examination of shoulder joint

THE SHOULDER JOINT

MAJ VM PHILIP JUNIOR RESIDENT ORTHOPAEDICS

FUNCTIONS OF SHOULDER PRIMARY: hand placement in

various positions to accomplish the upper limb tasks

SECONDARY: 1) Suspension of the upper

limb

2)Sufficient fixation for upper limb movement

3)Fulcrum for arm elevation

SHOULDER COMPLEX

Three bones

Three joints

One pseudojoint

1/3 - 1/4

Diameter: 37- 55 mm

Diameter: ≈ 41 mm

Humeral head is half a sphere roughly articulating with one third to one fourth of the surface of glenoid fossa

ball and socket

Anatomy Glenohumeral joint

“Ball and socket” vs “Golf ball and tee”

Very mobile

Price: instability

45% of all dislocations

Joint stability depends on multiple factors

Glenohumeral Joint Humeral head faces medially,

posteriorly and superiorly

Glenoid :laterally,anteriorly and superiorly at rest and lateral, inferior and posterior in dependant position

Head shaft angle : 130 – 150 deg (long axis) and 30 – 40 deg retroverted in the frontal plane

Glenohumeral Joint GLENOID LABRUM

Dense fibro cartilage attached the glenoid fossa and joint capsule

Forms a part of articular surface

Long head of biceps: half of the fibres originate from the superior labrum

Increases joint stability (75% vertical and 56% transverse)

Glenohumeral Joint Joint capsule: - laterally attached to the neck

of humerus - medially to the periphery of

glenoid and labrum

Capsule is lax with multiple recesses

Axillary recess: inferiorly is lax and redundant permitting normal arm elevation

Joint Capsule - Posterior View

A. AcromionB. Scapular spineC. Coracohumeral ligamentD. Supraspinatus muscle

(cut away)E. Infraspinatus muscle (cut

away)F. Teres minor muscle (cut

away)G. Triceps muscle (cut away)H. Capsule

Glenohumeral Joint: capsule

Joint capsule: -Anteriorly reinforced by

the ‘Z’ ligaments

Rotator cuff : stregthens capsule anterior, superior and posteriorly

lined by synovial membrane

from glenoid labrum to neck of humerus

Anatomy

Scapula Glenoid Acromion Coracoid Subscapular fossa Scapular spine Supraspinatus

fossa Infraspinatus

fossa

GLENOHUMERAL JOINT Humerus

Anatomical neck

Greater and lesser tuberosities

IT groove: angle of wall(60° to 75°)

Tendon of long h ead of biceps makes an

abrupt right angle turn to lie in the IT groove

GLENOHUMERAL JOINT

Surgical neck of humerus

region below greater and lesser tuberosities where head meets the shaft

Axillary nerve

Posterior circumflex humeral artery

Glenohumeral Joint Joint capsule: -Anteriorly reinforced by the ‘Z’

ligaments

Rotator cuff : stregthens capsule anterior, superior and posteriorly

lined by synovial membrane from glenoid

labrum to neck of humerus

Glenohumeral Joint Ligaments : function in a load

sharing fashion by reciprocal tightening and loosening.

Lax in mid range of motion where rotator cuffs maintain stability

Anterior aspect of GH joint: Gleno humeral ligaments(sup,middle and inf) + coraco humeral ligaments:Z ligaments

