General Part Head and Neck

Cardiovascular Abdomen

Lung Muscles Lung Exam

• Includes Vital Signs & Cardiac Exam • 4 Elements (cardiac & abdominal too) – Observation – Palpation – Percussion – Auscultation Pulmonary Review of Systems • All organ systems have an ROS • Questions to uncover problems in area • Need to know right questions & what the responses might mean! Exposure Is Key – You Cant Examine What You Can’t See! Anatomy Of The Spine

Cervical: 7 Vertebrae Thoracic: 12 Vertebrae Lumbar: 5 Vertebrae Sacrum: 5 Fused Vertebrae Note gentle curve ea segment Hammer & Nails icon indicates A Slide Describing Skills You Should Perform In Lab Spine Exam As Relates to the Thorax

• W/patient standing, observe: – shape of spine. – Stand behind patient, bend @ waist – w/Scoliosis (curvature) one shoulder appears “higher” Pathologic Changes In Shape Of Spine – Can Affect Lung Function

Scoliosis (curved to one side)

Thoracic Kyphosis (bent forward) Observation • ? Ambulates w/out breathing difficulty? • Readily audible noises (e.g. wheezing)? • Appearance →? sitting up, leaning forward, inability to speak, pursed lips → significant compromise • ? Use of accessory muscles of neck (sternocleidomastoids, scalenes), inter-costals → significant compromise

/ Make Note of Chest Shape: Changes Can Give Insight into underlying Pathology

Barrel Chested (hyperinflation secondary to emphysema) Examine Nails/Fingers: Sometimes Provides Clues to Pulmonary Disorders

Cyanosis Nicotine Staining

Clubbing Assorted other hand and arm abnormalities: Shape, color, deformity

Swelling Deformity

Discoloration Palpation • Patient in gown→chest accessible & exposed • Explore painful &/or abnormally appearing areas • Chest expansion – position hands as below, have patient inhale deeply→ hands lift out laterally Palpation – Assessing Fremitus

• Fremitus =s normal vibratory sensation w/palpating hand when patient speaks • Place ulnar aspect (pinky side) of hand firmly against chest wall • Ask patient to say “Boy” • You’ll feel transmitted vibratory sensation → fremitus! • Assess posteriorly & anteriorly (i.e. lower & upper lobes) • * Not Performed in the absence of abnormal findings * Lung Pathology - Simplified

• Lung =s sponge, pleural cavity =s plastic container • Infiltrate (e.g. pneumonia) =s fluid within lung tissue • Effusion =s fluid in pleural space (outside of lung) Fremitus - Pathophysiology • Fremitus: – Increased w/consolidation (e.g. pneumonia) – Decreased in absence of air filled lung tissue (e.g. effusion).

Normal Normal

Decreased Increased Percussion

• Normal lung filled w/air • Tapping generates drum-like sound →resonance • When no longer over lung, percussion → dull (decreased resonance) • Work in “alley” between vertebral column & scapula. Percussion - Technique • Patient crosses arms in front, grasping opposite shoulder (pulls scapula out of way) • Place middle finger of flat against back, other fingers off • Strike distal interphalangeal joint w/middle finger of other hand - strike 2-3 times @ ea spot Percussion (cont)

• Use loose, floppy wrist action – percussing finger =s hammer • Start @ top of one side→then 1 2 move across to same level, 4 3 other side → R to L (as shown) 5 6 • @ Bottom of lungs, detect 8 7 diaphragmatic excursion → difference between diaphragmatic level @ full inspiration v expiration (~5-6cm) • Percuss upper lobes (anterior) • Cut nails to limit bloodletting! Percussion (Cont)

• Difficult to master technique & detect tone changes - expect to be frustrated! • Practice – on friends, yourself (find your stomach, tap on your cheeks, etc) • Detect fluid level in container • Find studs in wall Percussion: Normal, Dull/Decreased or Hyper/Increased Resonance

