10/19/2012
PRINCIPLES OF Shoulder Issues EXAMINING THE Second most common musculoskeletal complaint SHOULDER Hmm..What was #1?
Difficult joint to examine
Greg Bennett, PT DSc Why is this? Excel Physical Therapy Multidirectional range of motion- Marymount University UNIQUE! How many “joints”?
Shoulder injury can affect nearly every sport and many daily activities
Objectives EXAMINATION GOALS
Global enough to rule out referred syndromes Review pertinent anatomy and/or associated pathologies. Specific focus on pathologic tissues as the diagnosis becomes clear. Discuss common pathologies Develop a prognosis that is realistic for the diagnosis, i.e. is therapy the appropriate intervention. Discuss historical Establish a treatment program according to the clues to diagnosis diagnostic with continuous modification to meet change. Select cases
Physical exam in small group discussions
Bony Anatomy Anterior Radiographic Anatomy
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Anatomy Anatomy
Glenohumeral joint Glenohumeral joint
• “Ball and socket” vs • Passive stability “Golf ball and tee” Joint conformity • Very mobile Glenoid labrum (50%) • Price: instability Joint capsule
• 45% of all dislocations Ligaments
• Joint stability depends Bony restraints on multiple factors
Anatomy Anatomy Rotator Cuff Muscles Muscles • Deltoid • Trapezius * • Rhomboids * • S – Supraspinatus • Levator scapulae * • I – Infraspinatus • Rotator cuff
• Teres major • T - Teres minor • Biceps • Pectoralis muscles * • S- Supscapularis • Serratus anterior * * Scapular stabilizers
Anatomy Anatomy
Bursae Neurologic
• Subacromial • Nerve roots
(Subdeltoid) • Brachial plexus • Subscapular • Peripheral nerves
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Anatomy “If we agree on everything, one of
Coordinated us is unnecessary” shoulder motion
• Glenohumeral motion
• Acromioclavicular motion
• Sternoclavicular motion
• Scapulothoracic Scapular-humeral rhythm motion
EXAMINATION GOALS CURRENT SYMPTOMS
1.ESTABLISH OR Swelling???
CONFIRM Instability DIAGNOSIS Pain 2.ESTABLISH Dysfunction TREATMENT Function 3.LIMIT PROGRESSION 4.BASELINE PATIENT STATUS
POSSIBILITIES: POSSIBILITIES: Sudden Onset: Trauma Sudden Onset: No Trauma
Labral tear Neoplasm
Capsular/ligament strain or sprain. Sub-clinical injury Overuse “Final Muscle tear Straw” Fracture GH/AC Dislocation
SC Injury
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POSSIBILITIES: POSSIBILITIES: Gradual onset: no trauma Gradual onset: trauma
SLAP-peel back mechanism Grade I or II Sprain/Strain
Subluxation or Subluxation dislocation?? DJD
OA, tendonitis Impingement
Impingement
Mechanism of Injury: CAPSULE INJURIES Associated Mechanics
FOOSH
Hyperextension
Deceleration
OVERUSE Fracture
Tendonitis common Direct blow Are these the same? Impingement FOOSH
The capsule is weak and prone to injury
Labrum together with biceps traction
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Where do things go wrong?? Fractures
Floating Shoulder
Superior Shoulder Suspensory Floating Shoulder Complex (SSSC)
Scapular fracture Bony/soft tissue ring composed of : combined with an upper humerus fracture or a Glenoid*Coracoid *Acromion *Distal clavicle* clavicular injury Connecting Ligaments True floating shoulder does not occur unless, in addition to a clavicular shaft fracture: • scapular spine/acromial fracture • or disruption of the acromioclavicular (AC) & coracoacromial (CC) ligaments
Superior Shoulder Suspensory Superior Shoulder Suspensory Complex (SSSC) Complex (SSSC) Double disruption is failure of the ring in Maintains the stable relationship between the upper extremity & the axial skeleton two or more places & results in delayed healing, ↓ strength, & other long-term problems
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Superior Shoulder Suspensory PAIN-beware of correlations (no Complex (SSSC) absolutes) Single soft tissue disruption + clavicle Sudden: Trauma; major injury fracture or the body/spine of scapula may produce the same result as double Prolonged rest: RTC, OA disruption Prolonged Activity: OA, tendonitis capsular deficiency
Overhead use: instability; subluxation; labral lesions
Evaluating Motion Types of End Feel
Capsular- “stretching leather", gradual increasing Parameters- resistance e.g.- full external shoulder rotation. physiologic, Ligamentous- similar to capsular, but harder accessory, e.g.-terminal knee extension. quantity, quality, Soft Tissue Approximation- painless compression of soft tissue e.g.- terminal elbow flexion. end feel Bone on Bone- hard, sudden stop e.g.- terminal Passive motion elbow extension exceeds active motion
Types of End Feel Pain/Motion Sequence
Spastic- palpable muscular resistance to stretch (splinting) e.g.- straight leg raise with tight Pain followed by hamstrings. resistance- acute Springy - e.g.-loose body blockage as with a tom lesion meniscus Empty- patient stops motion before resistance is Pain with/at felt resistance- subacute lesion
Pain after resistance- chronic lesion
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Cyriax Motion Grading Cyriax Motion Grading
Hypomobile 0 ankylosed Normal (surgery?)
