PRINCIPLES OF EXAMINING THE...

10192012

1

PRINCIPLES OF

EXAMINING THE

SHOULDER

Greg Bennett PT DSc

Excel Physical Therapy

Marymount University

Shoulder Issues Second most common

musculoskeletal complaint

HmmWhat was 1

Difficult joint to examine

Why is this

Multidirectional range of motion- UNIQUE

How many ldquojointsrdquo

Shoulder injury can affect nearly every sport and many daily activities

Objectives Review pertinent

anatomy

Discuss common pathologies

Discuss historical clues to diagnosis

Select cases

Physical exam in small group discussions

EXAMINATION GOALS

Global enough to rule out referred syndromes andor associated pathologies

Specific focus on pathologic tissues as the diagnosis becomes clear

Develop a prognosis that is realistic for the diagnosis ie is therapy the appropriate intervention

Establish a treatment program according to the diagnostic with continuous modification to meet change

Bony Anatomy Anterior

Radiographic Anatomy

10192012

2

Anatomy

Glenohumeral joint

bull ldquoBall and socketrdquo vs ldquoGolf ball and teerdquo

bull Very mobile

bull Price instability

bull 45 of all dislocations

bull Joint stability depends on multiple factors

Anatomy

Glenohumeral joint

bull Passive stability

Joint conformity

Glenoid labrum (50)

Joint capsule

Ligaments

Bony restraints

Anatomy

Muscles bull Deltoid bull Trapezius bull Rhomboids bull Levator

scapulae bull Rotator cuff bull Teres major bull Biceps bull Pectoralis

muscles bull Serratus

anterior

Scapular stabilizers

Anatomy Rotator Cuff

Muscles

bull S ndash Supraspinatus

bull I ndash Infraspinatus

bull T - Teres minor

bull S- Supscapularis

Anatomy

Bursae

bull Subacromial

(Subdeltoid)

bull Subscapular

Anatomy

Neurologic

bull Nerve roots

bull Brachial plexus

bull Peripheral nerves

10192012

3

Anatomy

Coordinated shoulder motion

bull Glenohumeral motion

bull Acromioclavicular motion

bull Sternoclavicular motion

bull Scapulothoracic motion

Scapular-humeral rhythm

ldquoIf we agree on everything one of

us is unnecessaryrdquo

EXAMINATION GOALS

1ESTABLISH OR CONFIRM DIAGNOSIS

2ESTABLISH TREATMENT

3LIMIT

PROGRESSION

4BASELINE PATIENT STATUS

CURRENT SYMPTOMS

Swelling

Instability

Pain

Dysfunction

Function

POSSIBILITIES

Sudden Onset Trauma

Labral tear

Capsularligament strain or sprain

Muscle tear

Fracture

GHAC Dislocation

SC Injury

POSSIBILITIES

Sudden Onset No Trauma

Neoplasm

Sub-clinical injury

Overuse ldquoFinal Strawrdquo

10192012

4

POSSIBILITIES

Gradual onset no trauma SLAP-peel back

mechanism

Subluxation or dislocation

OA tendonitis

Impingement

POSSIBILITIES

Gradual onset trauma

Grade I or II SprainStrain

Subluxation

DJD

Impingement

Mechanism of Injury

Associated Mechanics CAPSULE INJURIES

FOOSH

Hyperextension

Deceleration

OVERUSE

Tendonitis common

Impingement

The capsule is weak and prone to injury

Labrum together with biceps traction

Are these the same

Fracture

Direct blow

FOOSH

10192012

5

Where do things go wrong

Fractures

Floating Shoulder

Floating Shoulder

Scapular fracture combined with an upper humerus fracture or a clavicular injury

True floating shoulder does not occur unless in addition to a clavicular shaft fracture bull scapular spineacromial

fracture bull or disruption of the

acromioclavicular (AC) amp coracoacromial (CC) ligaments

Superior Shoulder Suspensory

Complex (SSSC) Bonysoft tissue ring composed of

GlenoidCoracoid Acromion Distal clavicle Connecting Ligaments


Complex (SSSC)

Maintains the stable relationship between the upper extremity amp the axial skeleton


Complex (SSSC) Double disruption is failure of the ring in

two or more places amp results in delayed healing darr strength amp other long-term

problems

10192012

6


Complex (SSSC) Single soft tissue disruption + clavicle

fracture or the bodyspine of scapula may produce the same result as double disruption

PAIN-beware of correlations (no

absolutes)

Sudden Trauma major injury

Prolonged rest RTC OA

Prolonged Activity OA tendonitis capsular deficiency

Overhead use instability subluxation labral lesions

Evaluating Motion

Parameters- physiologic accessory quantity quality end feel

Passive motion exceeds active motion

Types of End Feel

Capsular- ldquostretching leather gradual increasing resistance eg- full external shoulder rotation

Ligamentous- similar to capsular but harder eg-terminal knee extension

Soft Tissue Approximation- painless compression of soft tissue eg- terminal elbow flexion

Bone on Bone- hard sudden stop eg- terminal elbow extension

Types of End Feel Spastic- palpable muscular resistance to stretch

(splinting) eg- straight leg raise with tight hamstrings

Springy - eg-loose body blockage as with a tom meniscus

Empty- patient stops motion before resistance is felt

PainMotion Sequence

Pain followed by resistance- acute lesion

Pain withat resistance- subacute lesion

Pain after resistance- chronic lesion

10192012

7

Cyriax Motion Grading

Hypomobile 0 ankylosed (surgery)

1 moderate decrease (therapy-motion)

2 slight decrease (therapy-motion)


