SHOULDER JOINT ASSESSMENT Dr Ishaq Ahmed MSPT KMU

SHOULDER JOINT ASSESSMENT Dr. Ishaq Ahmed MSPT (KMU), BSPT (UHS), t-DPT (KMU)

NORMAL RANGE OF MOTION OF SHOULDER JOINT:

SPECIAL TESTS FOR SHOULDER JOINT: TESTS FOR ROTATOR CUFF/IMPINGM ENT TESTS FOR ACROMIOCLAVI CULAR JOINT 1. PAINFUL ARC 1. SPEED TEST 1. ANTERIOR 2. FORCED 2. YERGASON APPREHENSI ADDUCTION TEST 3. BICEP 2. POSTERIOR 3. FORCED TENDON APPREHENSI ADDUCTION WITH ON TEST IN TRANSVERS 3. ANTERIOR HANGING E HUMERAL POSTERIOR ARM LIGAMENT DRAWER 4. DUGA’S TEST 4. INFERIOR INSTABILITY TEST 5. SULCUS TEST NEER IMPINGMENT TEST 2. HAWKINS KENNEDY TEST 3. EMPTY CAN TEST 4. DROP ARM TEST 5. LIFT OFF. TEST 6. INFRASPINATUS TEST 7. SPRING BACK TEST 8. TERES MINOR TEST 9. TERES MAJOR TEST 10. APLEY SCRATCH TESTS FOR BICEP TENDON TESTS FOR INSTABILITY

TESTS FOR ROTATOR CUFF AND IMPINGMENT SYNDROME

IMPINGEMENT: Primary impingment Secondary impingment Occur because of degenerative changes to the rotator cuff, the acromian process, the coracoid process and anterior tissues from stress overload. Occurs due to problem with muscle dynamics with an upset in the normal force couple action leading to muscle imbalance and abnormal movement patterns at both the glenohumeral joint and the scapulothoracic articulation. Impingement is primary cause of pain. It is secondary to altered muscle dynamics. Occurs mostly in 40+ age group people. Occurs in young patients. (1535 years old) It is said to be intrinsic when rotator cuff degeneration occurs and extrinsic when the shape of the acromian and degeneration of the coracoacromial ligament occurs. Commonly seen with joint instability.

GRADING OF IMPINGEMET: Mostly impingement and instability often occurs together in throwing athletes and accordingly it is classified as: GRADE I: GRADE III: GRADE IV: Pure impingement with no instability. (ofte n seen in older patients) Secondary impingment and instability caused by chronic capsular and labral microtrauma. Secondary impingement and instability caused by generalized hypermobility or laxity. Primary instability with no impingement.

NEER IMPINGMENT TEST: PATIENT’S AFFECTED ARM IS PASSIVELY AND FORCIBLY FULLY ELEVATED IN THE SCAPULAR PLANE WITH THE ARM MEDIALLY ROTATED BY THE EXAMINER. • This passive stress causes “jamming of the greater tuberosity against the anteroinferior border of the acromian. • The patient’s face shows pain reflecting a +ve test.

HAWKIN’S KENNEDY IMPINGMENT TEST: PATIENT STAND WHILE THE EXAMINER FORWARD FLEXS THE ARM TO 90º AND FORCIBLY MEDIALLY ROTATES THE SHOULDER. • This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament and coracoid process. • Pain indicates +ve test.

SUPRASPINATUS TEST/EMPTY CAN TEST: THIS TEST MAY BE PERFORMED WITH THE PATIENT STANDING OR SEATED. WITH THE ELBOW EXTENDED, THE PATIENT’S ARM IS HELD AT 90° OF ABDUCTION, 30° OF HORIZONTAL FLEXION, AND IN INTERNAL ROTATION (WITH THUMB FACING DOWN). THE EXAMINER EXERTS PRESSURE ON THE UPPER ARM DURING THE ABDUCTION AND HORIZONTAL FLEXION MOTION. • When this test elicits severe pain and the patient is unable to hold his or her arm abducted 90° against gravity, this is called a positive empty can test/supraspinatus tendinitis. • The superior portions of the rotator cuff (supraspinatus) are particularly assessed in internal rotation (with the thumb down), and the • anterior portions in external rotation.