• Causes of Dullness: – Fluid outside of lung (effusion) Normal – Fluid or soft tissue filling parenchyma (e.g. Dull pneumonia, tumor) • Causes of hyper- resonance: – COPD→ air trapping – Pneumothorax (air filling pleural space)

Hyper-Resonant Hyper-Resonant R all fields→COPD lung→Pneumothorax Ausculatation

• Normal breathing creates sound→ appreciated via stethoscope over chest → “vesicular breath sounds” • Note sounds w/both expiration & inspiration – inspiration typically more apparent • Pay attention to: – quality – inspiration v expiration – location – intensity Lobes Of Lung

LUL RUL RUL LUL

LLL RLL

LLL RLL RML

Posterior View Anterior View Where you listen dictates what you’ll hear! Posterior View Anterior View

T1

LUL RUL RUL LUL

T-8 nipple LLL LLL RLL RLL RML

LUL RUL RUL LUL Oblique LLL Oblique RLL Oblique Fissure RLL Fissure Fissure LLL Oblique RML Fissure Horizontal Fissure Lobes Of The Lung (cont)

RUL LUL

RLL RML LLL

Lateral Views Right Lateral Left Lateral View View

RUL LUL

RLL RML LLL

Horizontal LUL RUL Fissure Oblique RML Fissure RLL LLL Oblique Fissure Trachea

Trachea Auscultation (listening w/Stethescope) - Technique • Stethescope - ear pieces directed away from you, diaphragm engaged • Patient crosses arms, grasping opposite shoulders Areas To Auscult • Posteriorly (lower lobes) ~ 6-8 1 2 places - Alternate R → L as 4 3 move down (comparison) - ask 5 6 patient to take deep breaths 8 7 thru mouth • Right middle lobe – listen in ~ 2 spots – lateral/anterior • Anteriorly - Upper lobes – listen ~ 3 spots ea side • Over trachea Pathologic Lung Sounds • Crackles (Rales): “Scratchy” sounds associated w/fluid in alveoli & airways (e.g. pulmonary edema, pneumonia); finer crackles w/fibrosis • Ronchi: “Gurgling” type noise, caused by fluid in large & medium sized airways (e.g. bronchitis, pneumonia) • Wheezing: Whistling type noise, loudest on expiration, caused by air forced thru narrowed airways (e.g. asthma) – expiratory phase prolonged (E>>>I) • Stridor: Inspiratory whistling type sound due to tracheal narrowing→ heard best over trachea Pathologic Lung Sounds (cont)

• Bronchial Breath Sounds: Heard normally when listening over the trachea. If consolidation (e.g. severe pneumonia) upper airway sounds transmitted to periphery & apparent upon auscultation over affected area. • Absence of Sound: In chronic severe emphysema, often small tidal volumes & thus little air movement. – Also w/very severe asthma attack, effusions, pneumothorax Pathologic Lung Sounds (cont)

• Egophony: in setting of suspected consolidation, ask patient to say “eee” while auscultating. Normally, sounds like “eee”.. • Listening over consolidated area generates a nasally “aaay” sound. • Not a common finding (but interesting) Putting It All Together: Few findings pathognomonic → put ‘em together to paint best picture. • Effusion • Consolidation – Auscultation→ Vs – Auscultation→ broncial decreased/absent breath sounds breath sounds – Percussion→dull – Percussion→ dull – Fremitus→increased – Fremitus→ decreased – Egophony→ present – Egophony→absent Summary of Skills □ Wash hands, Gown & drape

Observe & Inspect Hands □ Nails, fingers, hands, arms □ Respiratory rate Lungs and Thorax General observation & Inspection □ Patient position, distress, accessory muscle use □ Spine and Chest shape

Palpation □ Chest excursion □ Fremitus Percussion □ Alternating R & L lung fields posteriorly top → bottom □ R antero-lateral (RML), & Bilateral anteriorly (BUL) □ Determines diaphragmatic excursion Auscultation □ R & L lung fields posteriorly, top →bottom, comparing side to side □ R middle lobe □ Anterior fields bilaterally □ Trachea

□ Wash hands Time Target: < 10 minutes Musculoskeletal Examination: General Principles and Detailed Evaluation Of the Knee & Shoulder General Principles