Normal


3 normal

4 slight increase (therapy-exercise)


Hypermobile 4 slight increase (therapy-exercise)

5 moderate increase (therapy)

6 complete instability

(surgery)

Shoulder Stability

Circle Stability

Primary restraint is on the side of translation secondary restraint comes from the opposite side dynamic (muscular) restraint comes from both sides


Dislocations and Separations

Dislocations and separations are protected by both ldquostaticrdquo and ldquodynamicrdquo stabilizershellip



Arthritis can happen at these joints toohellip

10192012

8

Glenohumeral Joint

Shallow (ldquogolf ball sitting on a teerdquo) bull Inherently unstable (maximizes ROM)

Static stabilizers bull glenohumeral ligaments glenoid labrum and

capsule

Dynamic stabilizers bull Predominantly rotator cuff muscles

bull Also scapular stabilizers Trapezius leavator scapulae serratus anterior

rhomboids

Bony Anatomy

ldquoStatic Stabilizersrdquo

What goes wronghellip Besides separations and dislocations

Instability




LABRUM

Anterior StabilityRestraints

Arm Position (Adduction) 0

Tissue Tests

Superior G-H ligament

Middle G-H ligament

Posterior capsule

Drawerfulcrum

Sulcus

Sulcus

10192012

9



Tissue Tests

Middle G-H ligament

Inferior G-H ligament

Posterior capsule

Drawerfulcrum

Drawerfulcrum

Drawerfulcrum



Tissue Tests


Posterior capsule

Crank

apprehension

Classification of Instability

Grade

I Humeral head rides up but not over glenoid rim labrum

II Head rides up and over glenoid rim and reduces spontaneously as stress is removed

III Head rides up and over glenoid rim and remains dislocated

The Examination Process

Shoulder Examination Sitting

Resisted Tests

1 flexion

2 abduction

3 external rotation

4 internal rotation

5 horizontal abdadd


Special Tests

1 Yergason Test

2 Adson Test

3 Impingement Tests

Palpation

Neurological Assessment

1 Dermatomes

2 Reflexes

10192012

10

Examination of Shoulder Sitting

PROM Instability Testing 1 anterior 2 posterior Labrum Tests 1 Clunk Test 2 Grind Test 3 OBriens Impingement- see impingement outline Arthrokinematics 1 sternoclavicular joint 2 acromioclavicular joint 3 glenohumeral joint

Examination from PosteriorSide

C-spine clearance

Range of Motion AROMPROM

Examination of SC and AC joint

Impingement Tests

Scapula

Instability Tests

1 AP direction

2 Inferior direction

Examination of Shoulder Supine

PROM Instability Testing 1 anterior 2 posterior Labrum Tests 1 Clunk Test 2 Grind Test Impingement- see impingement outline Arthrokinematics 1 sternoclavicular joint 2 acromioclavicular joint 3 glenohumeral joint


Palpation

1 crepitus

2 biceps tendon

3 supraspinatus

Resisted Tests

Flexibility Tests

Shoulder Examination Prone

Palpation

1 posterior capsule

2 posterior cuff

Resisted Tests

bull Horizontal

bull ER

INTERPERTATION

RO referral

Scan spine

Analysis

Confirmation

Diagnosis

Problem list (goals)

10192012

11

Physical Examination OBSERVATION

Gait activities

Posture

Deformity alignment

Swelling

Atrophy

Ruborredness

Stress

PALPATION

Calortemperature

TTP

Swelling

Sensation

Structure

Pulses

Crepitus

ACTIVE MOTION

Deficits

Quality

Crepitance

Apprehension

Range of Motion

AROM

PROM

Accessory Motion

Total Motion Concept

Range of Motion

Forward flexion

160 - 180deg

Extension 40 - 60deg

Abduction 180

Adduction 45 deg

Internal rotation

60 - 90 deg

External rotation

80 - 90 deg

Apley Scratch Test

10192012

12


180 degrees total rotation

Increased ER accompanied by decreased IR

Loss of IR leads to

substantially increased shoulder paindysfunction

Wilk et al AJSM 2002

Apley Scratch Tests

Apley IR

Apley ER

Record Spinal Segment

Movements

Focus on specific bony landmarks

bull inferior angle

bull glenoid fossa

bull acromion process

Shoulder girdle movements = scapula movements

Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction

Crosbie J et al PHYS THER 201090679-692

Kinematic conventions for local segmental

coordinate system on the right scapula International Society of Biomechanics Anterior tilt is the clockwise rotation about the axis congruent with the spine of the scapula (Xs) and internal rotation is the clockwise rotation about the pseudo-vertical axis (Ys) perpendicular to Xs and in the plane of the body of the scapula Upward rotation is the clockwise rotation about the posteriorly directed axis perpendicular to the body of the scapula (Zs) and to the other axes

10192012

13

Scapular Mechanics

6 Motions 3 Planes AnteriorPosterior

(Sagittal)

InternalExternal Rotation (HorizTransverse)

ElevationDepression (CoronalFrontal)

SICK Scapula

Scapular malposition

Inferior medial-type 1 scapular winging

Coracoid

tenderness

Scapular dysKinesis

Burkhart Morgan Kibler Arthroscopy 2003

Protracted Depressed

Scapula Dyskinesis

3 types of scapula winging have been identified there may be overlap between the types

PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel

LIGAMENTCAPSULE TESTS

Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test

ldquoGold Standardrdquo

30˚ Abduction

MDI

10192012

14

Instability Sulcus Sign Inferior instability

Arm relaxed in neutral position

Arm pulled downward at wrist

Positive test is a visible sulcus at infra-acromial area bull Compare to

contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide

bull Posterior glide

Anteriorposterior

capsule dependent

Anterior CrankDrawer

Apprehension

Cautious application

90˚ ER

90˚ Abduction

Add hand for relocation

Glenoid Labral Tear

Tear in glenoid labrum

Usually due to instability

SLAP Tear (Superior Labrum Anterior to Posterior)

ndash Superior labral tear

ndash Fall on outstretched hand or shoulder

ndash Rotator cuff tendonosis or tears

Bankart Lesion

ndash Anterior-inferior labral tear

ndash Anterior shoulder dislocation subluxation

OrsquoBrienrsquos Active Compression Test

Labral AC or biceps pathology

Arm flexed to 90deg

Arm cross-arm adducted 10-15deg

Elbow extended Max pronation Resist downward force

Positive test if painful Beware location of pain

bull AC bull Biceps bull Internal +- click


For labral pathology

bull Repeat testing with

bull Max supination

bull Should be pain free

10192012

15

OBriens Test

AcromioclavicularLabral joint pathology

Flex to 90deg with the

elbow extended

Adduct the arm 10-15degmedial to sagittal

maximally internally rotated

Patient resists downward force

The procedure is repeated in supination

OBriens Test


Positive if

painsymptoms relieved in ER

httpwwwyoutubecomwatchv=0QbNRozDFwY

Sensitivity 100

Specificity

bull Labrum 985

bull AC 966

Am J Sports Med 1998 Sep-Oct26(5)610-3

Labral Tear Crank Test

Abduct arm to 90-120deg

Stabilize shoulder

Elbow secured with one hand

Axially load with ER IR at shoulder

Positive test audible or painful click catch grind

What goes wrong

Tears and tendonopathies

Biceps Load I (90) and Biceps

Load II (120) Tests

Shoulder is placed in 90 or 120 degrees of abduction and maximally externally rotated

Forearm in a supinated position

Instruct to perform a biceps contraction against resistance

AJSM 1999 May-Jun27(3)300-3 Biceps load test Kim SH Ha KI Han KY

Biceps Load II


Load II (120) Tests

Deep pain within the shoulder during this contraction is indicative of a SLAP lesion

I Sensitivity 91 Specificity 97

II Sensitivity 90 Specificity 97


Biceps Load II

10192012

16

Jobersquos Test (Empty Can)

Drop Arm Test Supraspinatus Specific

Repeat as ldquofull canrdquo test both apply

Finallyhellipthe subacromial space

What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test

Neer Impingement Test

Position the patient sitting Internally rotate the arm with the thumb facing downward and abduct and forward flex the arm

If impingement is present the patient will experience pain as the arm is abducted

10192012

17

Hawkins Test

Position the patient standing with the shoulder abducted 90 degrees and internally rotate

the forearm The presence of pain with movement is indicative of possible pathology

Muscle Testing Scapula ER

FlexionAbd Lift Off

Screening Evaluation Motor

Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation

bull Tests RTC muscle that IR the shoulder Subscapularis

bull Arms at the sides

bull Elbows flexed to 90 degrees

bull Internally rotates arms against resistance

bull Subscapularis Lift-Off Test

bull Other techniques

Scapular Retraction Test

Empty-can position

Maximum resistance against the handheld dynamometer

Weak cuff or

scapula

Kibler et al AJSM May 2006

Scapular Retraction Test Scapular retraction

position

Empty can position

The scapula is lightly held in retraction by forearm pressure on the medial scapular border

Decreased weakness indicts scapula


10192012

18

Scapular Assistance Test

Painful arc

Examiner assists lateral rotation

Pain decreased if related to serratus anteriorlower trap

Kibler WB Am J sports Med 199826

Palpation of Bicipital Groove

Position the patient sitting beginning with the arm straightened The patient should then flex his arm to contract the biceps muscles

The examiner palpates the bicipital groove to attempt to illicit pain

Acromioclavicular (AC) Joint

Testing

Palpation of AC

Joint

The patients arm is kept at his side and the examiner palpates the AC joint for discomfortpain and gapping

Cross-Arm Horizontal Adduction

Test

The patient places his hand on the opposite shoulder while the examiner exerts force horizontally

Again the presence of pain indicates possible pathology

SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan

Comminuted fracture of the humeral head

EXERCISE DYNAMOMETERS

Not diagnostic

Usually not appropriate with acute injury

10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA

Outcomes Measures Many Exist eg

Constant-Murley Shoulder Outcome Score

DASH Disabilities of the Arm Shoulder and Hand

Correlations exist between shoulder outcome scales

Existing shoulder scales are not equivalent in their assessments of function

Contain redundant information

May reflect a patients age better than shoulder function

Placzek et al Shoulder outcome measures a comparison of 6 functional tests AJSM 2004 Jul-Aug32(5)1270-7

CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation

Specific Orthopedic Tests

X-Ray

Correlation

Treatment plan

Shoulder Examination Summary

Systematic approach

Organize your evaluation

Evaluate slowly and cautiously

Examine other joints

10192012

20

Thank You

Pignon

Haiti

Case Examples and Questions

The physical exam will be demonstrated during lab

Which rotator cuff muscle(s) are

responsible for external rotation

1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4

The apex (bottom) of the scapula is

at what level of the spine

1 C7

2 T3

3 T7

4 T12

5 L4

Case 1

22-year-old male rugby player falls onto his right shoulder while being tackled

Severe pain on top of his right shoulder

Case 1

Notable deformity over superior shoulder

Painful range of motion

bull Unable to lift right arm above waist

Special Tests

Diagnosis

Ecchymossis

10192012

21

Acromioclavicular (A-C) Sprain

Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation

bull Resisted Extension

bull Active compression test

Which ones should we perform on this patient


Damage to A-C joint ligaments

Pain andor deformity over A-C joint

Graded I-VI

bull I-III usually treated non-operatively

bull IV-VI referred to orthopedic surgery

AC Joint Sprain

Treatment

Analgesics ice prn

Sling for as long as needed

Physical Therapy

bull ROM restoration

bull Gradual strength exercise

bull Return to sport activity as tolerated

Case 2

24-year-old male handball player

Fell onto his shoulder after being pushed

Intense pain

Hand is tingling and arm feels like itrsquos hanging

X-rays

X RAYS

DIAGNOSIS

Shoulder DislocationAnterior

Instability

Humeral head dislocates from glenoid fossa

Almost always anterior (95)

Usually traumatic with injury to capsule-labrum complex

10192012

22

Case 3

35-year-old male tennis player

Shoulder pain exacerbated by practicing serves

Develops dull aching pain in right shoulder

SHOULDER PAIN Physical Exam

Tenderness to palpation anterior shoulder

Pain with abduction starting around 90 degrees

Unable to lift arm past 120 degrees

Pain with forward flexion at 90-120 degrees

Special Tests Diagnosis

Shoulder Pain Physical Exam

Hawkinrsquos positive

Neerrsquos positive

IMPINGEMENT

Which of the following structures

can be ldquoimpingedrdquo

1 2 3 4

25 2525251 Biceps tendon

2 Subacromial Bursa

3 Rotator Cuff Tendons

4 All of the above

Impingement as a Clinical Sign

Repetitive overhead activities

Subacromial bursa andor rotator cuff impinged between acromion amp humerus

Physical therapy activity modification +- medications

Diagnoses associated with clinical

sign of Rotator Cuff Impingement Subacromial bone spurs and or bursal

hypertrophy AC joint arthrosis and or bone spurs Rotator cuff disease

Superior labral injury Glenohumeral instability Scapular dyskinesis Biceps tendinopathy A diagnostic injection sometimes helps to

clarify the diagnosis

10192012

23

Case 4

45-year-old weight lifter

Caught bar as it was falling off his shoulder

Sudden pain

Severe weakness left shoulder

Worse with overhead activities while sleeping at night

Pain in anterior lateral shoulder

Special tests

Case 4

Drop Arm Test Positive

External Rotation Lag Sign positive

Weakness with Empty Can Sign

Normal bear hug and belly press testshellip

Diagnosis

Rotator Cuff Tear

Supraspinatus tendon most common

Acute trauma or chronic tendinopathy

Treatment dependent upon ageactivity bull Young active usually require operative

treatment

bull Older low-activity usually respond to non-operative treatment

Case 5

42-year-old female with dull pain right shoulder

Pain is diffuse in nature

Sometimes spreads to between shoulder blades

Seems worse at night

Physical Exam

Obese pleasant female

Diffuse pain

Normal shoulder exam

Not able to reproduce pain during exam

What else do you want to do

Shoulder pain isnrsquot always the

shoulder

Get more historyhellip

Gall bladder disease

Peptic Ulcer Disease

Cervical radiculopathy

Cardiac ischemia

Pulmonary conditions

bull ie Pancoastrsquos tumor Pneumonia

10192012

24

Case 6

40-year-old male

Recently shoveled 16rdquo of snow

Can hardly lift left arm due to pain


Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation

Biceps Tendonopathies

Repetitive overhead activity

Repetitive forearm flexionsupination

Difficult to discern from rotator cuff tendinopathy or impingement

Conclusion

Shoulder injuries are common

Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis

Impingement is a clinical sign not a diagnosis

Donrsquot forget about medical causes

QUESTIONS

10192012

2

Anatomy

Glenohumeral joint

bull ldquoBall and socketrdquo vs ldquoGolf ball and teerdquo

bull Very mobile

bull Price instability

bull 45 of all dislocations

bull Joint stability depends on multiple factors

Anatomy

Glenohumeral joint

bull Passive stability

Joint conformity

Glenoid labrum (50)

Joint capsule

Ligaments

Bony restraints

Anatomy

Muscles bull Deltoid bull Trapezius bull Rhomboids bull Levator

scapulae bull Rotator cuff bull Teres major bull Biceps bull Pectoralis

muscles bull Serratus

anterior

Scapular stabilizers

Anatomy Rotator Cuff

Muscles

bull S ndash Supraspinatus

bull I ndash Infraspinatus

bull T - Teres minor

bull S- Supscapularis

Anatomy

Bursae

bull Subacromial

(Subdeltoid)

bull Subscapular

Anatomy

Neurologic

bull Nerve roots

bull Brachial plexus

bull Peripheral nerves

10192012

3

Anatomy









EXAMINATION GOALS



3LIMIT

PROGRESSION


CURRENT SYMPTOMS

Swelling

Instability

Pain

Dysfunction

Function

POSSIBILITIES

Sudden Onset Trauma

Labral tear


Muscle tear

Fracture

GHAC Dislocation

SC Injury

POSSIBILITIES


Neoplasm

Sub-clinical injury


10192012

4

POSSIBILITIES


mechanism


OA tendonitis

Impingement

POSSIBILITIES



Subluxation

DJD

Impingement

Mechanism of Injury


FOOSH

Hyperextension

Deceleration

OVERUSE

Tendonitis common

Impingement



Are these the same

Fracture

Direct blow

FOOSH

10192012

5


Fractures

Floating Shoulder

Floating Shoulder









Complex (SSSC)





problems

10192012

6





absolutes)