DROP ARM(CODMAN’S)TEST: THE PATIENT IS SEATED, AND THE EXAMINER PASSIVELY ABDUCTS THE PATIENT’S EXTENDED ARM APPROXIMATELY 120°. THE PATIENT IS ASKED TO HOLD THE ARM IN THIS POSITION WITHOUT SUPPORT AND THEN SLOWLY ALLOW IT TO DROP. Weakness in maintaining the position of the arm, with or without pain, or sudden dropping of the arm suggests a rotator cuff lesion. Most often this is due to a defect in the supraspinatus. In pseudoparalysis, the patient will be unable to lift the affected arm. This global sign suggests a rotator cuff disorder.

SUBSCAPULARIS TEST/LIFT OFF TEST: PATIENT IN STANDING POSITION PLACES THE DORSUM OF THE HAND ON THE BACK. THE PATIENT THEN LIFTS THE HAND AWAY FROM THE BACK. IF PATIENT IS ABLE TO DO THEN LOAD PUSHING ON HAND IS DONE BY THE EXAMINER TO CHECK THE STRENGTH. • A patient with a subscapularis tear will be unable to do this. • Abnormal motion in the scapula during the test may indicate scapular instability.

INFRASPINATUS TEST: COMPARATIVE TESTING OF BOTH SIDES IS BEST. THE PATIENT’S ARMS SHOULD HANG RELAXED WITH THE ELBOWS FLEXED 90° BUT NOT QUITE TOUCHING THE TRUNK. THE EXAMINER PLACES HIS OR HER PALMS ON THE DORSUM OF EACH OF THE PATIENT’S HANDS AND THEN ASKS THE PATIENT TO EXTERNALLY ROTATE BOTH FOREARMS AGAINST THE RESISTANCE OF THE EXAMINER’S HANDS. Pain or weakness in external rotation indicates a disorder of the infraspinatus (external rotator). As infraspinatus tears are usually painless, weakness in rotation strongly suggests a tear in the muscle. This test can also be performed with the arm abducted 90° and flexed 30° to eliminate involvement of the deltoid in this motion.

SPRING BACK TEST: PATIENT EITHER IN SITTING OR STANDING HOLD THE ELBOW IN FLEXION AT 90º BY THE SIDE. EXAMINER PASSIVELY BRING THE SHOULDER TO 90º ABDUCTION AND LATERALLY ROTATE TO THE END RANGE AND ASK THE PATIENT TO HOLD THE ARM TO THIS POSITION. FOR +VE TEST OF INFRASPINATUS WEAKNESS/LESION PATIENT CANNOT HOLD THE POSITION AND HAND SPRING BACK ANTERIORLY. TERES MINOR TEST: PATIENT LIES PRONE AND PLACES HIS HAND ON THE OPPOSITE POSTERIOR ILIAC CREST. ASK THE PATIENT TO EXTEND ADDUCT THE MEDIALLY ROTATED ARM AGAINST RESISTANCE. PAIN OR WEAKNESS INDICATE +VE TEST.

TERES MAJOR TEST: THE PATIENT IS STANDING AND RELAXED. THE EXAMINER ASSESSES THE POSITION OF THE PATIENT’S HANDS FROM BEHIND. THE TERES MAJOR IS AN INTERNAL ROTATOR. WHERE A CONTRACTURE IS PRESENT, THE PALM OF THE AFFECTED HAND WILL FACE BACKWARD . COMPARED WITH THE CONTRALATERAL HAND

APLEY’S SCRATCH TEST: THE SEATED PATIENT IS ASKED TO TOUCH THE CONTRALATERAL SUPERIOR MEDIAL CORNER OF THE SCAPULA WITH THE INDEX FINGER . Pain elicited in the rotator cuff and failure to reach the scapula because of restricted mobility in external rotation and abduction indicate rotator cuff pathology (most probably involving the supraspinatus).

ACROMIOCLAVICULAR JOINT TESTS

TOSSY CLASSIFICATION: TOSSY TYPE 1: CONTUSION OF THE ACROMIOCLAVICULAR JOINT WITHOUT SIGNIFICANT INJURY TO THE CAPSULE AND LIGAMENTS. TOSSY TYPE 2: SUBLUXATION OF THE ACROMIOCLAVICULAR JOINT WITH RUPTURE OF THE ACROMIOCLAVICULAR LIGAMENTS. TOSSY TYPE 3: DISLOCATION OF THE ACROMIOCLAVICULAR JOINTWITH ADDITIONAL RUPTURE OF THE CORACOCLAVICULAR LIGAMENTS.