• Musculoskeletal exam performed if symptoms (i.e. injury, pain, decreased function) – Different from “screening exam” • Focused on symptomatic area • Musculoskeletal complaints common→frequently examined Historical Clues •Onset, location, radiation, severity? •What makes it better? Worse? Treatments? •What’s functional limitation? •Symptoms in single v multiple joints? •Acute v slowly progressive? •If injury→ mechanism? •Prior problems w/area? •Systemic symptoms? Examination Keys To Evaluating Any Joint • Area well exposed - no shirts, pants, etc→ gowns – Make sure opposite arm or leg is visible for comparison • Inspect joint(s) in question. Signs inflammation, injury (swelling, redness, warmth)? Deformity? Compare w/opposite side • Understand normal functional anatomy • Observe normal activity – what can’t they do? Specific limitations? • Palpate joint→warmth? Point tenderness? Over what structure(s)? • Range of motion: active (patient moves it) and passive (you move it). • Strength, neuro-vascular assessment. • Specific provocative maneuvers • If acute injury & pain→ difficult to assess as patient “protects”→ limiting movement, examination – examine unaffected side first (gain confidence, develop sense of their normal) Anatomic Planes of The Body Terminology: Flexion/Extension, Abduction/Adduction

• Flexion: Moving forward out of the frontal plane of the body (except knee and foot) • Extension: Movement in direction opposite to flexion • Abduction: movement that brings a structure away from the body (along frontal plane) • Adduction: movement that brings a structure towards the body (along frontal plane)

Neck Extension Neck Flexion

Shoulder Shoulder Finger Shoulder Abduction Extension Flexion Abduction Knee Elbow Elbow Extension Knee Shoulder Finger Extension Flexion Flexion Adduction Adduction Dorsiflexion Hip Flexion Hip Extension HipAbduction Plantar Flexion

HipAdduction Anatomic Position Hammer & Nails icon indicates ASlide Describing Skills You Should Perform In Lab Knee Anatomy: Observation & Identification of Landmarks • Hinge-type joint - tolerates significant force, weight • Anatomy straight forward→ Exam make sense! • Fully expose→take off pants, use gown or shorts! • Surface land marks: patella (knee cap), patellar tendon, medial joint line, lateral joint line, quadriceps muscle, hamstring muscle group, tibia, anterior tibial tuberosity (insertion of patellar tendon), femur.

Hamstring Muscles Observation (cont) • Obvious pain w/walking? • Landmarks • Scars→ past surgery? • Swelling→fluid in the joint (aka effusion)? • Atrophic muscles (e.g. from chronic disuse)? • Bowing of legs (inward =s Valgus, outward =s Varus)?

Varus Deformity Surgical (bowing outward) Obvious right knee Scars effusion Range of Motion (ROM)

1. Active then passive (you move the joint) 2. Hand on patella w/extens. & flex →osteoarthritis, may feel grinding sensation (crepitus)

Normal range of motion: Full Flexion: 140 Full Extension: 0 Strength and Neuro/Vascular Assessment: Most Relevant in Setting of Traumatic Injury • Assess the strength of the major muscle groups: – Hamstrings→ flex the knee – Quadriceps→ extend the knee • Assess distal pulses – Dorsalis pedis and posterior tibibalis – Assessment of leg and foot perfusion • Distal sensation and reflexes→ will learn w/the neuro exam Assessment For A Large Effusion - Ballotment An effusion =s fluid w/in joint space – Large effusions → obvious Smaller effusions can be subtle

To Examine: 1. Flex knee 2. Hand on supra-pateallar pouch→above patella, communicates w/joint space. 3. Push down & towards patella→ fluid center of joint. 4. W/other hand - push down on patella w/thumb. 5. If large effusion → patella floats & "bounces" back up when pushed down. Menisci – Normal Function and Anatomy • Medial & lateral menisci on top of tibia→ cushioned articulating surface betwn femur & tibia • Provides joint stability, distributes force, & protects underlying articular cartilage (covers bone, allows smooth movement) • Menisci damaged by trauma or degenerative changes w/age. • Symptoms if torn piece interrupts normal smooth movement of joint→ pain, instability ("giving out"), locking &/or swelling

