Shoulder examination
-
Upload
dhananjaya-sabat -
Category
Education
-
view
6.959 -
download
1
description
Transcript of Shoulder examination
![Page 1: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/1.jpg)
SHOULDER EXAMINATION
Dr Vinod KumarDr Dhananjaya Sabat
Department Of OrthopaedicsMaulana Azad Medical College & LN Hospital
New Delhi
![Page 2: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/2.jpg)
Assessment: what is the primary problem ?
PAIN INSTABILITY LOSS OF MOTION
EXTRINSICOR
INTRINSIC
ACTIVEOR
PASSIVE
EVALUATION PRINCIPLESGet a History: Is this a new injury, old chronic injury
![Page 3: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/3.jpg)
Evaluation Order
• History
• Inspection
• Palpation
• Movement : ROM & strength
• Special tests: Rotator cuff disease & impingement
Instability & Laxity
Biceps tendon & SLAP
AC & SC joint
SEE
FEEL
MOVE
![Page 4: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/4.jpg)
INSPECTIONAnterior sidePosterior sideLateral OverheadAxillary
Sometimes too obvious
![Page 5: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/5.jpg)
DeltoidAtrophyPain at insertion site-mostly referred from rotator cuff pathology; rarely due to deltoid tendinitis
![Page 6: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/6.jpg)
Subacromial regionSwelling- bursitis
Biceps tendonRupture- Popeye bulge
![Page 7: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/7.jpg)
Posterior sideScapula
Position High – Sprengel’sSpineFossae –supraspinatus & infraspinatus atrophy
![Page 8: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/8.jpg)
Borders of scapula–lateral; prominent in LD
atrophysuperior; prominent in
supraspinatus & trapezius atrophy
Vertebral; prominent in serratus ant weakness/winging
![Page 9: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/9.jpg)
PALPATIONTendernessSwelling Palpable gap in muscles
Acromioclavicular jointCoracoid processSubacromial bursaBiceps tendon
![Page 10: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/10.jpg)
MOVEMENTSActive
Passive
Resistive
![Page 11: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/11.jpg)
FORWARD FLEXION- 0-160/180°
EXTENSION- 0-45°
ABDUCTION-0-180°
ADDUCTION- 0-45°
CROSS BODY ADDUCTION
![Page 12: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/12.jpg)
See scapulohumeral rhythm from backside
![Page 13: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/13.jpg)
EXTERNAL ROTATION- 0-45°
![Page 14: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/14.jpg)
INTERNAL ROTATION- 0-55°
![Page 15: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/15.jpg)
Appley’s scratch testPatient attempts to touch the opposite scapula thus testing abduction & ER and adduction & IRGood screening test for ROM assessment
![Page 16: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/16.jpg)
Muscle strength tests
Pectoralis major Latissimus dorsi
Deltoid
![Page 17: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/17.jpg)
Trapezius Serratusanterior
Rhomboids
![Page 18: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/18.jpg)
NEUROMUSCULAR EXAMINATIONMotor examinationSensory examinationDeep tendon reflexesCervical spineSpurling test, L-Hermitte sign
Thoracic outlet syndAdson’s test, Hyperabduction test, Roos test
Brachial Plexus InjuryBrachial Neuritis
Compression Neuropathies
![Page 19: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/19.jpg)
Axillary nerve injuryAnaesthesia in the ‘Regimental badge area’
![Page 20: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/20.jpg)
1. INSTABILITY2. IMPINGEMENT SYNDROME3. ROTATOR CUFF TEAR4. BICEPS TENDON PROBLEMS5. AC JOINT PROBLEMS6. STIFF SHOULDER
![Page 21: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/21.jpg)
![Page 22: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/22.jpg)