Evaluating Motion



Types of End Feel









PainMotion Sequence




10192012

7






Normal


3 normal






(surgery)

Shoulder Stability

Circle Stability








10192012

8

Glenohumeral Joint



capsule



rhomboids

Bony Anatomy



Instability




LABRUM



Tissue Tests


Middle G-H ligament

Posterior capsule

Drawerfulcrum

Sulcus

Sulcus

10192012

9



Tissue Tests

Middle G-H ligament


Posterior capsule

Drawerfulcrum

Drawerfulcrum

Drawerfulcrum



Tissue Tests


Posterior capsule

Crank

apprehension


Grade






Resisted Tests

1 flexion

2 abduction

3 external rotation

4 internal rotation

5 horizontal abdadd


Special Tests

1 Yergason Test

2 Adson Test

3 Impingement Tests

Palpation


1 Dermatomes

2 Reflexes

10192012

10




C-spine clearance



Impingement Tests

Scapula

Instability Tests

1 AP direction





Palpation

1 crepitus

2 biceps tendon

3 supraspinatus

Resisted Tests

Flexibility Tests


Palpation

1 posterior capsule

2 posterior cuff

Resisted Tests

bull Horizontal

bull ER

INTERPERTATION

RO referral

Scan spine

Analysis

Confirmation

Diagnosis


10192012

11


Gait activities

Posture

Deformity alignment

Swelling

Atrophy

Ruborredness

Stress

PALPATION

Calortemperature

TTP

Swelling

Sensation

Structure

Pulses

Crepitus

ACTIVE MOTION

Deficits

Quality

Crepitance

Apprehension

Range of Motion

AROM

PROM

Accessory Motion


Range of Motion

Forward flexion

160 - 180deg


Abduction 180

Adduction 45 deg

Internal rotation

60 - 90 deg

External rotation

80 - 90 deg

Apley Scratch Test

10192012

12




Loss of IR leads to



Apley Scratch Tests

Apley IR

Apley ER


Movements


bull inferior angle

bull glenoid fossa



Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction




10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

3

Anatomy









EXAMINATION GOALS



3LIMIT

PROGRESSION


CURRENT SYMPTOMS

Swelling

Instability

Pain

Dysfunction

Function

POSSIBILITIES

Sudden Onset Trauma

Labral tear


Muscle tear

Fracture

GHAC Dislocation

SC Injury

POSSIBILITIES


Neoplasm

Sub-clinical injury


10192012

4

POSSIBILITIES


mechanism


OA tendonitis

Impingement

POSSIBILITIES



Subluxation

DJD

Impingement

Mechanism of Injury


FOOSH

Hyperextension

Deceleration

OVERUSE

Tendonitis common

Impingement



Are these the same

Fracture

Direct blow

FOOSH

10192012

5


Fractures

Floating Shoulder

Floating Shoulder









Complex (SSSC)





problems

10192012

6





absolutes)





Evaluating Motion



Types of End Feel









PainMotion Sequence




10192012

7






Normal


3 normal






(surgery)

Shoulder Stability

Circle Stability








10192012

8

Glenohumeral Joint



capsule



rhomboids

Bony Anatomy



Instability




LABRUM



Tissue Tests


Middle G-H ligament

Posterior capsule

Drawerfulcrum

Sulcus

Sulcus

10192012

9



Tissue Tests

Middle G-H ligament


Posterior capsule

Drawerfulcrum

Drawerfulcrum

Drawerfulcrum



Tissue Tests


Posterior capsule

Crank

apprehension


Grade






Resisted Tests

1 flexion

2 abduction

3 external rotation

4 internal rotation

5 horizontal abdadd


Special Tests

1 Yergason Test

2 Adson Test

3 Impingement Tests

Palpation


1 Dermatomes

2 Reflexes

10192012

10




C-spine clearance



Impingement Tests

Scapula

Instability Tests

1 AP direction





Palpation

1 crepitus

2 biceps tendon

3 supraspinatus

Resisted Tests

Flexibility Tests


Palpation

1 posterior capsule

2 posterior cuff

Resisted Tests

bull Horizontal

bull ER

INTERPERTATION

RO referral

Scan spine

Analysis

Confirmation

Diagnosis


10192012

11


Gait activities

Posture

Deformity alignment

Swelling

Atrophy

Ruborredness

Stress

PALPATION

Calortemperature

TTP

Swelling

Sensation

Structure

Pulses

Crepitus

ACTIVE MOTION

Deficits

Quality

Crepitance

Apprehension

Range of Motion

AROM

PROM

Accessory Motion


Range of Motion

Forward flexion

160 - 180deg


Abduction 180

Adduction 45 deg

Internal rotation

60 - 90 deg

External rotation

80 - 90 deg

Apley Scratch Test

10192012

12




Loss of IR leads to



Apley Scratch Tests

Apley IR

Apley ER


Movements


bull inferior angle

bull glenoid fossa



Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction




10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

4

POSSIBILITIES


mechanism


OA tendonitis

Impingement

POSSIBILITIES



Subluxation

DJD

Impingement

Mechanism of Injury


FOOSH

Hyperextension

Deceleration

OVERUSE

Tendonitis common

Impingement



Are these the same

Fracture

Direct blow

FOOSH

10192012

5


Fractures

Floating Shoulder

Floating Shoulder









Complex (SSSC)





problems

10192012

6





absolutes)





Evaluating Motion



Types of End Feel









PainMotion Sequence




10192012

7






Normal


3 normal






(surgery)

