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Shoulder Evaluation

Shoulder Evaluation. Chapter 13, p. 424. Shoulder Anatomy: Scapula. Borders inferior superior Fossa supraspinous infraspinous Processes coracoid acromion Motion (scaption). Shoulder Anatomy: Humerus. Humeral head Tuberosities: Greater (lateral) Lesser (medial) Bicipital Groove

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Shoulder Evaluation

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  1. Shoulder Evaluation Chapter 13, p. 424

  2. Shoulder Anatomy: Scapula • Borders • inferior • superior • Fossa • supraspinous • infraspinous • Processes • coracoid • acromion • Motion (scaption)

  3. Shoulder Anatomy: Humerus • Humeral head • Tuberosities: • Greater (lateral) • Lesser (medial) • Bicipital Groove • Glenohumeral Joint • Instability/laxity • Labrum • Capsule

  4. Supraspinatus assists deltoid in ABD ER Infraspinatus ER/Hor. Abd Decelerator (ECC) Teres Minor ER/Hor. Abd Decelerator (ECC) Subscapularis only pure IR muscle Force Couple: RC:Deltoid Stabilizing effect Fig. 13-15, p. 433 Shoulder Anatomy: Rotator Cuff(P. 432)

  5. Shoulder Anatomy: Bursae(p. 437) • Purpose • Subacromial bursa • location • subacromial/subdeltoid

  6. Location know the anatomy know the biomechanics Onset: acute? chronic? worsen or improve with activity? Duration of pain? PMH (biomechanics) Mechanism of injury Overhead activity Collision Excessive ROM Repetitive motion Complaints “sliding out of place” aching or “dead” popping Shoulder Evaluation: History(p. 437-439)

  7. Shoulder Evaluation: Observation(p. 439) • Position of the head • 2º neck injury? • Muscle spasm? • Level of the shoulders • dominant=lower • clavicles & scapulae • Contour of clavicles • Fig. 13-18, p. 439

  8. Shoulder Evaluation: Observation(p. 439-442) • Symmetry • muscle tone • atrophy (infraspinatus) • levels • GH joint position • Vertebral alignment

  9. Shoulder Evaluation: Palpation(p. 442-444) • Clavicle • SC->AC • angulations • piano key sign • Rotator cuff insertions • Glenohumeral (GH) joint • Biceps Tendon • Anatomy: p.442, 444

  10. Shoulder Evaluation: Palpation • Deltoid • Spine of the scapula • Supraspinatus • Infraspinatus • Levator scapulae • Rhomboids • Trapezius

  11. Shoulder ROM • Apley’s Scratch Test • Apley’s Scratch test: p.447, Box 13-3 • opposite shoulder from front • opposite shoulder from behind • opposite shoulder over head • evaluates multiple ROM’s

  12. Shoulder ROM • Drop arm test • P. 449, Box 13-4 • (+)= Rotator cuff tear • Uncontrolled drop in AROM ABD

  13. Shoulder ROM(p. 437) • Scapulothoracic Rhythm • GH abduction • 2:1 ratio of GH to scapular movement • example: 180º = • 120º GH • 60º scapular rotation • bilateral/symmetrical

  14. Functional Testing(p.444-458) • Force Production • IR/ER: • 3:2 CON • 3:4 ECC • ROM • Flex/Ext • ABD/ADD • ER/IR • Hor. ABD/ADD

  15. Shoulder Pathologies: • Acromioclavicular injuries • Glenohumeral Instability • Rotator Cuff Strains • Rotator Cuff Impingement • Rotator Cuff Tendinitis • Biceps Tendon Injuries • Thoracic Outlet Syndrome

  16. Acromioclavicular (AC) Joint Injuries (p. 460-461, Table 13-8) • History • Acute trauma or overuse • FOOSH mechanism • “separated shoulder” • Observation • Step deformity possible • Clavicles not level • Examination • Traction Test • p. 462, Box 13-10 • Compression Test • p.463, Box 13-11 • Palpation • Tender AC joint • AC laxity • (piano key sign)

  17. Clavicle Fractures

  18. Glenohumeral Instability(p. 463) • History • Unidirectional or multidirectional • Anterior/inferior most common • Excessive ROM mechanism or FOOSH • Easily becomes chronic • “Dead Arm Syndrome” • Reports a pop • Subluxation->dislocation • Observation • Obvious deformity with dislocation • Guarded presentation • Bankart lesions • Hill-Sachs lesions • Palpation • Obvious GH deformity • Tender at RC insertions • Assess instability direction • Check radial pulse and sensation

  19. Glenohumeral Dislocations • Obvious deformity • Check distal pulse often • Reduction strategies • Humeral fx possible • Splint and refer +/- reduction

  20. GH Joint Damage Bankart Tear--p. 463 Torn anterior labrum following chronic GH instability Labrum avulses from glenoid fossa • Hill-Sachs Lesion—p.466 • posterolateral humeral head indentation fracture • soft base of humeral head impacts glenoid • occurs in 35-40% of anterior dislocations & up to 80 % of recurrent dislocat.