ANTERIOR DISLOCATION SHOULDER
Hamilton Ruler testDuga’s testCallaway’s test
![Page 23: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/23.jpg)
POSTERIOR DISLOCATION SHOULDER
LIGHT BULB SIGN
ER restrictedProminence in posterior deltoid
![Page 24: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/24.jpg)
Chronic InstabilityInstability can be-
Unidirectional- anterior, posterior, inferiorMultidirectional (MDI) – anterior &/ or posterior + inferior
TUBS AMBRI
•Traumatic•Unidirectional•Bankart’s lesion•Surgical t/t
•Atraumatic•Multidirectional•Bilateral•Rehabilitation•Inferior capsular shift
![Page 25: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/25.jpg)
CHRONIC UNIDIRECTIONAL INSTABILITY
PROVOCATIVE TESTS to document the presence
& direction of instability
QUANTITATIVE TESTSTo quantitate the amount of laxity
Anterior Instability•Crank test•Fulcrum test•Jobe’s relocation testPosterior Instability•Jerk test•Circumduction test
•Drawer tests•Load & shift testfor both anterior and posterior instability
![Page 26: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/26.jpg)
ANTERIOR INSTABILITYProvocative testsApprehension test
Crank test – Pt sitting; arm at 90° ABD. With increasing ER the examiner exerts an anterior translatory force with his thumb placed posteriorly on the humerus & watches for apprehension.Apprehension is diagnostic of instability. If only pain, subtle subluxation.
![Page 27: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/27.jpg)
Fulcrum test –Pt supine with the scapula supported by the edge of the table. The arm is positioned in 90°ABD. With increasing ER the examiner watches for apprehension.
![Page 28: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/28.jpg)
Examiner repeats apprehension test and notes the amount of ER before the onset of apprehension. Then apply a posterior stress over the humeral head & repeat the ER maneuver and again note amount of ER at onset of apprehension.Increase in the external rotation range = +veRelease test- apprehensionreappears on release
Jobe’s Relocation test
![Page 29: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/29.jpg)
POSTERIOR INSTABILITYProvocative testsJerk test
Pt supine with 90° forward flexion of shoulder & elbow flexed to 90°, examinor applies posterior directed force by holding the forearm.Jerk/Jump = diagnostic of instabilityPain/apprehension= subtle instability
![Page 30: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/30.jpg)
Circumduction testPt standing, examiner standing behind & holds the arm in extension & abduction; performs circumductionVisible subluxation/ apprehension in position of foreward flexion 160° & adduction (position of risk) = instability
![Page 31: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/31.jpg)
Inferior laxitySulcus sign
Patient in sitting or standing; the shoulder is in neutral position, muscles are relaxed. Downward traction applied+ = dimpling of the skin below the acromion or widening of the subacromial space on palpation; >2cm translationMDI
![Page 32: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/32.jpg)
Multidirectional instabilityInstability in more than one direction including inferior laxity
Voluntary dislocationAbnormal generalized laxityAbnormal scapular mechanicsPsychiatric illness
![Page 33: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/33.jpg)
![Page 34: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/34.jpg)
Painful arc syndromeIn abduction arc of motion, patient feels pain in the range 60-120°.
![Page 35: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/35.jpg)
O’Brien testThe patient flexes the arm to 90° with the elbow fully extended and then adducts the arm 10-15° medial to sagittal plane. The arm is then maximally internally rotated and the patient resists the examiner's downward force.
