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  1. 1. Physical Examination of theShoulder
  2. 2. Examination of shoulderAnatomyHistoryInspectionPalpationRange of MotionSpecial tests – Impingement testsLabral testsInstability testsRotator Cuff testsStrength testsAcromio-clavicular joint testsMeasurementsCervical Spine and Neurological Examination
  3. 3. Shoulder painCommon in all age groupsIntrinsic disorder (85%) vs referred painC-spine nerve impingement (disc herniation orspinal stenosis)Peripheral nerve entrapment distal to spinalcolumn (long thoracic, suprascapular)Diaphragm irritation, intrathoracic tumors, anddistension of Gleason’s capsule/gall bladderMyocardial ischemiaPancoast tumor
  4. 4. Review of shoulder anatomy
  5. 5. Review of shoulder anatomyBonesScapulaClavicleHumeral headPosterior rib cageJointsSternoclavicularAcromioclavicularGlenohumeralScapulothoracic
  6. 6. Glenohumeral joint25% humeral head surface in contact withglenoidJoint space thinning seen with OA
  7. 7. Glenohumeral jointHumeral head coverage increased to 75% withglenoid labrum
  8. 8. More shoulder anatomyLigamentsCoracoclavicularAcromioclavicularGlenohumeralSuperior GHMiddle GHInferior GHCoracohumeralSubacromial bursaSubdeltoid bursa
  9. 9. Rotator cuff musclesSupraspinatus,infraspinatus, teresminor, subscapularisForm cuff aroundhumeral headKeep humeral headwithin joint (counteractdeltoid)Abduction, externalrotation, internal rotation
  10. 10. Muscles of the Rotator CuffThe four major muscles of the rotator cuff rotate thehumerus and properly orient the humoral head in theglenoid fossa (socket).The tendons of these four muscles merge, forming a cuffaround the glenohumeral joint.Supraspinatus: abducts the humeral head and acts as ahumeral head depressorInfraspinatus: externally rotates and horizontally extendsthe humerusTeres minor: externally rotates and extends the humerusSubscapularis: internally rotates the humerus
  11. 11. HistoryAsk questions pertaining to the following: Chief complaint Mechanism of injury - Thrower, RTA,Thrower, RTA,sudden traction, repetitive overhead workersudden traction, repetitive overhead worker Unusual sounds or sensations Previous injury Previous injury to opposite extremity forbilateral comparison
  12. 12. History - PainHistory - PainType and location of pain or symptomsOnset of pain (traumatic, insidious)Onset of pain (traumatic, insidious)Location of painLocation of painAlleviating/Aggravating factorsAlleviating/Aggravating factorsNight painNight painPain/weakness overhead activitiesPain/weakness overhead activities
  13. 13. PainPain Where is the pain?(C4 or C5) How Long for? Other Joints?1. Able to lie on that side?2. Pain at rest?3. Pain down the arm? (how far) The last 3 questions determine theirritability of the joint
  14. 14. PainThe shoulder is derived from the fifthcervical segment and therefore refers paininto the C5 dermatome.The acromio-clavicular joint is a C4structure and refers pain into the C4dermatome.
  15. 15. PainThe extent of reference is governed by anumber of factors.The depth of the structure beneath theskin.The position of the structure within thedermatome.The severity of the lesion
  16. 16. PainThe shoulder is deep and proximal in theC5 dermatome, hence it can potentiallyrefer pain a great distance.Conversely the acromio-clavicular joint is asuperficial structure at the distal end of thedermatome causing it to give rise toaccurate, local pain
  17. 17. PainTypically pain of gleno-humeral origin isfelt in the upper arm, often at the insertionof the deltoid.Severe shoulder problems can cause pain toradiate as far as the radial side of the wrist.Other potential sources of pain at theshoulder need to be eliminated (angina,pleuritic pain or neck pain.)
  18. 18. PainPain behaves in a predictable manner.There are several rules of referralPain is generally referred distally.Pain is felt deeply.Pain does not cross the mid—line.Pain may occupy any part of thedermatome.Pain is felt segmentally.
  19. 19. PainThe exception to the rules of referred painis the dura mater which will give rise toextrasegmental referred pain.
  20. 20. Painful ArcThis is not a diagnosis but a localising sign.There are 4 common causes of a painful arcat the shoulder joint.All involve soft tissues being pinchedbetween the humerus and the underside ofthe acromion.
