Transcript File - Shabeer Dawar

SHOULDER JOINT
ASSESSMENT
NORMAL RANGE OF MOTION OF
SHOULDER JOINT:
SPECIAL TESTS FOR SHOULDER JOINT:
TESTS FOR
ROTATOR
CUFF/IMPING
MENT
TESTS FOR
ACROMIOCLA
VICULAR
JOINT
1.
1. PAINFUL
1. SPEED
ARC
TEST
2. FORCED
2. YERGASON
ADDUCTION
TEST
TEST
3. BICEP
3. FORCED
TENDON
ADDUCTION
WITH
TEST IN
TRANSVER
HANGING
SE
ARM
HUMERAL
4. DUGA’S
LIGAMENT
TEST
TEST
2.
3.
4.
5.
6.
NEER
IMPINGMENT
TEST
HAWKINS
KENNEDY TEST
EMPTY CAN
TEST
DROP ARM TEST
LIFT OFF.TEST
INFRASPINATUS
TEST
7.
SPRING BACK
TEST
8.
TERES MINOR
TEST
9.
TERES MAJOR
TEST
10. APLEY
SCRATCH TEST
TESTS FOR
BICEP
TENDON
TESTS FOR
INSTABILITY
1. ANTERIOR
APPREHEN
SION TEST
2. POSTERIOR
APPREHEN
SION TEST
3. ANTERIOR
POSTERIOR
DRAWER
TEST
4. INFERIOR
INSTABILIT
Y TEST
5. SULCUS
TEST
TESTS FOR ROTATOR CUFF
AND IMPINGMENT
SYNDROME
IMPINGEMENT:
Primary impingment
Secondary impingment
Occur because of degenerative
changes to the rotator cuff,the
acromian process,the coracoid
process and anterior tissues from
stress overload.
Occurs due to problem with
muscle dynamics with an upset
in the normal force couple action
leading to muscle imbalance and
abnormal movement patterns at
both the glenohumeral joint and
the scapulothoracic articulation.
Impingement is primary cause of
pain.
It is secondary to altered muscle
dynamics.
Occurs mostly in 40+ age group
people.
Occurs in young patients.(1535years old)
It is said to be intrinsic when
rotator cuff degeneration occurs
and extrinsic when the shape of
the acromian and degeneration
of the coracoacromial ligament
occurs.
Commonly seen with joint
instability.
GRADING OF IMPINGEMET:

Mostly impingement and instability often occurs
together in throwing athletes and accordingly it
is classified as:
GRADE I:
GRADE II:
GRADE III:
GRADE IV:
Pure
impingement
with no
instability.(of
ten seen in
older
patients)
Secondary
impingment
and
instability
caused by
chronic
capsular and
labral
microtrauma
.
Secondary
impingement
and
instability
caused by
generalized
hypermobilit
y or laxity.
Primary
instability
with no
impingement
.
NEER IMPINGMENT TEST:
PATIENT’S AFFECTED ARM IS PASSIVELY AND FORCIBLY FULLY
ELEVATED IN THE SCAPULAR PLANE WITH THE ARM MEDIALLY
ROTATED BY THE EXAMINER.
•This passive stress
causes “jamming of
the greater tuberosity
against the
anteroinferior border
of the acromian.
•The patient’s face
shows pain reflecting
a +ve test.
HAWKIN’S KENNEDY IMPINGMENT TEST:
PATIENT STAND WHILE THE EXAMINER FORWARD FLEXS THE
ARM TO 90º AND FORCIBLY MEDIALLY ROTATES THE SHOULDER.
•This movement
pushes the
supraspinatus
tendon against the
anterior surface of
the coracoacromial
ligament and
coracoid process.
•Pain indicates +ve
test.
SUPRASPINATUS TEST/EMPTY CAN TEST:
THIS TEST MAY BE PERFORMED WITH THE PATIENT STANDING
OR SEATED.WITH THE ELBOW EXTENDED, THE PATIENT’S ARM IS
HELD AT 90° OF ABDUCTION,30° OF HORIZONTAL FLEXION, AND
IN INTERNAL ROTATION (WITH THUMB FACING DOWN). THE
EXAMINER EXERTS PRESSURE ON THE UPPER ARM DURING THE
ABDUCTION AND HORIZONTAL FLEXION MOTION.
•When this test elicits severe
pain and the patient is
unable to hold his or her arm
abducted 90° against gravity,
this is called a positive empty
can test/supraspinatus
tendinitis.
•The superior portions of the
rotator cuff (supraspinatus) are
particularly assessed in
internal rotation (with the
thumb down), and the
•anterior portions in external
rotation.
DROP ARM(CODMAN’S)TEST:
THE PATIENT IS SEATED, AND THE EXAMINER PASSIVELY
ABDUCTS THE PATIENT’S EXTENDED ARM APPROXIMATELY 120°.
THE PATIENT IS ASKED TO HOLD THE ARM IN THIS POSITION
WITHOUT SUPPORT AND THEN SLOWLY ALLOW IT TO DROP.
Weakness in maintaining the
position of the arm, with or
without pain, or sudden dropping of
the arm suggests a rotator cuff
lesion. Most often this is due to a
defect in the supraspinatus. In
pseudoparalysis, the patient will be
unable to lift the affected arm. This
global sign suggests a rotator cuff
disorder.
SUBSCAPULARIS TEST/LIFT
OFF TEST:
PATIENT IN STANDING POSITION PLACES THE DORSUM OF THE
HAND ON THE BACK. THE PATIENT THEN LIFTS THE HAND AWAY
FROM THE BACK. IF PATIENT IS ABLE TO DO THEN LOAD
PUSHING ON HAND IS DONE BY THE EXAMINER TO CHECK THE
STRENGTH.
•A patient with a subscapularis
tear will be unable to do
this.
•Abnormal motion in the scapula
during the test may indicate
scapular instability.
INFRASPINATUS TEST:
COMPARATIVE TESTING OF BOTH SIDES IS BEST. THE PATIENT’S
ARMS SHOULD HANG RELAXED WITH THE ELBOWS FLEXED 90°
BUT NOT QUITE TOUCHING THE TRUNK. THE EXAMINER PLACES
HIS OR HER PALMS ON THE DORSUM OF EACH OF THE PATIENT’S
HANDS AND THEN ASKS THE PATIENT TO EXTERNALLY ROTATE
BOTH FOREARMS AGAINST THE RESISTANCE OF THE EXAMINER’S
HANDS.
Pain or weakness in external rotation
indicates a disorder of the
infraspinatus (external rotator).
As infraspinatus tears are usually
painless, weakness in rotation
strongly suggests a tear in the
muscle.
This test can also be performed with
the arm abducted 90° and flexed
30° to eliminate involvement of the
deltoid in this motion.
 SPRING
BACK TEST:
PATIENT EITHER IN SITTING OR STANDING HOLD THE
ELBOW IN FLEXION AT 90º BY THE SIDE. EXAMINER
PASSIVELY BRING THE SHOULDER TO 90º
ABDUCTION AND LATERALLY ROTATE TO THE END
RANGE AND ASK THE PATIENT TO HOLD THE ARM
TO THIS POSITION. FOR +VE TEST OF
INFRASPINATUS WEAKNESS/LESION PATIENT
CANNOT HOLD THE POSITION AND HAND SPRING
BACK ANTERIORLY.
TERES MINOR TEST:
PATIENT LIES PRONE AND PLACES HIS HAND ON THE
OPPOSITE POSTERIOR ILIAC CREST. ASK THE
PATIENT TO EXTEND AND ADDUCT THE MEDIALLY
ROTATED ARM AGAINST RESISTANCE. PAIN OR
WEAKNESS INDICATE +VE TEST.
TERES MAJOR TEST:
THE PATIENT IS STANDING AND RELAXED. THE EXAMINER
ASSESSES THE POSITION OF THE PATIENT’S HANDS FROM
BEHIND. THE TERES MAJOR IS AN INTERNAL ROTATOR. WHERE A
CONTRACTURE IS PRESENT, THE PALM OF THE AFFECTED HAND
WILL FACE BACKWARD COMPARED WITH THE CONTRALATERAL
.
HAND
APLEY’S SCRATCH TEST:
THE SEATED PATIENT IS ASKED TO TOUCH THE
CONTRALATERAL SUPERIOR MEDIAL CORNER OF THE SCAPULA
WITH THE INDEX FINGER
.
Pain elicited in the rotator cuff and failure
to reach the scapula because of restricted
mobility in external rotation and abduction
indicate rotator cuff pathology (most
probably involving the supraspinatus).
ACROMIOCLAVICULAR JOINT
TESTS
TOSSY CLASSIFICATION:



TOSSY TYPE 1: CONTUSION OF THE
ACROMIOCLAVICULAR JOINT WITHOUT
SIGNIFICANT INJURY TO THE CAPSULE AND
LIGAMENTS.
TOSSY TYPE 2: SUBLUXATION OF THE
ACROMIOCLAVICULAR JOINT WITH RUPTURE
OF THE ACROMIOCLAVICULAR LIGAMENTS.
TOSSY TYPE 3: DISLOCATION OF THE
ACROMIOCLAVICULAR JOINTWITH
ADDITIONAL RUPTURE OF THE
CORACOCLAVICULAR LIGAMENTS.
ACROMIOCLAVICULAR JOINT
PROBLEM

MAY BE ELICITED BY ANTERIOR PAIN WITH MOTION AND
TENDERNESS TO PALPATION OVER THE
ACROMIOCLAVICULAR JOINT.