Glenohumeral Joint : Ligaments

Superior GH ligament Origin - 12o’ clock of

glenoid rim Direction - inferior and

lateral Insertion - anatomical

neck Function - limits external

rotation and inferior translation of the humeral head with arm on the side


Middle GH ligament: poorly developed

Origin :2 or 3 o’ clock of glenoid rim

Direction: inferior and lateral Insertion: anatomical neck limits external rotation and

anterior translation of the humeral head with arm in 0 to 45° of abduction


Inferior GH ligament complex(IGHLC) Components:1. Anterior band2. Posterior band3. Axillary pouch Anterior band Origin : b/w 2 and 4 o’ clock of

glenoid rim Insertion : below lesser tuberosity Function : limits external rotation

and inferior translation of the humeral head with arm abducted to 90°


Inferior GH ligament complex

- Posterior band - b/w 7 and 9 o’ clock of

glenoid rim - limits internal rotation in

abduction - Anteror + posterior : anterior

translation at 90° abduction


Coracohumeral ligament: Functions

covers the Superior GH ligaments

fills the space b/w supraspinatus and subscapularis and complete the rotator cuff anteriorly

Ant band limits extension of GH Post band limits flexion of GHJ Both limit the inferior and posterior

translation of humeral head


Coraco acromial ligament: roof of the shoulder

From coracoid to antero inferior acromion ext into AC joints

Two bands near acromion

Prevent separation of AC jt

Glenohumeral Joint : Ligaments Coraco acromial arch: Ant inf

acromion + coracoacromial ligament +inf ascpect of AC jt

Scaption: supraspinatus tendon passes under the arch

Scaption + int rotation : SS tendon passes under coraco acromial ligament

Scaption + ext rotation: SS tendon passes under acromion

Glenohumeral Joint : Suprahumeral space

Boundaries:Inf : tuberosity of humerus

ant med : coracoid process sup : coraco acromial arch Structures (inf to sup)- Head of humerus- Long head of biceps tendon- Superior aspect of joint capsule- Supraspinatus,upper margins of

subscapularis and infraspinatus- Subacromial-subdeltoid bursae

Glenohumeral Joint : Suprahumeral space

Arm adducted by the side : 11 mm

Arm at 90° abduction : 5.7mm

Space is narrowest b/w 60° and 120°

Anatomy

Rotator Cuff Muscles

S – Supraspinatus

I – Infraspinatus

T - Teres minor

S- Supscapularis

Glenohumeral Joint : Bursae

Approx eight in shoulder complex

Subacromial Bursa: one of the largest

Two smooth serosal layers to deltoid and rotator cuff

Also connected to acromion,GT,coraco acromial ligament

Allows rotator cuff to slide easily beneath deltoid

Glenohumeral Joint Nerve supply

Derived from C5 to C8 nerve roots embryologically

Anterior shoulder joint : axillary(C5-C6) subscapular(C5-C6) lateral pectoral(C5-C6)

Posterior shoulder joint : suprascapular(C5-C6) axillary(C5-C6)

Glenohumeral Joint : Blood supply Branches of Axillary artery

- ant circumflex humeral

- post circumflex humeral

- suprascapular

- circumflex scapular

Glenohumeral Joint : Blood supply

Labrum: post cx humeral and subscapular ( capsule)

Rotator cuff: - supraspinatus : thoracoacromial

- subscapularis : ant cx humeral - infraspinatus post cx humeral - teres minor suprascapular

Glenohumeral Joint : Blood supply Biceps :Branches of Brachial artery Critical zones : supraspinatus and biceps

relatively avascular

Supraspinatus vulnerable: compressed by subacromial sructures Blood supply parallel to tendon fibres, susceptible to

stretch Critical zone proximal to insertion

Acromioclavicular Joint

Connects acromion process with lateral clavicle

Plane- synovial joint Gliding motion

occurs in all planes Suspends upper limb

from the trunk

Acromioclavicular Joint hyaline cartilage initially,

fibrous in adolescence

10 to 50 deg inclination

Acromion faces ant, med and sup

Thin capsule ,capsular lig

AC ligament prevents posterior translation and posterior axial rotation

Acromioclavicular Joint: ligaments

CORACOCLAVICULAR from coracoid to inferior

surface of clavicle Two parts: Conoid ligament Trapezoid ligament Vertical stability to AC

jt, superior & ant translation , ant axial rotation

Acromioclavicular Joint: ligaments Conoid ligament Fan shaped

Apex inferior

Medial of the two

Frontal pane

prevent coracoid movt away from clavicle

Acromioclavicular Joint: ligaments Trapezoid ligament Quadrilateral sheet From medial border of

upper surface of coracoid Runs supero laterally to

the inferior surface of clavicle

Larger,longer and stronger

Plane perpendicular to conoid

Blocks medial coracoid movt

Sternoclavicular Joint

Formed by- medial end of clavicle- claviclar notch of manubrium- first rib cartilage

