EVALUATION OF THE SHOULDER

Shoulder Injury Evaluation Overview

AnatomyHistoryObservationPalpationNeurological examCirculatory exam

Shoulder AnatomyClavicleScapulaHumerusArticulations:

◦ Sternoclavicular joint

◦ Acromioclavicular joint

◦ Glenohumeral joint

Scapula Winging

Shoulder AnatomyLigaments

◦ AC◦ Coracoclavicular

ligaments ◦ Glenohumeral

ligaments/joint capsule

Labrum

Shoulder AnatomyMusculature

◦ “Rotator cuff” Subscapularis Supraspinatus Infraspinatus Teres Minor

Shoulder AnatomyMusculature

◦ Pectoralis major◦ Deltoid◦ Trapezius

Shoulder AnatomySubacromial

bursa

HistoryMechanism of injury:1. Describe the mechanism of injury2. What was the position of the arm at impact?3. Did you hear or feel anything at the time of

injury?4. Was the arm forced beyond normal limits?5. Previous Injury? 6. P.Q.R.S.T.

Observation1. Swelling2. Skin color3. Signs of trauma4. Skin temperature5. Atrophy – Muscle shrinking6. Abnormal position

Observation8. Arm hanging limp9. Appear to be in pain 10. Compare 11. Symmetry 12. Deformities 13. Muscle spasm14. Holding or supporting arm 15. Moving or using involved extremity 16. Overall position, posture, and alignment

Palpation: Bone1. Acromion process 2. Clavicle 3. Acromio-Clavicular (AC) joint 4. Sterno-Clavicular (SC) joint 5. Coraco-Clavicular (CC) joint 6. Coracoid process 7. Axilla

Palpation: Bone8. Head of humerus 9. Greater tuberosity 10. Lesser tuberosity 11. Bicepital groove 12. Deltoid tuberosity 13. Humerus 14. Scapula

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)

Apprehension Test (GH instability):

Pt. begins in seated or supine w/ shoulder relaxed, elbow flexed to 90 degrees, and arm abducted to 90 degrees

Examiner then passively externally rotates pt’s arm, looking for resistance, slipping, or obvious signs of apprehension

If pt demonstrates or exhibits any of the preceding signs, test is positive for anterior glenohumeral capsule laxity

Cross Arm Test (GH instability):

Examiner begins by facing the standing pt

Examiner passively crosses the pt’s arms and simultaneously pulls both of the pt’s arms across the body

Examiner then changes the directions and repeats the test

For example, if the left arm was initially on top, the arms should be positioned so that the right arm is on top for the second portion of the test

If pt experiences pain, the test is positive for glenohumeral capsule (most likely posterior) sprain

Sulcus Sign (GH instability): Pt either seated or standing with the

arms relaxed at the sides Examiner palpates the humeral head

with one hand and grasps the pt’s distal arm at the wrist with the other hand

Examiner then pulls inferiorly on the pt’s arm, looking for inferior movement

A positive sulcus will typically demonstrate a “dimple” where the humeral head should be when it is pulled inferiorly

The dimple will disappear when the arm is released

If inferior translation is apparent, the test is positive for inferior glenohumeral capsule laxity.

Sulcus Test

Anterior-Posterior (A-P) Drawer Test (GH instability):

Pt begins from the supine position with the arm abducted to 90 degrees and the shoulder unsupported and off of the table

Examiner then uses both hands (interlocked) to grasp the pt near the tricep

Examiner then slowly moves the pt’s arm so as to translate the humeral head anteriorly and posteriorly

This is performed simply by pulling up on the proximal arm and then releasing

Test is positive for anterior and/or posterior glenohumeral instability if the examiner observes noticeable excessive movement or laxity

Clunk Test (GH instability):

Examiner begins by placing one hand over the anterior and posterior aspects of the pt’s shoulder (the humeral head is palpated) while the other hand is used to grasp the pt’s distal humerus just above the elbow

Examiner then passively internally and externally rotates the pt’s arm in varying degrees of abduction and flexion

A palpable “clunking” or grinding sensation indicates a positive test and is indicative of a possible glenoid labrum tear

Obvious apprehension may indicate anterior glenohumeral instability

Relocation (Fowler’s) Test (GH instability):

Pt begins from the supine position with the shoulder supported by the examination table and abducted to 90 degrees

Pt’s elbow is also flexed to 90 degrees. The examiner then exerts a downward pressure to the humeral head (at the anterior shoulder)

Pain on reduction (after pressure is removed) indicates a positive test for glenohumeral instability.