ACROMIOCLAVICULAR JOINT PROBLEM MAY BE ELICITED BY ANTERIOR PAIN WITH MOTION AND TENDERNESS TO PALPATION OVER THE ACROMIOCLAVICULAR JOINT. FINDINGS WILL OFTEN INCLUDE PALPABLE BONY THICKENING OF THE ARTICULAR MARGIN. TOSSY CLASSIFIES ACROMIOCLAVICULAR JOINT INJURIES INTO THREE DEGREES OF SEVERITY:

PAINFUL ARC: THE PATIENT’S ARM IS PASSIVELY AND ACTIVELY ABDUCTED FROM THE REST POSITION ALONGSIDE THE TRUNK. PAIN IN THE ACROMIOCLAVICULAR JOINT OCCURS BETWEEN 140°AND 180° OF ABDUCTION. INCREASING ABDUCTION LEADS TO INCREASING COMPRESSION AND CONTORTION IN THE JOINT. I(N AN IMPINGEMENT SYNDROME OR A ROTATOR CUFF TEAR, BY COMPARISON, PAIN SYMPTOMS WILL OCCUR BETWEEN 70° AND 120°. In the evaluation of the active and passive ranges of motion, the patient can often avoid the painful arc by externally rotating the arm while abducting it. This increases the clearance between the acromion and the diseased tendinous portion of the rotator cuff, avoiding impingement in the range between 70° and 120°.

FORCED ADDUCTION TEST: THE 90°-ABDUCTED ARM ON THE AFFECTED SIDE IS FORCIBLY ADDUCTED ACROSS THE CHEST TOWARD THE NORMAL SIDE. FORCED ADDUCTION TEST ON HANGING ARM: THE EXAMINER GRASPS THE UPPER ARM OF THE AFFECTED SIDE WITH ONE HAND WHILE THE OTHER HAND RESTS ON THE CONTRALATERAL SHOULDER AND IMMOBILIZES THE SHOULDER GIRDLE. THEN THE EXAMINER FORCIBLY ADDUCTS THE HANGING AFFECTED ARM BEHIND THE PATIENT’S BACK AGAINST THE PATIENT’S RESISTANCE. Pain across the anterior aspect of the shoulder suggests acromioclavicular joint disease or subacromial impingement.

DUGA’S TEST: THE PATIENT IS SEATED OR STANDING AND TOUCHES THE CONTRALATERAL SHOULDER WITH THE HAND OF THE 90°FLEXED ARM OF THE AFFECTED SIDE THEN ATTEMPT TO LOWER THE ELBOW TO THE CHEST IS MADE. Acromioclavicular joint pain suggests joint disease (osteoarthritis, instability, disk injury, or infection). A differential diagnosis must exclude anterior subacromial impingement

BICEP TENDON TEST THE CLOSE ANATOMIC PROXIMITY OF THE INTRAARTICULAR PORTION OF THE TENDON TO THE CORACOACROMIAL ARCH PREDISPOSES IT TO INVOLVEMENT IN DEGENERATIVE PROCESSES IN THE SUBACROMIAL SPACE. A ROTATOR CUFF TEAR IS OFTEN ACCOMPANIED BY A RUPTURE OR INJURIES OF THE BICEPS TENDON.

SPEED TEST: IN SITTING THE EXAMINER RESISTS SHOULDER FORWARD FLEXION BY THE PATIENT WHILE THE PATIENT’S FOREARM IS IN SUPINATION. PAIN IN THE REGION OF THE BICIPITAL GROOVE SUGGESTS A DISORDER OF THE LONG HEAD OF THE BICEPS TENDON.

YERGASON TEST: WITH THE PATIENT’S ELBOW FLEXED TO 90º AND STABILIZED AGAINST THORAX AND WITH FOREARM PRONATED, THE EXAMINER RESISTS SUPINATION WHILE THE PATIENT ALSO LATERALLY ROTATES THE ARM AGAINST RESISTANCE. DURING THIS MOVEMENT WHEN THE TENDON . IS FELT IN GROOVE AS “POP OUT” • Pain in the bicipital groove is a sign of a lesion of the biceps tendon, its tendon sheath, or its ligamentous connection via the • transverse ligament. • The typical provoked pain can be increased by pressing on the tendon in the bicipital groove.

