Study Notes on Shoulder Complex Assessment

Shoulder Complex Assessment

Introduction to the Shoulder Complex

  • The shoulder complex is crucial for upper limb movement and function.

  • Assessment encompasses various observational and physical examination skills.

Learning Objectives

  • Apply observational and palpation skills to the shoulder complex: Develop skills to visually and physically assess shoulder function.

  • Apply assessment of active/passive range and resistance tests to the shoulder complex: Determine the functional limitations using a range of motion tests.

  • Understand the limitations of special tests and some short cuts: Recognize that special tests may not always provide a definitive diagnosis and learn alternative methods.

  • Understand the difference between a structural diagnosis and symptom-based classification: Differentiate between diagnosing specific pathologies versus classifying symptoms in terms of functionality.

Components of Subjective Assessment

  • Introduction of some new ideas:
      - Understanding the patient’s perspective is critical in assessing their condition.

  • Dominant Hand: Identify the patient’s dominant hand for context regarding activity and injury.

  • Main Problem (order/prioritize from patient’s perspective): Focus on the patient's immediate concerns.

  • ICE (Ideas, Concerns, Expectations):
      - Patient's Concerns: What worries the patient about their condition?
      - Patient's Ideas: Any self-perceptions regarding the injury.
      - Able to sleep on affected side?: Assess this to understand the impact of pain on daily activities.

  • Guarding: Observe if the patient is protecting the shoulder region.

  • Fear Avoidance: Recognize any avoidance behavior due to fear of pain.

  • Instability, Weakness, Stiffness, Pain: Document all symptomatic issues reported by the patient.

  • Patient’s Expectations of Recovery/Physiotherapy: Understand what recovery looks like from the patient's viewpoint.

  • Mechanism of Injury:
      - Trauma (e.g., FOOSH: Fall On Outstretched Hand)
      - Sudden: Quick onset of symptoms.
      - Insidious: Gradual progression of symptoms.

Common Components of Objective Assessment

  • Special Tests: Utilize specific tests to assess for particular shoulder injuries.

  • Observation: Initial visual assessment of shoulder appearance and posture.

  • Initial Palpation: Begin palpation techniques to assess tender areas.

  • Functional Tests: Examine the ability to perform tasks involving shoulder movement.

  • Detailed Palpation (Accessory Movements): Subject the joint to various movements to assess joint integrity.

  • Resisted Movements: Evaluate the strength of shoulder muscles.

  • Passive Movements: Assess the movement ability of the joint with assistance.

  • Active Movements: Assess the patient's voluntary movements of the shoulder.

  • Overpressure: Apply additional pressure at the end of the range of active movements to assess limitations.

Observation and Initial Palpation

  • Shoulder Complex Assessment: Identifying key observation features:
      - Discolouration/Bruising: Note signs of trauma.
      - Swelling/Deformity: Assess for any abnormalities in structure.
      - Surface Anatomy: Identify bony landmarks and muscle contours.
      - Bony Points: Pay attention to prominent bony structures.
      - Difference in Muscle Bulk: Note any atrophy or hypertrophy.
      - Volitional Movement: Assess for any intended movement.

  • Techniques:
      - Begin palpation posteriorly and move anteriorly to address asymmetry.
      - Discuss palpation process with the patient to increase comfort.
      - Document both positive findings (e.g., no pain) and negative findings (e.g., pain).
      - Identify both limitations and areas of functional capability.
      - Illustrations utilized to enhance understanding and communication during assessment.

Anatomy Overview of Shoulder Girdle

  • Components include:
      - Acromion Process: The bony projection on the scapula.
      - Acromioclavicular Joint & Ligaments: Key site for joint stability.
      - Coracoid Process: Important for muscle attachment.
      - Glenoid Cavity (Fossa): The socket for the humeral head.
      - Scapulothoracic Joint: Connects shoulder blade to the thorax.

  • Key Ligaments:
      - Coracoclavicular Ligaments (Conoid and Trapezoid): Stabilize AC joint.
      - Costoclavicular Ligament: Connects the clavicle to the first rib.
      - Interclavicular Ligament: Stabilizes the sternoclavicular joint.

