Pocket-Guide-to-Musculoskeletal-Assessment.pdf

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Bihliography

References

1. Magee DJ: Orthopedic Physical Assessment, 3rd ed.Philadelphia, WB Saunders, 1997.

2. Bland JH: Disorders of the Cervical Spine: Diagnosis andMedical Management, 2nd ed. Philadelphia, WB Saunders, 1994.

3. Maitland GD: Vertebral Manipulation, 4th ed. Boston,Butterworths, 1973.

4. Cote P, Kreitz BG, Cassidy JD, Thiel H: The validity of theextension-rotation test as a clinical screening procedure beforeneck manipulation: A secondary analysis. J Manipulative PhysiolTher 19:159-164,1996.

5. Butler DS: The upper limb tension test revisited. In Grant R(ed): Physical Therapy of the Cervical and Thoracic Spine, 2nd ed.New York, Churchill Livingstone, 1994.

6. Kandell ER, Schwartz JH, Jessell TM (eds): Principles ofNeural Science, 3rd ed. New York, Elsevier Science Publishing,1991 .

Hertling D, Kessler RM: Management of CommonMusculoskeletal Disorders: Physical Therapy PrinCiples andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

Highland TR, Dreisinger TE, Vie LL, et al: Changes in isometricstrength and range of motion of the isolated cervical spineafter eight weeks of clinical rehabilitation. Spine17(Supplement 6)S77-S82, 1992.

Jones H, Jones M, Maitland GD: Examination and treatment bypassive movement. In Grant R (ed): Physical Therapy of theCervical and Thoracic Spine, 2nd ed. New York, ChurchillLivingstone, 1994.

Kisner C, Colby LA: Therapeutic Exercise: Foundations andTechniques, 2nd ed. Philadelphia, FA Davis, 1990.

Magarey ME: Examination of the cervical and thoracic spine. InGrant R (ed): Physical Therapy of the Cervical and ThoracicSpine, 2nd ed. New York, Churchill Livingstone, 1994.

Saunders HD, Saunders R: Evaluation, Treatment and Preventionof Musculoskeletal Disorders: Spine, 3rd ed, vol 1. Chaska,Minnesota, Educational Opportunities, 1993.

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SubjectiveExamination

SQ, if applicable: night pain, bilateral UE numb-ness/tingling, unexplained weight loss)

Review of systems (cardiovascular, pulmonary, gas-trointestinal)

Pt Hx (region specific): which isthe dominant UE, radicular Sx (der-matomal or sclerotomal)? (see Ap-pendices A and B)

Functional limitations

(f)

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20--------------

Objective ExaminationI. Standing

A. Observation1. Posture2. Abnormalities, deformities, atrophy

B. AROM (note quality, scapulohumeral rhythm,pain, and common substitutions)

1. Shoulder flex (165-180 deg)

2. Shoulder ext (50-60 deg)

3. Shoulder abd (170-180 deg)

4. Shoulder horizontal abd and add

C. PROM if lacking AROM in any motions

D. Special tests (as applicable)

1. Impingement: impingement relief test

II. SittingA. R/O cervical pathology (see Special Tests for

the Cervical Spine in Chapter 2)

B. Observation

1. Posture2. Abnormalities, deformities, atrophy

C. AROM may also be assessed in sittingD. PROM if lacking AROM in any motions

E. GMMT and myotomal screen

1. Shoulder elevation/shrug (C3-C4)

2. Shoulder abd (C5)

3. Shoulder flex (C5-C7)

4. Shoulder ext

5. Elbow flex/wrist ext (C6)

6. Elbow ext/wrist flex (C7)

7. Thumb IP joint ext/finger flex (C8)

8. Finger add (T1)

F. MSRs, if applicable

1. Biceps (C5-C6)

2. Brachioradialis (C5-C6)

--------------21

3. Triceps (C7)G. Special tests (as applicable)

1. Instability: anterior/posterior apprehensiontests, relocation test. sulcus sign

2. Biceps tendinitis/tendon instability:Yergason's, Speed's, Ludington's, and THLtests

3. Impingement: painful arc test, Hawkin'simpingernent test, impingement relief test,Neer's impingement test

4. Rotator cuff tear: drop-arm test,supraspinatus test (empty can test)

5. Thoracic outlet syndrome: Adson'smaneuver, costoclavicular syndrome test.or Halstead's maneuver; hyperabductionsyndrome test

