Shoulder

Look

 

Exposure

Splint

Sling

 

From Front

 

Skin

- scars

 

Swelling

- SCJ

- clavicle

- ACJ

- biceps (rupture long head)

 

Popeye Biceps

 

Wasting

- deltoid

- trapezius

- arm

 

Deltoid Wasting

 

From Side

 

Turn affected side towards you

Wasting

- pectoral contour

 

From Back

 

Scapular symmetry

- height

- winging 

 

Wasting

- supraspinatus

- infraspinatus

 

SS IS Clinical Photo 1SS IS Clinical Photo 2

 

Feel

"Where is it painful ?"

 

Bony prominences

- SCJ

- clavicle

- ACJ (compare with other side)

- acromium

- biceps tendon

 

Scapular spine

 

Supraspinous fossa

- ganglion

- osteochondroma

 

Infraspinous fossa

- tenderness

- cuff defect

 

Move

 

Forward flexion

 

Active

- both arms raised forward, supinated

- range

- check axilla

 

Abduction

 

Active

- elevate both arms in coronal plane, supinated

- initiation

- range (160°-180°)

- rhythm

- arc of pain

- shoulder hiking

 

Passive

- if not full, passive to 180?

- active v passive

 

Observe arm lowering 

- arc of pain

- drop arm

 

Extension

 

Active

- both arms raised backward

 

External rotation

 

Active

 

Elbows flexed to 90o and arms by side

- start with arms forward

- rotate arms outwards (90°)

 

Passive

If not full, passive

 

Reduced ER

 

Internal rotation

 

Active

- ask to run thumb up spine

- mark good and compare bad

- thigh / buttocks / waist / LS / T12 / angle of scapula (T7) / tip of scapula (T2)

 

Rotator Cuff Power / Integrity

 

Power of supraspinatous

- 30° abduction

- in plane of scapula (30° forward from coronal plane)

- forearm pronated (thumb to the ground)

- resisted abduction

 

Supraspinatous testing

 

Power of Infraspinatous

 

1. Grade power external rotation

 

Infraspinatous Power

 

2.  Extensor lag

- take out to full passive ER

- release and see if lags

 

3.  Hornblower's

- positive if drop and IR

- suggests massive PS tear

- teres minor

 

Power of Subscapularis

 

1.  Gerber's Lift off test

- Gerber's test is normal if patient can hold hand off buttock

- patient must have full IR & not be limited by pain to use this test

- "Pathological lift off test - patient is unable to lift the dorsum of his hand off his back"

- put dorsum of patient's hand on buttock then lift it off buttock & let go

 

Subscapularis Lift Off Test 1Subscapularis Lift Off Test 2

 

2. Belly Press Test / Nelaton Test

- resisted internal rotation with hand on belly

- must keep elbow forward

- otherwise patient uses shoulder retractors

- positive if drop elbow

 

Subscapularis Belly Press Test

 

Impingement tests

 

Neer's impingement test

- passive forward flexion 

- forearm pronated

- scapula stabilised

- positive test - pain at arc 70-120°

 

Shoulder Neers Test

 

Hawkin's impingement test

- forward flex elbow to 90°

- internally rotate and adduct arm

- positive test - pain

 

Shoulders Impingement Test

 

ACJ

 

Cross body adduction

 

ACj Cross Body Adduction Test

 

Biceps

 

Speed's test

- resisted forward flexion at 90° with forearm supinated

- assess pain or popping at bicipital groove (long head of biceps)

 

Speeds Test

 

Yergason's Test

- externally rotate arm with elbow 90°

- resisted supination

- assess pain or popping at bicipital groove (long head of biceps)

 

Yergason's Test

 

Compression-Rotation test / McMurray's Shoulder test

- test for SLAP lesion

- patient supine 

- shoulder abducted 90°, elbow flexed 90°

- compression force to humerus

- humerus rotated

- attempt to trap torn labrum, positive if pain & click

 

O'Brien's

- SLAP lesion

- arm across body, in plane of scapula

- pain with stress abduction, thumb down

- nil pain with thumb up

 

Obriens Test

 

Instability

 

Sulcus sign

- needs to be compared to the opposite side

- patient

- in front of patient

- hands in lap

- pull down on both elbows

- look for sulcus

 

Shoulder Sulcus Sign

 

Anterior / Posterior Drawer

- sit next to patient

- stabilise shoulder girdle with 1 hand

- thumb on spine of scapula

- forefinger on coracoid

- centralize humerus

- must compare to normal side

- translate humeral head forward with other hand

- anterior & posterior translation noted

 

Anterior Apprehension Test

- patient lying

- shoulder abducted and elbow flexed 90°

- externally rotate shoulder

- positive test - look for apprehension 

 

Jobe Relocation Test

- patient supine

- arm abducted to 90°

- forced external rotation

- relocate by pushing humeral head posteriorly & superiorly

- usually described by putting hand on humeral shaft

 

Posterior Stress Test 

- stabilise scapula

- place shoulder in 90° forward flexion & 90° IR & adducted

- apply posterior force

- patient experiences pain +/- apprehension

- unlike anterior test patient has positive test if pain only

- note should reproduce the patients symptoms

 

Load and Shift

- patient lying down

- their hand under examiners armpit

- grasp neck of humerus with both hands

- load humerus into glenoid axially

- examinate stability annterior and posterior

 

Ligamentous Laxity

 

Wynne-Davies Criteria

1. Thumb touching forearm on flexing wrist

2. Fingers parallel to forearm with wrist extension

3. Elbows extend past 180°

4. Knees extend past 180°

5. Foot dorsiflex past 45°

 

Ligamentous Laxity Elbow HyperextensionLigamentous Laxity Thumb to Forearm

 

"If 3 of the 5 pairs of joints examined in any one individual showed this degree of laxity it is taken as positive."

 

Thoracic Outlet Tests

 

Adson Manoeuvre

- head toward side tested, neck extended

- palpate radial pulse of extended arm

- patient inhales deeply

- positive test if decrease or obliteration in pulse with concomitant reproduction of symptoms

 

Wright's Manoeuvre

- head turned away from tested arm, neck extended

- arm in 90° abduction & 90° extension

- palpate radial pulse 

- patient inhales deeply

- positive test if decrease or obliteration in pulse with concomitant reproduction of symptoms

 

4C's

 

Cephalad Joint Neck

 

ROM

 

Compression Test

- slight extension

- compression

 

Spurling's test

- neck in lateral flexion, rotation

- stressed with compression

- positive if pain in ipsilateral extremity

 

Circulation

 

Radial pulse

 

Concealed

 

Axilla

 

Collagen