Saddle/plane joint Fibrocartilagenous articular

disc Angulated 20° posterolaterally Lateral aspect of the joint acts

as an ovoid

Sternoclavicular Joint In vertical: proximal

end of clavicle is convex and manubrium concave

In AP view: proximal clavicle is concave and the manubrium convex

Sternoclavicular Joint (cont’d)

Articular disk - attached to the upper and

posterior end of clavicle and cartilage of first rib

- thick in perphery - divides the joint into two unequal

parts - more movt occurs b/w clavicle and

disk - prevents medial displacement of

clavicle -

Sternoclavicular Joint : ligaments Anterior Sternoclavicular Posterior Sternoclavicular Interclavicular Costoclavicular

Ant sternoclavicular Covers ant aspect Runs obliquely from clavicle to

sternum

Sternoclavicular Joint (cont’d)

Post SC ligaments Posterior aspect of jt Runs down and medially

Interclavicular ligaments Connects the

superomedial sternal ends of both clavicles with the capsular ligaments and upper sternum

Scapulothoracic Articulation

Not a joint anatomically Scapula moves over the rib cage of the

thorax Not directly attached

Connected indirectly via the clavicle and several muscles

Provides motion and flexibility to the body

15-18 cms of translation at ST jt normally

Anterior Shoulder Muscles

Coracobrachialis Pectoralis Major Subscapularis Biceps Brachii

Biceps Brachii Origin Short head:

coracoid process of scapulaLong head: supraglenoid tubercle of scapula

Insertion Tuberosity of radius

Action Flexion of the elbow and shoulder, Supinates forearm

***the long head is the “5th rotator cuff”

Coracobrachialis O: Coracoid process I: Anteromedial

surface of midshaft of humerus

Actions: (WEAK!) Flexion Adduction of the

shoulder

Pectoralis Major Origin:

Medial two-thirds of clavicle Sternum

Insertion: intertubercular groove

Actions Upper fibers (Clavicular)

• Flexion• Horizontal Adduction

Lower fibers (Sternal)• Internal/medial Rotation• Horizontal adduction

Subscapularis O: Subscapular fossa

I: Lesser tubercle and crest of humerus

Actions: Internal Rotation

Stabilization

Anterior Rotator Cuff Muscle.

Superior Shoulder Muscles Deltoid Supraspinatus

Deltoid Origin

Lateral 1/3 of clavicle (Anterior fibers)

Acromion process (Middle fibers)

Spine of scapula (Posterior fibers)

Insertion – deltoid tuberosity

ActionsAnterior –FlexionMiddle – AbductionPosterior –Extension

Inferior Shoulder Muscles Latissimus Dorsi Teres Major

Latissimus Dorsi O: Spinous process of

lower 6 thoracic and all lumbar and sacral vertebrae; iliac crest

I: Intertubercular groove

Actions:

Adduction Internal Rotation Extension

Teres Major O: Inferior angle of

scapula

I: Intertubercular groove

Actions: Adduction Internal rotation

“Lats little helper”

Posterior Shoulder Muscles Infraspinatus Teres Minor Triceps

Brachii

Triceps Brachii Origin

Long head: infraglenoid tubercle of scapula

Lateral head: posterior surface of humerus,

Medial head: posterior surface of humerus

Insertion Olecranon process of ulna

Action Chief extensor of elbow (long head extends the shoulder)

Infraspinatus O: Infraspinous fossa I: Greater tubercle Actions:

External rotation Stabilization Posterior Rotator Cuff

Muscle Second most commonly

injured rotator cuff muscle

Teres Minor O: lateral border of

scapula I: Greater tubercle Actions:

External rotation Stabilization Posterior Rotator

Cuff Muscle

Trapezius Origin occipital

bone, nuchal ligament, and spinous processes of C7 - T12 vertebrae

Insertion Lateral third of clavicle, acromion, and spine of scapula

Action superior fibers

elevate, middle fibers retract, inferior fibers

depress scapula;

Levator Scapula Origin C1 - C4

vertebrae Insertion

Superior angle Action Elevates

scapula

Rhomboid major and minor Origin Minor: spinous

processes of C7 and T1 vertebraeMajor: spinous processes of T2 - T5 vertebrae

Insertion Medial border of scapula

Action Retract scapula

Serratus Anterior Origin the eight

upper frontal ribs

Insertion lateral border of scapula

Action protracts scapula

Glenohumeral Joint: Biomechanics

Complex interaction amongst the joints in a smooth harmonious movt

G-H :: ball on a seal’s nose

Greatest ROM

2:1 at gh:st joints


Three DOF:- flexion/extension

- abduction/adduction

- internal/ext rotation

Glenohumeral Joint:biomechanics

Scapula: stable base Attaches indirectly to the rib

cage• Anteriorly concave and glides over

the convex rib• Located between the second and

seventh ribs

• Position : 30 degrees (frontal) 3 degree superior

FRONTAL PLANE

SAGITTAL PLANESCAPULAR PLANE

30 degrees

Glenohumeral Joint

Scaption : arm elevation occuring at 30 to 45 degrees anterior to the frontal plane


Static shoulder stabilisation- requires very little muscle support- provided by trapezius and supraspinatus- vertical stability:glenoid facing up by trapezius- inferior stability: intra articular pressure and adhesion/cohesion of articular surfaces- anatomic curvature of humerus- glenoid labrum- negative intraarticular pressure


Dynamic shoulder stabilisation - requires complex factors

Major dynamic stabilisers- long head of triceps and biceps - humeral head max stabilisation: subscapularis

Posterior restraints- <90° abduction : post capsule- 90° abduction : IGHLC

Scapulohumeral Rhythm

Describes the movement relationship between the scapula and humerus to maintain angle b/w scapula and humerus <30°

First 30° of shoulder joint motion pure GH motion

After that, for every 2° of shoulder flexion or abduction, the scapula rotates 1°

2:1 ratio → scapulohumeral rhythm

Full abduction: glenoid completely support humerus

0-80° →more humeral motion 80-140° → more scapular motion 140-170° →neighbouring joints

Scapulothoracic Articulation:Biomechanics 0-90°=60°+30° at GH and ST

- St movt = 20-25°of clavicular elevation at SC jt 05-10° of upward rotation at AC jt

90 to 180° = 60° of GH movt + 30° ST movt

- St movt = 05-10°of clavicular elevation at SC jt 20-25° of upward rotation at AC jt

Glenohumeral Joint:Biomechanics

Close Pack position : 90° abduction and full external rotation

Open Pack position : 55°abduction with 30° horizontal adduction

Zero position : 0 degree abduction,12° flexion,10° external rotn

Capsular pattern-Ext rotn:abduction: internal rotation = 3:2:1

Acromioclavicular Joint:Biomechanics Three types: rotation,spin,glide Rotation: - AP rotatation

- superoinferior

AP rotation: longitudinal Through SC and AC jts

30 to 50 deg -mostly SC

Acromioclavicular Joint:Biomechanics Protraction:ant movt of

acromial end of clavicle

Retraction: post movt of acromial end

Acromioclavicular Joint: Biomechanics Close Packed position 90° GH joint abduction

