PALPATION_SHOULDER_2019.pptx

Physical Examination of Shoulder

1. PHYSICAL EXAMINATION OF SHOULDER Shamima Akter B. Sc (Honors) in Occupational Therapy & M. Sc in Rehabilitation Science Assistant Professor , Department of Occupational Therapy Bangladesh Health Professions Institute (BHPI) Centre for the Rehabilitation of the Paralysed (CRP) Chapain , Savar

2. Bony Palpation area of Shoulder Suprasternal notch Sternoclavicular joint Clavicle Coracoid process Acromioclavicular joint Acromion Acromion process Spine of scapula Greater tuberosity Lesser tuberosity Bicipital groove Border of scapula 13. Superior medial angle 14. Inferior angle 15. Supraglenoid tubercle 16. Infraglenoid tubercle

3. Suprasternal Notch Position: Behind the seated patient Instruction: Move hands medially from their position on the deltoid and acromion until you feel suprasternal notch.

4. Sternoclavicular joint Position: Behind the seated patient Instruction: Immediately lateral to suprasternal notch.

5. Clavicle Position: Behind the seated patient Instruction: Move laterally from the sternoclavicular joint and palpate in a sliding motion along the smooth anterior superior surface of the clavicle. First palpate the convex medial 2/3 , then palpate along the concave lateral 1/3 . Convex medial 2/3 Concave lateral 1/3

6. Coracoid process Position: Behind the seated patient Instruction: At the portion of the clavicular concavity , lower the fingers distally about one inch from the anterior edge of the clavicle, press laterally and posteriorly in an oblique line until you feel the coracoid process. The process facess anterolaterally . One inch below to clavicular concavity

7. Acromioclavicular articultation Position: Behind the seated patient Instruction: Palpate clavicle laterally for approximate one inch to the subcutaneous acromioclavicular articulation. During flexion and extension of shoulder it can be easily palpated. If you place three fingers (of the opposite hand) on top of the shoulder the AC joint will be beneath them. If you now swing the arm forward and back you will appreciate movement (rotation) between the acromion and the collarbone.

8. Continue… Acromion (part of scapula) Position: Behind the seated patient Instruction: The rectangular acromion , sometimes referred as the shoulder’s summit. Palpate its bony dorsum and anterior portion. Acromion Process (part of scapula) P osition: Behind the seated patient Instruction: Located on the lateral part of the shoulder, right above the shoulder joint.

9. Greater tuberosity Position: Beside the seated patient Instruction: From the lateral lip of the acromion , palpate laterally to the greater tuberiosity of the humerous , this lies inferior to the acromion’s lateral edge. Located just below acromion when arm is resting by the side. (proximal end of humerus ).

10. Lesser Tuberiosity Position: Beside the seated patient Instruction: Easiest to palpate with arm in shoulder external rotation. located medial to greater tuberosity on proximal end of humerus .

11. Bicipital groove Position: Beside the seated patient Instruction: The bicipital groove is located anterior and medial to the greater tuberosity and is bordered laterally by the greater tuberosity and medially by the lesser tuberosity, easiest to palpate with arm in external rotation .

12. Position: Back of the patient Spine of scapula Instruction: Move posteriorly and medially and palpate the acromion as it tapers to the spine of the scapula. Medial (vertebral) border Instruction: The edge of the scapula closest to the vertebral column (about 2 inches from the spinous processes). The medial border runs in a superior-inferior direction. Lateral ( axillary ) border Instruction: The lateral (or outer) edge of the scapula located between the inferior angle and the shoulder joint.

13. Superior medial angle Located above the vertebral border or medial aspect of scapula, level T2. Inferior angle Located between vertebral and axillary borders. The “point” at the bottom of scapula, level T7.

14. SOFT TISSUE PALPATION OF SHOULDER

15. Zones of shoulder The examination of the soft tissue structures of the shoulder has been divided into four clinical zones: Zone 1: Rotator cuff Zone 2: Subacromial and subdeltoid bursa Zone 3: Axilla Zone 4: Prominent muscle of shoulder girdle

16. Zone 1- Rotator cuff The cuff is composed of four muscles , three of which are palpable at their insertions into their greater tuberiosity of the humerous . These three, the supraspinatus , the infraspinatus and the teres minor,, are called the SIT muscles , since, in the order of their attachment, their initials spell ‘sit’.

17. Continue… In a modified anatomical position (with the arm hanging at the side), the supraspinatus lies directly under the acromion ; the infraspinatus is posterior to the supraspinatus and the teres minor is immediately posterior to the other two muscles . The forth muscle in the rotator cuff, the subscapularis , is located anteriorly and is not palpable .

