Evidence-Based Shoulder Assessment - Cloud Object …€¦ · EVIDENCE-BASED SHOULDER ASSESSMENT...

E V I D E N C E - B A S E D S H O U L D E R A S S E S S M E N T A O TA C O N F E R E N C E 2 0 1 6

DANA WASHBURN, MS, OTR/ L, CKTP T M

Netter 2011

LEARNING OBJECTIVES

• Gain evidence-based knowledge in at least five areas of

shoulder assessment

• Be aware of at least five evidence-based special tests for

the shoulder

• Be able to construct a comprehensive strategy for

evidence-based assessment of shoulder dysfunction

INTRODUCTION: SHOULDER PAIN IS A COMMON

MEDICAL CONDITION

• Shoulder pain is the third most common musculoskeletal

reason for seeking medical care (Hermans et al 2013)

• Rotator cuff disease is the most common cause of shoulder

pain seen by physicians (Hermans et al 2013)

• 1% of adults over the age of 45 present with present with

shoulder pain each year (Donnelly et al 2013)

SHOULDER DYSFUNCTION IS COMPLEX

• The shoulder has the greatest range of motion of any joint

in the body (Cooper 2014) and restriction of it can have a

significant effect on functional ability (Donnelly 2013)

• The etiology of shoulder dysfunction is often complex and

difficult to assess clinically (Donnelly 2013)

• Causality of shoulder dysfunction is difficult to quantify

yet occupational therapists are asked do this every day by

general practice doctors

COMMON TYPES OF SHOULDER DYSFUNCTION

• Acute: fracture, dislocation, muscular injury, glenoid labral

tears

• Chronic: osteoarthritis, rotator cuff tears, recurrent

dislocations (instability), biceps long head tendonitis,

rotator cuff tendonitis, adhesive capsulitis, impingement

• Neuropathic: cervical spine pathology, herpes zoster

infection, or brachial neuritis

• (Donnelly et al 2013, Durall 2013)

UPPER EXTREMITY ANATOMY REVIEW: SHOULDER COMPLEX

(COOPER 2014)

• Has the greatest range of motion (ROM) in the entire body

• Has three bones: the humerus, the clavicle, and the scapula

• Has three joints: glenohumeral, acromioclavicular, and

sternoclavicular

• Has one pseudojoint: the scapulothoracic articulation

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IMPORTANCE OF ROTATOR CUFF (RC)

• Primary mover of GH joint

• Supraspinatus, infraspinatus, subscapularis, and teres minor

• Accessory muscles can be very important as well: e.g., serratus anterior causes scapular winging; lower trapezius weakness can cause elevation of the shoulder

• Supraspinatus most frequently injured

ROTATOR CUFF MUSCLES H T T P : / / P H Y S IO W O R K S . C O M . A U/ IM A G E S / IN J U R IE S -

C O N D IT IO N S / R O T A T O R% 2 0 C U F F % 2 0 M U S C L E S % 2 0 IN J U R Y . J P G

EVIDENCE-BASED SHOULDER ASSESSMENT STRATEGY:

OVERVIEW

• History of shoulder dysfunction: occupational history,

onset process (or event) and symptoms

• “Look, Feel, Move”: inspect for abnormalities during

clinical examination

• Special tests & individual muscle testing

STEP 1: PATIENT HISTORY OF SHOULDER DYSFUNCTION

(DONNELLY ET AL 2013)

• Onset: gradual or sudden?

• Symptoms: pain at rest & with movement, neurological

complaints (e.g., sensation), kinematics (joint issues and/or

instability), stiffness, & when symptoms occur, pain

pattern?

H T T P : / / W W W . T H E B O X M A G . C O M / C O N T E N T / C O N T E N T / 1 1 8 3 0 / S H O U L D E R - P A I N . J P G

H T T P : / / A T H L E T E C U L T U R E . C O M /W P -C O N T E N T / U P L O A D S / 2 0 1 3 /0 3 / 1 6 -S H O U L D E R -P A IN -6 2 0 X 3 5 0 . J P G ? B 9 3 D B 2

STEP 1: PATIENT HISTORY OF SHOULDER DYSFUNCTION

(DONNELLY ET AL 2013)

• Occupational history: ADL and IADL (especially work)

• Results of history should begin to suggest etiology

STEP 2: CLINICAL EXAMINATION

• “Look”: Check for abnormalities (bilateral shoulders are

exposed) (Limb & Limb 2014)

– Redness or swelling

– Bony prominences (e.g., scapula, clavicle)

– Muscle wasting and/or asymmetry

– Postural abnormalities: Rounded shoulders, forward head,

kyphotic thoracic spine, shoulder height differential,

bilateral shoulder elevation

– Scapular winging

EX AMPLE #1

ROUNDED

SHOULDERS

C/o bilateral

shoulder pain when

doing strengthening

at the gym (resistive

overhead lifting),

crepitus in left

shoulder, history of

neck pain and

difficulty with jaw

pain/locking

MMT: 3/5 in B

middle trapezius

muscles, B

rhomboids 4/5

EX AMPLE #2

MUSCLE

ASYMMETRY

C/o right shoulder pain

when washing dishes

using bilateral UE’s;

Left upper trapezius

and infraspinatus are

larger than right, is a

student. Carries grocery

bags on left side.

