SHOULDER

CHAPTER 4


SHOULDER


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Précis of the Shoulder Assessment*




History (sitting)


Observation (sitting or standing)


Examination



Active movements (sitting or standing)



Passive movements (sitting)



Special tests (sitting or standing)



Instability tests



Impingement tests



Labral tears



Scapular stability



Other shoulder joint tests



Muscle/tendon pathological conditions



Thoracic outlet test



Reflexes and cutaneous distribution (sitting)



Palpation (sitting)


Resisted isometric movements (supine lying)



Special tests (supine lying)



Joint play movements (supine lying)



Diagnostic imaging



*This assessment is shown in an order that limits the amount of movement the patient must do but ensures that all necessary structures are tested. After any examination, the patient should be warned that symptoms may be exacerbated as a result of the assessment.




SELECTED MOVEMENTS



ACTIVE MOVEMENTS1–21 image











Elevation Through Scaption






Elevation Through Abduction




INDICATIONS OF A POSITIVE TEST


Active abduction normally is 160° to 180°. Inability to attain this ROM and/or pain during the performance of this test is considered a positive test result. Altered mechanics during motion also may be an indication of a pathological condition.


When examining the movement of elevation through abduction, the examiner must take time to observe the scapulohumeral rhythm of the shoulder complex both anteriorly and posteriorly. During 180° of abduction, there is roughly a 2:1 ratio of movement of the humerus to the scapula, with 120° of movement occurring at the glenohumeral joint and 60° at the scapulothoracic joint. However, the examiner must keep in mind that a great deal of variability exists among individuals and may depend on the speed of movement; also, authors do not completely agree on the exact amounts of each movement.18–20


In the unstable shoulder, the scapulohumeral rhythm commonly is altered because of incorrect dynamic functioning of the scapular or humeral stabilizers or both. This may be related to incorrect arthrokinematics at the glenohumeral joint. Kibler21 pointed out that watching the movement of the scapula in both the ascending and descending phases of abduction is especially important. Commonly, weakness of the scapular control muscles is more evident during descent as many of the muscles are required to work eccentrically. An instability jog, hitch, or jump may occur when the patient loses control of the scapula.



CLINICAL NOTES


This movement occurring simultaneously at the four joints involves three phases. There is variability regarding the amount of motion and the timing of motion that occurs at each phase of movement. Other authors will give values for the amount of each movement that differ from those noted here.



• In the first phase of 30° of elevation through abduction, the scapula is said to be “setting.” This means that the scapula moves minimally during this stage—rotating slightly in, rotating slightly out, or not moving at all. Therefore, there is no 2:1 ratio of movement during this phase. The angle between the scapular spine and the clavicle also may increase up to 5° at the sternoclavicular and acromioclavicular joints when elevating the arm; however, this depends on whether the scapula moves during this phase.


• During the next 60° of upper extremity elevation (second phase), the scapula rotates about 20°, and the humerus elevates 40° with minimal protraction or elevation of the scapula. Therefore, there is a 2:1 ratio of scapulohumeral movement. During phase 2, the clavicle elevates because of the scapular rotation, but the clavicle still does not rotate or does so minimally.


• During the final 90° of motion (third phase), the 2:1 ratio of scapulohumeral movement continues and the angle between the scapular spine and the clavicle increases an additional 10°. Therefore, the scapula continues to rotate and now begins to elevate. The amount of protraction continues to be minimal when the abduction movement is performed. During this stage, the clavicle rotates posteriorly 30° to 50° on a long axis and elevates up to a further 15°. Also during this final stage, the humerus laterally rotates 90° so that the greater tuberosity of the humerus avoids the acromion process.


• During the second and third phases, rotation of the scapula (total, 60°) is possible because of the 20° of motion at the acromioclavicular joint and 40° at the sternoclavicular joint.



Medial Rotation





CLINICAL NOTES





Lateral Rotation





CLINICAL NOTES/CAUTIONS





Extension







Horizontal Adduction/Cross Flexion








Scapular Retraction and Protraction






APLEY’S SCRATCH TEST22 image












CLINICAL NOTES




• Often the dominant shoulder shows greater restriction than the nondominant shoulder, even in the absence of a pathological condition. An exception would be individuals who continually use their arms at the extremes of motion (e.g., baseball pitchers). Because of the extra ROM developed over time doing the activity, the dominant arm may show greater ROM. However, the examiner must always be aware that shoulder movements include movements of the scapula and clavicle, as well as the glenohumeral joint. Many glenohumeral joint problems actually are scapular muscle control problems, which may secondarily lead to glenohumeral joint problems, especially in people under 40 years of age.