1 moderate 2 slight decrease decrease (therapy- (therapy-motion) motion) 3 normal 2 slight decrease (therapy-motion) 4 slight increase (therapy-exercise)
Shoulder Stability Cyriax Motion Grading "Circle Stability"
Hypermobile 4 slight increase Primary restraint is on the side of (therapy-exercise) translation, secondary restraint 5 moderate comes from the opposite side, increase (therapy) dynamic (muscular) restraint comes 6 complete from both sides. instability (surgery)
Where do things go wrong?? Where do things go wrong?? Dislocations and Separations Dislocations and Separations
Arthritis can happen at these joints, too… Dislocations and separations are protected by both “static” and “dynamic” stabilizers…
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Bony Anatomy Glenohumeral Joint “Static Stabilizers”
Shallow (“golf ball sitting on a tee”) • Inherently unstable (maximizes ROM)
Static stabilizers • glenohumeral ligaments, glenoid labrum and capsule
Dynamic stabilizers • Predominantly rotator cuff muscles • Also scapular stabilizers Trapezius, leavator scapulae, serratus anterior, rhomboids
What goes wrong… Superior Shoulder Suspensory Besides separations and dislocations?? Complex (SSSC) Bony/soft tissue ring composed of : Glenoid*Coracoid *Acromion *Distal clavicle* Connecting Ligaments
Instability !!!
Anterior Stability/Restraints LABRUM Arm Position (Adduction) 0
Tissue Tests:
Superior G-H Drawer/fulcrum ligament Middle G-H Sulcus ligament
Posterior capsule Sulcus
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Anterior Stability/Restraints Anterior Stability/Restraints Arm Position (Adduction) 45 Arm Position (Adduction) 90
Tissue Tests: Tissue Tests:
Middle G-H Drawer/fulcrum Inferior G-H Crank/ ligament ligament apprehension Inferior G-H Posterior capsule Drawer/fulcrum ligament
Posterior capsule Drawer/fulcrum
Classification of Instability The Examination Process Grade I. Humeral head rides up but not over glenoid rim /labrum II. Head rides up and over glenoid rim and reduces spontaneously as stress is removed III. Head rides up and over glenoid rim and remains dislocated
Shoulder Examination Sitting Shoulder Examination Sitting
Resisted Tests Special Tests 1. flexion 1. Yergason Test 2. abduction 2. Adson Test 3. external rotation 3. Impingement Tests Palpation 4. internal rotation Neurological Assessment 5. horizontal abd/add 1. Dermatomes 2. Reflexes
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Examination of Shoulder Sitting Examination from Posterior/Side
PROM C-spine clearance Instability Testing 1. anterior Range of Motion AROM/PROM 2. posterior Labrum Tests Examination of SC and AC joint 1. Clunk Test 2. Grind Test Impingement Tests 3. O'Brien's Scapula Impingement- see impingement outline Arthrokinematics Instability Tests 1. sternoclavicular joint 2. acromioclavicular joint 1. A/P direction 3. glenohumeral joint 2. Inferior direction
Examination of Shoulder Supine Examination of Shoulder Supine
PROM Palpation Instability Testing 1. anterior 1. crepitus 2. posterior Labrum Tests 2. biceps tendon 1. Clunk Test 2. Grind Test 3. supraspinatus Impingement- see impingement outline Resisted Tests Arthrokinematics 1. sternoclavicular joint Flexibility Tests 2. acromioclavicular joint 3. glenohumeral joint
Shoulder Examination Prone INTERPERTATION
Palpation R/O referral 1. posterior capsule Scan spine 2. posterior cuff Analysis Confirmation Resisted Tests Diagnosis • Horizontal Problem list (goals) • ER
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Physical Examination OBSERVATION
Gait/ activities
Posture
Deformity/ alignment
Swelling
Atrophy
Rubor/redness
Stress
PALPATION ACTIVE MOTION
Calor/temperature Deficits
TTP Quality