Role of the Menisci

Femur

Without Meniscus

Lateral Collateral Ligament Medial Collateral Ligament

With Meniscus

Tibia Fibula Evaluating for Menisal Injury – Joint Line Palpation

Joint Line Tenderness→ medial or lateral meniscal injury (& OA)

1. Slightly flex knee. Lateral 2. Find joint space along lateral & medial margins. Joint line perpendicular to long axis tibia. 3. Palpate along medial, then Medial lateral margins. 4. Pain suggest underlying meniscus damage or OA Additional Tests For Meniscal Injury McMurray’s Test – Medial Meniscus

McMurray’s manipulates knee→ torn meniscus “pinched”→ pain & click

Medial meniscus: 1. Left hand w/middle, index, & ring fingers on medial joint line. 2. Grasp heel w/right hand, fully flex knee. 3. Turn ankle→ foot pointed outward (everted). Direct knee → pointed outward. Simulated McMurray’s – Note 4. Holding foot in everted position, pressure placed on medial meniscus extend & flex knee. 5. If medial meniscal injury, feel "click" w/hand on knee w/extension. May also elicit pain. McMurray’s Test – Lateral

1. ReturnMeniscusknee to fully flexed position, turn foot inwards (inverted). 2. Direct knee so pointed inward. 3. Hand on knee, fingers along joint lines 4. Extend and flex knee. 5. If lateral meniscal injury→ feel "click" w/fingers on joint line; May also elicit pain.

Note: McMurray’s Test for medial and lateral meniscus injuries are performed together Additional Assessment For Meniscal Injury – Appley Grind Test

1. Patient lies on stomach. 2. Grasp ankle & foot w/both hand, flex knee to ninety degrees. 3. Hold leg down w/your leg on back of thigh 4. Push down while Simulated Appley – Note how downward rotating ankle. pressure pinches menisci 5. Puts direct pressure on menisci→if injured→ pain. 6. Test opposite leg Ligaments – Normal Anatomy and Function

• 4 bands tissue, connecting femur→tibia – provide stability • Ligamentous injury (requires significant force – eg leg struck from side w/foot planted)→acute pain, swelling & often report hearing a "pop" (sound of ligament tearing). • After acute swelling & pain, patient may report pain & instability (sensation of knee giving out) w/maneuver exposing deficiency assoc w/damaged ligament

Femur

(covers bone)

Lateral Collateral Ligament Medial Collateral Ligament

Fibula Tibia Specifics of Testing – Medial Collateral Ligament (MCL)

1. Flex knee ~ 30 degrees. 2. Left hand on lateral aspect knee. 3. Right hand on ankle or calf.

4. Push inward w/left hand while Direction of Force supplying opposite force w/ right. 5. If MCL torn, joint "opens up" along medial aspect. 6. May also elicit pain w/direct palpation over ligament

Compare w/non-affected side – Direction of Force “normal” laxity varies from LCLTear patient to patient MCLTear Lateral Collateral Ligament (LCL)

1. Flex knee ~ 30 degrees. 2. Right hand medial aspect knee. 3. Left hand on ankle or calf. 4. Push steadily w/right Direction of Force hand while supplying opposite force w/ left.

5. If LCL torn, joint will Direction of Force "open up" on lateral aspect. 6. May elicit pain on direct palpation of injured ligament Another Method For Assessing The LCL and MCL

