MSK UQ Unit 2 COMBO set

History components for a shoulder exam

-Age

-Condition (MOI, location, symptoms)

-Occupation/recreational activities

-Hand dominance

-Upper quarter screens

-Medical screen

-Imagine results

-Post op reports, precautions

why is looking at age important for shoulder exam?

different conditions are more common for certain ages

potential referred pain to the shoulder

-Radicular

-Thoracic outlet

-Cervical facets

-cancer

medical screening with shoulder

High risk of thoracic and abdominal referral

lung and breast cancer can cause shoulder pain

Red flag

Outcome measures for the shoulder

-SPADI

-DASH

-Patient specific functional scale (general)

-Simple shoulder test

-UCLA shoulder scale

-Penn shoulder scale

DASH Vs SPADI

Both are UE specific, dont use together

Posture observation for shoulder

look for protective postures, head/neck position, scapular position, thoracic curvatures, muscle symmetry/atrophy(rtc and inter/parascapular muscle)

1cm incision

arthroscopy

Ecchymosis

bruising/staining of the skin due to subcutaneous bleeding caused from muscle tear, joint separation.

edema and shoulder conditions

common from immobilization, from being splinted for protection of injured tissue. Can cause DVT in UE.

How to address edema in shoulder conditions

circulation promotion and edema management

Scapular slide test

Scapular position with regard to spinous process

Start in neutral→hands on hip→shoulder abduction

PROM for shoulder always in what position?

Always in supine

AROM measurements for the shoulder can be done in what position?

seated (against gravity)

what to look for when assessing the quality, quantity, and provocation of joint motion.

-End range symptoms

-Painful arc

-Ratio of IR/ER

-Compensatory movement patterns

painful arc

mid range issue

between 60-120º

GIRD

glenohumeral internal rotation deficit

GIRD may indicate

posterior capsular tightness or shortening

End range symptoms occur when?

when joint tissues are most tense

Painful arc looks for potential symptoms when?

Mid-range

why might we assess scapulo-humeral rhythm anteriorly?

to see gross changes, facial expressions

Why to assess scapulo-humeral rhythm posteriorly?

To view specific scapular movement patterns

what functional motions to assess with shoulder exam?

-Hand behind head (Abd, ER)

-Hand behind back (Ext, Add, IR)

hand behind head - combined abd/ER

note where finger tips touch

Goal is to reach opposite spine of scapula or thoracic SPs

hand behind back - combined ext, add, IR

note where thumb touches

Thumb should reach T8

Subacromial pain tests

-Neers

-Hawkins-Kennedy

Neers test

Shoulder flexion with arm in IR, given OP

Hawkin's-Kennedy

combo of 90 degrees of flexion and IR, grinding greater tuberosity against the acromion

Drop Arm Test

Arm up in 90, actively bring up and try to control the descent. Indicative of Rotator cuff pathology.

muscle performance test for shoulder.

grade strength, and note the symptom response, compare to uninvolved side. Possibly repeated motions for endurance

what to observe when assessing muscle performance for the shoulder

observe quality, motor control. Timing, activation, sequencing, coordination of muscles working together.

supraspinatus strength test

Empty can (thumb down), full can (thumb up). If one hurts or weak, generally both will be.

teres minor mmt

An external rotator

Patient position: supine

Test: examiner applies counter pressure to inner aspect of the distal humerus, lateral rotation of the humerus with elbow held at a right angle

Pressure: in the direction of medial rotation (or IR)

**patient's arm is hardly off table, closer to their bodies

infraspinatus strength test

Arms at sides; elbows flexed to 90° with thumbs up, provide resistance as pt presses forearms outward

Positive for bicipital tendinitis and possible rotator cuff tear if weakness present

subscapularis test

"lift off" test.

ACJ provocation tests

-Cross body adduction

-Resisted horizontal extension/abduction

Cross body adduction

Horizontal adduction with OP

Resisted horz ext/abd

Horizontal abd and ext w/ resistance looking for provocation

Biceps tendon and ACJ/labrum tests

-Speed's test

-Active compression (Obrien's)

Speed's test

assesses long head bicep, bicipital tendonitis test.

Obrien's test

ACJ pathology and/or labral.

Positive O'Brien's Test

Positive test = hurts when thumb down, not when thumb up.

Bicep test

yergason's test

Yergason's test

Assess the stability of biceps tendon in bicipital groove

- pt flexes elbow to 90 while physician grasps elbow w/ one hand and wrist other pull and physician resists supination of forearm + external rotation of shoulder

(+) Test = pain as biceps tendon pops out of bicipital groove

Where to palpate during shoulder exam

entire shoulder complex, cervicothoracic spine, arm.

what to look for with shoulder palpations

-Soft tissue temp, symmetry, muscle mobility

-scan for provocation

locations of likely tenderness with shoulder pathology

-Sub-acromial space

-supraspinatus tendon

-greater tuberosity

-Bicipital groove

-ACJ line

-Upper trap

-Levator scap

What joints to include in joint mob of the shoulder?

GH, SC, AC, ST, cervical and thoracic spine and ribs

what to assess with joint mobs

quantity, quality, symptom response, end-feel. compare with uninvolved side.