Special Tests (13)Biceps tendon tests (6)Impingement tests (3)Thoracic outlet tests (4)

Yeargason Test (LH biceps):Examiner begins by positioning the standing

pt into 90 degrees of elbow flexion with the arm at the side

Examiner uses one hand to palpate the long head of the biceps and the other at the distal arm to provide resistance

Examiner then instructs pt to attempt to first externally then internally rotate the shoulder as the examiner resists the movement

Test is positive for biceps tendon subluxation (and subsequent tenosynovitis) if pt experiences pain or the examiner notes palpable crepitus.  

Speed’s Sign (LH biceps):Examiner first palpates the

tendon of the long head of the biceps (deep in the anterior deltoid)

Examiner then instructs pt to flex the elbow as the examiner resists

Pain indicates a positive sign for bicepital tenosynovitis

Speeds test

Lippman’s Test (LH biceps):

Pt begins with the elbow flexed to 90 degrees and the humerus resting at the side

Examiner palpates the long head of the biceps and moves 3 inches distally

Examiner then rolls the biceps tendon against the humerus

Pain indicates a positive test for long head biceps tendon subluxation

Hawkins-Kennedy Test (impingement):Examiner passively positions pt’s

shoulder in 90 degrees of flexion, 90 degrees of elbow flexion, and end-range shoulder internal rotation

Apprehension or sensations of pain are considered a positive test for subacromial impingement syndrome

Impingement

Adson Test (thoracic outlet syndrome):Examiner begins by palpating pt’s radial

pulsePt’s arm is then abducted, extended, and

externally rotated while the examiner continues to palpate the pulse

Pt is then instructed to take a deep breath and turn the head toward the arm being tested

A disappearance of the radial pulse is a positive test that indicates a compression of the subclavian artery by the medial scalene muscle

Allen Test (thoracic outlet syndrome):Pt begins from a standing positionExaminer passively flexes pt’s elbow

to 90 degrees, then abducts and externally rotates pt’s shoulder

Examiner then palpates pt’s radial pulse and instructs pt to look away from the side being tested

A disappearance of the radial pulse indicates a positive test for thoracic outlet syndrome

Shoulder Injuries Clavicle Fracture:

Fall On Out-Stretched Hand (FOOSH) or direct blow

Athlete will usually support arm w/ non-injured arm

Gross deformity Immobilize & treat for shock. Refer for

X-rays/consult Splint in figure 8 brace for 6-8 weeks

Humeral Fracture: Direct blow, dislocation, or FOOSH Need X-ray…usually hard to recognize Splint & refer Out 2-6 months :(

Fractures

Shoulder InjuriesAnterior Glenohumeral Dislocation

◦ Usually posterior force w/ forced external rotation (arm tackle)

◦ Obvious deformity Flattened deltoid contour Humerus comes to rest in axilla

◦ Immobilize immediately◦ RICE

Anterior dislocation

Shoulder InjuriesSternoclavicular sprain

◦ Relatively common in sports; FOOSH of direct blow◦ Usually clavicle will be upward & forward ◦ RICE, immobilization 3-5 weeks

Acromioclavicular sprain◦ “Separated shoulder”◦ Direct blow to tip of shoulder or FOOSH◦ “Piano-key” sign◦ RICE, immobilize, & refer

Shoulder InjuriesShoulder impingement syndrome

◦ Compression of supraspinatus, subacromial bursa, and/or LHBB

◦ Pain, numbness, and tingling◦ Restore normal biomechanics to shoulder (ther. ex)◦ Cease causative activity

Rotator cuff tears◦ Rare in people under 40, but do happen in sports◦ Usually @ humeral insertion◦ Pain & weakness◦ RICE, exercises to restore function

Low weights!!!!!! High reps okay, though

Shoulder InjuriesThoracic Outlet Compression Syndrome

◦ Overuse disorder◦ Numbness, burning & tingling in arms & hands◦ Caused by compression of brachial plexus

between upper ribs and clavicle◦ Treat with therapeutic exercise

Retraction exercises Upper rib mobilizations

Rehabilitation of The Shoulder Complex

Immobilization after injuryGeneral body conditioningShoulder joint mobilizationFlexibilityMuscular strengthRegaining neuromuscular controlFunctional progressionReturn to activity