1. Flex knee ~ 30 degrees, cradle heel between arm & body. 2. Place index fingers across joint lines. 3. Using your body & index fingers, provide medial then lateral stress to joint Anterior Cruciate Ligament (ACL) – Lachman’s Test 1. Grasp femur w/left hand, tibia w/right. 2. Flex knee slightly. Direction of Force 3. Pull up sharply (towards belly button) w/right hand, stabilizing femur w/left. 4. Intact ACL limits amount of distraction, described as “firm end point” w/Lachmans 5. If ACL torn, tibia feels unrestrained in forward movement. Drop Lachman’s Test For Patient’s With Big Legs &/or Examiners With Small Hands 1. Patient hangs leg off table 2. Place ankle between your legs to stabilize & hold knee in ~30 degrees flexion 3. Place hand on femur, holding it on table 4. Grasp tibia w/other hand & pull forward Anterior Cruciate Ligament (ACL) – Anterior drawer

1. Patient lies down, knee flexed ~ 90 degrees. 2. Sit on foot. Grasp below knee w/both hands, thumbs meeting @ front of tibia. 3. Pull forward - Intact ACL limits amount of distraction, described as “firm end point” 4. If ACL torn, tibia feels Direction of Force unrestrained in forward movement. *Anterior drawer less sensitive than Lachman’s Posterior Cruciate Ligament (PCL) – Posterior Drawer Test

1. Patient lies down, knee flexed ~ 90 degrees. 2. Sit on foot. Grasp below knee w/both hands, thumbs meeting @ front Direction of Force of tibia. 3. Push backward, noting movement of tibia relative to femur. Intact PCL→discrete end point. 4. If PCL torn, tibia feels unrestrained in Direction of movement backwards. Force Anterior Knee Pain: Assessment for Patellofemoral Problems and Chondromalacia Common source anterior knee pain – secondary to patella articulation w/femur – To Test: • 1. Slightly flex knee. 2. Push down on patella w/both thumbs→elicits pain in setting Chondromalacia (osteoarthritis underside patella). 3. Move patella side to side→ palpate its undersurface. May elicit pain if Chondromalacia. 4. Hold patella in place w/ hand & direct patient to contract quadriceps→forces inferior surface patella onto femur, eliciting pain if Chondromalacia Summary of Maneuvers – Knee Exam Name of Maneuver Clinical □ Observe knee & surroundingInterpretation structures, identify surface Variety of pathologic processes anatomy, palpation for pain/explore abnormal appearing areas □ Range of motion (with palpation) Abnormal w/variety pathologic processes, crepitus with DJD

□ Assess strength, distal pulses, distal sensation, reflexes Most important in setting of trauma→ identify co-existing injuries

□ Joint line tenderness Meniscal injury, djd

□ McMurray’s Test (foot everted, knee varus position, flex/extend Pain or palpable click with hand on joint line suggestsMeniscal while palpate medial joint line; then invert foot, knee valgus, injury palpate lateral joint line while flex/extend)

□ Appley Grind Test (patient supine, knee flexed 90degrees, Pain suggests meniscal injury along side being palpated examiner rotates foot while providing downward pressure)

□ Medial and Lateral joint line stress Excessive laxity suggest MCL or LCL tear

□Lachman’s Test (stabilize femur with one hand, pull anteriorly Excessive laxity suggests ACL tear on tibia with other) □Drop Lachman’s Test – useful if large leg or small hands (leg positioned over side of table, stabilize ankle between examiner’s legs, hold femur down w/one hand, pull upward on tibia w/other) □ Anterior Drawer test □ Posterior Drawer Test (knee 90 degrees, examiner sitson Excessive laxity suggests PCL tear patient’s foot and pushes posteriorly on tibia)

□ Assorted patellar manipulation (push down on patella, palpate Pain suggests Chondromalacia Patellae undersurface) The Shoulder Exam Overview of Anatomy

• Shoulder created by 3 bony structures: scapula, humerus & clavicle. • Held together by ligaments & web of muscles • Tremendous range of motion→ “golf ball on a

tee” structure Humeral Head • Compared w/knee, Humerus shoulder anatomy more Glenoid complex – exam w/more