![Page 36: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/36.jpg)
Hawkins-Kennedy Testpatient sitting with arm at 90° forward elevation and elbow flexed to 90°. Examiner then quickly moves the arm into internal rotation. +ve = Pain located to the sub-acromial spaceSubacromial impingement, rotator cuff tendinitis
![Page 37: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/37.jpg)
Neer Impingement SignExaminer performs maximal passive forward flexion with internal rotation whilst stabilizing the scapula.+ = Pain located to the sub-acromial space or anterior edge of acromionSubacromial impingement of supraspinatius & anterior part of infraspinatus
![Page 38: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/38.jpg)
Neer’s Impingement Test
Examiner after eliciting impingement sign, injects local anesthetic soln. to subacromial space.Disappearance of pain is diagnostic
![Page 39: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/39.jpg)
![Page 40: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/40.jpg)
Inability to abduct or flex forewardAtrophy of supra & infraspinatus fossaeEmpty can test - for supraspinatusER at arm at side with elbow flexed- for infraspinatusLift off test/ abdominal compression test – for subscapularisDrop Arm signExternal rotation lag sign
![Page 41: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/41.jpg)
Supraspinatus “Empty Can Test”Pt attempts to elevate the arms against resistance with arms at 90°abduction in a plane 30°anterior true coronal plane and full IR (thumb pointing downward) with elbows extended. Positive = supraspinatus tear
![Page 42: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/42.jpg)
Patient’s arms at the sides with elbows flexed to 90, attempts to do ER
Infraspinatus & Teres minor
![Page 43: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/43.jpg)
Subscapularis 1. “Lift off test/ Gerber’s test”Patient standing with hand behind back with the dorsum of the hand resting on the back. The hand is raised off the back by maintaining or increasing internal rotation of the humerus and extension at the shoulder. Full passive internal rotation is prerequisite. Inability = subscapularis tear/ dysfunction
![Page 44: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/44.jpg)
Subscapularis2. Abdominal compression test
Patient attempts to press the hand down against abdomen with examiner preventing it. Useful when IR restricted.Inability = subscapularis tear/ dysfunction
![Page 45: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/45.jpg)
Drop Arm signExaminer abducts patient’s shoulder to maximum. After warning the patient, examiner releases pt’s arm & asks him to lower the arm back to the side. Pt able to lower the arm part way & then suddenly loses control- arm drops suddenly to the side.Indicates large rotator cuff tearAlso seen in axillary nerve palsy
![Page 46: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/46.jpg)
External rotation lag signPt’s arm is externally rotated maximally and released- arm rotates internally spontaneously (passive ER>active ER).Seen when subscapularis is intact but infraspinatus & teres minor is torn.
![Page 47: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/47.jpg)
![Page 48: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/48.jpg)
Yergasson’s testThe patient's elbow is flexed and their forearm pronated. The examiner holds their arm at the wrist. Patient actively supinates against resistance.Pain located to bicipital groove = +ve
![Page 49: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/49.jpg)
Speed’s testThe patient's elbow is extended, forearm supinated and the humerus elevated to 60°. The examiner resists humeral forward flexion.Pain located to bicipital groove = +ve
![Page 50: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/50.jpg)
![Page 51: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/51.jpg)
Cross chest adduction testPt. elevates the affected arm to 90°, then actively adducts it.
![Page 52: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/52.jpg)
![Page 53: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/53.jpg)
Restriction of all range of motion, esp-Abduction & ERPain on attempted movements
![Page 54: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/54.jpg)
Note –ER restriction occurs in 2 conditions only
1. Stiff shoulder2. Posterior dislocation
Overhead athletes may have restriction of IR due to posterior capsular tightness
![Page 55: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/55.jpg)
SUMMARYInstability Instability Provocative
QuantitativeImpinge-ment
Pain O’Brien, Hawkins-Kennedy, Neer’s
Cuff tear Painloss of motion
Drop arm test, Test for SS, IS & SS
Biceps tendinitis
PainInstability
Yergasson, Speed, Biceps instability
AC jt injury Pain Tenderness, Cross chest abduction
Stiff shoulder
Painstiffness
Passive motion restriction
![Page 56: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/56.jpg)
Conclusion
Clinical examination of shoulder should be guided according to patient's age, chief complains and professional activities.All tests needn’t be performed to clinch the diagnosis.Merely knowledge of test is not enough, good practice is essential to perform the tests.
![Page 57: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/57.jpg)
“It is more important to knowwhat patient the disease has rather than what disease the patient has”
William Osler
![Page 58: Shoulder examination](https://reader034.fdocuments.in/reader034/viewer/2022050906/554b6754b4c90564168b46ae/html5/thumbnails/58.jpg)