Shoulder Stability

Circle Stability








10192012

8

Glenohumeral Joint



capsule



rhomboids

Bony Anatomy



Instability




LABRUM



Tissue Tests


Middle G-H ligament

Posterior capsule

Drawerfulcrum

Sulcus

Sulcus

10192012

9



Tissue Tests

Middle G-H ligament


Posterior capsule

Drawerfulcrum

Drawerfulcrum

Drawerfulcrum



Tissue Tests


Posterior capsule

Crank

apprehension


Grade






Resisted Tests

1 flexion

2 abduction

3 external rotation

4 internal rotation

5 horizontal abdadd


Special Tests

1 Yergason Test

2 Adson Test

3 Impingement Tests

Palpation


1 Dermatomes

2 Reflexes

10192012

10




C-spine clearance



Impingement Tests

Scapula

Instability Tests

1 AP direction





Palpation

1 crepitus

2 biceps tendon

3 supraspinatus

Resisted Tests

Flexibility Tests


Palpation

1 posterior capsule

2 posterior cuff

Resisted Tests

bull Horizontal

bull ER

INTERPERTATION

RO referral

Scan spine

Analysis

Confirmation

Diagnosis


10192012

11


Gait activities

Posture

Deformity alignment

Swelling

Atrophy

Ruborredness

Stress

PALPATION

Calortemperature

TTP

Swelling

Sensation

Structure

Pulses

Crepitus

ACTIVE MOTION

Deficits

Quality

Crepitance

Apprehension

Range of Motion

AROM

PROM

Accessory Motion


Range of Motion

Forward flexion

160 - 180deg


Abduction 180

Adduction 45 deg

Internal rotation

60 - 90 deg

External rotation

80 - 90 deg

Apley Scratch Test

10192012

12




Loss of IR leads to



Apley Scratch Tests

Apley IR

Apley ER


Movements


bull inferior angle

bull glenoid fossa



Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction




10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

5


Fractures

Floating Shoulder

Floating Shoulder









Complex (SSSC)





problems

10192012

6





absolutes)





Evaluating Motion



Types of End Feel









PainMotion Sequence




10192012

7






Normal


3 normal






(surgery)

Shoulder Stability

Circle Stability








10192012

8

Glenohumeral Joint



capsule



rhomboids

Bony Anatomy



Instability




LABRUM



Tissue Tests


Middle G-H ligament

Posterior capsule

Drawerfulcrum

Sulcus

Sulcus

10192012

9



Tissue Tests

Middle G-H ligament


Posterior capsule

Drawerfulcrum

Drawerfulcrum

Drawerfulcrum



Tissue Tests


Posterior capsule

Crank

apprehension


Grade






Resisted Tests

1 flexion

2 abduction

3 external rotation

4 internal rotation

5 horizontal abdadd


Special Tests

1 Yergason Test

2 Adson Test

3 Impingement Tests

Palpation


1 Dermatomes

2 Reflexes

10192012

10




C-spine clearance



Impingement Tests

Scapula

Instability Tests

1 AP direction





Palpation

1 crepitus

2 biceps tendon

3 supraspinatus

Resisted Tests

Flexibility Tests


Palpation

1 posterior capsule

2 posterior cuff

Resisted Tests

bull Horizontal

bull ER

INTERPERTATION

RO referral

Scan spine

Analysis

Confirmation

Diagnosis


10192012

11


Gait activities

Posture

Deformity alignment

Swelling

Atrophy

Ruborredness

Stress

PALPATION

Calortemperature

TTP

Swelling

Sensation

Structure

Pulses

Crepitus

ACTIVE MOTION

Deficits

Quality

Crepitance

Apprehension

Range of Motion

AROM

PROM

Accessory Motion


Range of Motion

Forward flexion

160 - 180deg


Abduction 180

Adduction 45 deg

Internal rotation

60 - 90 deg

External rotation

80 - 90 deg

Apley Scratch Test

10192012

12




Loss of IR leads to



Apley Scratch Tests

Apley IR

Apley ER


Movements


bull inferior angle

bull glenoid fossa



Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction




10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

6





absolutes)





Evaluating Motion



Types of End Feel









PainMotion Sequence




10192012

7






Normal


3 normal






(surgery)

Shoulder Stability

Circle Stability








10192012

8

Glenohumeral Joint



capsule



rhomboids

Bony Anatomy



Instability




LABRUM



Tissue Tests


Middle G-H ligament

Posterior capsule

Drawerfulcrum

Sulcus

Sulcus

10192012

9



Tissue Tests

Middle G-H ligament


Posterior capsule

Drawerfulcrum

Drawerfulcrum

Drawerfulcrum



Tissue Tests


Posterior capsule

Crank

apprehension


Grade






Resisted Tests

1 flexion

2 abduction

3 external rotation

4 internal rotation

5 horizontal abdadd


Special Tests

1 Yergason Test

2 Adson Test

3 Impingement Tests

Palpation


1 Dermatomes

2 Reflexes

10192012

10




C-spine clearance



Impingement Tests

Scapula

Instability Tests

1 AP direction





Palpation

1 crepitus

2 biceps tendon

3 supraspinatus

Resisted Tests

Flexibility Tests


Palpation

1 posterior capsule

2 posterior cuff

Resisted Tests

bull Horizontal

bull ER

INTERPERTATION

RO referral

Scan spine

Analysis

Confirmation

Diagnosis


10192012

11


Gait activities

Posture

Deformity alignment

Swelling

Atrophy

Ruborredness

Stress

PALPATION

Calortemperature

TTP

Swelling

Sensation

Structure

Pulses

Crepitus

ACTIVE MOTION

Deficits

Quality

Crepitance

Apprehension

Range of Motion

AROM

PROM

Accessory Motion


Range of Motion

Forward flexion

160 - 180deg


Abduction 180

Adduction 45 deg

Internal rotation

60 - 90 deg

External rotation

80 - 90 deg

Apley Scratch Test

10192012

12




Loss of IR leads to



Apley Scratch Tests

Apley IR

Apley ER


Movements


bull inferior angle

bull glenoid fossa



Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction




10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

7






Normal


3 normal






(surgery)