Swelling Crepitance
Sensation Apprehension
Structure
Pulses
Crepitus
Range of Motion Range of Motion Forward flexion: 160 - 180° AROM
PROM Extension: 40 - 60°
Accessory Motion Abduction: 180◦ Total Motion Concept Adduction: 45 °
Internal rotation: 60 - 90 °
Apley Scratch Test External rotation: 80 - 90 °
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Total Motion Concept Apley Scratch Tests
180 degrees total Apley IR
rotation Apley ER
Increased ER Record Spinal accompanied by Segment decreased IR
Loss of IR leads to substantially increased shoulder pain/dysfunction Wilk et al AJSM 2002
Shoulder Movements Girdle Elevation Movements
Focus on specific bony landmarks • inferior angle • glenoid fossa Adduction Abduction • acromion process
Shoulder girdle movements = scapula movements Depression
Kinematic conventions for local segmental coordinate system on the right scapula International Society of Biomechanics
Anterior tilt is the clockwise rotation about the axis congruent with the
spine of the scapula (Xs), and internal rotation is the clockwise rotation about the pseudo-vertical
axis (Ys) perpendicular to Xs and in the plane of the body of the scapula.
Upward rotation is the clockwise rotation about the posteriorly directed axis perpendicular to the
body of the scapula (Zs) and to the other axes.
Crosbie, J. et al. PHYS THER 2010;90:679-692
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Scapular Mechanics: S.I.C.K. Scapula 6 Motions 3 Planes
Anterior/Posterior Scapular Protracted (Sagittal) malposition Depressed Internal/External Inferior medial- Rotation type 1 scapular (Horiz./Transverse winging
) Coracoid Elevation/Depressi tenderness
on Scapular (Coronal/Frontal) dysKinesis. Burkhart, Morgan, Kibler, Arthroscopy, 2003
Scapula Dyskinesis PASSIVE MOTION
3 types of scapula winging have been Deficits
identified, there may be overlap End feel between the types. Painful arc
Crepitance
Joint play
Flexibility
End Feel!
LIGAMENT/CAPSULE TESTS Sulcus Test
Sulcus “Gold Standard”
Drawer 30˚ Abduction
Load and Shift MDI
Fulcrum
Labral
Axillary Lick Test
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Instability: Sulcus Sign LOAD and SHIFT
Inferior instability START • Seat joint Arm relaxed in neutral position • Anterior glide • Posterior glide Arm pulled downward at wrist Anterior/posterior Positive test is a capsule dependent visible sulcus at infra-acromial area • Compare to contralateral side
Anterior Crank/Drawer Glenoid Labral Tear
Apprehension Tear in glenoid labrum Usually due to instability Cautious application SLAP Tear (Superior Labrum 90˚ ER Anterior to Posterior) – Superior labral tear 90˚ Abduction – Fall on outstretched hand or shoulder Add hand for – Rotator cuff tendonosis or relocation tears
Bankart Lesion – Anterior-inferior labral tear – Anterior shoulder dislocation / subluxation
O’Brien’s Active Compression Test O’Brien’s Active Compression Test
Labral, AC, or biceps pathology For labral Arm flexed to 90° pathology Arm cross-arm adducted 10-15° • Repeat testing Elbow extended with Max pronation • Max supination Resist downward force • Should be pain Positive test if painful free Beware location of pain • AC • Biceps • Internal +/- click
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OBriens Test OBriens Test Acromioclavicular/Labral joint pathology Acromioclavicular/Labral joint pathology
Flex to 90° with the Positive if elbow extended pain/symptoms
Adduct the arm 10- relieved in ER 15°medial to sagittal http://www.youtube.c
maximally internally om/watch?v=0QbNRoz rotated DFwY
Patient resists Sensitivity 100% downward force. Specificity
The procedure is • Labrum 98.5% repeated in supination • AC 96.6%
Am J Sports Med. 1998 Sep-Oct;26(5):610-3.