H. Sensation: LT and 2-point discriminationI. Palpation

1. Tendons of the rotator cuff2. Bicipital groove/biceps tendon3. Bony landmarks

III. SupineA. Special tests (as applicable)

1. Impingement: impingement relief test(may be performed standing or supine)

2. Joint playa. AP glideb. Long-axis distractionc. AP motions of the clavicle at the AC

and SC jointsIV. Prone

A. AROM1. Shoulder IR (70-80 deg)2. Shoulder ER (80-90 deg)

B. GMMT1. Shoulder IR2. Shoulder ER

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SPECIAL TESTS FOR THE SHOULDER

Test Detects Test Procedure Positive Sign

m 191 lei T

Neer's impingement test' 2 Impingement of long head of biceps PI sitting or standing. PI's arm is passively Reproduction of PI's Sxtendon and/or supraspinatus tendon elevated through forward flex by examiner,

forcing greater tubercle of humerus againstacromion.

Hawkin's impingement test' Impingement of inflamed supraspinatus Pt sitting or standing. Examiner forward Reproduction of PI's Sxtendon flexes PI's arm to 90 deg, and flexes PI's

elbow to 90 deg, then passively internallyrotates shoulder, forcing supraspinatustendon against coracoacromial ligament.

Painful arc' test Pathology of subacromial origin (e.g., Pt sitting or standing. Pt abducts arm in Reproduction of Sx in a 60-120 deg arc.impingement, rotator cuff tendinitisl neutral position (no IR or ERI Pain stops or is dramatically reduced when

humeral head glides inferiorly.

"No pain --> pain --> no pain"

NW

Impingement relief test' Helps confirm Ox of impingement Pt standing, performs active flex and abd3-5 times while examiner records locationof onset of painful arc range. Pt asked togive a subjective indication of amount ofpain. Test is then repeated while examinerapplies a gentle inferior or posteroinferiorglide just before onset of recorded painfularc. PI is then asked again to give asubjective indication of amount of pain.Test may be modified to a supine position

Outcomes and their interpretations are asfollows:

Complete relief of pain: indicates thathumeral head is capable of moving undersubacromial arch without impinging. Thisindicates contractile tissue as primary causeand recommend a Rx regimen aimed attraining contractile tissue to balance forcecouple and scapulohumeral rhythm le.g.,strengthening, proprioception, scapularstabilizationl.

Partial relief of pain at same point in rangeof motion: suggests that, in addition tocontractile tissue weakness, noncontractiletissue is involved. Joint mobilization inaddition to strengthening and re-educationshould be part of Rx regimen.

No relief or reduction of pain: indicatesinability of humeral head to depress becauseof noncontractile tissue tightness. As part oftreatment program, perform jointmobilization to restore accessory motions toachieve inferior and posteroinferior glide ofhumeral head. Inability to reduce pain bystretching and joint mobilization mayindicate pathology other than impingementas source of pain.

Conti/wct! ...

N

~ SPECIAL TESTS FOR THE SHOULDER Continued

Test Detects Test Procedure Positive Sign

Stability Tests

Anterior apprehension test' Anterior instability PI sitting, standing, or supine. Examiner Pt has look of alarm or apprehension andplaces PI's shoulder in abd and ext rot (90 resists further motion. PI may also have paindeg/90 deg). Then examiner applies an ext with this movement.rot force.

Relocation test' Anterior instability PI supine. Same procedure as apprehension PI's alarm or apprehension disappears, paintest. Upon finding a positive anterior may be relieved, and further ext rot isapprehension test, maintain that position allowedand apply a posterior force with one hand tothe PI's arm.

Sulcus sign' Inferior instability Pt standing or sitting with arm by side and Sulcus (gapl appears at glenohumeral jointwith shoulder muscles relaxed. Examiner Must compare with uninvolved shouldergrasps PI's forearm below elbow and pullsdistally/inferiorly.

