Shoulder Evaluation

1
Shoulder Evaluation

• Part Deux

2
Overview

• Soft tissue palpation
• Muscular anatomy
• Evaluation
• Special tests

3
Soft Tissue Palpation

• Sterno-Clavicular (SC) ligament
• Acromio-Clavicular (AC) ligament
• Coraco-Clavicular (CC) ligament
• Coraco-Acromioclavicular (CA) ligament
• Glenohumeral joint
• Subacromial bursa
• Subdeltoid bursa

4
Muscular Anatomy

• Supraspinatus
• Infraspinatus
• Teres minor
• Subscapularis
• Pectoralis major
• Pectoralis minor
• Scalenes

• Teres major
• Latissimus dorsi
• Serratus anterior
• Biceps brachii
• Triceps brachii
• Rhomboid major minor
• Deltoid

5
Intrinsic Musculature Supraspinatus

• O Supraspinous fossa
• I Superior greater trochanter
• A?
• N Suprascapular nerve

6
Intrinsic Musculature Infraspinatus

• O Infraspinous fossa
• I Posterior greater tubercle
• A ?
• N Suprascapular nerve

7
Intrinsic Musculature Teres Minor

• O Lateral scapula
• I Posterior greater tubercle
• A ?
• N Axillary nerve

8
Intrinsic Musculature Subscapularis

• O Anterior surface of scapula (subscapular
  fossa)
• I Lesser tubercle of humerus
• A ?
• N Subscapular

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Pectoralis Major

• O Clavicle, sternum, and ribs
• I Intertubercular groove of humerus
• A Int. rot, horiz. add, flex, add below 90, abd
  above 90
• N pectoral

11
Pectoralis Minor

• O Anterior surfaces of ribs 3-5
• I Coracoid process
• A Abd, Down rot, dep
• N Medial pectoral

12
Scalenes

• O Transverse processes of C2-C7
• I First second ribs
• A Rib elevation head rotation (same side)
• I Spinal nerves C3-C8

13
Teres Major

• O Inferior 1/3 of lateral border of scapula
• I Medial intertubercular groove of humerus
• A Ext, add, IR
• N Lower subscapular

14
Latissimus Dorsi

• O Ilium, sacrum, lumbar vertebrae, and lower 6
  thoracic vertebrae
• I Anterior humerus
• A Add, in rot, ext
• N Thoracodorsal

15
Serratus Anterior

• O Ribs 1-9 on lateral thorax
• I Medial border of scapula
• A Abduction, up rot
• I Long thoracic nerve

16
Biceps Brachii

• O LH-Superior glenoid SH-Coracoid
• I Radial tuberosity
• A Elbow flexion supination, shoulder flexion
• N Musculocutaneous

17
Triceps Brachii

• O LoH- infraglenoid lip of scapula LaH-
  posterior humerus MH- medial posterior humerus
• I Olecranon process
• A Elbow extension, shoulder extension
• N Radial

18
Rhomboids

• O Spinous processes of C5-T5
• I Medial border of scapula
• A Adduction, down rot, elev
• N Dorsal scapular nerve

19
Deltoid

• O Clavicle, acromion, scapular spine
• I Lateral humerus
• A flex, ext, in rot, ex rot, add, abd, horiz
  add, horiz abd (everything!)
• N Axillary

20
Evaluation

• Passive/Active ROM (Shoulder)
• Flexion
• Extension
• Abduction
• Adduction
• External rotation
• Internal rotation

21
Evaluation

• Passive/Active ROM (Scapula)
• Elevation
• Depression
• Abduction (protraction)
• Adduction (retraction)
• Internal rotation
• External rotation
• Circumduction
• Apley scratch test

22
Special Tests (31)

• Fracture/sprain test (1)
• Rotator cuff tests (6)
• Glenohumeral instability tests (11)
• Biceps tendon tests (6)
• Impingement tests (3)
• Thoracic outlet tests (4)

23
AC-SC Stress Test (fracture/sprain)

• The examiner palpates the patients clavicle and
  manipulates it inferiorly, superiorly, medially,
  and laterally
• Pain or crepitus indicates a positive test for
  possible clavicular fracture

24
Drop Arm Test (rotator cuff)

• Patient begins by abducting both arms to 90
  degrees
• Examiner then pushes downward on both arms with
  equal force
• Test is positive for rotator cuff injury if
  patient experiences pain or pts arm(s) can be
  pushed down without springing back into position
  once the examiner suddenly stops applying the
  downward force

25
Empty Can Test (rotator cuff)

• Pt in standing, the examiner instructs pt to
  internally rotate the shoulder and point the
  thumb toward the floor
• Examiner then resists the pts movement into full
  abduction
• Examiner should perform the test in four
  different planes
• Abduction between 0 and 45 degrees in front of
  the body supraspinatus
• Abduction/flexion greater than 45 degrees in
  front of the body but less than 90 degrees
  infraspinatus
• Shoulder flexion in the empty can position
  straight out in front of the body teres minor
• Test performed across the body subscapularis
• Any pain or weakness in any of the movements is a
  positive test for strain of the affected rotator
  cuff muscle(s).

26
Arms Over Head (rotator cuff)

• Pt in standing, the examiner instructs the pt to
  externally rotate the shoulders and actively lift
  both arms overhead
• Test positive for rotator cuff strain if the pt
  notes pain and/or is unable to perform the
  movement 

27
High Five Test (rotator cuff)

• Pt begins standing with the arms abducted to 90
  degrees and externally rotated, and the elbows
  flexed to 90 degrees
• From this position, pts hands will remain in the
  frontal plane, however, the palmar surface will
  be positioned anteriorly and the hands will be
  held overhead
• Examiner then uses both of his/her hands to
  forcefully push the pts hands posteriorly while
  pt resists
• Pain indicates a positive test for muscle strain
  to one or more of the rotator cuff muscles

28
Lift Off Sign (rotator cuff)

• The examiner prepositions the pt with dorsal
  surface of pts hand over the lumbar spine (end
  range shoulder internal rotation)
• Examiner applies resistance as pt attempts to
  lift the hand off the spine and push posteriorly
• Weakness indicates a positive test for
  subscapularis muscular injury

29
Resisted Pull Test (tendinitis vs. bursitis)

• Examiner stabilizes the pts involved upper arm
  and resists active shoulder external rotation
  and/or abduction
• Pt is asked to rate his/her pain
• Obvious pain is a positive sign for rotator cuff
  tendon pathology and/or subacromial bursitis
• Examiner then applies a caudal pull to the upper
  arm, resulting in a traction force at the
  glenohumeral joint
• During the pull, pt is instructed to repeat the
  resisted active shoulder external rotation and/or
  abduction
• If pain was present when the test was performed
  with no pull, reduced pain with a pull is
  indicative of subacromial bursitis, while no
  change or increased pain is indicative of rotator
  cuff pathology.