• The scapular reach test (neck and back) is a similar test in which the patient does medial rotation and adduction (back reach) of both arms at the same time, then lateral rotation and adduction (neck reach) of both arms at the same time. By having the patient do the combined movements, the examiner gets some idea of the individual’s functional capacity and can easily see differences between the two sides. (See Figure 5-29 in Magee DJ: Orthopedic Physical Assessment, ed. 5.)



PASSIVE MOVEMENTS22–26 image






TEST PROCEDURE


Starting with the unaffected side, the examiner grasps the patient’s forearm with one hand and places the other hand on the patient’s shoulder to monitor shoulder compensation (i.e., movement at the glenohumeral joint, scapulothoracic joint, and acromioclavicular joint) while watching the sternoclavicular joint. While palpating the shoulder, the examiner passively lifts the patient’s arm sequentially into flexion, then abduction, then scaption or brings it backward to assess shoulder extension.


The examiner then can assess passive medial and lateral rotation by bringing the patient’s elbow to the side and medially or laterally rotating the arm. Rotation also can be assessed at varying degrees of shoulder abduction (most commonly, 90º).


Finally, the shoulder can be brought to 90º of shoulder abduction, provided the patient can achieve 90°. From this starting point, the shoulder can be brought across the body to assess shoulder horizontal adduction or extended backward to assess shoulder horizontal abduction.






POSTERIOR CAPSULAR TIGHTNESS TEST image














RESISTED ISOMETRIC MOVEMENTS image










TEST PROCEDURE


The muscles of the shoulder are tested isometrically, with the examiner positioning the patient and saying, “Don’t let me move you.” Pressure and force should be increased slowly and gradually. From this position, the examiner tests shoulder flexion, extension, abduction, adduction, medial rotation, and lateral rotation, as well as elbow flexion (biceps) and extension (triceps).



Flexion. The examiner places the palm of one hand on the anterior distal humerus to provide resistance near the elbow and uses the other hand to support the patient’s hand at the wrist.


Extension. The examiner places the palm of one hand on the posterior distal humerus to provide resistance near the elbow and uses the other hand to support the patient’s hand at the wrist.


Abduction. The examiner places the palm of one hand on the lateral distal humerus to provide resistance near the elbow and uses the other hand to support the patient’s hand at the wrist.


Adduction. The examiner places the palm of one hand on the medial distal humerus to provide resistance near the elbow and uses the other hand to support the patient’s hand at the wrist.


Medial rotation. The examiner places the palm of one hand on the distal forearm at the palmar aspect of the wrist to provide resistance, and the other hand just above the elbow.


Lateral rotation. The examiner places the palm of one hand on the distal forearm at the posterior aspect of the wrist to provide resistance and the other hand just above the elbow.


Elbow flexion. The examiner places the palm of one hand near the anterior wrist to provide resistance and uses the other hand to support the elbow.


Elbow extension. The examiner places the palm of one hand near the posterior wrist to provide resistance and uses the other hand to support the elbow.




CLINICAL NOTES




• The disadvantage of testing shoulder isometrics with the patient in the supine position is that the examiner cannot observe the stabilization of the scapula during the testing. Normally, the scapula should not move during isometric testing. Scapular protraction, winging, or tilting during isometric testing indicates weakness of the scapular control muscles.


• Although all the muscles around the shoulder can be tested with the patient in the supine lying position, some recommend testing the muscles in more than one position (e.g., different amounts of abduction or forward flexion) to determine the mechanical effect of the contraction in different situations.


• If the patient history includes a complaint of pain in one or more positions, these positions also should be tested. If the initial position causes pain, other positions (e.g., position of injury, position of mechanical advantage) may be tried to further differentiate the specific contractile tissue that has been injured.


• The relative percentages for isometric testing will be altered if tests are performed at faster speeds and in different planes.


• If the patient history includes a complaint that concentric, eccentric, or econcentric (biceps and triceps) movements are painful or cause symptoms, these movements should be tested with loading or no loading as required.


• When testing isometric elbow flexion, the examiner should watch for the possibility of a third-degree strain (rupture) of the long head of the biceps tendon (“Popeye muscle”).



SPECIAL TESTS FOR ANTERIOR GLENOHUMERAL INSTABILITY27–37


General Information


Two types of anterior instability may be found in the shoulder. Type I, which is more closely related to muscle weakness and labral tears, can be found in any part of the ROM (translational instability). Type II, which is related to end-range instability and trauma will typically present with apprehension when tested at end ROM. Type II instability is often associated with tearing of the labrum and/or capsule.

Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on SHOULDER
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