Posterior drawer sign' Posterior instability PI supine. Examiner grasps PI's proximal Posterior displacement can be felt as thumbforearm with one hand and flexes elbow 120 slides along lat aspect of coracoid processdeg. Then examiner positions PI's shoulder PI may also have apprehensionin 80-120 deg abd and 20-30 deg flex.With other hand, examiner stabilizes PI'sscapula. As PI's arm is internally rotated andflexed, examiner attempts to sublux humeralhead with thumb.

load-shift test'

Miscellaneous Tests

Cross-arm adduction test'

AC joint shear test'

Yergason's test"

Speed's test'

Anterior, posterior, or multidirectionalinstability

AC joint pathology

AC joint lesion/DJD

Unstable biceps tendon due to THl tear

Could also detect biceps tenosynovitis

Bicipital tendinitis

Pt sitting. First, examiner places one handover PI's clavicle and scapula for stability.Then, grasping proximal arm near humeralhead, examiner "loads" humeral head suchthat it is in a neutral position in glenoidfossa. Examiner then applies an anterior orposterior force, noting amount of translationand end-feel.

Pt sitting. Examiner horizontally adducts(passive) PI's arm across chest wall.

PI sitting. Examiner cups hands, with onehand on PI's scapula and other hand overclavicle and then squeezes, causing a shearforce at AC joint.

Pt sitting or standing. PI's elbow flexed 90deg, with arm at side of body. Examinerresists at wrist while PI attempts tosupinate a pronated forearm.

Pt sitting or standing. PI's shoulder is flexedwith forearm supinated, and elbow iscompletely extended. Examiner palpatesbiceps tendon in bicipital groove and forcesarm down in ext as PI resists.

Excessive displacement anteriorly,posteriorly, or both compared withuninvolved shoulder

Reproduction of PI's Sx at AC joint

Reproduction of Pt's Sx at or excessivemotion in AC joint

localized reproduction of PI's Sx in bicipitalgroove

Reproduction of PI's Sx localized to bicipitalgroove

COllt;lIIU'd ~

1 SPECIAL TESTS FOR THE SHOULDER Continued

Test I Detects Test Procedure Positive Sign

Ludington's test" I Rupture of long head of biceps tendon Pt sitting or standing. Pt clasps both hands Examiner feels tendon on uninvolved sideon top of head and interlocks fingers. Pt but not on involved side during contractionthen simultaneously contracts and relaxes of biceps muscle

I biceps muscles while examiner palpatesbiceps tendon proximally at bicipital groove.Apley's scratch test' Functional method of assessing shoulder Pt performs combined IR with add in Gives examiner an idea of functional

in IR and ER attempt to touch or "scratch" opposite capacity/AROM of Pt's shouldersscapula. Second motion involves combined This is recorded by the anatomic landmarkER with abd in attempt to place hand that Pt is able to reach and touch (e.g., tobehind head and touch top of opposite inferior angle of scapula1shoulder.

Drop-arm test' Rotator cuff tear (specifically, Pt sitting or standing. Examiner passively Arm drops suddenly to side because ofsupraspinatus tendon) abducts PI's shoulder to 90 deg. Pt is then weakness and/or pain

instructed to maintain arm in that position.Examiner then presses inferiorly on PI's arm.

Supraspinatus test (empty Torn supraspinatus muscle or tendon Pt sitting or standing. Pt in "empty can.. Reproduction of PI's Sx or weakness

can testI' Supraspinatus tendinitis position 90-deg shoulder abd, 30-deg Compare with uninvolved side

Neuropathy of suprascapular nervehorizontal abd, and maximum IR. Examinerresists PI's attempt to abduct.

----~

Test*

Adson's maneuver"

Costoclavicular syndrome test"

Hyperabduction syndrometest 14

Halstead's maneuver'

L

Detects

Entrapment in scalene triangle

Entrapment between 1st rib and clavicle

Entrapment between coracoid processand pectoralis minor

Entrapment in scalene triangle

Test Procedure

Pt sitting. Examiner locates Pt's radial pulse.Pt then rotates head toward test shoulderand extends head/neck. Examiner thenexternally rotates and extends Pt's shoulderas Pt takes a deep breath and holds it.

