Shoulder

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Shoulder

• Ross Brakeville PT, DPT, STC
• Woodstock Physical Therapy Performance Institute

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Evaluation Strategies

• Test, dont guess!
• George Davies

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Anatomy
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Anatomy
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Anatomy
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Anatomy
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MD

• Limited clinical evaluation (labrum)
• Specificity 85
• Sensitivity 90
• X-ray
• Bone versus tissue
• MRI
• Specificity 85
• Sensitivity 59
• Liu SH, et al. AJSM 24(2) 149-154, 1996

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Subjective Exam History(Goal to confirm PE
with SE)

1. Onset
2. Etiology (Macro vs. Micro trauma)
3. Past treatments and tests with results
4. Current c/o
5. PMHx
6. Review of symptoms
7. Subjective Score with limitations
8. Pain levels
9. Patient Goals

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Mechanism of Injury

• Self Imposed 80
• Overuse
• Poor Mechanics
• Trauma 20
• Batt

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Physical Exam

• Posture
• Head and Neck
• Scapula
• Shoulder position
• Atrophy/Deformity
• Supine shoulder position
• Skin

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Physical Exam

• Active Range of Motion
• Painful Arc pain free movement at the beginning
  of the motion, a painful portion usually in the
  mid-ROM, and pain-free movement to the terminal
  ends.
• bursitis
• impingement
• subluxation
• capsular hypomobility
• scapular mobility
• Cyriax

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Physical Exam

• Active Range of Motion
• Shoulder Shrug Sign Shoulder complex elevation
  due to compensation of the upper trapezius muscle
  and leaning in the opposite direction. Due to
  pain, weakness, rotator cuff tear or capsular
  hypomobility.
• Davies, GJ

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Physical Exam

• Lateral Scapular Slide test 0, 45, 90, 120,
  150.
• gt1cm difference is positive
• Kibler
• Davies

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Physical Exam

• Neurovascular
• Sensation
• dermatome specific
• Reflexes
• biceps C5
• brachioradialis C6
• triceps C7
• Pulses
• Skin changes
• Nail beds

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Physical Exam

• Brachial Plexus

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Physical Exam

• Neurovascular
• MMT
• Trapezius CN XI, C2 - 4 (spinal accessory
  nerve)
• Rhomboid/Levator C4-5 (dorsal scapular nerve)
• Serratus anterior C5-7 (long thoracic nerve)
• Deltoid/Teres minor C5-6 (axillary nerve)
• Supra/Infraspinatus C4-6 (suprascapular nerve)
• Latissimus dorsi C6-8 (thoracodorsal nerve)
• Pec major C5-T1 (lateral medial anterior
  thoracic)
• Pec minor C7-T1 (medial anterior thoracic)
• Subscapularis C5-7 (subscapular nerve)
• Teres Major C5-7 (lower subscapular nerve)

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Physical Exam

• Supraspinatus tear
• Normal - lag
• Partial tear lt 1cm lag
• Full tear gt 1cm lag
• Davies

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Physical Exam

• Infraspinatus/Teres minor tear position at 45
  abd and 90 abd
• Normal - lag
• Partial tear lt 1cm lag
• Full tear gt 1cm lag
• Davies

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Physical Exam

• Subscapularis tear
• Normal - lag
• Partial tear lt 1cm lag
• Full tear gt 1cm lag
• Davies

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Physical Exam

• Sulcus Sign (0 90) tests instability
• Grade I 5-10mm Humeral head rides up the
  glenoid slope but not over the rim.
• Grade II 10-15mm Humeral head rides over
  glenoid rim but spontaneously reduces when stress
  is removed.
• Grade III - gt15mm Humeral head dislocation
  without reduction.
• Davies, GJ

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Physical Exam

• Anterior Impingement
• Neer
• Supraspinatus, LHB
• Hawkins-Kennedy Supraspinatus
• Coracoid
  Supraspinatus, LHB, subscapularis
• Cross-over
• Med., Lat., Sup., Post.
• Jobes
• Supraspinatus
• Davies

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Physical Exam

• Load Shift (ant. post.) - Sitting
• tests instability
• Davis
• Tzannes et al

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Physical Exam

• Compression with rotation test SLAP
• c/o
• pain deep or in shoulder
• Locking
• Clicking/clunking
• Davies
• Huijbregts

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Physical Exam

• Anterior Posterior slide test (passive) SLAP
• c/o
• pain deep or in shoulder
• Locking
• Clicking/clunking
• Davies
• Huijbregts

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Physical Exam

• Anterior slide test (active) SLAP
• Patient pushes back against force.
• c/o
• pain deep or in shoulder
• Locking
• Clicking/clunking
• Sensitivity 78.4
• Specificity 91.5
• Kibler

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Physical Exam

• OBrien test SLAP
• Resisted flexion in 10 H/Add with internal
  rotation that is when performed in external
  rotation.
• c/o
• pain deep or in shoulder
• Locking
• Clicking/clunking
• Sensitivity 100
• Specificity 98.5
• Kibler

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Physical Exam

• Speeds test Biceps and SLAP
• c/o
• pain along biceps tendon
• Davies

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Physical Exam

• Yeargasons Test Biceps
• Elbow supination with shoulder external rotation.
• c/o
• Biceps pain
• Long head of biceps subluxes
• Davies

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Physical Exam

• Crank Test SLAP
• axial load with internal rotation sitting and
  supine
• c/o
• pain deep or in shoulder
• Locking
• Clicking/clunking
• Sensitivity 91
• Specificity 93
• Liu et al

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Physical Exam

• Provocation test SLAP
• Check max supination to max pronation
• Sensitivity 100
• Specificity 90
• Mimori et al

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Physical Exam

• Passive Range of Motion
• Elevation
• Internal Rotation with Extension
• Horizontal Abduction with External Rotation
• Internal Rotation without Protraction
• Total arc of motion for I.R/E.R. in 90 H.Abd
  160
• Davies GJ. Advances and Evidence-based Practice
  of Examination and Treatment
• of Patients with Selected Shoulder Conditions.
  Oct. 25-26, 2003

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Physical Exam

• Clunk test Labrum
• Supine axial compression and rotate pushing
  humeral head anterior, posterior, inferior.
• c/o
• pain deep or in shoulder
• Locking
• Clicking/clunking
• Davies

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Physical Exam

• Jerk test and Posterior glide posterior
  capsule, ligaments and labrum.
• Pain with pressure
• Jerk
• Click/clunk
• Sublux
• Davies

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Physical Exam

• Jobes/Apprehension Anterior, middle, and
  inferior ligaments/capsule instability
• Davies

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Physical Exam

• Jobes subluxation Internal Impingement
  articular side of infraspinatus, supraspinatus,
  possible SLAP
• Davies

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Physical Exam

• Kinesthetic/Proprioception testing
• Flexion lt90, gt90
• Abduction lt90, gt90
• External rotation lt45, gt45
• Internal rotation lt45
• Avg Males 3 Range 5
• Females 4 Range 7
• Davies GJ, Hoffman SD.

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Physical Exam

• Functional Testing

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Physical Exam

• Functional Testing