Eponyms! Golf -ball-on-a-Tee structure of shoulder Anatomy – Anterior

View Sterno-clav Jt Acromio-Clav Joint Sternum

Anatomy – Posterior View Observation & Palpation

• Expose both shoulders • Compare sides, noting: Swelling? Discoloration? Deformity? Atrophy? Surgical incisions or scars? • Remember: problems elsewhere (e.g. neck, abdomen) can cause referred pain (i.e. appreciated in shoulder) – should be uncovered via good Hx and P.E. • Identify & palpate each of the surface landmarks: – Clavicle - Scapula – Acromion - Deltoid muscle – Sternum - Supraspinatus region – Acromio-clavicular joint - Infraspinatus region – Sterno-clavicular joint - Teres Minor region Active Range Of Motion Flexion/Extension and Abduction/Adduction 1. Trace arc while reaching forward with elbow straight (forward flexion)

a. Should be able to move hand to Forward Flexion position over head - normal range is 0 to 180 degrees. Extension 1. Reverse direction & trace arc backwards (extension). a. Should be able to position hand behind their back 1. Direct patient to abduct their arm to position with hand above their head a. Movement should be smooth and Abduction painless

b. Normal range is 0 to 180. Adduction ROM Cont – Internal/External Rotation

Abduction and External Rotation: 1. Direct patient to place hand behind head. 2. Then, reach as far down spine as possible. 3. Note extent of reach in relation to cervical spine 4. Should be able to reach ~C 7 level (C-7 has most prominent posterior “bump” on cervical spine & easily palpated).

Adduction and Internal rotation: 1. Direct patient to place hand behind back. 2. Instruct them to reach as high up spine as possible. 3. Note extent of reach in relation to scapula or thoracic spine. 4. Should be able to reach lower border of scapula (~ T 7 level). Passive ROM • If pain w/active ROM, assess same w/passive ROM. 1. Grasp humerus & move shoulder through ROMs described previously. 2. Feel for crepitus (indicative of arthritis) w/hand placed on shoulder. • Note which movement(s) precipitate pain. Pain/limitation on active ROM but not passive suggests a structural problem w/muscles/tendons (they’re firing w/active ROM but not passive). • Note limitations in movement. Where exactly in the arc does this occur? Due to pain or weakness? How compare w/other side? Neuro/Vascular Assessment

• Palpate radial artery, assess hand perfusion • Assess distal sensation and reflexes – Concurrent neurological dysfunction and/or Neurological based etiology for symptoms *We’ll teach these techniques w/the neuro exam The Rotator Cuff

• 4 major muscles = Rotator Cuff • Allow wide range arm movement @ shoulder & keeps humerus in close contact w/scapula • RC muscles and function: Supraspinatus – Abducts shoulder (up to ~ 80 degrees) Infraspinatus – External rotation Teres Minor – External rotation Subscapularis – Internal rotation RC Testing – Supraspinatus Anatomy: Connects top of (“empty can test”) scapula→humerus. W/Firing→shoulder abducts. Most commonly damaged of rotator cuff muscles. Testing as follows:

1. Patient elevates shoulder 30 degrees (30 degrees forward flexion & full internal rotation - i.e. turned so thumb pointing downward). 2. Forward flex shoulder, w/o resistance. Supraspinatus (“Empty can”) Test 3. Repeat w/resistance 4. Note that Deltoid responsible for abduction beyond ~ 70 degrees 5. If partial tear of Supraspinatus, patient experiences pain & some element weakness w/above maneuver. Complete disruption of muscle prevents patient from achieving any abduction

Supraspinatus – Posterior View RC Testing – Infraspinatus and Teres Minor Anatomy: Both muscles connect scapula→humerus. Firing→arm rotates externally. Specifics of testing: 1. Patient slightly abducts (20-30 degrees) shoulders, elbows @ 90 degrees. 2. Place your hands on outside of their forearms. 3. Direct pt to push arms outward (externally rotate) while you resist. 4. Tears in tendon→ weakness and/or pain

Infraspinatus and Teres Minor – Posterior View RC Testing - Subscapularis

Anatomy: Connects scapula to humerus, w/origin on anterior surface of scapula. Firing→internal rotation. Function can be tested using "Gerber's lift off test:"

1. Patient places hand behind back, palm facing out. 2. Pt lifts hand away from back. 3. If tendon partially torn, movement limited or causes pain. Complete tears prevents any movement in this direction