Pt sitting. Examiner palpates radial pulseand then draws PI's shoulder down andback (depression and retractionI.

Pt sitting. Examiner palpates radial pulseand hyperabducts Pt's arm so that PI's armis overhead. Pt takes a deep breath andholds it.

Pt sitting. Examiner palpates radial pulse. Ptthen rotates head away from test shoulderand extends head/neck. Examiner thenexternally rotates and extends PI's shoulder,applying downward traction as Pt takes adeep breath and holds it.

Positive Sign

Reproduction of pain and paresthesia intested UE with diminished or absent pulse




'These tests detect subclavian artery and brachial plexus entrapment.

Nco

TREATMENT OPTIONS FOR THE SHOULDER

Special Condition Hx/Symptoms Signs/Objective Findings Treatment Options

Impingement syndrome Pain with overhead motion or when Positive painful arc Acute: relative rest, ice, NSAIDshand is placed behind back Positive Hawkin's impingement test Gentle ROM ICodman's/pendulum, wandPain may refer down lat arm or anterior Positive Neefs impingement test exercisesIhumerus Must R/O cervical pathology Subacute/chronic: isometric shoulder flex!

Check for instability that may be allowing exVIR/ER exercises progressing to isotonicimpingement (tubing or free weights) as Sx improve

Check for tight posterior and/or inferior May consider ultrasound to aid in healing/capsule or muscle imbalance improve blood flow

PI may have poor posture as a causative Shoulder proprioception exercisesfactor Closed chain shoulder stabilization leg.,

quadruped position and examiner appliesperturbation to Pt)

Work on neuromuscular control of rotatorcuff/shoulder girdle musculature

Scapular stabilization exercises le.g., push-up with a plus, seated press-upsIPosterior/inferior capsule stretch ifindicated

Avoid overhead activities/work thataggravates Sx

Nto

Supraspinatus tendinitis Pain with overhead motion or whenhand is placed behind back

Pain may refer down lat arm or anteriorhumerus

Key finding is exquisite pain with resistedmovement involving supraspinatus muscleipositive supraspinatus/empty can test)

R/O cervical pathology

Will also have positive impingement tests

Acute: relative rest. ice, NSAIDsGentle ROM iCodman's, wand exercises)

Subacute/chronic: isometric shoulder flex/ext/IR/ER exercises progressing to isotonic(tubing or free weightsl as Sx improve

Supraspinatus-specific exercises

May consider ultrasound to aid in healing/improve blood flow

Closed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to Pt)


Scapular stabilization exercises le.g., push-up with a plus, seated press-upsIPosterior/inferior capsule stretching ifindicated

Avoid overhead activities/work thataggravates Sx

COli till "I'd ...

~ TREATMENT OPTIONS FOR THE SHOULDER Continued


Bicipital tendinitis Pain over anterior shoulder Exquisite tenderness to palpation over Acute: Relative rest, ice, NSAIDsDoes Pt perform repetitive curls/elbow bicipital groove Gentle ROM ICodman's, wand exercisesIflex against high resistance at work or Mayor may not have positive Vergason's Avoid AGG and initiate Pt educationrecreation/weight lifting? or Speed's tests

Pt may report "snapping" in region of May have exquisite pain with resisted Subacute/chronic: isometric shoulder flex/

bicipital groove horizontal add of shoulder that is in 90 ext/IR/ER exercises progressing to isotonic

deg ER Itubing or free weightsl as Sx improve(avoid strenuous resistance in early

Check for posterior capsule tightness phaseslR/O cervical pathology IR stretch (towel/door stretch)

May consider ultrasound to aid in healing/improve blood flow or phonophoresis/iontophoresis for pain relief and todecrease inflammation

Shoulder proprioception exercises

Closed chain shoulder stabilization le.g"quadruped position and examiner appliesperturbation to Pt)


Scapular stabilization exercises (e.g., push-up with a plus, seated press-ups)

w....

