Shoulder Evaluation

1
Shoulder Evaluation
2
Shoulder Injuries

• Soft Tissue
• Contusions shoulder pointer
• Acute bursitis subdeltoid, subacromial
  (impingement)
• Sprains AC, SC
• Strains rotator cuff, deltoid, pectoralis major
• Tendonitis rotator cuff, biceps
• Structural
• Impingement Syndrome
• Biceps Rupture
• Brachial plexus (traction or compression)
• Thoracic Outlet Syndrome
• Luxations
• GH dislocation usually anteriorly
• GH subluxation
• Multi-directional instability
• Fractures
• Humeral
• Clavicular
• Sternum

3
Anatomy

• Bony
• Shoulder Girdle Clavicle, Scapula,
  Humerus Humerus bicipital groove, greater/lesser
• tubercle, head, deltoid tuberosity
• Scapula glenoid fossa, acromion process,
• coracoid process, spine, lateral (axial)
• border, medial border, supraspinatus
• fossa, infraspinatus fossa, superior
  angle,
• inferior angle
• Clavicle acromial end, sternal
  end Sternum manubrium, xiphoid process,
• body

4
Anatomy

• Muscles
• Rotator Cuff Supraspinatus, Infraspinatus, Teres
  Minor, Subscapularis (SITS)
• Scapular Rhomboids (major minor), Pectoralis
  Minor, Trapezius, Levator Scapulae, Serratus
  Anterior (winging scapula/long thoracic nerve)
• Humeral Latissimus Dorsi, Triceps, Pectoralis
  major, Biceps, Deltoid, Coracobrachialis, Teres
  Major

5
Anatomy

• Ligaments
• Acromioclavicular, Coracoclavicular (trapezoid
  conoid), Transverse, Sternoclavicular,
  Corocoacromial, Costoclavicular
• Joints
• Glenohumeral (made for mobility, not stability)
• Acromioclavicular
• Sternoclavicular
• Coracoclavicular
• Scapulothoracic (not a true joint)
• Bursa
• Subacromial
• Subdeltoid

6
Anatomy

• Blood Supply
• Subclavian artery vein, Brachial artery
• Nerve Supply
• Cervical Plexus (C1, C2, C3, C4)
• Brachial Plexus (C5, C6, C7, C8, T1)
• Axillary
• Median
• Musculocutaneous
• Radial
• Ulnar

7
Forces Acting on the Shoulder

• During the later stages of abduction, the Rotator
  Cuff muscles provide a downward pull on the
  humeral head
• Allows for the humeral head to pass under the
  acromion unimpeded
• Deceleration of the humerus in throwing is
  assisted by eccentric contractions of the
  infraspinatus teres minor

8
Forces Acting on the Shoulder

• Force Couple during abduction a force couple
  exists between the line of pull between the
  supraspinatus the deltoid m. group

9
Scapulothoracic Rhythm (Scapulohumeral)

• 0-30 All humerus movement
• setting phase
• 30-90 21 humerus abduction scapula abduct
• 90-full abduction 11 ratio

10
Evaluation - History

• MOI direction of arm, was it planted on the
  ground, fall on outstretched arm, land on the
  tip, was it abducted w/ ext. rotation
• Location of pain (Can you touch it or is it
  deep?)
• Onset (acute vs. chronic)
• Sounds/Noises
• Did you feel anything slip?
• Training Techniques
• Prior history
• Pain scale (scale from 1-10)
• What activities recreates the pain?

11
Evaluation - Observation

• How is the arm being held? Willingness to move
  limb?
• Deformities are the shoulders square or is
  there a drop off? Step Deformity? Levels of
  Shoulders even, uneven
• Musculature - Are there any noticeable spasms in
  the muscles?
• Bony Is anything sticking out in an abnormal
  direction?
• Discoloration
• Swelling

12
Painful Arc

• Pain is absent at the beginning of the ROM but
  develops near the midrange of a movement and then
  ceases as this is passed.
• Pain is caused when a tender tissue is painfully
  squeezed in the passing of a certain point during
  the ROM.
• Best seen in AROM, normally indicates impingement
  as tissue is pinched between the acromion process
  and one of the humeral tubercles.
• Usually occurs between 60-120º abduction.

