Transcript Evaluation of the Shoulder

EVALUATION OF THE
SHOULDER
Shoulder Injury Evaluation
Overview
 Anatomy
 History
 Observation
 Palpation
 Neurological
exam
 Circulatory exam
Shoulder Anatomy
Clavicle
 Scapula
 Humerus
 Articulations:

◦ Sternoclavicular joint
◦ Acromioclavicular
joint
◦ Glenohumeral joint
Scapula Winging
Shoulder Anatomy
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Ligaments
◦ AC
◦ Coracoclavicular
ligaments
◦ Glenohumeral
ligaments/joint capsule
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Labrum
Shoulder Anatomy

Musculature
◦ “Rotator cuff”
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Subscapularis
Supraspinatus
Infraspinatus
Teres Minor
Shoulder Anatomy
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Musculature
◦ Pectoralis major
◦ Deltoid
◦ Trapezius
Shoulder Anatomy
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Subacromial bursa
History
Mechanism of injury:
1.
Describe the mechanism of injury
2.
What was the position of the arm at impact?
3.
Did you hear or feel anything at the time of injury?
4.
Was the arm forced beyond normal limits?
5.
Previous Injury?
6.
P.Q.R.S.T.
Observation
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6.
Swelling
Skin color
Signs of trauma
Skin temperature
Atrophy – Muscle shrinking
Abnormal position
Observation
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Arm hanging limp
Appear to be in pain
Compare
Symmetry
Deformities
Muscle spasm
Holding or supporting arm
Moving or using involved extremity
Overall position, posture, and alignment
Palpation: Bone
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7.
Acromion process
Clavicle
Acromio-Clavicular (AC) joint
Sterno-Clavicular (SC) joint
Coraco-Clavicular (CC) joint
Coracoid process
Axilla
Palpation: Bone
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10.
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14.
Head of humerus
Greater tuberosity
Lesser tuberosity
Bicepital groove
Deltoid tuberosity
Humerus
Scapula
Special Tests (31)
Fracture/sprain test (1)
 Rotator cuff tests (6)
 Glenohumeral instability tests (11)
 Biceps tendon tests (6)
 Impingement tests (3)
 Thoracic outlet tests (4)

Apprehension Test (GH
instability):
Pt. begins in seated or supine w/
shoulder relaxed, elbow flexed to
90 degrees, and arm abducted to
90 degrees
 Examiner then passively externally
rotates pt’s arm, looking for
resistance, slipping, or obvious
signs of apprehension
 If pt demonstrates or exhibits any
of the preceding signs, test is
positive for anterior glenohumeral
capsule laxity
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Cross Arm Test (GH instability):
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Examiner begins by facing the standing
pt
Examiner passively crosses the pt’s arms
and simultaneously pulls both of the pt’s
arms across the body
Examiner then changes the directions
and repeats the test
For example, if the left arm was initially
on top, the arms should be positioned
so that the right arm is on top for the
second portion of the test
If pt experiences pain, the test is
positive for glenohumeral capsule (most
likely posterior) sprain
Sulcus Sign (GH instability):
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Pt either seated or standing with the arms
relaxed at the sides
Examiner palpates the humeral head with
one hand and grasps the pt’s distal arm at the
wrist with the other hand
Examiner then pulls inferiorly on the pt’s
arm, looking for inferior movement
A positive sulcus will typically demonstrate a
“dimple” where the humeral head should be
when it is pulled inferiorly
The dimple will disappear when the arm is
released
If inferior translation is apparent, the test is
positive for inferior glenohumeral capsule
laxity.
Sulcus Test
Anterior-Posterior (A-P)
Drawer Test (GH instability):
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Pt begins from the supine position with the arm abducted to
90 degrees and the shoulder unsupported and off of the table
Examiner then uses both hands (interlocked) to grasp the pt
near the tricep
Examiner then slowly moves the pt’s arm so as to translate the
humeral head anteriorly and posteriorly
This is performed simply by pulling up on the proximal arm
and then releasing
Test is positive for anterior and/or posterior glenohumeral
instability if the examiner observes noticeable excessive
movement or laxity
Clunk Test (GH instability):
Examiner begins by placing one hand
over the anterior and posterior aspects
of the pt’s shoulder (the humeral head is
palpated) while the other hand is used
to grasp the pt’s distal humerus just
above the elbow
 Examiner then passively internally and
externally rotates the pt’s arm in varying
degrees of abduction and flexion
 A palpable “clunking” or grinding
sensation indicates a positive test and is
indicative of a possible glenoid labrum
tear
 Obvious apprehension may indicate
anterior glenohumeral instability
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Relocation (Fowler’s) Test (GH
instability):
Pt begins from the supine position
with the shoulder supported by
the examination table and
abducted to 90 degrees
 Pt’s elbow is also flexed to 90
degrees. The examiner then
exerts a downward pressure to
the humeral head (at the anterior
shoulder)
 Pain on reduction (after pressure
is removed) indicates a positive
test for glenohumeral instability.

