shoulder function. Glenohumeral internal rotation deficit creates abnormal scapular kinematics. Many types of tests may be used to estimate or measure core strength. Physical examination of the scapula is designed to establish the presence or absence of scapular dyskinesis. If the examiner detects scapular dyskinesis, corrective maneuvers can be applied. (J Musculoskel Med. 2011;28:58-64)

Persons performing complex ath- lar dyskinesis is found in a par- BIOMECHANICAL BASIS letic and work tasks achieve opti- ticularly high percentage of pa- The shoulder and core stability mal shoulder function because of tients with shoulder injury. The various body segments play the kinetic chain. This coordinated, The “nonshoulder” shoulder ex- specific roles in the kinetic chain sequenced activation of body seg- amination—a screening examina- activation sequence. The muscles ments places the distal segment in tion of areas proximal to the and joints of the hips, pelvis, and the optimal position at the opti- shoulder that often are associated spine (known collectively as the mal velocity with the optimal tim- with shoulder injury—helps phy- core) are centrally located and can ing to produce the desired task.1 sicians understand the entire perform many of the stabilizing Alterations in the kinetic spectrum of alterations in the ki- functions that the body requires chain—including core instability, netic chain that contribute to the for the distal segments (eg, the scapular dyskinesis (alteration of diagnosis of shoulder injury in limbs) to perform their specific scapular motion), and glenohu- patients who present with chron- functions. Thus, core stability meral internal rotation deficit ic shoulder pain. If alterations are provides proximal stability for (GIRD)—have been associated found, more specific and detailed the distal mobility and function with shoulder injury in 50% to orthopedic examination can pro- of the limbs.6 100% of reported cases.2-5 Scapu- ceed. In addition, the alterations The shoulder acts as a funnel, that are identified can be man- regulating and transferring forces aged as part of treatment of pa- generated from the core struc- Mr Sciascia is program coordinator and tients with shoulder injury. tures to the hand. The scapula Dr Kibler is medical director of the In this article, we describe the (Figure 1) acts as the platform for Shoulder Center of Kentucky in Lexington. biomechanical basis of kinetic the rotator cuff to work from and For this article, the authors have updated chain alterations that are associat- is the stable base of control for their discussion of the “nonshoulder” shoulder examination that first appeared ed with shoulder injury. Then we the arm during activity. in 2006 in The Journal of Musculoskeletal outline the key aspects of the non- Scapular motion has been ex- Medicine. shoulder physical examination. amined in a 3-dimensional con-

58 THE JOURNAL OF MUSCULOSKELETAL MEDICINE | FEBRUARY 2011 www.musculoskeletalnetwork.com text. Studies have shown that it is ward/downward translation on and it must internally/externally a composite of 3 motions: up- the thoracic wall and retraction/ rotate and posteriorly tilt to main- ward/downward rotation around protraction around the ellipsoid tain the glenoid as a congruent a horizontal axis perpendicular to curve of the rib cage. socket for the moving arm and to the scapular plane, internal/ex- In this more complex framework, maximize concavity/compression ternal rotation around a vertical the scapula is shown to have sev- as well as ball-and-socket kine- axis through the plane, and ante- eral additional roles in shoulder matics.8 In addition, it must be sta- rior/posterior tilt around a hori- function: it must posteriorly tilt bilized dynamically in a position zontal axis in the plane.2,7 With an and externally rotate to clear the of relative retraction during arm intact acromioclavicular (AC) acromion from the arm moving in use to maximize activation of all joint, there are 2 translations: up- forward elevation or abduction,3,7 the muscles that originate on it.9

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Scapular dyskinesis trol of the translation of scapular and nerve injury—and usually are This kinetic chain alteration is a retraction—regarded as a key ele- managed with rehabilitation. combination of decreased poste- ment in closed-chain coupled Muscle weakness has been dem- rior tilt and decreased external scapulohumeral rhythm2,7,10—and onstrated in the serratus anterior rotation as well as decreased up- of the motion of external rotation. and lower trapezius muscles in ward rotation.2,3 The predominant If control is lost, gravity, forward patients with impingement.3,13 In- finding on clinical examination is arm motion, and muscle activa- flexibility in the pectoralis minor prominence of the medial border tions take the arm and shoulder muscle—an absolute decrease in of the scapula on observation at girdle forward. The biomechani- muscle length and increased mus- rest or on motion of the arm in el- cal result is a tendency toward cle activation in response to ten- evation (Figure 2). The prominence scapular internal rotation and sile loads—is a common finding represents loss of dynamic con- protraction around the rib cage. in these patients.14 A somewhat Excessive scapular protraction rare proximal cause is true nerve alters the roles of the scapula in injury to the long thoracic or shoulder function.11 The normal accessory nerve. Bony proximal timing and magnitude of acromial causes include thoracic kyphosis motion are changed; the subacro- and scoliosis with resultant al- mial space distance is altered; teration in scapular position. the glenohumeral (GH) arm angle Distal causative factors most may be increased, resulting in the often are associated with anatom- “hyperangulated” joint; and max- ical injuries in the AC or GH joints. imal muscle activation may be They also alter muscle activation decreased. patterns or activations by causing There are 2 categories of causes instability of the bones or through Figure 2 – Medial border prominence of scapular dyskinesis: those pain-based inhibition; they often of the scapula is seen in this patient. proximal and those distal to the require surgery to eliminate their This is the predominant finding on scapula.12 Proximal causative fac- effects and provide the basis for clinical examination in patients with scapular dyskinesis, a kinetic chain tors most often include direct al- effective rehabilitation. GH insta- alteration that is common in shoul- teration of muscle properties— bility is associated with altered der injury. inflexibility, weakness, fatigue, serratus anterior activation.15 (continued on page 61)

