Shoulder Examination and Evaluation

what history questions should be asked when doing the shoulder examination?

• consider age

• ask about specific motions/activities that cause symptoms

• Hx of subluxation/giving way

• numbness/tingling

• functional limitations

• duration of symptoms

• weakness/heaviness/spasms

• comorbidities

• Hx of shoulder pain/neck pain or surgeries

• medication review

• hand dominance

what about pain needs to be assessed in the subjective?

• number

• quality

• nature

• duration

• location

• travels (referred vs radicular)

what might you need to consider when making/ascertaining goals during the interview?

• should ask directly the pt what their goals are

• can ascertain some goals from the self-reported outcomes

• consider using a scale such as the patient specific functional scale

where might the myocardium refer pain to?

the left arm

where might the diaphragm/pleura refer pain to?

shoulder/upper back

where might the ureters refer pain to?

iliopsoas/anterior to the midline groin

where might the bladder refer pain to?

suprapubic region

where might the gallbladder refer pain to?

shoulder, posterior/lateral t-spine

where might the pancreas refer pain to?

shoulder, T6-9 region (lateral flank)

what are the sources of R scapular pain?

• gallstones/gallbladder pathology

• liver

what are the risk factors of gallstones?

8Fs

• fertile (3rd trimester)

• female

• BMI > 30

• fourty

• family Hx

what are the red flags of pericarditis?

• sharp anterior chest/shoulder pain

• increased temp, HR, RR

what are the red flags of ischemia?

• neck, jaw, L arm and chest pain

• SOB/palpitations

• increased BP

• syncope

what do you need to assess with posture of the shoulder?

• position of the head on the neck, and the neck on the trunk

• position of the shoulders

• position of the scapula

• position of the thoracic spine

• influence of handedness or other activities that may create a normal variation

what do we need to look at with the anterior posture?

• AC position and shape

• sulcus deformity

• clavicle alignment

• atrophy

• rounding of shoulders

• symmetry of trapezius and scalenes

• head carriage

what is upper cross syndrome?

A musculoskeletal condition characterized by a specific pattern of muscle imbalances, including tightness in the upper trapezius and pectorals along with weakness in the deep neck flexors and lower scapular stabilizers. This leads to poor postural alignment of the shoulders and head. See forward head, rounded shoulders, can see kyphosis

what is the SICK scapula?

• Scapular malposition

• Inferior medial border prominent

• Coracoid pain/malposition

• scapular dysKinesia

should we still do a neuro screen during the shoulder exam?

• need to screen ROM of cervical and assess for possible spinal contributions to the issues, neurogenic source or upper trunk C5 radiculopathy vs impingement

• all aspects need to be included

  • myotomes, dermatomes, DTR/MSR, and UMN reflexes

what is the closed pack position of the GHJ?

Max ABD and ER

what is the resting position of the GHJ?

55 ABD and 30 degrees horizontal adduction

what is the resting position of the SC and AC joints?

arm at side

what is the closed position SC joint?

max elevation and protraction

what is the closed position of the AC joint?

90 ABD

what is the resting position of the scapulothoracic joint?

30-60 flexion, and 30-60 degrees horizontal adduction

what is the closed pack position of the ST joint?

max ABD and ER

what is the capsular pattern at the GHJ?

ER > ABD > IR (flexion)

what are the capsular patterns of the SC and AC joints?

restriction at end range

what are the normal values of ROM for horizontal adduction?

130 degrees

what is the normal ROM for ER and IR?

ER: 80-90

IR: 60-100

what is apley’s scratch test?

A assessment method used to evaluate shoulder mobility and range of motion (functional ER and IR) by having the patient reach over their shoulder to scratch their back and touch the opposite scapula or reach the hand behind the low back up towards the middle of the back

what are some causes of scapular imbalance patterns?

increased protraction caused by tight pectoralis minor, weak/lengthened LT, serratus anterior; increased depression by the weak upper traps, loss of scapular stabilization

what are the associated effects of inadequate serratus anterior activation?

lesser scapular upward rotation and posterior tilt

what are the associated effects of excess upper trapezius activation?

greater clavicular elevation

what are the associated effects of pectoralis minor tightness?

greater scapular medial rotation and anterior tilt

what are the associated effects of posterior glenohumeral joint soft tissue tightness?

greater scapular anterior tilt

what are the associated effects of thoracic kyphosis or flexed posture?

greater scapular medial rotation and anterior tilt, lesser scapular upward rotation

how do you rule in adhesive capsulitis based on the CPG?

see image

how would you rule in/out shoulder stability and movement coordination impairments/dislocation of shoulder joint, or sprain and strain of shoulder joint?

see image

how would you rule in/out shoulder pain and muscle power deficits/rotator cuff syndrome?

see image

what interventions should be used for high irritability in the shoulder?

see image

what interventions should be used for moderate irritability in the shoulder?

see image

what interventions should be used for low irritability?

see image

what might subacromial edema signify?

might indicate bursitis, biceps tendon involvement, or rotator cuff (blood from tears) pathology. look for distal bruising which might indicate a rotator cuff tear as the fluid migrates distally

which tests can be used for muscle power deficits?

• speed’s test

• drop arm test

• lift off test/IR lag

• resisted ER

what special tests can be used to assess movement coordination deficits?

• sulcus sign

• jerk test

• apprehension/relocation test

• crank test

• o’brien’s test

• scapular assist test

• scapular reposition test

• biceps load II

what tests can be used to assess impingement?

• hawkin’s kennedy test

• neer’s test

• full vs empty can

what test can be used to assess the AC joint?

the ACJ cluster

what is the acromioclavicular shear test?

a test that evaluates the integrity of the acromioclavicular joint by applying a shear/compression force to the joint, provoking symptoms if there is dysfunction or injury. see image

what cluster of tests is useful for post-test probability for any degrees of impingement syndrome or full thickness RC tear?

• hawkin’s kennedy

• painful arc

• infraspinatus muscle test

what is the cluster for a rotator cuff full thickness tear?

• drop arm test

• painful arc sign

• infraspinatus (dropping sign) test

what are some diagnostic predictors of rotator cuff tears?

• weakness on ER

• age greater than or equal to 65

• presence of night pain

what is important to note about rotator cuff vs impingement?

• clinical tests are not useful for determining size of tear unless they are large tears

• lag signs may indicate a tear of a larger size

• pain and weakness may be a small tear or impingement

what are the signs of ACJ pathology?

• + shoulder anterior pain above 170-180 degrees

• crepitus

• + ACJ special tests

• altered scapulohumeral rhythm

• may still have + RC impingement signs

what are signs of labrum tears?

• ache usually more diffuse

• if long standing possible RC weakness

• sense of instability and weakness

• sharp pain may be position dependent

• + clunk of crank with O’briens

• May or may not have + biceps pain

what are the signs of biceps tendon pathology?

• pain to anterior shoulder may radiate to anterior arm

• snapping biceps tendon

• + pain to resisted elbow flexion

• + speed’s or yergason’s test

• need to r/o labrum if possible

what are some patient reported outcomes that can be used for shoulder pathology?

• Quick DASH/DASH (higher score means more disability)

• SPADI (higher score means more disability)

• PSFS (lower score means more disability)