Apprehension test

arm in 90/90, slowly watching for patient response. Will make patient apprehensive as if their shoulder is going to pop out anteriorly.

Relocation test

Applying posterior glide-->ER+ABD. Patient won't feel apprehensive, adds an anterior restraint the patient is lacking

Apprehension / Relocation tests for

anterior instability

Apprehension / Relocation test internal or posterior pain

posterior pain in ER, relief of pain w/ posterior glide

Bicep load test II

shoulder abducted 120 degrees, flexed/supinated elbow, bicep isometric muscle test.

Positive bicep load test II

if patient has labral pathology involving the bicep tendon, this will provoke it by pulling on the tendon attached to the labrum.

Scapular tests are what kind of tests?

alleviating tests to see if there is a scapular control problem causing/contributing to glenohumeral pain.

Scapular assistance test

assisting scapular motion, seeing if ROM improves

Scapular repositioning test

stabilizing the scapula in a retracted and posteriorly tilted position so the GHJ can clear and abduct.

wall pushup assesses what?

Serratus anterior strength/weakness and control. Scapular winging presents with weakness.

differential diagnosis process for the shoulder

1. Pre test probability (patient reported symptoms)

2. Clinical impression (based on experience)

3. Create hypothesis

4. Post-test probability (increased with special tests)

choose what kind of special tests for the shoulder?

Those with appropriate clinical utility and psychometric properties.

general subjective history info during shoulder exam

-Acute, or gradual?

-Instability?

-Catching, locking, mechanical symptoms.

-Neuro symptoms

-location of symptoms

-complaints of stiffness/loss of motion

Red/yellow flags for during shoulder exam

-Pain during sleep

-Insidious onset

-Systemic signs

-Cardiovascular sign

-malignancies

-Kehr's sign

Kehr's sign

spleen referral to the left shoulder

ages 13-20 generally present with what shoulder condition?

Instability

ages 20-40 generally present with what shoulder condition?

Instability, biceps/labral complex, frozen shoulder

ages 40-60 generally present with what shoulder condition?

Rotator cuff, arthritis, frozen shoulder

ages 60+ generally present with what shoulder condition?

rotator cuff, arthritis, fracture

Frozen shoulder most common in

middle-aged women d/t hormonal changes around menopause and those with diabetes and thyroid dz

GHJ ROM Combing hair

ABD 105º-120º

ER 90º

ADD 30°-70°

Perineal Care Sh ROM

ABD 30º-45º

IR 90º+

ABD 75°-90°

Washing contralateral ueROM

FLEX 60º-90º

IR 90°

ADD 60°-120°

Overhead shelf flexion ROM

FLEX 70º-80º

ER 45º

ADD 70°-80°

Internal rotation loss (GIRD)

Glenohumeral internal rotation deficit

GIRD contributing factors

-Bony adaptation

-Scapular posture

-Posterior musculotendinous tightness

-Shoulder fatigue

-Posterior capsule tightness

what bony adaptations contribute to GIRD?

A lot of ER (with throwing) can cause some retroversion at the head of the humerus, causing a lack of IR.

How do the ER's contribute during throwing?

-Concentrically during cocking phase

-Eccentrically decelerate during throwing

static posture observation for the shoulder

-Shoulder height asymmetry

-Hands on hips position

-Muscle development/atrophy

-Scapular posture

what to observe with scapular posture

-asymmetries

-resting and elevation

-dyskinesis (aberrant motion)

Kibler's Type 1

Prominent inferior angle: RTC Tendinopathy

Kibler's Type 2

prominent medial border from GH instability

Kibler's Type 3

Superior migration of medial border from RTC weakness

Thrower's SICK scapula

-Scapular malposition

-Inferior medial border prominence

-Coracoid pain and malposition

-dysKinesis

Labral dyskinesis

Inferior/medial border

RTC Dykinesis

superomedial border

Scapular malposition

-scapular tilting/protraction

-lateral displacement

-scapular abduction

Spinal accessory nerve palsy identified by what?

upper trap atrophy, scapular depression. No medial winging with flexion, or abduction. Flip sign

flip sign

Scapula flips off ribscage

Long thoracic nerve palsy identified by what?

Medial scapular winging with active flexion

common faults with scapular dyskinesia

-Increased anterior tilt

-Increased IR of the scapula

-Decreased upward rotation

With limited upward rotation of the scap, stretch what?

Upper trap, pec minor, levator, rhomboids

With limited upward rotation of the scap, strengthen what?

Serratus anterior, Low trap

With limited posterior tilt of the scap, stretch what?

Pec minor

With limited posterior tilt of the scap, strengthen what?

serratus, low trap

with increased internal rotation of the scap, stretch what?

Pec minor, major

with increased internal rotation of the scap, strengthen what?

Mid and low trap, rhomboids, serratus

A "thrower's" scap often appears how?

protracted, depressed, anteriorly tilted.

with scapular testing, what factors to assess?

-scapular stabilization

-muscular control

-scapulothoracic mobility

scapular assistance test

assist the scap into upward rotation, and look for a decrease in pain

scapular reposition test

assist ER and posterior tilt, and assess strength