Subacromial/subdeltoid bursitis Pain at superior portion ofglenohumeral joint

Pain at night with difficulty sleeping

Paln may radiate down arm

Marked restriction of shoulder flex andabdTenderness to palpation over deltoidaround acromion

Distraction of glenohumeral joint inferiorlymay relieve Sx

R/O cervical pathology

Acute: relative rest. ice, NSAIDs,phonophoresis or iontophoresis

Subacutelchronic: gentle prom (Codman's)progressing to AAROM (wand, pulleyl

Isometric shoulder flex/ext/IR/ER exercisesprogressing to isotonic (tubing or freeweightsl as Sx improve

Joint mobilizationMay consider ultrasound

Closed chain shoulder stabilization (e.g.,quadruped position and examiner appliesperturbation to Pt)


Scapular stabilization exercises (e.g., push-up with a plus. seated press-upsI

Pt education to avoid overhead activities/work

Avoid overhead work/activities thataggravate Sx

WN

TREATMENT OPTIONS FOR THE SHOULDER Continued


Anterior shoulder instability (after Hx of acute traumatic abd-ER injury Positive apprehension and/or relocation Acute: radiographs to R/O Hill-Sach's orsubluxation or dislocation) Ifall on outstretched arm or grasp of test Bankhart lesion (if Pt being seen for the

arm during throwing motion! Positive load-shift test (with anterior first time!

translation! Protection (immobilization and PI educationto avoid shoulder ER with abdl. ice, NSAIOs

Gentle ROM (Codman's, wand exercisesi inpainfree and apprehension-free range

Subacute/chronic: isometric shoulder ftex/ext/IR/ER exercises progressing to isotonic(tubing or free weightsI as Sx improve


Closed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to Ptl


Scapular stabilization exercises le.g., push-up with a plus, seated press-ups!

Pylometrics progressing to least stableosition

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Posterior instability (aftersubluxation or dislocation)

Hx of trauma Positive posterior drawer sign

Positive load-shift test (with posteriortranslation)

Refer PI to orthopedic surgeon if stabilitynot improvingAcute: radiographs lif PI being seen forfirst timelProtection (immobilization and Pteducation), ice, NSAIDsGentle ROM (Codman's, wand exercises) inpainfree and apprehension-free range

Subacute/chronic: isometric shoulder flex/ext/IR/ER exercises progressing to isotonic(tubing or free weightsl as Sx improve


Closed chain shoulder stabilization (e.g.,quadruped position and examiner appliesperturbation to Pt!Work on neuromuscular control of rotatorcuff/shoulder girdle musculatureScapular stabilization exercises (e.g., push-up with a plus, seated press-upsI

Pt education to avoid overhead activities/work that aggravates SxRefer Pt to orthopedic surgeon if stabilitynot improving

COlltllllU'd T


Special Condition

Multidirectional instability

Hx/Symptoms

Pt C/O instability and may be able todemonstrate

Pt may have pain or impingement typeSx due to excessive movement/laxity ofglenohumeral joint

Signs/Objective Findings

Positive sulcus sign

Positive load-shift test (with both anteriorand posterior translation!

Treatment Options ~

Acute relative rest. Ice, NSAIOsGentle ROM ICodman's, wand exercises)

Subacute/chronic: isometric shoulder flex/ext/IR/ER exercises progressing to isotonic(tubing or free weights! as Sx improve


Closed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to Pt!


Scapular stabilization exercises le.g., push-up with a plus, seated press-upsl

Pt education to avoid activities/work thataggravates Sx or places PI in an unstableposition

If stability does not improve over severalmonths of aggressive rehabilitation, referPt to orthopedic surgeon

w(Jl

Rotator cuff tear May have Hx of FOOSH, throwing, orlifting injuryMay be seen in older individuals as aresult of degeneration of rotator cuff

Positive drop-arm test

Positive impingement signs

Positive painful arc test

Weakness of specific rotator cuff muscles

May observe abnormal scapulohumeralmotion li.e.. scapular hiking before upwardrotl