Figure 3 – This patient presented with glenohumeral internal rotation deficit (GIRD) (A), another common kinetic chain alteration. Side-to-side A comparison (B) is used to demonstrate the asymmetry that is character- istic of GIRD.

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(continued from page 60) GIRD This common distal causative factor—defined as side-to-side asymmetry of greater than 25° or an absolute value of less than 25° (Figure 3)—is thought to be pro- duced by acquired posterior cap- sular contracture and posterior muscle stiffness; it is seen fre- quently in all types of shoulder injuries.16,17 GIRD creates abnormal scapular kinematics as a result of the “windup” effect of the arm on the scapula. As the arm is forward flexed, horizontally ad- ducted, and internally rotated during a throwing or working activity, the tight capsule and mus- B cles pull the scapula into a protracted, internally rotated, and anteriorly tilted position; this Figure 4 – The 1-leg standing balance causes downward rotation of the test (A) is used to assess a patient’s core strength and stability. A positive acromion, thus creating unde- Trendelenburg test result (B) indicates sired scapular positioning. A inability to control the posture and suggests proximal core weakness. THE PHYSICAL EXAMINATION sulting motions in the 3 planes posture and suggests proximal Assessing quality of movement of trunk motion. This method of core weakness. Many types of tests have been de- analysis is difficult to quantify, The 1-leg squat increases load scribed to estimate or measure but it is similar to actual 3-planar and may show deficits that are core strength. Because core core function testing. not seen in stance. The patient as- strength and core stability are One assessment method that sumes the same starting point as composite actions that involve incorporates many of these vari- in the standing balance test; he or many segments, tests of individu- ables is a 3-part protocol: a 1-leg she is asked to perform repetitive al joints and muscles usually are standing balance ability test; a partial (quarter to half) squats not satisfactory. Evaluation of 1-leg squat test; and a standing, and is given no other verbal cues. specific patterns of motion and 3-plane core strength test.6 The Deviations in the quality of the sequences of muscle activation screening part of the evaluation movement similar to those in the and assessment of the result—the includes the 1-leg standing and standing balance test are as- quality of the movement—is most 1-leg squat tests. sessed. A Trendelenburg sign may beneficial for determining how to In the standing balance test, not be noted on standing balance institute rehabilitation.18 the patient is asked to stand on 1 but may be elicited with a 1-leg In assessment of core stability leg and is given no other verbal squat. The patient may use his and strength, it is important cue (Figure 4). A positive test re- arms for balance or may go into to evaluate the muscles working sult, known as the Trendelenburg an exaggerated flexed or rotated in an eccentric, load-absorbing sign, is seen when the hip drops posture known as “corkscrewing” func tion; the body segments in a on the unsupported side. This in- to provide the gluteal or short ro- closed-chain manner; and the re- dicates inability to control the tator muscles with greater ten- www.musculoskeletalnetwork.com FEBRUARY 2011 | THE JOURNAL OF MUSCULOSKELETAL MEDICINE 61 Conducting the “nonshoulder” shoulder examination