Shoulder Stability

Circle Stability








10192012

8

Glenohumeral Joint



capsule



rhomboids

Bony Anatomy



Instability




LABRUM



Tissue Tests


Middle G-H ligament

Posterior capsule

Drawerfulcrum

Sulcus

Sulcus

10192012

9



Tissue Tests

Middle G-H ligament


Posterior capsule

Drawerfulcrum

Drawerfulcrum

Drawerfulcrum



Tissue Tests


Posterior capsule

Crank

apprehension


Grade






Resisted Tests

1 flexion

2 abduction

3 external rotation

4 internal rotation

5 horizontal abdadd


Special Tests

1 Yergason Test

2 Adson Test

3 Impingement Tests

Palpation


1 Dermatomes

2 Reflexes

10192012

10




C-spine clearance



Impingement Tests

Scapula

Instability Tests

1 AP direction





Palpation

1 crepitus

2 biceps tendon

3 supraspinatus

Resisted Tests

Flexibility Tests


Palpation

1 posterior capsule

2 posterior cuff

Resisted Tests

bull Horizontal

bull ER

INTERPERTATION

RO referral

Scan spine

Analysis

Confirmation

Diagnosis


10192012

11


Gait activities

Posture

Deformity alignment

Swelling

Atrophy

Ruborredness

Stress

PALPATION

Calortemperature

TTP

Swelling

Sensation

Structure

Pulses

Crepitus

ACTIVE MOTION

Deficits

Quality

Crepitance

Apprehension

Range of Motion

AROM

PROM

Accessory Motion


Range of Motion

Forward flexion

160 - 180deg


Abduction 180

Adduction 45 deg

Internal rotation

60 - 90 deg

External rotation

80 - 90 deg

Apley Scratch Test

10192012

12




Loss of IR leads to



Apley Scratch Tests

Apley IR

Apley ER


Movements


bull inferior angle

bull glenoid fossa



Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction




10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

8

Glenohumeral Joint



capsule



rhomboids

Bony Anatomy



Instability




LABRUM



Tissue Tests


Middle G-H ligament

Posterior capsule

Drawerfulcrum

Sulcus

Sulcus

10192012

9



Tissue Tests

Middle G-H ligament


Posterior capsule

Drawerfulcrum

Drawerfulcrum

Drawerfulcrum



Tissue Tests


Posterior capsule

Crank

apprehension


Grade






Resisted Tests

1 flexion

2 abduction

3 external rotation

4 internal rotation

5 horizontal abdadd


Special Tests

1 Yergason Test

2 Adson Test

3 Impingement Tests

Palpation


1 Dermatomes

2 Reflexes

10192012

10




C-spine clearance



Impingement Tests

Scapula

Instability Tests

1 AP direction





Palpation

1 crepitus

2 biceps tendon

3 supraspinatus

Resisted Tests

Flexibility Tests


Palpation

1 posterior capsule

2 posterior cuff

Resisted Tests

bull Horizontal

bull ER

INTERPERTATION

RO referral

Scan spine

Analysis

Confirmation

Diagnosis


10192012

11


Gait activities

Posture

Deformity alignment

Swelling

Atrophy

Ruborredness

Stress

PALPATION

Calortemperature

TTP

Swelling

Sensation

Structure

Pulses

Crepitus

ACTIVE MOTION

Deficits

Quality

Crepitance

Apprehension

Range of Motion

AROM

PROM

Accessory Motion


Range of Motion

Forward flexion

160 - 180deg


Abduction 180

Adduction 45 deg

Internal rotation

60 - 90 deg

External rotation

80 - 90 deg

Apley Scratch Test

10192012

12




Loss of IR leads to



Apley Scratch Tests

Apley IR

Apley ER


Movements


bull inferior angle

bull glenoid fossa



Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction




10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

9



Tissue Tests

Middle G-H ligament


Posterior capsule

Drawerfulcrum

Drawerfulcrum

Drawerfulcrum



Tissue Tests


Posterior capsule

Crank

apprehension


Grade






Resisted Tests

1 flexion

2 abduction

3 external rotation

4 internal rotation

5 horizontal abdadd


Special Tests

1 Yergason Test

2 Adson Test

3 Impingement Tests

Palpation


1 Dermatomes

2 Reflexes

10192012

10




C-spine clearance



Impingement Tests

Scapula

Instability Tests

1 AP direction





Palpation

1 crepitus

2 biceps tendon

3 supraspinatus

Resisted Tests

Flexibility Tests


Palpation

1 posterior capsule

2 posterior cuff

Resisted Tests

bull Horizontal

bull ER

INTERPERTATION

RO referral

Scan spine

Analysis

Confirmation

Diagnosis


10192012

11


Gait activities

Posture

Deformity alignment

Swelling

Atrophy

Ruborredness

Stress

PALPATION

Calortemperature

TTP

Swelling

Sensation

Structure

Pulses

Crepitus

ACTIVE MOTION

Deficits

Quality

Crepitance

Apprehension

Range of Motion

AROM

PROM

Accessory Motion


Range of Motion

Forward flexion

160 - 180deg


Abduction 180

Adduction 45 deg

Internal rotation

60 - 90 deg

External rotation

80 - 90 deg

Apley Scratch Test

10192012

12




Loss of IR leads to



Apley Scratch Tests

Apley IR

Apley ER


Movements


bull inferior angle

bull glenoid fossa



Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction




10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

10




C-spine clearance



Impingement Tests

Scapula

Instability Tests

1 AP direction





Palpation

1 crepitus

2 biceps tendon

3 supraspinatus

Resisted Tests

Flexibility Tests


Palpation

1 posterior capsule

2 posterior cuff