BICEP TENDINITIS WITH TRANSVERSE HUMERAL LIGAMENT TEST: THE PATIENT IS SEATED WITH THE ARM ABDUCTED 90°, INTERNALLY ROTATED, AND EXTENDED AT THE ELBOW. FROM THIS POSITION, THE EXAMINER EXTERNALLY ROTATES THE ARM WHILE PALPATING THE BICIPITAL GROOVE TO VERIFY WHETHER THE TENDON SNAPS. • In the presence of ligamentous insufficiency, this motion will cause the biceps tendon to spontaneously displace out of the bicipital groove. • Pain reported without displacement suggests biceps • tendinitis.

INSTABILITY TESTS SHOULDER PAIN MAY BE ATTRIBUTABLE TO AN UNSTABLE SHOULDER. USUALLY HISTORY OF A PERIOD OF INTENSIVE SHOULDER USE (SUCH AS COMPETITIVE SPORTS), AN EPISODE OF REPEATED MINOR TRAUMA (OVERHEAD USE), OR GENERALIZED LIGAMENT LAXITY. BOTH YOUNG ATHLETES AND INACTIVE PERSONS ARE AFFECTED, MEN AND WOMEN ALIKE.

ANTERIOR APPREHENSION TEST: PATIENT LIE SUPINE OR IN SITTING. ARM IS ABDUCTED TO 90º AND LATERALLY ROTATED SLOWLY BY THE EXAMINER. WHILE PERFORMING PATIENT’S EXPRESSIONS ARE NOTED FOR APPREHENSION/FURTHER RESISTENCE TO ROTATION. THE TEST IS PERFORMED AT 60°, 90°, AND 120° OF ABDUCTION TO EVALUATE THE SUPERIOR, MEDIAL, AND INFERIOR GLENOHUMERAL LIGAMENTS. WITH THE GUIDING HAND, THE EXAMINER PRESSES THE HUMERAL HEAD IN AN ANTERIOR AND INFERIOR DIRECTION Shoulder pain with reflexive muscle tensing is a sign of an anterior instability syndrome. This muscle tension is an attempt by the patient to prevent imminent subluxation or dislocation of the humeral head.

NOTE: When the patient complains of sudden stabbing pain with simultaneous or subsequent paralyzing weakness in the affected extremity, this is referred to as the “dead arm sign. ” It is attributable to the transient compression the subluxated humeral head exerts on the plexus. It is important to know that at 45° of abduction, the test primarily evaluates the medial glenohumeral ligament and the subscapularis tendon. At or above 90° of abduction, the stabilizing effect of the subscapularis is neutralized and the test primarily evaluates the inferior glenohumeral ligament.

POSTERIOR APPREHENSION TEST: PATIENT LIES SUPINE OR IN SITTING POSITION AND EXAMINER FORWARD FLEX SHOULDER TO 90º WHILE STABILIZING THE SCAPULA WITH OTHER HAND. EXAMINER THEN APPLIES A POSTERIOR FORCE ON THE ELBOW AND MOVES THE ARM IN ADDUCTION AND MEDIALLY ROTATION.

ANTERIOR AND POSTERIOR DRAWER TEST: THE PATIENT IS SEATED. THE EXAMINER STANDS BEHIND THE PATIENT. TO EVALUATE THE RIGHT SHOULDER, THE EXAMINER GRASPS THE PATIENT’S SHOULDER WITH THE LEFT HAND TO STABILIZE THE CLAVICLE AND SUPERIOR MARGIN OF THE SCAPULA WHILE USING THE RIGHT HAND TO MOVE THE HUMERAL HEAD ANTERIORLY AND POSTERIORLY.

INFERIOR APPREHENSION TEST/FEAGIN TEST: PATIENT STANDS WITH THE ARM ABDUCTED TO 90º AND ELBOW EXTENDED AND RESTING ON TOP OF THE EXAMINER’S SHOULDER. EXAMINER CLASP HIS/HER HANDS AROUND THE PATIENT’S HUMERUS AND PUSHES THE HUMERUS DOWN AND FORWARD. IN THIS SULCUS MAY ALSO BE SEEN ABOVE THE CORACOID PROCESS.

SULCUS TEST: PATIENT STANDS WITH ARM BY THE SIDE AND SHOULDER MUSCLE RELAXED. THE EXAMINER GRASPS THE PATIENT’S FOREARM BELOW THE ELBOW AND PULLS THE ARM DISTALLY. THE PRESENCE OF SULCUS/INDENTATION INFERIOR TO ACROMIAN IS THE INDICATIVE.

THANK YOU