Labral Tear: Crank Test What goes wrong? Tears and tendonopathies Abduct arm to 90- 120°
Stabilize shoulder
Elbow secured with one hand
Axially load with ER / IR at shoulder
Positive test: audible or painful click / catch / grind
Biceps Load I (90) and Biceps Biceps Load I (90) and Biceps Load II (120) Tests Load II (120) Tests
Shoulder is placed in Deep pain within 90 or 120 degrees of the shoulder during abduction and this contraction is maximally externally indicative of a rotated SLAP lesion Forearm in a I supinated position Sensitivity: 91%, Instruct to perform a Specificity: 97% biceps contraction II against resistance Sensitivity: 90%, Biceps Load II Specificity: 97% Biceps Load II AJSM 1999 May-Jun;27(3):300-3. AJSM 1999 May-Jun;27(3):300-3. Biceps load test Kim SH, Ha KI, Han KY. Biceps load test Kim SH, Ha KI, Han KY.
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Jobe’s Test (Empty Can) Finally…the subacromial space Drop Arm Test
Supraspinatus Specific??
Repeat as “full can” test, both apply
What can go wrong??? Impingement
Impingement!!!!! !!
Impingement Tests Neer Impingement Test
Position the patient sitting. Internally
rotate the arm with Neer’s Test the thumb facing downward, and abduct and forward flex the arm.
If impingement is Hawkin’s Test present, the patient will experience pain as the arm is abducted.
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Hawkin's Test Muscle Testing
Scapula ER Position the patient standing with the shoulder abducted 90 degrees, and internally rotate the forearm. The presence of pain with movement is indicative of possible pathology.
Flexion/Abd. Lift Off
Screening Evaluation: Motor Strength Testing
Internal rotation
Flexion • Tests RTC muscle that Abduction/Scaption IR the shoulder Subscapularis ER-2 positions IR • Arms at the sides • Elbows flexed to 90 Scapular degrees • Internally rotates arms against resistance
• Subscapularis Lift-Off Test
• Other techniques
Scapular Retraction Test Scapular Retraction Test
Scapular retraction Empty-can position position Maximum Empty can resistance against position. the handheld The scapula is dynamometer lightly held in retraction by Weak cuff or forearm pressure scapula? on the medial scapular border Decreased Kibler et al, AJSM, May 2006 weakness indicts scapula Kibler et al, AJSM, May 2006
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Scapular Assistance Test Palpation of Bicipital Groove
Painful arc Position the patient sitting, beginning Examiner assists with the arm lateral rotation straightened. The Pain decreased if patient should then related to serratus flex his arm to anterior/lower trap contract the biceps muscles. The examiner palpates the bicipital groove to attempt to illicit Kibler WB. Am J sports Med 1998;26. pain.
Acromioclavicular (AC) Joint Cross-Arm Horizontal Adduction Testing Test
Palpation of AC The patient places Joint his hand on the opposite shoulder, The patient's arm while the examiner is kept at his side exerts force and the examiner horizontally. palpates the AC Again, the presence joint for of pain indicates discomfort/pain possible pathology. and gapping.
SPECIAL TESTS EXERCISE DYNAMOMETERS
Diagnostic Imaging Comminuted fracture Not diagnostic of the humeral head X-ray Usually not MRI appropriate with CT Scan acute injury
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GENERAL HEALTH GENERAL HEALTH
Hypermobility Allergies
Joint conditions Infections
Neurology Weight
Medications Mental status
Injections/steroids History CA
Outcomes Measures Many Exist e.g. Constant-Murley Shoulder Outcome Score DASH "Disabilities of the Arm, Shoulder and Hand Correlations exist between shoulder outcome scales CONCLUSIONS Existing shoulder scales are not equivalent in their assessments of function Contain redundant information May reflect a patient's age better than shoulder function.
Placzek et al. Shoulder outcome measures: a comparison of 6 functional tests. AJSM. 2004 Jul-Aug;32(5):1270-7
MUSCULOSKELETAL Shoulder Examination Summary EXAMINATION
History Systematic approach Active Movements Organize your evaluation Passive Movements Evaluate slowly and cautiously Resisted Movements Palpation Examine other joints Specific Orthopedic Tests X-Ray Correlation Treatment plan
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Thank You! Case Examples and Questions
The physical exam will be demonstrated Pignon, during lab Haiti
Which rotator cuff muscle(s) are The apex (bottom) of the scapula is responsible for external rotation at what level of the spine?
