Shoulder Examinations and assessment PPT

Shoulder Examinations and assessment PPT

1. SHOULDER EXAMINATION

2. P A I N I NS T A B I L I T Y LOSS OF MOTION EX T R I NS I C O R I N T R I NS IC A C TI V E O R PASSIVE EVALUATION PRINCIPLES Get a History: Is this a new injury, old chronic injury Assessment: what is the primary problem ?

3. Evaluation Order H is t o ry I n s p ect ion Palpation Movement : ROM & strength Special tests: Rotator cuff disease & impingement Instability & Laxity , Biceps tendon & SLAP , AC & SC joint S EE FEEL M OVE

4. Subjective assessment What is the patient’s age? Does the patient support the upper limb in a protected position or hesitate to move it? If there was an injury, what exactly was the mechanism of injury? Are there any movements or positions that cause the patient pain or symptoms? What is the extent and behaviour of the patients pain?

5. Subjective assessment 6. are there any activities that cause or increase the pain? 7. do any positions relieve the pain? 8. What is the patient unable to do functionally? 9. How long has the problem bothered the patient? 10. Is there any indication of muscle spasm, deformity, bruising, wasting, paresthesia or numbness?

6. Subjective assessment 11. Does the patient complain of weakness and heaviness in the limb after activity? 12. Is there any indication of nerve injury? 13. Which hand is dominant?

7. Observation

8. INSPECTION Anterior side Posterior side Lateral Overhead Axillary Sometimes too obvious

9. Anterior view Forward head posture Step deformity (AC joint dislocation Sulcus sign for shoulder instability

10. Wasting of deltoid muscles

11. Deltoid Atrophy Pain at insertion site- mostly referred from rotator cuff pathology; rarely due to deltoid tendinitis

12. Subacromial region Swelling- bursitis Biceps tendon Rupture- Popeye bulge

13. Posterior side Scapula Position High – Sprengel’s Spine Fossae – supraspinatus & infraspinatus atrophy Winging of the scapula

14. Sprengel’s deformity

15. Lennie test

16. Winging of the scapula

17. Scapular winging

18. L ateral : prominent in LD atrophy S uperior : prominent in Supraspinatus & Trapezius atrophy Vertebral ; prominent in serratus ant . weakness/winging Borders of scapula

19. PALPATION T e n d er n e s s Swelling Palpable gap in muscles Acromioclavicular joint Coracoid process Subacromial bursa Biceps tendon

20. MOVEMENTS Active Passive R e sistiv e

21. FLEXION- 0- 16 / 1 8 ° - 0-45 ° - 18 ° FORWARD EXTENSION ABDUCTION- ADDUCTION - 0-45 ° CR O S S B O DY A DD UC TI O N

22. EXTERNAL ROTATION- 0-45 °

23. INTERNAL ROTATION- 0-55 °

24. Shoulder impingement syndrome

25. Reverse scapulohumeral rhythm

26. Internal and external rotation

27. Scapulohumeral rhythm

28. Apley’s scratch test Patient attempts to touch the opposite scapula thus testing abduction & ER and adduction & IR Good screening test for ROM assessment

29. Muscle strength tests Pectoralis major Latissimus d o rs i Deltoid

30. T r a p e z i us S err a t u s an t er io r R h o mb o i d s

31. NEUROMUSCULAR EXAMINATION Motor examination Sensory examination Deep tendon reflexes Cervical spine Spurling test, L- Hermitte sign Thoracic outlet syndrome Adson’s test, Hyperabduction test, Roos test Brachial Plexus Injury Brachial Neuritis Compression Neuropathies

32. SPECIAL TEST NEUROLOGICAL FUNCTION Upper limb neurodynamic test

33. SPECIAL TEST THORACIC OUTLET SYNDROME Roos test (Elevated arm stress test) Adson maneuver

34. Axillary nerve injury Anaesthesia in the ‘ Regimental badge area ’

35. INSTABILITY IMPINGEMENT SYNDROME ROTATOR CUFF TEAR BICEPS TENDON PROBLEMS AC JOINT PROBLEMS STIFF SHOULDER

36. Chronic Instability Instability can be- Unidirectional - anterior, posterior, inferior Multidirectional (MDI) – anterior &/ or posterior + inferior T U B S A M BRI Traumatic Unidirectional Bankart’s lesion Surgical t/t A t r a um a t i c Multidirectional Bilateral Rehabilitation Inferior capsular shift

37. CHRONIC UNIDIRECTIONAL INSTABILITY PROVOCATIVE TESTS to document the presence & direction of instability QUANTITATIVE TESTS To quantitate the amount of laxity Anterior Instability Crank test Fulcrum test Jobe’s relocation test Posterior Instability Jerk test Circumduction test Drawer tests Load & shift test for both anterior and posterior instability

38. Anterior shoulder instability Anterior apprehension (crank) test Anterior drawer test Crank and relocation test Fulcrum test Load and shift test

39. Anterior apprehension crank test

40. Anterior drawer test The patient's arm is pulled  anteriorly  to apply a gliding force to the glenohumeral joint. If an audible click is heard/ felt apprehension during the movement, the glenoid labrum may be torn, or the joint may be sufficiently lax to allow the humeral head to glide over the glenoid labrum rim.