18. Clinical significance of rotator cuff Rotator cuff tear Overuse injuries for repetitive movement Shoulder pain Shoulder subluxation due to paralysis of rotator cuff muscle

19. ORIGIN: Supraspinatous fossa of the scapula INSERTION : Superior facet on the greater tubercle of the humerus ACTION : initiation of abduction (15*) & lateral Rotation N.SUPPLY : Suprascapular.N (C5,C6)

20. INFRASPINATUS ORIGIN: Infraspinatous fossa of the scapula INSERTION: Middle facet on the gr.tubercle of the humerus ACTION : Lateral rotation of shoulder, strengthen the shoulder by bracing the head of humerus . N.SUPPLY : Suprascapular Nerve (C5,C6)

21. ORIGIN: lateral border of the scapula INSERTION : Inferior facet on the greater tubercle of the humerus ACTION: Ext.rotator & weak adductor N.SUPPLY : Axillary .N.(C5,C6)

22. ORIGIN: Medial 2/3 subscapular fossa, lateral border of tha scapula INSERTION : Lesser tubercle of the humerus ACTION: Stabilise the shoulder & prevents anterior displacement of the shoulder (med. rotation, adduction of arm) N.SUPPLY : Upper &Lower Subscapular .N (c5,c6)

23. Zone 2- Subacromial and subdeltoid bursa At points just below the anterior edge of the acromion , the bursa may extend as far as the bicipital groove. The subacromial bursa is a sac of fluid that separates the acromion from the rotator cuff. The bursa is underneath the coracoacromial ligament, acromion bone, and the deltoid muscle as shown in the illustration.

24. Clinical significance of Shoulder Zone- II Subacromial bursitis- It is a common cause of shoulder pain that is usually related to shoulder impingement of your bursa between rotator cuff tendons and bone (acromion) Subacromial impingement- Shoulder impingement syndrome, also called subacromial impingement, painful arc syndrome, supraspinatus syndrome, swimmer's shoulder, and thrower's shoulder, is a clinical syndrome which occurs when the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion.

25. Zone 3- Axilla The axilla (also, armpit , underarm or oxter ) is the area on the human body directly under the joint where the arm connects to the shoulder. The axilla is quadrilateral pyramidal structure through which vessels and nerves pass to the upper extremity. It also provides the under-arm sweat gland.

26. Palpation process Stand in front of the patient and abduct his arm with one hand as you gently insert your index and middle fingers into the axilla .

27. Boundary of axilla The fleshy anterior wall of axilla is formed by the pectoralis major muscle, it can be palpated during abduction (away from midline). The posterior wall formed by latissimus dorsi muscle, can be grasped by index and middle finger during abducted arm away from the midline. The medial wall is defined by ribs two to six and the overlying serrstus anterior muscle and The lateral wall by the bicipital groove of the humerous .

28. Contents of axilla Axillary artery and its branches Axillary vein and its tributaries Infraclavicular part of the brachial plexus Long thoracic and intercostobrachial nerves Five groups of axillary lymph nodes and the associated lymphatics Axillary fat and areolar tissue in which the other contents are embedded

29. Clinical significance of axilla Lymphogenic spread of breast cancer Breast cancer typically spreads via lymphatic vessels to the lymph nodes found in the axilla . Axillary intertrigo Excessive perspiration can result in axillary intertrigo. Intertrigo is an inflamed skin condition caused by heat, friction, and moisture . A warm, wet underarm may accommodate the growth of pathogenic bacteria, yeasts, and fungi.

30. Axillary artery

31. Axillary vein

32. Brachial Plexus

33. Continue..

34. Zone 4- the prominent muscles of shoulder girdle The muscles that move the shoulder girdle and glenohumearl joint can be divided into three Sternocleidomastoid muscle Pectoralis major Biceps

35. Continue… Sternocleidomastoid muscle The muscle will be more prominent on the site of opposite that to which the head is turned, and The muscle can be palpated at its distal origin more easily if the patient turns his head first to one side, then to the other. Pectoralis major To plapate pectoralis major muscle, instruct the client to adduct the arm at the shoulder joint against resistance. Feel the contraction of sternocostal head and palpate toward its proximal attachment. Biceps The biceps become more prominent and more easily palpable when the elbow is flexed.

36. Possible Question Describe physical examination/ soft tissue palpation of shoulder zone 1/2/3/4 Describe the physical examination procedure of axilla / rotator cuff/ subacromial or subdeltoid bursa/ prominent muscle of shoulder In which shoulder zone, one can palpate axilla, describe the palpation procedure of axilla. Write down the names of shoulder zone with their corresponding clinical significance.