Resisted Tests

bull Horizontal

bull ER

INTERPERTATION

RO referral

Scan spine

Analysis

Confirmation

Diagnosis


10192012

11


Gait activities

Posture

Deformity alignment

Swelling

Atrophy

Ruborredness

Stress

PALPATION

Calortemperature

TTP

Swelling

Sensation

Structure

Pulses

Crepitus

ACTIVE MOTION

Deficits

Quality

Crepitance

Apprehension

Range of Motion

AROM

PROM

Accessory Motion


Range of Motion

Forward flexion

160 - 180deg


Abduction 180

Adduction 45 deg

Internal rotation

60 - 90 deg

External rotation

80 - 90 deg

Apley Scratch Test

10192012

12




Loss of IR leads to



Apley Scratch Tests

Apley IR

Apley ER


Movements


bull inferior angle

bull glenoid fossa



Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction




10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

11


Gait activities

Posture

Deformity alignment

Swelling

Atrophy

Ruborredness

Stress

PALPATION

Calortemperature

TTP

Swelling

Sensation

Structure

Pulses

Crepitus

ACTIVE MOTION

Deficits

Quality

Crepitance

Apprehension

Range of Motion

AROM

PROM

Accessory Motion


Range of Motion

Forward flexion

160 - 180deg


Abduction 180

Adduction 45 deg

Internal rotation

60 - 90 deg

External rotation

80 - 90 deg

Apley Scratch Test

10192012

12




Loss of IR leads to



Apley Scratch Tests

Apley IR

Apley ER


Movements


bull inferior angle

bull glenoid fossa



Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction




10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

12




Loss of IR leads to



Apley Scratch Tests

Apley IR

Apley ER


Movements


bull inferior angle

bull glenoid fossa



Shoulder

Girdle

Movements

Elevation

Depression

Abduction Adduction




10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

13

Scapular Mechanics


(Sagittal)



SICK Scapula



Coracoid

tenderness

Scapular dysKinesis



Scapula Dyskinesis


PASSIVE MOTION

Deficits

End feel

Painful arc

Crepitance

Joint play

Flexibility

End Feel


Sulcus

Drawer

Load and Shift

Fulcrum

Labral

Axillary Lick Test

Sulcus Test


30˚ Abduction

MDI

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

14





contralateral side

LOAD and SHIFT

START

bull Seat joint

bull Anterior glide


Anteriorposterior

capsule dependent


Apprehension


90˚ ER

90˚ Abduction


Glenoid Labral Tear







Bankart Lesion





Arm flexed to 90deg








bull Max supination


10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

15

OBriens Test



elbow extended





OBriens Test


Positive if



Sensitivity 100

Specificity

bull Labrum 985

bull AC 966




Stabilize shoulder




What goes wrong



Load II (120) Tests





Biceps Load II


Load II (120) Tests





Biceps Load II

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

16





What can go wrong

Impingement

Impingement

Impingement Tests

Neerrsquos Test

Hawkinrsquos Test




10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

17

Hawkins Test




FlexionAbd Lift Off


Flexion

AbductionScaption

ER-2 positions

IR

Scapular

Strength Testing

Internal rotation








Empty-can position


Weak cuff or

scapula



position

Empty can position




10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

18


Painful arc








Testing

Palpation of AC

Joint



Test



SPECIAL TESTS

Diagnostic Imaging

X-ray

MRI

CT Scan



Not diagnostic


10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

19

GENERAL HEALTH

Hypermobility

Joint conditions

Neurology

Medications

Injectionssteroids

GENERAL HEALTH

Allergies

Infections

Weight

Mental status

History CA









CONCLUSIONS

MUSCULOSKELETAL

EXAMINATION History

Active Movements

Passive Movements

Resisted Movements

Palpation


X-Ray

Correlation

Treatment plan


Systematic approach




10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

20

Thank You

Pignon

Haiti





1 Supraspinatus

2 Infraspinatus

3 Subscapularis

4 Teres Minor

5 Both 2 and 4



1 C7

2 T3

3 T7

4 T12

5 L4

Case 1



Case 1




Special Tests

Diagnosis

Ecchymossis

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

21


Special Tests

bull Shear Test

bull Cross Arm Test

bull A-C Palpation







Graded I-VI



AC Joint Sprain

Treatment

Analgesics ice prn


Physical Therapy




Case 2



Intense pain


X-rays

X RAYS

DIAGNOSIS


Instability




10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

22

Case 3












Neerrsquos positive

IMPINGEMENT



1 2 3 4


2 Subacromial Bursa


4 All of the above










10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

23

Case 4



Sudden pain




Special tests

Case 4





Diagnosis

Rotator Cuff Tear




treatment


Case 5





Physical Exam


Diffuse pain





shoulder





Cardiac ischemia



10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

10192012

24

Case 6

40-year-old male




Biceps Tendonopathy

Speed Test

Yergason Test

Direct palpation





Conclusion





QUESTIONS

PRINCIPLES OF EXAMINING THE...

Documents

Transcript of PRINCIPLES OF EXAMINING THE...