Active Movements of the Shoulder Girdle

  • Movements include:
      - Elevation/Depression: Movement towards or away from the body.
      - Protraction/Retration: Forward and backward movement along the thorax.
      - Lateral/Medial Rotation: Movements of the scapula within the shoulder girdle.

  • Scapulo-humeral Rhythm: Coordination between scapular and humeral movement during elevation.

Detailed Assessment: Active Movements with Overpressure

  • Engagement with the Patient: Explain the movements thoroughly and note findings.

  • Evaluated Movements: Elevation, Depression, Protraction, and Retraction required during assessment.

Active Movements of the Shoulder Joint

  • Assessment setup: Perform assessments while the patient is either standing or sitting.

  • Comparison with the Other Side: Evaluate the symmetrical functioning of both shoulders.

  • Willingness to Move/S-T Rhythm/Painful Arc: Note any apprehension and signs of discomfort in movements.

  • Definitions:
      - Painful Arc: A specific range in which pain is experienced (usually between 60 to 120 degrees of shoulder elevation).
      - Safe Zone: Range of motion where the patient feels most comfortable.

  • Measurement tools:
      - Goniometer: For precise angle measurements.
      - Inclinometer: An alternative measurement tool.
      - Eyeball Method: Quick visual assessment of motion.

Active Movement Considerations

  • Order of Movements: Determine a systematic approach based on patient symptoms and comfort.

  • Factors Indicating Pain Management: Determine how to proceed based on patient feedback regarding pain during movement.

  • Variations in Approach for Different Patients: Adjust technique based on age (elderly or frail), history of dislocation, or instability characteristics.

  • Application of Overpressure & Measuring Techniques: Identify when to apply physical pressure or simply assess visually.

Passive Movements

  • Purpose: Assess range of motion without patient effort.

  • Considerations: Optimal position (sitting or lying) and which movements to include:
      - Flexion/Abduction: Significant for assessing active range.
      - Anchor Scapula: Stabilize proximal structures during manipulation.
      - External Rotation: Critical for evaluating rotator cuff integrity.

Resisted Movements

  • Muscle Groups to Consider:
      - Abduction/Adduction
      - Lateral/External Rotation and Medial/Internal Rotation
      - Shoulder/Elbow Flexion and Extension
      - Horizontal Flexion/Extension

  • Test Movements: Focus on compound movements rather than isolating single muscles.

Active vs Passive vs Resisted Movements

  • Explain Pain Mechanisms:
      - Active and Passive Abduction Pain but not Resisted Abduction: Indicates possible structural issues rather than muscular.
      - Resisted Lateral Rotation Pain but not Passive Lateral Rotation: Could be related to tendon involvement or muscle strain.

Accessory Movements at GHJ and ACJ

  • Movements to Assess:
      - Anterior-Posterior (AP) Glide of the humerus.
      - Lateral Glide of the humerus.
      - AP and Caudad Movements at the Acromioclavicular Joint: Assess joint play and mobility.

  • Problem Solving with Mobs Principles:
      - Perform AP Glide of Acromion on Clavicle.
      - Perform Caudad Glide of Acromion on Clavicle.

Special Tests

  • Focus: Assessment tools that can reveal specific shoulder pathologies.

  • Painful Arc and Rotator Cuff Tests such as:
      - External Rotation Lag Sign (ERLS): Involves slight flexion and lateral rotation while holding.
      - Apprehension Test: Evaluates anterior instability, particularly in supine position.

Clinical Diagnosis: Symptom-Based Classification

  • Classification Factors:
      - Movement Dysfunction metrics include:
        - Pain
        - Stiffness
        - Weakness
        - Instability
        - Fear Avoidance
        - Guarding

Objective Baseline Measures

  • Tools for Assessment:
      - Numerical Rating Scale (NRS) for pain measurement.
      - Goniometer for measuring stiffness through range of motion.
      - ER Lag Test/Myometer for assessing weakness.
      - Instability Assessment via Safe Zone: Identifying limits of mobility.

  • Guarding: Observe physical signs of protective movement.

Conclusion

  • Understanding the shoulder complex necessitates a comprehensive assessment approach that marries subjective reporting with objective clinical testing. Each component of assessment contributes towards a functional diagnosis that maximizes patient recovery and rehabilitation efficacy.