Open Packed position Arm is on the side Clavicle is 15° retracted

and 2° elevated Capsular pattern pain in extremes of

horizontal adduction and full elevation

Sternoclavicular Joint: Biomechanics Two types of translations A-P & sup-inf (2:1) allowing1. Elevation/depression2. Protraction/retraction3. Backward /forward rotation

Elevation and depression - 35 to 40 deg of elevation

- 15 deg depression

Sternoclavicular Joint: Biomechanics

Protraction/retraction - 15 to 20 deg both

- on protraction the concave surface of clavicle moves on convex sternum producing an anterior glide of clavicle and anterior rotation of lateral clavicle

- on retraction medial clavicle articulates with flat surface and posterior rotation of lateral end

Sternoclavicular Joint: Biomechanics

Rotationspin of the clavicle on manubrium

40° anterior and 5° posterior rotation Close Packed position

maximum arm elevation and protraction Open Packed position

arm by the side (postulated) Capsular pattern

full elevation and horizontal adduction

Scapulothoracic Articulation:Biomechanics scapula has five degrees of

freedom for movement on the thorax:

two translations and rotate in three planes around three different axes.

translations: - Elevation /Depression

- retraction &Protraction

Rotations: - scapular winging . - scapular tipping - up & down rotation

Rotational Movement of the Scapula

All three parts work together (synergists) to retract the scapula

Rotational Movement of the Scapula (cont’d)

Middle trapezius - prime mover Upper and lower trapezius are antagonistic in

elevation/ depression Upper and lower trapezius are agonistic in upward

rotation

Clinical Examination History Inspection Palpation Range of Motion Measurements Special Tests

History - PainHistory - Pain

Type and location of pain or symptoms Onset of pain (traumatic, insidious) Onset of pain (traumatic, insidious) Location of pain Location of pain Alleviating/Aggravating factors Alleviating/Aggravating factors Night pain Night pain Pain/weakness overhead activitiesPain/weakness overhead activities

Pain

Typically pain of gleno-humeral origin is felt in the upper arm, often at the insertion of the deltoid.

Severe shoulder problems can cause pain to radiate as far as the radial side of the wrist.

Impingement/rotator cuff pathology:anterior/lateral shoulder pain aggrevated with overhead activities

Pain The shoulder is derived from the fifth

cervical segment and therefore refers pain into the C5 dermatome.

The acromio-clavicular joint is a C4 structure and refers pain into the C4 dermatome.

Pain The shoulder is deep and proximal in the

C5 dermatome, hence it can potentially refer pain a great distance.

Conversely the acromio-clavicular joint is a superficial structure at the distal end of the dermatome causing it to give rise to accurate, local pain

Physical Exam – Inspection

Front & Back Height of shoulder

& scapulae Asymmetry Obvious deformity Ecchymosis Muscle atrophy

Supraspinatus Infraspinatus Deltoid

Physical Exam –Inspection




Physical Exam – Inspection




Palpation

At rest & with movement

Bony structures Joints Soft tissues

Palpation Surface Anatomy

(Anterior)

Clavicle SC Joint Acromion process AC Joint GH joint Coracoid process LT GT Subacromial bursa Pectoralis major Trapezius Biceps (long head)

AC joint

SC joint

biceps

Palpation Surface Anatomy

(Posterior)

Scapular spine Acromion process Supraspinatus Infraspinatus Teres Minor Trapezius Latissumus dorsi Scapula

• Inferior angle• Medial border

Supraspinatus

Infraspinatus

Inferior angle of scapula

Range of Motion

Forward flexion:160 - 180°

Extension: 40 - 60° Abduction: 180◦ Adduction: 45 ° External rotation:

80 - 90 ° Internal rotation:

60 - 90 °

Range of Motion

Scapular dyskinesis (Scapulothoracic dysfuntion)