MMT: middle trapezius

R 3+/5, L 3/5; lower

trapezius R 4/5, L 4+/5

EX AMPLE #3

SHOULDER

HEIGHT

DIFFERENTIAL

Student’s left shoulder is

higher than right, history

of initial right shoulder

injury 5 years ago during

heavy lifting with no

medical treatment; second

injury was during resistive

right shoulder horizontal

abduction with pain in

deltoid (snapping sound);

no complaints at present.

MMT results: 3+/5 R

posterior deltoid & middle

trapezius vs. 3/5 LUE


• “Feel”: Bony landmarks are palpated systematically

(Limb & Limb 2014)

– AC, SC & GH joints

– Overall palpation during movement especially when

patient reports ‘crunching’ (helps to localize crepitus as

specific region/joint)

– Neuro signs are noted

EX AMPLE #4

SCAPULAR

WINGING

Student has winging L

greater than R with

“pinching” on L side at

times with trunk

movement and

protracted kyphotic

posture; history of

dancing 15 years until

18 years old (now 25

yrs); palpation of T12 is

painful on left, no neuro

signs


• “Move”: Assess fluidity, quality, & quantity (AROM,

then PROM) (Donnelly et al 2013)

– Sternoclavicular (SC) movement: palpate SC joint &

clavicle

– Acromioclavicular (AC) movement: note any

dyskinesis especially with shoulder abduction and

horizontal abduction/adduction

– Scapulothoracic (ST) movement: note that GH to ST

movement should be 5:4 after 30 degrees of abduction

– Glenohumeral (GH) movement: all planes

STEP 2 TO STEP 3 TRANSITION

• Once analysis of Step 2 is complete the clinician should select special tests (Donnelly et al, 2013) and/or individual manual muscle testing to investigate abnormalities such as:

– Abnormal posture

– Muscle wasting

– Abnormal bone position

– Abnormal movement and joint structure

– A/PROM deficits

– Pain and neurological signs

STEP 3: SPECIAL TESTS & MMT

• Please note that to select special tests and individual muscle testing

effectively one must have basic knowledge of common shoulder

conditions for which these tests are given

• Recommended readings:

– Fundamentals of Hand Therapy: Clinical Reasoning and

Treatment Guidelines for Common Diagnoses of the Upper

Extremity (2nd Ed.), Cooper (2014), Chapter 22

– Special Tests for Orthopedic Examination (4th Ed.) by Konin et al.

(2016), Sections 1 & 2

– Muscles: Testing and Function with Posture and Pain (5th Edition)

by Kendall et al. (2005)

STEP 3: SPECIAL TESTS

• Review of research/statistical terms

– Sensitivity: Ability of a test to identify people who

have a condition

– Specificity: Ability of a test to identify people who

don’t have a condition

• Both sensitivity and specificity range from 0 to 1 with

values closer to 1 being considered more accurate

• Remember, no clinical test is 100% accurate

STEP 3: SPECIAL TESTS FOR CERVICAL SCREENING

• Note that if your patient has signs of cervical spine dysfunction you should do special tests to screen for this

• Symptoms that suggest cervical dysfunction:

– Forward head posture

– Dizziness

– Headaches (frequent – can be daily or multiple per day)

– Unilateral or bilateral shoulder pain & numbness

– Limited and/or painful cervical A/PROM

– Pain referral pattern for cervical spine dysfunction

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CERVICAL RADICULOPATHY PATTERNS

CERVICAL DISC PAIN REFERRAL PATTERNS

Grubb, et al

2000

STEP 3: SPECIAL TESTS (CERVICAL RADICULOPATHY)

(WAINNER R. ET AL., 2003)

• Patients referred for shoulder pain sometimes have cervical radiculopathy that has been misdiagnosed

• If neuro symptoms are present special tests can be done:

– Spurling’s Test

– Distraction Test

– Upper Limb Tension Test for Median Nerve

– Ipsilateral cervical rotation AROM < 60 degrees

• If all four of the above are positive this indicates .99 specificity that patient has cervical radiculopathy and he/she could be referred to PT for cervical treatment if needed

EX AMPLE #5

C/o pain in C5-6 disc

distribution with

corresponding forward

head posture

History: Aggressive

exercise program with

“plyometric” pushups,

thoracic spine “went

out”; cervical rotation is

70 degrees to R, 80

degrees to L

Special Tests:

Spurling’s – negative;

Distraction – positive;

ULTT - negative

STEP 3: SPECIAL TESTS (SHOULDER)

• Special tests for the shoulder should be selected based on

history, clinical exam and symptomatology

• The following is a summary of common types of shoulder

dysfunction and evidence-based special tests for each

• Sensitivity and specificity have been converted to

percentages for ease of understanding

• Remember, special tests are positive only if specific test

criteria are met


• AC Joint Pathology

– Sensitive Test (rules-out when negative)

• AC Joint Palpation (97%), Walton et al. 2004

– Specific Tests (rules-in when positive)

• Cross-Body Adduction (79%), Chronopoulos et al. 2004

• Active Compression Test (~95%), Chronopoulos et al. 2004,

Walton et al. 2004


• Shoulder Impingement


• Neer Test (~80%), Calis et al. 2000, MacDonald et al. 2000,

Park et al. 2005

• Hawkins-Kennedy Test (~80%), Calis et al. 2000,

MacDonald et al. 2000, Park et al. 2005


• Hawkins-Kennedy Test + painful arc + ER weakness in

neutral (~95%) Park et al. 2005


• Anterior Instability


• Release/Surprise Test (~64%) Lo et al. 2004


• Apprehension Test (>90%) Lo et al. 2004, Farber et al. 2006

• Relocation Test (>90%) Lo et al. 2004, Farber et al. 2006

• Release/Surprise Test (~64%) Lo et al. 2004, Gross &

Distefano 1997


• Biceps Tendonitis/Pathology

– Sensitive Tests (rule-out when negative)

• Upper cut (77%) Kibler et al. 2009

– Specific Tests (rule-in when positive)

• Speed’s test (~83%) Kibler et al. 2009

• Belly Press (~83%) Kibler et al. 2009

• Anterior-Inferior Labral Pathology


• Crank Test + history of popping, clicking, or catching (91%) Walsworth et al. 2008


• Supraspinatus Tear


• Drop Arm Test (~90%) Calis et al. 2000, Murrell &

Walton 2001, Park et al. 2005

• Infraspinatus Tear


• External Rotation Lag Sign (~90%), Park et al.

2005, Miller et al. 2008, Walch et al. 1998


• Subscapularis Tear


• Bear Hug Test (82%) Barth et al. 2012

– Specific Test (rules-in when positive)

• Lift-Off Test (~70%) Leroux et al. 1995, Barth et

al. 2012

EX AMPLE #6

C/o pain after 5 months of

working as a waitress,

postural asymmetry with left

scapula higher than right;

states “it doesn’t feel like it’s

in the right place”

History: Waitress for 10

months, carries trays on left

side but is right dominant

Special Tests/MMT: Negative

Hawkins-Kennedy & Drop

Arm but lower trapezius

MMT is 2/5, rhomboid MMT

4/5

EX AMPLE #7

C/o brief shoulder pain on

waking in the AM,

hypermobility, can’t do

standard push-up

History of Pottenger’s Saucer,

nursemaid’s elbow; brief 7/10

pain in morning if sleeping

with right shoulder in external

rotation and will get “stuck”;

received exercises from

chiropractor for improving

thoracic spine flexibility

MMT: Rhomboids R 4/5, L

5/5; Middle Trapezius R 4/5,

L 3/5; Lower Trapezius R

3+/5, L 3+/5

EX AMPLE #8

C/o pain in right UT,

deltoid & scapula at times,

forward head posture, slight

right scapular winging,

lacks fluidity of movement

during shoulder abduction

History of violin playing on

and off for 7 years

Special Tests/MMT:

Hawkins-Kennedy & Drop

Arm negative; lower traps

R 2+/5 L 3/5, rhomboids B

3+/5

PRESENTATION REVIEW: EVIDENCE-BASED OT

ASSESSMENT OF SHOULDER PATIENTS

• Step 1: Patient history of shoulder dysfunction

• Step 2: Clinical examination: “Look, Feel, Move”

• Step 3: Special tests & individual muscle tests

ACKNOWLEDGEMENTS

• A big thank you to my UWM occupational therapy students who

agreed to be photographed for this presentation

• My appreciation to my UWM colleagues and my family for their

guidance regarding this presentation

QUESTIONS? EMAIL: [email protected]

REFERENCES

• Barth, J., Audebert, S., Toussaint, B., Charousset, C., Godeneche, A., Graveleau, N., Joudet, T., Lefebvre, Y., Nove-Josserand, L., Petroff, E., Solignac, N. Scymanski, C., Pitermann, M., Thelu, C.E. (2012). Diagnosis of subscapularis tendon tears: Are available diagnostic tests pertinent for a positive diagnosis? Orthopaedics & Traumatology: Surgery & Research (98S): S178-S185

• Calis, M., Akgun, K., Birtane, M., Karacan, I., Calis, I., Tuzun, R. (2000). Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Annals of the Rheumatic Diseases 59(1): 44-47.

