Shoulder assessment

1. Observation
a. b. c. d. Swelling, heat, redness Muscle wasting / muscle bulk Shoulder height i. Elevated overactive trapz and or levator scapula. Lev scap causes sheer anterior sheer force on c spine and cause scapular n neck pain) Scapular position i. Winging Serratus anterior weakness or long thoracic nerve lesion ii. Acromian process - equal to or higher than point of root of scapular. If root of scap higher, indicates tightness/over-activity levator scapular, rhomboids and pect minor, which causes downward rotation of scapular n the glenoid fossa a precursor of impingement. Consequently, upward rotators (upper/lower trapz n Serratus anterior become long/inhibited. iii. Elevation trapz / levator scap iv. Protraction usually with kythosis. Tight pect minor. (Serratus ant? As its a protractor) Shoulder position i. Medial rotation Thumbs facing towards body. Tight pectoralis major / latissimus Doris (subscapularis / teres major) Neck position Thoracic spine position Anterior translation i. Head of humerus 1/3 normal. Short infraspinatus and teres minor with associated lengthening of subscapularis and teres major/ tight posterior capsule or tight pectoral muscles with elongation of posterior capsule) Clavicles

e. f. g. h.

i. 2.

Clear C-spine a. b. Flexion, extension, lateral side flexion, rotation (with overpressure if full ROM and pain free) Accessory movements i. Note reproduction of pain

3.

Active ROM a. Flexion i. Range, restrictions, asymmetry, pain response ii. Pain full arc biceps tendon coracohumeral space iii. Protraction tight pect minor. Reduces subacromial and coraco humeral space. Impingement Risk iv. Scapular rhythm 1. Early rotation and elevation (reversed) may implicate weakness in stabilisers (Serratus anterior, lower trapz, rhomboids) or shortness and over-activity in upper trapz n levator scapulae Impingement risk and can occur in adhesive capsulitis 2. Juddering movement on downward rotation = poor eccentric control of upper, lower trapz and Serratus anterior v. Winging Medial border (weak Serratus anterior) vi. Medial rotation of humerus on full flexion Tightness latissimus dorsi or pect

major (medial rotators). Associated weak infraspinatus (external rotator). Greater tubercle does not clear Acromion, full flexion not achievable and impingement risk. vii. Note lumbar extension or chest elevation with humeral lateral rotation tight latissimus dorsi b. Abduction i. Range, restrictions, asymmetry, pain response ii. Pain full arc between 90 130 degrees supraspinatus tendon subacromial space. iii. Protraction tight pect minor. Reduces subacromial and coraco humeral space. Impingement Risk iv. Scapular rhythm v. Upward displacement humerus against acromion short overactive deltoid & supraspinatus with poor rotator cuff stabilising function (subscapularis, infraspinatus and teres minor) vi. Humeral lateral rotation timing - (medial rotator tightness and or weak infraspinatus) vii. Note side flexion with humeral lateral rotation tight latissimus dorsi c. Lateral Rotation i. Elbows at side & 90 deg abduction ii. NOTE Range, restrictions, asymmetry, pain response, scapular give iii. End feel 1. Hard - Capsular pattern 2. Soft correct scapula or glenohumeral translation d. Medial Rotation i. At 90 deg abduction - superior test to reach up behind back test which has 7 degrees of freedom. ii. Restricted & posterior pain tight posterior capsule e. f. Extension i. NOTE Range, restrictions, asymmetry, pain response Horizontal flexion (scarf test) i. ii. iii. iv. g. NOTE Range, restrictions, asymmetry, pain response Specific pain over AC joint Posterior pain tight posterior capsule Anterior pain nipped bursa

Functional tests i. Hand behind back ii. Hand behind neck 1. grossly restricted in adhesive capsulitis

h. Sporting activities i. Golf swing etc assessed to determine faulty mechanics 4. Passive ROM

a. b. 5.

As above Difference in end feel

Accessory movements (test joint restrictions) a. Acromioclavicular and sternoclavicular joints i. Test AP, PA, and caudal glide

b. Glenohumeral joint

i. AP - The A-P glide is given to increase the flexion range of motion or to

decrease the pain associated with the flexion and Internal rotation. ii. PA useful with GH pain with external rot or restriction of ext rot iii. Caudal glide distal humerus is grasped and pulled towards patients feet (distraction) iv. Cephalad glide compression v. Lateral distraction right hand placed in patients axilla and glides head of humerus laterally while left hand feels the movement.

6.

Resisted ROM a. Flexion (coracoradialis, biceps long head, pect major, deltoid anterior) i. Isometric 30-60 degrees ii. Biceps tendinopathy (flexion painful arc) 1. Speeds test a. Elbow extension and supination whilst resisting shoulder flexion. Pain in bicipital groove indicates tendinopathy

b. Abduction (supraspinatus, deltoid)

i. Neutral supraspinatus ii. 90 degrees neutral rotation (palm down) Deltoid iii. isometric 30-60 degrees

iv. Supraspinatus abnormality (weakness and/or partial tendon tear)

1. 2. Empty can position. 90 deg abduction, 30 degrees horizontal flexion, full internal rotation. Resisted abduction Active trigger points in supraspinatus and deltoid can be expected to weaken both muscles and produce intolerable pain when challenged by this test Repeat with retraction. Improved strength indicates that supraspinatus is not injured but is weak due to scapular dyskinesis.