  21. 21. Painful ArcThese are:supraspinatus (pain on resisted abduction)infraspinatus (pain on resisted lateralrotation).subscapularis (pain on resisted medialrotation).sub-acromial bursa (pain at extremes of allpassive ranges
  22. 22. Examination of the Shoulder1. Observe the wholepatient, front and back.2. Observe the shoulder.3. Observe the axilla.View from rear withpatient standing straightand look for lateralsymmetry, swelling,position of scapula andsigns of muscle wasting.
  23. 23. InspectionPosture: Cervical lordosis, thoracicPosture: Cervical lordosis, thoracickyphosis, and rounded shoulderskyphosis, and rounded shouldersRelative elevation or depression shoulderRelative elevation or depression shoulderMuscle atrophyMuscle atrophyProminent AC jointProminent AC jointScapula motion during arm elevationScapula motion during arm elevationActive/Passive range of motionActive/Passive range of motion
  24. 24. InspectionVisible facial expressions of painSwelling, deformity, abnormal contours, ordiscolorationDoes the arm hang and swing, or does he hold orsplint the arm?Overall position, posture, and alignmentMuscle development—are there areas of muscularatrophy?Bilateral comparison of acromions, SC joints,inferior border of scapula, and scapular spineIs the inferior tip of scapula level with T7 and thesuperior medial ridge level with T2?
  25. 25. Observe shoulderabduction from infront and behind,through the entirerange of movement.Note the presence ofdifficulty in initiationor a painful arc.
  26. 26. PalpationBilaterally palpate for pain,tenderness, and deformity overthe following: SC joint, clavicle, AC joint,acromion, coracoid process,subacromial bursa, greatertuberosity, lesser tuberosity,bicipital groove Spine, superior and inferiorangles of scapula, lowercervical and upper thoracicspinous processes
  27. 27. PalpationRotator cuff insertionSternocleidomastoid,pectoralisBiceps tendon andmuscleTrapezius, rhomboid,latissimus dorsi,serratus anteriorAxillary structures
  28. 28. Range of Motion Testsconducted both actively and passivelyThe reason for this is that if the patient isexperiencing pain, he/she may restrictmovement.Furthermore, the opposing limb should beexamined in an identical fashion in order toevaluate bilateral symmetry.
  29. 29. External Rotationpatient is positionedsitting and the elbowis flexed 90 degrees.While the elbow isheld against thepatients side, theexaminer externallyrotates the arm aspermitted.
  30. 30. Internal RotationThe patient should bepositioned sitting.Again with the elbows atthe patients side, theexaminer should raise thethumb up the spine, andrecord the position inrelation to the spine(reaching T7 is normal,unless bilateral symmetry isobserved).
  31. 31. Internal Rotation at 90 degrees of ForwardflexionThe patient is positionedsitting with the elbow andshoulder supported toprevent muscle contraction.The arm is at 90 degrees withthe fingers pointingdownward and palm facingposteriorly.The examiner attempts torotate the forearm posteriorlyas far as possible.
  32. 32. Forward flexionThe arm is keptstraightened and broughtupward through the frontalplane, and moved as far asthe patient can go above hishead.Note: for recordingpurposes, 0 degrees isdefined as straight down atthe patients side, and 180degrees is straight up.
  33. 33. Shoulder Abduction: Active TestThe arm is again keptstraightened, while raisedand abducted.Observe the twisting of hand-- facing outward, notforward, as in forwardflexion.The ROM is measured indegrees as decribed forforward flexion.As pictured, this test is beingdone actively by the patient,but may be performed bythe examiner as well.
  34. 34. Other movementsExtension-with arm by the patient’s side,lift the arm back wards as far as possible.Adduction-draw the arm across theanterior chest wall as far as possible.