Acute: relative rest, ice, NSAIDsGentle ROM ICodman's exercisesI

Subacute/chronic: isometric rotator cuffstrengthening progressing to isotonicItubing or free weights) as Sx improve

Shoulder proprioception exercisesClosed chain shoulder stabilization le.g.,quadruped position and examiner appliesperturbation to Pt!Work on neuromuscular control of rotatorcuff/shoulder girdle musculature

Scapular stabilization exercises le.g., push-up with a plus, seated press-ups)

If severity of tear warrants, surgicalintervention/repair may be necessary

C lit III ...

wOl



AC joint separation Hx of fall onto shoulder Depending on severity of injury, Pt mayor Immobilization in Kenny-Howard/AC jointmay not have a noticeable "step-off" from sling (type I. 1 wk; type II, 2 wks; type III,clavicle to acromion IV, or V. until Sx subsidelPositive AC joint shear test Ice

Positive cross-arm adduction test Early ROM within limits of pain

Tenderness to palpation over involved AC Progress to general rotator cuff andjoint shoulder strengthening as Sx subside

Rx of type III still controversial; somerecommend surgical Rx, and others haveobtained good results with nonoperativeRx. However, acute Rx of type III shouldbe the same as for a type II injury. Seethe Cook, Dias, and Mulier entries in theBibliography for treatment options.

For type IV and V injuries, surgery is moreof a consideration. See the Cook and Diasentries in the Bibliography for treatmentoptions.

Adhesive capsulitis

Thoracic outlet syndrome

Common for ages 40-60 yr

Several weeks' Hx of shoulder pain andrestriction

Pt may not be able to pull wallet fromback pocket or fasten clothes thatfasten in back

Sx include pain and paresthesia andpossibly muscle weakness in shoulder,arm, and/or hand

Very similar to cervical radiculitis/radiculopathy

Restricted ARDM in a clear capsularpattern IER > abd > IRI

Positive thoracic outlet syndrome tests

Must differentiate from cervical pathology

Acute: ice, NSAIDs, pain-relievingmodalities in initial stages

Codman's exercises for 2-3 min every 1-2hr

Subacute/chronic: after pain subsidessomewhat. begin stretching to increaseER, abd, and IR through wand exercisesand joint mobilization

Ultrasound to axilla to heat joint capsulebefore joint mobilization and AAROM/stretches (remember to addressglenohumeral, scapulothoracic, and ACjoints)

NSAIOs

Avoid AGG

Stretch appropriate structures causing Sx

Neural stretch (scalenes, levator scapulae,pectoralis minorl

Strengthen scapular stabilizers

(f)

IoCrom:JJ

38 -------------

References

1. Neer CS, Welsh RP: The shoulder in sports. Orthop ClinNorth Am 8583-591,1977.

2. Neer CS: Impingement lesions Clin Orthop 173:70-77,1983.

3. Hawkins RJ, Bokor DJ: Clinical evaluation of shoulderproblems. In Rockwood CA, Matsen FA (eds): The Shoulder.Philadelphia, WB Saunders, 1990.

4. Kessell L, Watson M The painful arc syndrome J BoneJoint Surg Br 59:166-172,1977.

5. Corso G: Impingement relief test: An adjunctive procedureto traditional assessment of shoulder impingement syndrome. JOrthop Sports Phys Ther 22: 183-192, 1995.

6. Magee DJ: Orthopedic Physical Assessment, 3rd ed.Philadelphia, WB Saunders, 1997.

7. Gerber C. Ganz R: Clinical assessment of instability of theshoulder. J Bone Joint Surg Br 66:551-556, 1984.

8. Silliman JF, Hawkins RJ: Clinical examination of theshoulder complex. In Andrews JR, Wilk KE (eds) The Athlete'sShoulder New York, Churchill Livingstone, 1994.

9 Davies GJ, Gould JA, Larson RL Functional examinationof the shoulder girdle. Phys Sports Med 9:82-104, 1981

10. Yergason RM: Supination sign. J Bone Joint Surg Am13160,1931.

11. Ludington NA: Rupture of the long head of the bicepsflexor cubiti muscle. Ann Surg 77:358-363, 1923.

12. Adson AW, Coffey JR Cervical rib: A method of anteriorapproach for relief of symptoms by division of the scalenusanticus. Ann Surg 85:839-857, 1927.