• Chronopoulos, E., Kim, T., Park, H., Ashenbrenner, D., McFarland, E. (2004). Diagnostic value of physical tests for isolated chronic acromioclavicular lesions. American Journal of Sports Medicine 32: 655-661.

• Cooper, Cynthia (Ed.). (2014). Fundamentals of hand therapy: clinical reasoning and treatment guidelines for common diagnoses of the upper extremity (2nd Ed.). St. Louis: Mosby Elsevier.

REFERENCES

• Donnelly, T., Ashwin, S., MacFarlane, R., Waseem, M. (2013). Clinical assessment of

the shoulder. Open Orthopaedics Journal, 7 (Suppl 3: M3): 310-315.

• Durall, C. (2013). Evidence-based clinical examination of the shoulder complex. From

North American Seminars, Inc. continuing education course, “Comprehensive

Examination and Treatment of Shoulder Disorders: What are you missing?” Kenosha,

WI.

• Farber, A., Castillo, R., Clough, M., Bahk, M., McFarland, E. (2006). Journal of Bone

& Joint Surgery 88(7): 1467-74.

• Gross, M., Distefano, M. (1997). Anterior release test: a new test of occult shoulder

instability. Clinical Orthopaedics and Related Research Jun; (339): 105-8.

• Grubb, S., Kelly, C. (2000). Cervical discography: clinical implications from 12 years

of experience. Spine 25 (11): 1382-1389.

REFERENCES

• Hermans, J., Luime, J., Meuffels, D., Reijman, M., Simel, D., Bierma-Zeinstra, S.

(2013). Does this patient with shoulder pain have rotator cuff disease? The rational

clinical examination systematic review. Journal of the American Medical Association

310(8): 837-847.

• Kilber, W., Sciascia, A., Hester, P., Dome, D., Jacobs, C. (2009). Clinical utility of

traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum

anterior and posterior lesions in the shoulder. American Journal of Sports Medicine 37:

1840-1847.

• Leroux, J., Thomas, E., Bonnell, F., Blotman, F. (1995). Diagnostic value of clinical

tests for shoulder impingement syndrome. Revue du Rheumatisme, English Edition 62:

423-8.

• Limb, D., Limb, R. (2014). Clinical assessment of the shoulder. Archives of

Orthopaedic & Trauma Surgery 28(6): 355-364.

REFERENCES

• Lo, I., Nonweiler, B., Woolfrey, M., Litchfield, R., Kirkley, A. (2004). An evaluation of

the apprehension, relocation, and surprise tests for anterior shoulder instability.

American Journal of Sports Medicine 32(2): 301-307.

• MacDonald, P., Clark P., Sutherland, K. (2000). An analysis of the diagnostic accuracy

of the Hawkins and Neer subacromial impingement signs. Journal of Shoulder and

Elbow Surgery 9(4): 299-301.

• Miller, C., Forrester, G., Lewis, J. (2008). The validity of the lag signs in diagnosing

full-thickness tears of the rotator cuff: a preliminary investigation. Archives of

Physical Medicine and Rehabilitation Jun; 89(6): 1162-8.

• Murrell, G., Walton, J. (2001). Diagnosis of rotator cuff tears. Lancet Mar 10; 357

(9258): 769-70.

• Netter, F. (2011). Atlas of human anatomy (5th Ed.) Philadelphia: Saunders Elsevier.

REFERENCES

• Park, H., Yokota, A., Gill, H., El Rassi, G., McFarland E. (2005). Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. Journal of Bone & Joint Surgery (American) Jul; 87(7): 1446-55.

• Wainner r. et al. (2003). Reliability and Diagnostic Accuracy of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy. Spine 1 January 2003, Vol.28(1), pp.52-62.

• Walch, G., Boulahia, A., Calderone, S. (1998). The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. Journal of Bone & Joint Surgery (British) 80: 624-8.

• Walsworth, M. Doukas, W., Murphy, K., Mielcarek, B., Michener, L. (2008). Reliability and diagnostic accuracy of history and physical examination for diagnosing glenoid labral tears. American Journal of Sports Medicine Jan; 36(1): 162-8.

• Walton, J. Mahajan, S. Paxinos, A., Marshall, J., Bryant, C., Shnier, R., Quinn, R., Murrell, G. (2004). Diagnostic values of tests for acromioclavicular joint pain. Journal of Bone & Joint Surgery (American) 86: 807-812.

Evidence-Based Shoulder Assessment - Cloud Object …€¦ · EVIDENCE-BASED SHOULDER ASSESSMENT...

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