sion to compensate for other mus- slowly, keeping his feet flat on the strength of the quadratus lumbo- cular weakness (Figure 5). floor, to just barely touch his head rum, hip abductors, and some against the wall. This can be done long spinal muscles that are 3-Plane core testing with both legs on the ground ini- working in a frontal plane. This is a more in-depth evaluation tially and progress to partial As in the sagittal plane test, used to quantify core control in the weight bearing on each side and, transverse plane motion is evalu- various planes of spine and core ultimately, to single-leg standing. ated by asking the patient to stand motion. Reliability and validity Sagittal plane core strength test- 3 inches away from the wall and studies of specific tests have not ing creates eccentric activation in progress from bilateral weight been done, but clinical experience the abdominal, quadriceps, and bearing to a single-leg stance and has demonstrated that this bat- hip flexor muscles and concentric touch one shoulder and then the tery of tests provides useful infor- activation in the hip and spine ex- other just barely against the wall. mation that allows specific reha- tensor muscles. Quality of motion and speed can bilitation protocols to be institut- Frontal plane testing (Figure 7) be assessed. With lesser degrees ed for increased core function.6 is done by asking the patient to of core strength, there is a greater Testing is done with the patient stand with one side and then the breakdown in the patient’s ability standing a given distance (usually other 3 inches away from the wall. to maintain a single-leg stance 3 inches) away from a wall (Figure While he is standing on the out- and to just barely touch the wall. 6). In sagittal plane testing, he side leg, he is asked to barely Transverse plane motions as- faces away from the wall. He is touch his inside shoulder to the sessed with this test incorporate asked to move his body backward wall. This test evaluates eccentric abdominal, hip rotator, and spine extensor muscles. If muscles and planes of motion are found to be deficient, appropriate therapy may be instituted.

Examining the scapula Physical examination of the scapula is designed to establish the presence or absence of scapular dyskinesis and evaluate proximal and distal causative factors. Dy- namic maneuvers may be used to assess the effect of correction of dyskinesis on impingement symptoms. The examination results help establish the complete diag- Figure 6 – Three-plane core testing is nosis of all the elements of the an in-depth evaluation used to quan- dysfunction and guide treatment tify core control in the various planes and rehabilitation. of spine and core motion. In sagittal plane testing, the patient is asked The scapular examination Figure 5 – The 1-leg squat test may to move his or her body backward should be conducted mostly from show deficits that are not seen in slowly to just barely touch his head the posterior aspect.8 The scapula standing tests. To compensate for against the wall. Sagittal plane core should be exposed for complete other muscular weakness, the patient strength testing creates eccentric ac- visualization by having the pa- may go into “corkscrewing,” an exag- tivation in the abdominal, quadri- gerated flexed or rotated posture, to ceps, and hip flexor muscles and con- tient wear gowning or a tank top provide the gluteal or short rotator centric activation in the hip and or remove his shirt. The patient muscles with greater tension. spine extensor muscles. should be checked in the resting

62 THE JOURNAL OF MUSCULOSKELETAL MEDICINE | FEBRUARY 2011 www.musculoskeletalnetwork.com posture for side-to-side asymme- vers can be applied. Maneuvers try and, especially, for evidence of that alter the injury symptoms inferior medial or medial border provide the examiner and the pa- prominence. If determining the tient with information about the positions is difficult, marking the role of scapular dyskinesis in the superior and inferior medial bor- total picture of dysfunction that ders may help. accompanies shoulder injury and needs to be corrected. Screening for dyskinesis The scapular assistance test Such screening may be done by (SAT) and the scapular retraction asking the patient to move his test (SRT) are useful corrective ma- arms in ascent and descent 3 to 5 neuvers. In the SAT (Figure 8), the times. Usually, this movement examiner applies gentle pressure demonstrates muscle weakness to assist scapular upward rotation and medial border prominence, and posterior tilt as the patient which indicates dyskinesis. If elevates the arm. The result is necessary, performance of up to Figure 7 – Frontal plane core stability positive when the painful arc im- testing evaluates eccentric strength of 10 more repetitions or addition the quadratus lumborum, hip abduc- pingement symptoms are relieved of 3- to 5-lb weights will further tors, and some long spinal muscles and the arc of motion is increased. highlight the weakness.19 Alter- that are working in a frontal plane. This finding helps the clinician ation in medial scapular border identify weakness or inhibition of motion in any plane, singly or in Corrective maneuvers scapular muscles, especially the combination, is recorded in a If the examiner detects scapular lower trapezius muscle. “yes” (present) or “no” (absent) dyskinesis, then corrective maneu- In the SRT, the examiner places fashion. The clinically observed yes/no evaluation has a correla- tion of 0.84 with biomechanically determined abnormalities in symptomatic patients and has a high predictive value.20,21 Watching scapular position for dyskinesis while the patient per- forms wall push-ups may help assess periscapular muscle strength. Isolated serratus anterior and trapezius muscle testing can be done for nerve-related palsies. Any deficits found dur- A ing the screening examination should be evaluated in more Figure 8 – The scapular assistance test is a useful corrective maneuver depth. Often found is some evi- for identifying weakness or inhibi- dence of proximal muscle weak- tion of scapular muscles. In this test, ness or inflexibility, which af- the examiner applies gentle pressure fects the optimum mechanics of to assist scapular upward rotation scapulohumeral rhythm. It may and posterior tilt (A) as the patient elevates the arm (B). The result is posi- not be the sole factor, but it must tive when the painful arc impinge- be considered in the rehabilita- ment symptoms are relieved and the B tion protocols.22 arc of motion is increased.

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