Special Tests (13)
Biceps tendon tests (6)
 Impingement tests (3)
 Thoracic outlet tests (4)

Yeargason Test (LH biceps):
Examiner begins by positioning the standing pt into 90
degrees of elbow flexion with the arm at the side
 Examiner uses one hand to palpate the long head of the
biceps and the other at the distal arm to provide
resistance
 Examiner then instructs pt to attempt to first externally
then internally rotate the shoulder as the examiner
resists the movement
 Test is positive for biceps tendon subluxation (and
subsequent tenosynovitis) if pt experiences pain or the
examiner notes palpable crepitus.
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Speed’s Sign (LH biceps):
Examiner first palpates the tendon of the
long head of the biceps (deep in the
anterior deltoid)
 Examiner then instructs pt to flex the
elbow as the examiner resists
 Pain indicates a positive sign for bicepital
tenosynovitis
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Speeds test
Lippman’s Test (LH biceps):
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Pt begins with the elbow flexed to
90 degrees and the humerus
resting at the side
Examiner palpates the long head of
the biceps and moves 3 inches
distally
Examiner then rolls the biceps
tendon against the humerus
Pain indicates a positive test for
long head biceps tendon
subluxation
Hawkins-Kennedy Test
(impingement):
Examiner passively positions pt’s shoulder
in 90 degrees of flexion, 90 degrees of
elbow flexion, and end-range shoulder
internal rotation
 Apprehension or sensations of pain are
considered a positive test for subacromial
impingement syndrome
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Impingement
Adson Test (thoracic outlet
syndrome):
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Examiner begins by palpating pt’s radial pulse
Pt’s arm is then abducted, extended, and externally
rotated while the examiner continues to palpate
the pulse
Pt is then instructed to take a deep breath and turn
the head toward the arm being tested
A disappearance of the radial pulse is a positive test
that indicates a compression of the subclavian
artery by the medial scalene muscle
Allen Test (thoracic outlet
syndrome):
Pt begins from a standing position
 Examiner passively flexes pt’s elbow to 90
degrees, then abducts and externally
rotates pt’s shoulder
 Examiner then palpates pt’s radial pulse
and instructs pt to look away from the
side being tested
 A disappearance of the radial pulse
indicates a positive test for thoracic
outlet syndrome
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Shoulder Injuries
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Clavicle Fracture:
 Fall On Out-Stretched Hand (FOOSH) or
direct blow
 Athlete will usually support arm w/ noninjured arm
 Gross deformity
 Immobilize & treat for shock. Refer for Xrays/consult
 Splint in figure 8 brace for 6-8 weeks
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Humeral Fracture:
 Direct blow, dislocation, or FOOSH
 Need X-ray…usually hard to recognize
 Splint & refer
 Out 2-6 months :(
Fractures
Shoulder Injuries
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Anterior Glenohumeral Dislocation
◦ Usually posterior force w/ forced external rotation (arm tackle)
◦ Obvious deformity
 Flattened deltoid contour
 Humerus comes to rest in axilla
◦ Immobilize immediately
◦ RICE
Anterior dislocation
Shoulder Injuries
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Sternoclavicular sprain
◦ Relatively common in sports; FOOSH of direct blow
◦ Usually clavicle will be upward & forward
◦ RICE, immobilization 3-5 weeks
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Acromioclavicular sprain
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“Separated shoulder”
Direct blow to tip of shoulder or FOOSH
“Piano-key” sign
RICE, immobilize, & refer
Shoulder Injuries
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Shoulder impingement syndrome
◦ Compression of supraspinatus, subacromial bursa, and/or
LHBB
◦ Pain, numbness, and tingling
◦ Restore normal biomechanics to shoulder (ther. ex)
◦ Cease causative activity
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Rotator cuff tears
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Rare in people under 40, but do happen in sports
Usually @ humeral insertion
Pain & weakness
RICE, exercises to restore function
 Low weights!!!!!! High reps okay, though
Shoulder Injuries
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Thoracic Outlet Compression Syndrome
◦ Overuse disorder
◦ Numbness, burning & tingling in arms & hands
◦ Caused by compression of brachial plexus between upper
ribs and clavicle
◦ Treat with therapeutic exercise
 Retraction exercises
 Upper rib mobilizations
Rehabilitation of The Shoulder
Complex
Immobilization after injury
 General body conditioning
 Shoulder joint mobilization
 Flexibility
 Muscular strength
 Regaining neuromuscular control
 Functional progression
 Return to activity
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