13 Falconer MA, Weddell G: Costoclavicular compression ofthe subclavian artery and vein. Lancet 2539-544, 1943

14. Wright IS: The neurovascular syndrome produced byhyperabduction of the arms Am Heart J 29: 1-19, 1945.

Bibliography

Boissonnault WG, Janos SC Dysfunction, evaluation, andtreatment of the shoulder. In Donatelli R, Wooden MJ (eds):Orthopaedic Physical Therapy. New York, Churchill Livingstone,1989.

Cook DA, Heiner JP: Acromioclavicular joint injuries: A reviewpaper. Orthop Rev 19510-516,1990.

Dias JJ, Gregg PJ: Acromioclavicular joint injuries in sport:Recommendations for treatment: Sports Med 11:125-132,1991.

-------------- 39

Ellman H: Diagnosis and treatment of rotator cuff tears. ClinOrthop 25464-74, 1990.

Hawkins RJ, Abrams JS: Impingement syndrome in the absenceof rotator cuff tear (stages 1 and 21. Orthop Clin North Am18373-382, 1987.

Hertling D, Kessler RM: Management of CommonMusculoskeletal Disorders. Physical Therapy Principles andMethods, 2nd ed. Philadelphia, JB Lippincott, 1990.

Itoi E, Tabata S: Conservative treatment of rotator cuff tears. ClinOrthop 275:165-173,1992.

Karas SE: Thoracic outlet syndrome. Clin Sports Med 9:297-310,1990.

Kisner C, Colby LA: Therapeutic Exercise. Foundations andTechniques, 2nd ed. Philadelphia, FA Davis, 1990.

Mulier 1. Stuyck J, Fabry G: Conservative treatment ofacromioclavicular dislocation: Evaluation of functional andradiological results after six years' follow-up. Acta Orthop Belg59255-262, 1993.

Neviaser RJ, Neviaser TJ: The frozen shoulder Diagnosis andmanagement: Clin Orthop 223:59-63, 1987.

Pink M, Jobe FW: Shoulder injuries in athletes. Orthopedics1139-47, 1991.

0:Wo--.J::JoI(f)

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nr-------------41

illHBOW

SubjectiveExamination

Pt Hx (region specific): dominanthand, radicular Sx (dermatomal orsclerotomal) 7 (see Appendices Aand B)

SO (if applicable)

soco.-JW

mr-eoo:2

42 ---------------

Objective ExaminationI. Standing

A. Observation

1. Posturea. Carrying angle for males (normal 5-10

deg valgus)

b. Carrying angle for females (normal 15deg valgus)

II. Sitting

A. R/O cervical or shoulder pathology

B. Observation

1. Posture2. Atrophy or deformities

3. Edema

C. AROM1. Elbow flex (140-150 deg)

2. Elbow ext (0 deg)

3. Elbow pronation (70-80 deg)

4. Elbow supination (80-90 deg)

D. GMMT and myotomal screen

1. Shoulder elevation/shrug (C3-C4)

2. Shoulder abd (C5)

3. Shoulder flex (C5-C7)

4. Elbow flex/wrist ext (C6)

5. Elbow ext/wrist flex (0)

6. Forearm pronation/supination

7. Thumb IP joint ext/finger flex (C8)

8. Finger add (T1)

E. MSRs, if applicable

1. Biceps (C5)

2. Brachioradialis (C6)

3. Triceps (0)

F. Special tests (as applicable)1. Instability: varus/valgus stress test

2. Epicondylitis: tests for lateral and medialepicondylitis

3. Nerve impingement/entrapment tests:Tinel's sign at the elbow, Wartenberg's sign,elbow flex test, test for pronator teressyndrome

G. Sensation: LT and 2-point discrimination

H. Palpation

1. Soft tissue

2. Bony landmarks

I. Joint play1. Radial and ulnar deviation (similar to valgus/

varus testing)

2. Ulnar distraction with the elbow in 90 degflex

3. AP glide of radius

43

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