FINDINGS WILL OFTEN INCLUDE PALPABLE BONY
THICKENING OF THE ARTICULAR MARGIN.

TOSSY CLASSIFIES ACROMIOCLAVICULAR JOINT
INJURIES INTO THREE DEGREES OF SEVERITY:
PAINFUL ARC:
THE PATIENT’S ARM IS PASSIVELY AND ACTIVELY ABDUCTED
FROM THE REST POSITION ALONGSIDE THE TRUNK. PAIN IN THE
ACROMIOCLAVICULAR JOINT OCCURS BETWEEN 140°AND 180°
OF ABDUCTION. INCREASING ABDUCTION LEADS TO INCREASING
COM-PRESSION AND CONTORTION IN THE JOINT. (IN AN
IMPINGEMENT SYNDROME OR A ROTATOR CUFF TEAR, BY
COMPARISON, PAIN SYMPTOMS WILL OCCUR BETWEEN 70°
AND 120°.
In the evaluation of the active
and passive ranges of motion,
the patient can often avoid the
painful arc by externally
rotating the arm while
abducting it. This increases
the clearance between the
acromion and the diseased
tendinous portion of the
rotator cuff, avoiding
impingement in the range
between 70° and 120°.
FORCED ADDUCTION TEST:
THE 90°-ABDUCTED ARM ON THE AFFECTED SIDE IS FORCIBLY
ADDUCTED ACROSS THE CHEST TOWARD THE NORMAL SIDE.
FORCED ADDUCTION TEST ON HANGING ARM:
THE EXAMINER GRASPS THE UPPER ARM OF THE AFFECTED SIDE
WITH ONE HAND WHILE THE OTHER HAND RESTS ON THE
CONTRALATERAL SHOULDER AND IMMOBILIZES THE SHOULDER GIRDLE.
THEN THE EXAMINER FORCIBLY ADDUCTS THE HANGING AFFECTED
ARM BEHIND THE PATIENT’S BACK AGAINST THE PATIENT’S RESISTANCE.
Pain across the
anterior aspect of the
shoulder suggests
acromioclavicular joint
disease or subacromial
impingement.
DUGA’S TEST:
THE PATIENT IS SEATED OR STANDING AND TOUCHES THE
CONTRALATERAL SHOULDER WITH THE HAND OF THE 90°FLEXED ARM OF THE AFFECTED SIDE THEN ATTEMPT TO
LOWER THE ELBOW TO THE CHEST IS MADE.
Acromioclavicular joint pain
suggests joint disease
(osteoarthritis,
instability, disk injury, or
infection).
A differential diagnosis
must exclude anterior
subacromial impingement
BICEP TENDON TEST
THE CLOSE ANATOMIC PROXIMITY OF
THE INTRAARTICULAR PORTION OF THE
TENDON TO THE CORACOACROMIAL
ARCH PREDISPOSES IT TO INVOLVEMENT
IN DEGENERATIVE PROCESSES IN THE
SUBACROMIAL SPACE. A ROTATOR CUFF
TEAR IS OFTEN ACCOMPANIED BY A
RUPTURE OR INJURIES OF THE BICEPS
TENDON.
SPEED TEST:
IN SITTING THE EXAMINER RESISTS SHOULDER FORWARD
FLEXION BY THE PATIENT WHILE THE PATIENT’S FOREARM
IS IN SUPINATION. PAIN IN THE REGION OF THE BICIPITAL
GROOVE SUGGESTS A DISORDER OF THE LONG HEAD OF
THE BICEPS TENDON.
YERGASON TEST:
WITH THE PATIENT’S ELBOW FLEXED TO 90º AND STABILIZED
AGAINST THORAX AND WITH FOREARM PRONATED, THE
EXAMINER RESISTS SUPINATION WHILE THE PATIENT ALSO
LATERALLY ROTATES THE ARM AGAINST RESISTANCE.
DURING
THIS MOVEMENT WHEN THE TENDON IS FELT IN GROOVE AS “POP
OUT”
.
•Pain in the bicipital groove is a sign
of a lesion of the biceps tendon, its
tendon sheath, or its ligamentous
connection via the
•transverse ligament.
•The typical provoked pain can be
increased by pressing on the tendon in
the bicipital groove.
BICEP TENDINITIS WITH TRANSVERSE
HUMERAL LIGAMENT TEST:
THE PATIENT IS SEATED WITH THE ARM ABDUCTED 90°,
INTERNALLY ROTATED, AND EXTENDED AT THE ELBOW. FROM
THIS POSITION, THE EXAMINER EXTERNALLY ROTATES THE ARM
WHILE PALPATING THE BICIPITAL GROOVE TO VERIFY WHETHER
THE TENDON SNAPS.
•In the presence of
ligamentous insufficiency,
this motion will cause the
biceps tendon to
spontaneously displace out of
the bicipital groove.
•Pain reported without
displacement suggests biceps
•tendinitis.
INSTABILITY TESTS
SHOULDER
PAIN MAY BE ATTRIBUTABLE TO AN
UNSTABLE SHOULDER.
USUALLY HISTORY OF A
PERIOD OF INTENSIVE SHOULDER USE (SUCH AS
COMPETITIVE SPORTS), AN EPISODE OF REPEATED
MINOR TRAUMA (OVERHEAD USE), OR
GENERALIZED LIGAMENT LAXITY. BOTH YOUNG
ATHLETES AND INACTIVE PERSONS ARE
AFFECTED, MEN AND WOMEN ALIKE.
ANTERIOR APPREHENSION TEST:
PATIENT LIE SUPINE OR IN SITTING . ARM IS ABDUCTED
TO 90º AND LATERALLY ROTATED SLOWLY BY THE
EXAMINER. WHILE PERFORMING PATIENT’S EXPRESSIONS
ARE NOTED FOR APPREHENSION/FURTHER RESISTENCE TO
ROTATION. THE TEST IS PERFORMED AT 60°, 90°, AND
120° OF ABDUCTION TO EVALUATE THE SUPERIOR,
MEDIAL, AND INFERIOR GLENOHUMERAL LIGAMENTS.
WITH THE GUIDING HAND, THE EXAMINER PRESSES THE
HUMERAL HEAD IN AN ANTERIOR AND INFERIOR
DIRECTION
Shoulder pain with reflexive
muscle tensing is a sign of an
anterior instability syndrome.
This muscle tension is an
attempt by the patient to prevent
imminent subluxation or
dislocation of the humeral
head.
NOTE:
When the patient complains of sudden stabbing
pain with simultaneous or subsequent
paralyzing weakness in the affected extremity,
this is referred to as the “dead arm sign.” It is
attributable to the transient compression the
subluxated humeral head exerts on the plexus.