Compare scapular motion through ROM on both sides

Wall push-ups

Symmetrical Smooth No or minimal winging

Strength Testing External rotation

Tests RTC muscles that ER the shoulder

• Infraspinatus• Teres minor

Arms at the sides

Elbows flexed to 90 degrees

Externally rotates arms against resistance

Strength Testing Internal rotation

Tests RTC muscle that IR the shoulder

• Subscapularis

Arms at the sides Elbows flexed to 90

degrees Internally rotates arms

against resistance

Subscapularis Lift-Off Test

Other techniques

Strength Testing Supraspinatus

“Empty can" testJobe’s Test

Tests Supraspinatus

Attempt to isolate from deltoid

Special Tests

Impingement

Rotator Cuff Integrity

Labrum and Biceps

AC (SC) Joints

Instability

:TESTS FOR ROTATOR CUFF/IMPINGMENT

TESTS FOR ACROMIOCLAVICULAR JOINT

TESTS FOR BICEP TENDON

TESTS FOR INSTABILITY

Neer impingment test

Hawkins kennedy test

Empty can test

Drop arm test

Lift off.Test

Infraspinatus test

Spring back test

Teres minor test

Teres major test

Apley scratch test

Painful arc

Forced adduction test

Forced adduction test in hanging arm

Duga’s test

1. Speed test

2. Yergason test

3. Bicep tendon with transverse humeral ligament test

1. Anterior apprehension test

2. Posterior apprehension test

3. Anterior posterior drawer test

4. Inferior instability test

5. Sulcus test

Impingement

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.(15-35years 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.

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 STANDS / SITS 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 isunable 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 orwithout pain, or sudden dropping of the arm suggests a rotator cufflesion. Most often this is due to a defect in the supraspinatus.

APLEY’S SCRTCH 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).

YOCUM TEST

LIFT PATIENT’S ELBOW TO SHOULDER HEIGHT WITH ARM RESTING ON THE NORMAL SHOULDER

HORNBLOWER’S SIGN (PATTE TEST)

determines the strength of the teres minor.

The examiner elevates the patient’s arm to 90 degrees in the scapular plane. The therapist then flexes the elbow to 90 degrees, and the patient is asked to laterally rotate the shoulder. A positive test occurs with weakness and/or pain.

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 STRENGH.

•A patient with a subscapularis tear will be unable to dothis.

•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).

.

SPRING BACK TEST:Infraspinatus

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 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.

LABRAL TEARS

Clunk test

Crank Test

O Brien’s Test

Compression-rotation test akin to Apley’s grinding

Biceps load test

CLUNK TEST Patient supine, examiner

puts hand on the posterior aspect of the shoulder, other hand hold the humerus above the elbow and abducts the arm over the head. Then pushing anteriorly with the hand under the shoulder and rotating the humerus laterally with the other hand, feel for a grind or clunk which may indicate a tear of the labrum.

O’BRIEN’S TEST Labral, AC, or biceps

pathology

Arm flexed to 90° Arm cross-arm

adducted 10-15° Elbow extended Max pronation Resist downward force

Positive test if painful Beware location of

pain AC Biceps

LABRAL TEAR: CRANK TEST

Abduct arm to 90-120° Stabilize shoulder Elbow secured with

one hand Axially load with ER /

IR at shoulder

Positive test: audible or painful click / catch / grind

ACROMIOCLAVICULAR JOINT TESTS

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. IN 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 SIDEWITH 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 suggestsacromioclavicular 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 diagnosismust 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 WITH OTHER HAND ON THE HUMERAL HEAD AND LATERALLY ROTATED SLOWLY BY THE EXAMINER. WHILE PERFORMING PATIENT’S EXPRESSIONS ARE NOTED FOR APPREHENSION/FURTHER RESISTENCE TO ROTATION. . 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 humeralhead.

SURPRISE TEST

Similar to apprehension test

But at max ext rotation the posterior force on the humerus is removed and we look for apprehension

Most accurate single test for anterior instability

ROCKWOOD TEST

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 ABDUCTS ARM IN SCAPULAR PLNE 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

examination of shoulder joint

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