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Shoulder Examination Sitting Shoulder Examination Sitting 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 1 10/19/2012 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 2 10/19/2012 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 3 10/19/2012 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 4 10/19/2012 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 5 10/19/2012 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 6 10/19/2012 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… 7 10/19/2012 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 8 10/19/2012 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 9 10/19/2012 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 Scan spine 1. posterior capsule Analysis 2. posterior cuff Confirmation Resisted Tests Diagnosis • Horizontal Problem list (goals) • ER 10 10/19/2012 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 ° 11 10/19/2012 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
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