13
Evaluation - Observation

• Level of Scapula Inferior angle _at_ T7, superior
  angle _at_ T2
• Position of Scapula winging, rotated

14
Evaluation - Palpation

• Jugular notch
• SC joint
• Clavicle
• AC joint
• Coracoid process
• Humeral head greater lesser tuberosity,
  bicipital groove
• Scapula spine, superior angle, medial lateral
  border, inferior angle

• Deltoid
• Rotator Cuff
• Pectoralis Major
• Trapezius
• Levator Scapulae
• Rhomboid major/minor
• Teres major
• Biceps brachii
• Triceps brachii
• Latissimus dorsi
• Serratus anterior

15
Evaluation Stress Tests

• ROM
• Apleys Scratch Test
• Shoulder flexion neutral to 170-180
• Shoulder extension neutral to 50-60
• Shoulder abduction neutral to 170-180
• Shoulder adduction because of the torso, there
  is no true adduction
• Shoulder internal rotation neutral to 80-90
• Shoulder external rotation neutral to 80-90
• Gerber Lift-off Test

16
Evaluation Stress Tests

• AC sprain
• Shoulder shrugs
• Compression test
• Distraction (traction) test
• Piano Key Sign
• Rotator Cuff Strain
• Drop Arm test
• Empty Can test (Centinella Test)
• Gerbers Lift Off test

17
Evaluation Stress Tests

• Biceps Tendonitis
• Yergasons Stability of tendon of long head of
  biceps in bicipital groove
• Speeds test Tendon of long head of biceps
• Ludingtons test
• Impingement
• Impingement Sign/Neer Impingement passive
  flexion
• Hawkins-Kennedy Impingement Sign passive
  internal rotation _at_ 90 shoulder flexion, elbow
  at 90
• Cross-over test

18
Evaluation Stress Tests

• Dislocation
• Anterior Apprehension test for Anterior GH laxity
• Relocation test (Jobes Relocation test) for
  Anterior GH laxity
• Posterior Apprehension test for GH laxity
• Glenohumeral Glide tests
• Sulcus sign for interior GH laxity hollowing
  out
• Anterior/Posterior Drawer test
• Glenoid Labrum
• Grind test
• Clunk test
• OBriens test SLAP lesion

19
Evaluation Stress Tests

• Thoracic Outlet Syndrome pressure is applied on
  the trunks medial cord of the brachial plexus,
  subclavian artery or subclavian vein
• Neurological onset numbness, pain, paresthesia
• Arterial onset coldness of skin, pallor,
  cyanosis in fingers, muscular weakness
• Venous onset muscular joint stiffness, edema,
  venous engorgement, thrombophlebitis

20
Evaluation Stress Tests - ? Pulse

• Adsons loss of radial pulse (compression of
  subclavian artery)
• Caused by ant. scalene muscle pec. minor
• Head looks towards abducted (30) externally
  rotated shoulder, elbow extended w/ thumb
  pointing up deep breath
• Allen Test loss of radial pulse (compression of
  neurovascular bundle)
• Caused by the pectoralis minor muscle
• Head looks away while elbow is flexed (90)
  shoulder abducted (90) shoulder passively
  horiz. abducted ext. rotated

21
Evaluation Stress Tests

• Military Brace Position loss of radial pulse
  (compression of subclavian artery by
  costoclavicular structures of shoulder)
• Humerus extended abducted 30 while neck head
  are hyperextended

22
Upper Extremity Neurological Exam - Sensory

• C5 lateral aspect of shoulder (deltoid),
  policemans patch
• C6 lateral elbow, lateral forearm, thumb
  index finger
• C7 middle finger
• C8 4th 5th fingers, medial forearm
• T1 medial elbow, medial humerus

23
Upper Extremity Neurological Exam - Motor

• C5 shoulder abduction
• C6 elbow flexion, wrist extension
• C7 elbow extension, wrist flexion
• C8 finger flexion, extension
• T1 finger abduction, adduction

24
Upper Extremity Neurological Exam - Reflex

• C5 biceps brachii
• C6 brachioradialis
• C7 triceps brachii
• C8 none
• T1 none

25
Nerves Branches of C5-T1

• Axillary
• Musculocutaneous
• Median
• Radial
• Ulnar