1. Supraspinatus 1. C7 2. T3 2. Infraspinatus 3. T7
4. T12 3. Subscapularis 5. L4 4. Teres Minor
5. Both 2 and 4
Case #1 Case #1
22-year-old male Notable deformity rugby player falls over superior onto his right shoulder
shoulder while Painful range of being tackled motion • Unable to lift right arm above waist Severe pain on top Ecchymossis of his right shoulder Special Tests?? Diagnosis???
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Acromioclavicular (A-C) Sprain Acromioclavicular (A-C) Sprain
Special Tests Which ones should Damage to A-C • Shear Test we perform on this joint ligaments patient? Pain and/or • Cross Arm Test deformity over A-C • A-C Palpation joint Graded I-VI • Resisted Extension • I-III usually treated
non-operatively • Active compression test • IV-VI referred to
AC Joint Sprain Case #2 Treatment
Analgesics, ice prn 24-year-old male Sling for as long as needed handball player Physical Therapy Fell onto his shoulder • ROM restoration after being pushed
• Gradual strength exercise Intense pain
• Return to sport activity as Hand is tingling and tolerated arm feels like it’s hanging X-rays
Shoulder Dislocation/Anterior X RAYS Instability
Humeral head dislocates from glenoid fossa
Almost always anterior (95%)
Usually traumatic with injury to capsule-labrum DIAGNOSIS??? complex
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Case #3 SHOULDER PAIN Physical Exam
35-year-old male Tenderness to palpation anterior tennis player shoulder
Pain with abduction starting around Shoulder pain 90 degrees exacerbated by practicing serves Unable to lift arm past 120 degrees Pain with forward flexion at 90-120
Develops dull, degrees aching pain in right Special Tests??? Diagnosis??? shoulder
Shoulder Pain Which of the following structures Physical Exam can be “impinged”?
1. Biceps tendon 25% 25% 25% 25%
Hawkin’s positive 2. Subacromial Bursa
Neer’s positive 3. Rotator Cuff Tendons 4. All of the above IMPINGEMENT???
1 2 3 4
Diagnoses associated with clinical Impingement as a Clinical Sign sign of Rotator Cuff Impingement:
Repetitive overhead Subacromial bone spurs and / or bursal activities hypertrophy AC joint arthrosis and /or bone spurs Subacromial bursa Rotator cuff disease and/or rotator cuff Superior labral injury impinged between Glenohumeral instability acromion & humerus Scapular dyskinesis Biceps tendinopathy Physical therapy, activity modification A diagnostic injection sometimes helps to +/- medications clarify the diagnosis
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Case #4 Case #4
45-year-old weight Drop Arm Test Positive lifter Caught bar as it was External Rotation Lag falling off his shoulder Sign positive
Sudden pain Weakness with Empty Severe weakness left Can Sign shoulder
Worse with overhead Normal bear hug and activities; while belly press tests… sleeping at night Pain in anterior lateral shoulder Diagnosis????? Special tests?
Rotator Cuff Tear Case #5
Supraspinatus tendon most common 42-year-old female with dull pain right shoulder
Acute trauma or chronic Pain is diffuse in nature tendinopathy Sometimes spreads to between shoulder blades Treatment dependent upon Seems worse at night age/activity • Young, active usually require operative treatment • Older, low-activity usually respond to non-operative treatment
Shoulder pain isn’t always the Physical Exam shoulder!! Get more history… Obese, pleasant female
Gall bladder disease Diffuse pain Peptic Ulcer Disease Normal shoulder exam Cervical radiculopathy
Cardiac ischemia Not able to reproduce pain during exam Pulmonary conditions
• ie Pancoast’s tumor, Pneumonia What else do you want to do???
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Biceps Tendonopathy Case #6
40-year-old male Speed Test Recently shoveled 16” of snow
Yergason Test Can hardly lift left arm due to pain Direct palpation
Special Tests? Diagnosis?
Biceps Tendonopathies Conclusion
Repetitive overhead Shoulder injuries are common. activity
Knowledge of the anatomy is crucial Repetitive forearm flexion/supination to correct patho-anatomic diagnosis.
Difficult to discern from Impingement is a clinical sign, not a rotator cuff tendinopathy diagnosis. or impingement Don’t forget about medical causes.
QUESTIONS?
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