41. Anterior drawer test

42. Crank and relocation test A. Perform the crank test B. Add fulcrum test C. If the examiner then applies a posterior translation stress to the head of the humerus or the arm (relocation test), the patient commonly loses the apprehension, any pain that is present commonly decreases, and further lateral rotation is possible before the apprehension or pain returns (Fowler sign or test or the Jobe relocation test) D. If the arm is released, pain and forward translation indicates positive test (SLAP /Bankart lesion,

43. Fulcrum test By placing a hand under the GH joint to act as a fulcrum, apprehension test becomes the fulcrum test

44. LOAD AND SHIFT TEST Grasp the humeral head and stabilize the shoulder. Seat the humerus on the glenoid fossa and push anteriorly and posteriorly to check for instability

45. Load and shift test in supine lying

46. POSTERIOR DISLOCATION SHOULDER ER restricted P r o m in e nc e in posterior deltoid LIGHT BULB SIGN

47. Posterior shoulder instability Jerk test Load and shift test Posterior apprehension test Push pull test

48. Jerk test The patient sits with the arm medially rotated and forward flexed to 90°. The examiner grasps the patient’s elbow and axially loads the humerus in a proximal direction. While maintaining the axial loading, the examiner moves the arm horizontally ( crossflexion /horizontal adduction) across the body A positive test for recurrent posterior instability is the production of a sudden jerk or clunk as the humeral head slides off ( subluxes ) the back of the glenoid

49. Jerk test

50. Load and shift test for posterior instability

51. Posterior apprehension test The patient is in a supine lying or sitting position. The examiner elevates the patient’s shoulder in the plane of the scapula to 90° while stabilizing the scapula with the other hand. The examiner then applies a posterior force on the patient’s elbow. While applying the axial load, the examiner horizontally adducts and medially rotates the arm. A positive result is indicated by a look of apprehension or alarm on the patient’s face

52. Circumduction test Pt standing, examiner standing behind & holds the arm in extension & abduction; performs circumduction Visible subluxation/ apprehension in position of foreward flexion 160 ° & adduction (position of risk) = instability

53. Push pull test The patient lies supine. The examiner holds the patient’s arm at the wrist, abducts the arm 90°, and forward flexes it 30°. The examiner places the other hand over the humerus close to the humeral head. The examiner then pulls up on the arm at the wrist while pushing down on the humerus with the other hand Normally, 50% posterior translation can be accomplished. If more than 50% posterior translation occurs or if the patient becomes apprehensive or pain results, the examiner should suspect posterior instability.

54. Inferior and multidirectional shoulder instability Sulcus sign Feagin test

55. Sulcus sign The patient stands with the arm by the side and shoulder muscles relaxed. The examiner grasps the patient’s forearm below the elbow and pulls the arm distally The presence of a sulcus sign indicate inferior instability or glenohumeral laxity but should only be considered positive for instability if the patient is symptomatic (e.g., pain/ache on activity)

56. The Feagin test arm abducted to 90° and the examiner pushes the humerus down and forward the examiner holds the patient’s arm at the elbow (elbow straight) abducted to 90° with one hand and arm holding the arm against the examiner’s body. The other hand is placed just lateral to the acromion over the humeral head. Ensuring the shoulder musculature is relaxed, the examiner pushes forward and downward Positive signs are apprehension on the patient’s face and sulcus

57. Anterior impingement test Hawkins kennedy test Neer’s test Yokum test

58. posterior impingement test Posterior internal impingement test

59. Labral lesions Active compression test of O’brien

60. Hawkins-Kennedy Test patient sitting with arm at 90 ° forward elevation and elbow flexed to 90 ° . Examiner then quickly moves the arm into internal rotation. +ve = Pain located to the sub-acromial space , Subacromial impingement, rotator cuff tendinitis involves horizontally adducting the arm across the body 10° to 20° before doing the medial rotation ( corocoid impingement test)

61. Yocum test

62. Neer Impingement test Examiner performs maximal passive forward flexion with internal rotation whilst stabilizing the scapula. + = Pain located to the sub- acromial space or anterior edge of acromion Subacromial impingement of supraspinatius & anterior part of infraspinatus

63. Posterior internal impingement test To perform the test, the patient is placed in the supine lying position. The examiner passively abducts the shoulder to 90° to 110°, with 15° to 20° extension and maximum lateral rotation The test is considered positive if it elicits localized pain in the posterior shoulder.

64. LABRAL TEARS A Bankart lesion occurs most commonly with a traumatic anterior dislocation leading to anterior instability Injury results in the labrum being detached anywhere from the 3 o’clock to the 7 o’clock position resulting in both anterior and posterior structural injury the stability of the inferior glenohumeral ligament is lost. The SLAP lesion has the labrum detaching (pulled or peeled depending on the mechanism) from the 10 o’clock to the 2 o’clock position Results from a FOOSH injury, occurs during deceleration when throwing, or arises when sudden traction is applied to the biceps the support of the superior glenohumeral ligament is lost.