It is important to know that at 45° of abduction,
the test primarily evaluates the medial
glenohumeral ligament and the subscapularis
tendon. At or above 90° of abduction, the
stabilizing effect of the subscapularis is
neutralized and the test primarily evaluates the
inferior glenohumeral ligament.
POSTERIOR APPREHENSION TEST:
PATIENT LIES SUPINE OR IN SITTING POSITION AND EXAMINER
FORWARD FLEX SHOULDER TO 90º WHILE STABILIZING THE
SCAPULA WITH OTHER HAND. EXAMINER THEN APPLIES A
POSTERIOR FORCE ON THE ELBOW AND MOVES THE ARM IN
ADDUCTION AND MEDIALLY ROTATION.
ANTERIOR AND POSTERIOR DRAWER TEST:
THE PATIENT IS SEATED. THE EXAMINER STANDS BEHIND THE
PATIENT. TO EVALUATE THE RIGHT SHOULDER, THE EXAMINER
GRASPS THE PATIENT’S SHOULDER WITH THE LEFT HAND TO
STABILIZE THE CLAVICLE AND SUPERIOR MARGIN OF THE
SCAPULA WHILE USING THE RIGHT HAND TO MOVE THE
HUMERAL HEAD ANTERIORLY AND POSTERIORLY.
INFERIOR APPREHENSION TEST/FEAGIN
TEST:
PATIENT STANDS WITH THE ARM ABDUCTED TO 90º AND ELBOW
EXTENDED AND RESTING ON TOP OF THE EXAMINER’S
SHOULDER. EXAMINER CLASP HIS/HER HANDS AROUND THE
PATIENT’S HUMERUS AND PUSHES THE HUMERUS DOWN AND
FORWARD. IN THIS SULCUS MAY ALSO BE SEEN ABOVE THE
CORACOID PROCESS.
SULCUS TEST:
PATIENT STANDS WITH ARM BY THE SIDE AND SHOULDER
MUSCLE RELAXED. THE EXAMINER GRASPS THE PATIENT’S
FOREARM BELOW THE ELBOW AND PULLS THE ARM
DISTALLY. THE PRESENCE OF SULCUS/INDENTATION
INFERIOR TO ACROMIAN IS THE INDICATIVE.
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