3.

c. Lateral rotation (infraspinatus, teres minor, deltoid posterior)

i. Elbow into body elbow flexed.

ii. Drop sign (weak infraspinatus)

1.

Tests power of external rotation at 0 deg of abduction; 45 deg of external rotation, patient is asked to externally rotate against examiner's hand; if the patient's arm falls back to 0 deg of external rotation then a positive test recorded

iii. Lag test (weak infraspinatus)

1. Take the arm of the patient with 90 degree flexed elbow to fullest possible external rotation passively. Ask the patient to sustain and hold the arm in that position. If the infraspinatus is weak, the patient is not able to hold the arm in external rotation and the test is positive

iv. These tests could detect muscle weakness and rot cuff tear but combined effects of infraspinatus and subscap trigger points would also make it difficult to move your arm into lateral rotation and keep it there.

v. Hornblowers test (teres minor / infraspinatus tear)

1. Inability to hold arm in 90 deg abduction and full lateral rotation with 90 deg elbow flexion. Massive tear

d. Medial rotation (deltoid anterior, latissimus dorsi, teres major, pect major,
subscapularis) i. Elbow into body elbow flexed. Resisted ii. Subscapularis lift off test 1. Only if full medial rotation and no pain 2. In standing, hand behind back, able to lift hand off back (normal) if unable, indicates subscapularis rupture or dysfunction

iii. Gerbers test (only if lift off test normal)

1. Hand behind back. 2. Passively pulls hand away from back asks to hold it there 3. POSITIVE: for tear if hand immediately returns to back. 4. If able to hold it there. Examiner pushes hand as patient tries to resist. 5. POSITIVE: for weakness if hand gives way. 6. Normal: subscapularis will hold hand in place. Trigger points in supraspinatus, subscap and infraspin could cause these same effects, rendering the test unreliable for detecting rotator cuff tear

iv. Spring back test (subscap)

1. 2. 3. 4. Hand behind back. Passively lift hand off back and ask patient to keep arm there. Positive if hand springs back to spine. Indicates tendon tear If able to hold arm in place. Resistance given. If gives way, subscap weakness demonstrated Trigger points in infraspinatus, subscap, and supraspinatus could cause these same effects.

v. Abdominal compression test (subscap)

1. 2. Used when placing hand behind back too painful Press on abdomen with both hands while bringing elbows forward.

3. 4.

POSITIVE: when one elbow doesnt come forward demonstrates weakness in subscapularis muscle Restricted medial rotation can be sign of infraspinatus trigger point that prevents full medial rot. And subscap trigger points can be cause of weakness

7.

Palpation a. AC joint b. Bicipital groove with arm in lateral rotation. Lies medial to greater tuberosity. The biceps is located right under the groove between the middle portion (pars acromialis) and the anterior portion (pars clavicularis) of the deltoid. This groove can be made visible if the patient is asked to abduct the arm against resistance. c. Supraspinatus tendon in passive arm extension to expose the tendon d. Deltoid tendon midway down lateral aspect of humerus e. Subscapularis tendon - The palpating thumb is placed flat on the groove, the arm is brought in a neutral position along the body, the elbow flexed to 90. By executing small rotatory movements of the arm, the sharp (lateral) border of the lesser tuberosity can be felt cathing against the thumb. The subscapularis tendon itself is difficult to palpate as it is partly covered by the anterior portion of the deltoid muscle. It has a broad insertion of 3 to 4 cm. f. Infraspinatus tendon - maximum visual exposure of the Infraspinatus and teres minor tendons with the least amount of overlying tissue was shoulder flexion to 90 degrees, 10 degrees of shoulder adduction and 20 degrees of shoulder lateral rotation. In this position, the infraspinatus tendon is deep to the posterior deltoid muscle and inferior to the acromial angle. g. Upper Trapz h. Mid and lower Trapz i. Deltoids j. Rhomboids k. Infraspinatus Partially covered by posterior deltoid and trapz. l. Subscapularis m. Teres major n. Teres minor o. Serratus anterior p. Levator scapular q. Pectoralis major r. Pectoralis minor s. Latissimus dorsi