Sucscapularis – Anterior View Impingement, Rotator Cuff Tendonitis and Sub-Acromial Bursitis • 4 tendons of RC pass underneath acromion & coraco-acromion ligament→ insert on humerus. • • Space between acromion/coracoacromial lig & tendons can become narrowed • Causes tendons (in particular, supraspinatus) to become "impinged upon.”→resulting friction inflames tendons & subacromial bursa (between tendons & acromion). • Net result =s shoulder pain, particularly raising arm over head (e.g. swimming, reaching up on a top shelf, arm positioning during sleep). Neer’s Test For Impingement 1. Place 1 hand on patient's scapula, & grasp forearm w/other. Arm internally rotated (thumb pointed downward). 2. Foreward flex arm, positioning hand over the head. 3. Pain→ impingement. Hawkin’s Test For Impingement and Subacromial Palpation

Hawkin’s Test: 1. Raise patient's arm to 90 degrees forward flexion. 2. Rotate internally (i.e. thumb pointed down)→places greater tubercle humerus in position to further compromise space beneath acromion. 3. Pain→ impingement.

Subacromial Palpation: 1. Identify acromion by following scapular spine laterally to tip 2. Palpate in region sub-acromial space→ pain if tendons/bursa inflamed.

Subacromial Palpation Biceps Tendon – Anatomy and Function • Long head biceps tendon runs in bicipital groove humerus, inserting @ top of glenoid. • Subject to same forces/stresses as tendons of RC. • Biceps flexes & supinates forearm • Inflammation (tendonitis)→pain @ top & anterior shoulder areas, particularly w/flexion or supination. Biceps Tendon Testing and Pathology

Palpation: 1. Palpate biceps tendon bicipital groove. Pain→tendonitis. 2. Confirm you’re on tendon→ patient supinates while you palpate

Resisted Supination (Yergason’s Test): 1. Elbow flexed 90 degrees, shoulder adducted (ie elbow bent @ right angle, arm against body). Palpation Yergason’s 2. Grasp patient's hand, direct them to rotate arm such that hand is palm up (supinate) while you resist. 3. Pain→tendonitis

“Popeye Muscle”→Bicep’s Rupture Summary of Maneuvers – Shoulder Exam Maneuver Clinical Interpretation

□ Observe shoulder & surrounding structures, identifysurface General orientation, obvious abnormalities anatomy, palpation for pain/explore abnormal appearing areas

□ Range of motion (flexion/extension, abduction/adduction, Decreased with variety shoulder pathology, crepitus onpalpation internal/external rotation), with palpation with DJD □ Neuro/Vascular assessment: radial pulse, perfusion of hand, Particularly important if traumatic injury to identify other affected distal sensation, reflexes organ systems; Also sometimes disorders affecting the nervous system can sometimes present as shoulder pain (e.g. pathology of spine, cervical nerve roots, brachialplexus) □“Empty can test” (arm abducted 60 degrees, forward flexed ~ 30 Pain/weakness suggests Supraspinatustear degrees, thumb down, resistance to additionalflexion) □ Resisted externalrotation Pain/weakness suggests Infraspinatus or Teres Minortear

□ Resisted internal rotation and lift off from back (Gerber’s test) Pain/weakness suggests Subscapularistear

□ Sub-acromial palpation Pain suggests bursitis/impingement

□ Hawkin’s test (elbow 90 degrees, arm forward flexed 90 Pain suggests bursitis/impingement degrees, examiner internallyrotates) □ Neer’s test (thumb down, elbow straight, examiner raisesarm Pain suggests bursitis/impingement thru forward flexion)

□ Long head biceps palpation Pain suggests biceps tendonitis

□ Yergason’s (elbow 90 degrees, arm adducted, patientattempts Pain suggests biceps tendonitis supination while examiner resists)

□ A-C joint tenderness, Cross arm test (reach acrosstowards Pain suggests a-c joint pathology (djd,dislocation) opposite shoulder)