65. Bankart lesions

66. SLAP LESIONS

67. Mechanism of injury for SLAP lesions

68. The patient flexes the arm to 90 ° with the elbow fully extended and then adducts the arm 10-15 ° medial to sagittal plane. The arm is then maximally internally rotated and externally rotate the patient resists the examiner's downward force. Pain on the joint line or painful clicking is produced in the first part of the test and decreased in the second part, the test is positive O’Brien test

69. CLUNK TEST The patient lies supine. The examiner places one hand on the posterior aspect of the shoulder over the humeral head. The examiner’s other hand holds the humerus above the elbow. The examiner fully abducts the arm over the patient’s head. The examiner then pushes anteriorly with the hand over the humeral head (a fist may be used to apply more anterior pressure) while the other hand rotates the humerus into lateral rotation A clunk or grinding sound indicates both a positive test and a tear of the labrum. The test may also cause apprehension if anterior instability is present.

70. Empty can test and drop arm test - Supraspinatus Dropping sign, Infraspinatus test and Lateral rotation lag sign - Infraspinatus Hornblower’s sign – Teres minor Lift off test/ abdominal compression test /bear hug test – Subscapularis Speed test / Yergason’s test- Biceps Rotator cuff tears

71. SUPRASPINATUS TEST

72. Supraspinatus “Empty Can Test” Pt attempts to elevate the arms against resistance with arms at 90 ° abduction in a plane 30 ° anterior true coronal plane and full IR (thumb pointing downward) with elbows extended. Positive = supraspinatus tear

73. Drop Arm test Examiner abducts patient’s shoulder to maximum. After warning the patient, examiner releases pt’s arm & asks him to lower the arm back to the side Pt able to lower the arm part way & then suddenly loses control- arm drops suddenly to the side Indicates large rotator cuff tear Also seen in axillary nerve palsy

74. INFRASPINATUS AND TERES MINOR TEST

75. Dropping sign The patient stands with the test arm by the side. The examiner stands by the test side and passively places the patient’s elbow in 90° flexion with the arm in 45° lateral rotation. The patient is then asked to isometrically laterally rotate the arm against resistance and then relax. If the patient is not able to maintain the laterally rotated position and the arm drops back to the neutral position - positive for an infraspinatus tear.

76. Lateral rotation lag sign The patient is seated or in standing position with the arm by the side and the elbow flexed to 90° The examiner passively abducts the arm to 90° in the scapular plane, laterally rotates the shoulder to end range and asks the patient to hold it For a positive test, the patient cannot hold the position and the hand springs back anteriorly toward midline, indicating infraspinatus and teres minor cannot hold the position due to weakness or pain

77. Hornblower’s sign The examiner elevates the patient’s arm to 90° in the scapular plane ( scaption ). The examiner then flexes the elbow to 90°, and the patient is asked to laterally rotate the shoulder against resistance. A positive test is indicated when the patient is unable to laterally rotate the arm and indicates a tear of teres minor. The patient is standing with the arms by the side and then is asked to bring the hands to the mouth. With a massive posterior rotator cuff tear, the patient is unable to do this without abducting the arm first This abduction with hands to the mouth is called hornblower’s sign.

78. Su b s c a p u l a r i s test

79. 1. “Lift off test/ Gerber’s test” Patient standing with hand behind back with the dorsum of the hand resting on the back. The hand is raised off the back by maintaining or increasing internal rotation of the humerus and extension at the shoulder. Full passive internal rotation is prerequisite. Inability = subscapularis tear/ dysfunction

80. 2. Abdominal compression test Patient attempts to press the hand do wn against abdomen with examiner preventing it. Useful when IR restricted. Inability = subscapularis tear/ dysfunction

81. 3. Bear hug test The patient stands with the hand of the test shoulder on top of the other shoulder with the fingers extended and the elbow in front of the body The examiner stands in front of the patient and tries to lift the hand away from the shoulder applying a perpendicular lateral rotation force while the patient resists the movement The examiner’s other hand stabilizes the patient’s elbow If the patient cannot hold the hand on top of the shoulder because of weakness, it is considered a positive test for subscapularis strain

82. The patient's elbow is flexed and their forearm pronated. The examiner holds their arm at the wrist. Patient actively supinates against resistance. Pain located to bicipital groove = +ve Yergasson’s test

83. Speed’s test The patient's elbow is extended, forearm supinated and the humerus elevated to 60 ° The examiner resists humeral forward flexion Pain located to bicipital groove = +ve

84. AC crossover Pt. elevates the affected arm to 90 ° , then actively adducts it If the patient feels localized pain over the AC joint, the test is positive

85. Crank test for different ligaments

86. Restriction of all range of motion, esp - Abduction & ER Pain on attempted movements Adhesive capsulitis

87. Note – ER restriction occurs in 2 conditions only Stiff shoulder Posterior dislocation Overhead athletes may have restriction of IR due to posterior capsular tightness

88. C o n c l u s i on Clinical examination of shoulder should be guided according to patient's age, chief complains and professional activities. All tests needn’t be performed to clinch the diagnosis. Merely knowledge of test is not enough, good practice is essential to perform the tests.