  21. SLAP Lesions • Superior Labrum AnteroPosterior lesion • Near LH Biceps tendon • Pain worsens with ECC biceps work (follow-through motions) • Sx repair slow rehab progression • Classifications: • 4 Classes • P. 480: Table 13-13

  22. Special Tests: SLAP Lesions • O’Brien Test • Active Compression test • 90-90position with HAdd • RROM Trials in IR and ER • (+) test= pain or clicking at GH joint (not AC) • False (+) common

  23. Special Tests: GH Joint(p. 453) • Anterior Apprehension Test • Identifies chronicity of anterior instability • Figure Box 13-5 • PROM ER of GH in 90-90 position • Positive (+)= Extreme guarding during test indicates ant laxity or labrum tear

  24. Special Tests: GH Joint(p. 465) • Relocation Test • Confirms instability in GH joint • Box 13-12 • Apprehension test with posterior GH pressure • Positive (+)= increased ER or decreased pain without extreme guarding

  25. Special Tests: GH Joint(p. 456) • Posterior Apprehension Test • Box 13-13 • PROM post. Force in 90 shoulder/elbow flex • Positive (+)= Extreme guarding during test • Indicates post. Laxity or labrum tear

  26. Special Tests: GH Joint(p. 469) • Sulcus Sign • Confirms instability in GH joint • Box 13-15 • Traction on humerus • Positive (+)= increased opening/laxity at GH joint (AC joint remains NML)

  27. Rotator Cuff Strainsp. 474—Table 13-12 • History • excessive ECC motions • excessive ROM • Dislocation/subluxation • PMH of RC tendonitis • Palpation • tender at RC insertions • possible posterior pain • Crepitus possible • Observation • no significant swelling • altered posture • overhead motions painful • painful arc

  28. Special Tests: Rotator Cuffp. 475 • Empty Can Test • Cintinela Test • Box 13-19 • (+)= Rotator cuff strain • Test (B) • Multiple tests/trials

  29. Special Tests: Rotator Cuffp. 455 • Gerber Lift-Off Test • Box 13-7 • Position: shoulder IR behind back • Lift hand away from back • Isolates subscapularis

  30. Shoulder Impingement(P. 470, p. 471--Table 13-11) • History: • usually chronic • common with overhead sports • Observation: • limited AROM • painful arc • altered mechanics • usually no obvious inflammation • Palpation: • possible crepitus • tender RC insertions • possible bicipital groove pain • Examination • Neer’s test • Hawkins test

  31. Rotator Cuff Impingement: Special Tests • Neer’s test • P. 472: Box 13-16 • PROM shoulder flexion • (+)= pain at endrange • May indicate LHB pathology

  32. Rotator Cuff Impingement: Special Tests • Hawkin’s test • P. 473—Box 13-17 • PROM shoulder IR with flexion • (+)= pain at endrange • May indicate LHB pathology

  33. Rotator Cuff Tendinitis(P. 471) • History: • slow onset • PMH~impingement or instability • Observation: • decreased AROM • guarded presentation • possible post. Atrophy • Palpation: • subacromial/deltoid pain • Posterior pain possible • RC insertions painful • Examination: • Drop arm test • Empty can test • Impingement tests

  34. Biceps Tendon Pathology(p. 4476) • History: • PMH~RC pathology • Overuse or acute onset • Forced ROM (ER or Ext) with elbow ext.--ECC or CON • Observation: • altered mechanics • Inflammation • Palpation: • Tender at bicipital groove • Transverse ligament • Subluxation of BT • dec. MMT in biceps • Examination: • Yergason test • Speed’s test • Impingement tests

  35. Biceps Tendon Pathology: Special Tests(p. 477 • Yergason Test: • Attempt to sublux BT • Resisted elbow flexion/supination • (+)=pop/snap with pain • transverse lig. Sprain • biceps tendonitis • biceps impingement • Box 13-20

  36. Biceps Tendon PathologySpecial Tests:(p. 478 • Speed’s Test: • Confirms BT inflammation • Resisted flexion with GH in anatomical position • (+)= pain at BT with RROM • no pop/snap felt • Box 13-21

  37. Thoracic Outlet Syndrome(P. 480) • History: • Usu. congenital problem • C7 “extra rib” • Neurovascular complaints as structures are compressed • Observation: • x-rays indicates “extra” rib • Poor posture (rounded shoulders, forward head) • Palpation: • Decreased pulse with Adson’s test • Altered sensation/temperature • Joint edema possible • Examination • Adson’s test • Allen test

  38. Thoracic Outlet SyndromeSpecial tests:p.482—Box 13-24 • Adson’s test: • Attempt to reproduce pressure on neurovasc. bundle • ER/ext of shoulder with ext of neck • Monitor radial pulse during test • (+)= diminished pulse during test • false (+) frequent • test (B)

  39. Thoracic Outlet Syndrome Special tests:p. 483—Box 13-25 • Allen test: • Attempt to reproduce pressure on neurovasc. bundle • ABD/ Hor. ABD of shoulder with rot of neck • Monitor radial pulse during test • (+)= diminished pulse during test • false (+) frequent • test (B)

  40. Pitching Motion(P. 438) • 5 phases • 90 º GH ABD • Trunk and legs for power • CON-ECC forces for power and protection • Pitcher vs. Catcher?

  41. Shoulder Motion • Mobility > Stability • OveruseAltered Biomechanicsinjury • Good biomechanics prevent injury

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