8. Muscle length tests

a. Rhomboids i. In sitting with scapula stabilised. Actively flex arms to 90 deg and protract taking arms into horizontal adduction so they cross at the elbows. ii. POSTIVE: tightness felt between scapula over rhomboids

b. Levator scapulae i. In sitting. Actively flex neck, rotate and side flex looking down towards armpit ii. POSITIVE: tightness compared to other side, or if scapula moves upwards c. Upper trapz i. In sitting. Actively flex neck, rotate and side flex away from problem side ii. POSITIVE: tightness compared to other side, or if scapula moves upwards

d. Pect minor i. In supine lying. Lateral border of spine of scapula should lie within 1 inch of the bed. ii. POSITIVE: lateral border of spine of scapula is over 1 inch from bed e. f. Deltoid n supraspinatus i. Scapula in neutral. The arm rests in abducted position if deltoid short Latissimus dorsi i. Lying supine. Patient unable to take arm into full flexion with lateral rotation of humerus without compensating with excessive lumber extension or chest elevation Pect major i. CLAVICLE POSITION: Lying supine. Be able to extend arm to bed with 90 deg abduction without anterior displacement of humerus ii. STERNAL POSITION: as above but with 120 deg abduction

g.

h. Infraspinatus and teres minor i. Short if there is not 70 deg of medial rotation with arm in 90 degrees abduction with scapula and humerus maintaining neutral position

9. Special Tests
a. Scapular assistance test
i. One hand placed on upper trapz, other on inferior border scapula. Assist scapular upward rotation as arm is elevated. ii. POSITIVE: reduces impingement signs and symptoms and indicates scapular control is required as part of rehab.

b. Impingement tests
i. All tests place infraspinatus on stretch. Trigger points in this area will send sharp pain to front of shoulder ii. Empty can test supraspinatus iii. Neers impingement test 1. Passive forward flex with internal rotation whist stabilising scapular.

2. False positive - Internal impingement Macdonald et al (2000)

- Bankart 25% - SLAP 46.1 %

iv. Hawkins/kennedy test

1. 2. Same concept (passively stressing the structures under acromion) but different forearm position. Passively raise the elbow to 90 deg forward flex whilst patient inwardly rotates arm

c. Instability tests
Tests the integrity of the shoulder joint for dislocations and subluxations. Important because dislocations and subluxation causes injury to connective tissue, strain or tear rotator cuff and damage glenoid labrum. Dislocations can lead to frozen shoulder in older people. Anterior dislocation: can cause Bankart lesion, in which anterior glenoid labrum has torn loose. Recurrent ant dislocation in an unstable shoulder occur when arm lifted out outwardly rotated. Posterior dislocation: make it impossible to outwardly rotate arm. Once capsule is damaged or torn, humeral head has difficulty staying in glenoid fossa, it easily pops out. Shortening of subscapularis and muscle imbalance caused by trigger points contribute to subluxation of humeral head, this means that trigger points can keep joint subluxed. Chronic subluxation in upward and forward direction could be primary cause of impingement syndrome, which in turn may be ultimate reason for most rotator cuff tears, especially supraspinatus tendon. Physicians use the sulcus test to see if theres too much laxity in joint 1. Sulcus test (inferior instability) a. Pulls down on arm (inferior traction) whilst feeling the sulcus, or gap

under the acromion for excessive downward movement of head of humerus

b. c. 2.

Physiotherapy usually recommended for strengthening rotator cuff, especially subscapularis Recurrent dislocation may require surgical repair of labrum and joint capsule.

Apprehension test a. c. Detects instability in anterior direction Guarding against further movement and fear in face is positive apprehension sign

b. Patient in supine, arm passively abducted and laterally rotated

a.

Can be augmented by pushing head anteriorly from behind b. The relocation test: pushing posteriorly on upper part of humerus. c. POSITIVE: if apprehension and pain is relieved by relocation test Reliability of test is undermined by extreme pain patient may feel with frozen shoulder and extremely active subscapularis trigger points 3. Load and shift test a. Actively moves humeral head forward, back and downwards in socket to see if there is excessive movement. Forward and back movement can actually dislocate the shoulder when joint is sufficiently lax b. Right hand grasps humeral head, left hand stabilises scapula c. Right hand loads joint to ensure concentric reduction and then applies anterior and posterior shearing forces. The direction and translation can be graded using scale 0-3

d.

Unless the looseness of joint is extremely obvious, test is quite subjective and relies very much on experience and skill of examiner

d. Slap lesion tests (To detect glenoid labrum tear)

i. Crank test (compression rotation test) 1. 2. 3. 4. To detect anterior labrum tear, or Bankart lesion Shoulder abduction 90 deg passively and slowly internally rotate while gental axial load (force on elbow towards GH joint) is applied through GH joint POSITIVE: pain, catching or grinding. Indicates disruption in labral rim. Common in recurrent dislocation

Crank test not possible to do with frozen shoulder ii. OBrien test 1. 2. 3. Arm held at 90 deg forward flexion, 10 deg horizontal adduction and maximal internal rotation Hold the patients wrist and resists patients attempt to horizontally adduct and forward flex the shoulder. The procedure is repeated in supination POSITIVE: if first manoeuvre produces pain and the 2nd manoeuvre doesnt bring on pain or symptoms

4.

e. ULTT
i. Rule out pain from neural structures