  35. 35. Functional examination- Thirteen tests:Bilateral elevation through abduction:— pain? / R.O.M?Passive elevation:- pain? / R.O.M? / end feel?Painful ARC:— (active elevation, encourage beyond pain)Passive abduction:- fix scapula, cf other sidePassive lat. rotn:— fix other shoulder R.O.M? / end feel?Passive med. rotn:- fix other shoulder R.O.M? / end feel?Resisted adduction:- (pec major, lat dorsi, teres maj, teres min)Resisted abduction:- (SUPRASPINATUS, deltoid)Resisted lateral rotation:- (INFRASPINATUS, teres minor)Resisted medial rotation:- (SUBSCAPULARIS, P.macj.L.Dor. T.maj)Resisted elbow flexion:- (BICEPS long head)Resisted elbow extension:- (SUB ACROMIAL BURSA,TRICEPS)Passive horizontal adduct ion:- (A-C joint, subscapularis)
  36. 36. Special TestsSpecial TestsA variety of tests have been described forA variety of tests have been described forexamination of the shoulderexamination of the shoulderA positive test is usually associated withA positive test is usually associated withpain in a specific location for each testpain in a specific location for each testNo single test is diagnostic, but several testsNo single test is diagnostic, but several teststogether along with the history is usuallytogether along with the history is usuallyvery accurate at locating the source ofvery accurate at locating the source ofpathologypathology
  37. 37. Special testsImpingement testsLabral testsInstability testsRotator Cuff testsStrength testsAcromio-clavicular joint tests
  38. 38. Tests Used in Shoulder Evaluation and Significance ofPositive FindingsTest Maneuver Diagnosissuggested bypositive resultApleyscratch testPatient touches superiorand inferior aspects ofopposite scapulaLoss of range ofmotion: rotator cuffproblemNeers sign Arm in full flexion SubacromialimpingementHawkinstestForward flexion of theshoulder to 90 degreesand internal rotationSupraspinatustendonimpingement
  39. 39. Tests Used in Shoulder Evaluation and Significance ofPositive FindingsTest Maneuver Diagnosissuggested bypositive resultDrop-armtestArm lowered slowly towaistRotator cuff tearCross-armtestForward elevation to 90degrees and activeadductionAcromioclavicularjoint arthritisSpurlingstestSpine extended withhead rotated to affectedshoulder while axiallyloadedCervical nerve rootdisorder
  40. 40. Tests Used in Shoulder Evaluation and Significance ofPositive FindingsTest Maneuver Diagnosissuggested bypositive resultApprehension testAnterior pressure on thehumerus with externalrotationAnteriorglenohumeralinstabilityRelocationtestPosterior force onhumerus while externallyrotating the armAnteriorglenohumeralinstabilitySulcus sign Pulling downward onelbow or wristInferiorglenohumeralinstability
  41. 41. Tests Used in Shoulder Evaluation and Significance ofPositive FindingsTest Maneuver Diagnosissuggested bypositive resultYergasontestElbow flexed to 90degrees with forearmpronatedBiceps tendoninstability ortendonitisSpeedsmaneuverElbow flexed 20 to 30degrees and forearmsupinatedBiceps tendoninstability ortendonitis"Clunk"signRotation of loadedshoulder from extensionto forward flexionLabral disorder
  42. 42. Impingement SignsImpingement SignsNeer (maximal forward flexion)Neer (maximal forward flexion)Hawkins (90o flexion, internal rotation,Hawkins (90o flexion, internal rotation,adduction)adduction)
  43. 43. Neers Test (Neers impingement sign )is elicited when the patientsrotator cuff tendons are pinchedunder the coracoacromial arch.The test is performed by placingthe arm in forced flexion with thearm fully pronated.The scapula should be stabilizedduring the maneuver to preventscapulothoracic motion.Pain with this maneuver is a signof subacromial impingement.
  44. 44. Hawkins Testperformed by elevatingthe patients armforward to 90 degreeswhile forcibly internallyrotating the shoulder.Pain with this maneuver suggests subacromialimpingement or rotator cuff tendonitis.One study found Hawkins test more sensitive forimpingement than Neers test.
  45. 45. Hawkins TestPosition the patientstanding with theshoulder abducted 90degrees, and internallyrotate the forearm.The presence of painwith movement isindicative of possiblepathology
  46. 46. Labral TestsLabral TestsRelocationRelocationActive Compression (O’Brien’s)Active Compression (O’Brien’s)Abduction external rotationAbduction external rotationLoad and shiftLoad and shiftShearShearAnterior SlideAnterior SlideClunk SignClunk Sign
  47. 47. InstabilityInstabilityApprehensionApprehensionSulcusSulcusRelocationRelocationLoad and shiftLoad and shift
  48. 48. Clunk SignGlenoid labral tears are assessed with thepatient supine.The patients arm is rotated and loaded(force applied) from extension through toforward flexion.A "clunk" sound or clicking sensation canindicate a labral tear even withoutinstability.
  49. 49. Drawer TestThe patient is seated with the forearm resting onthe lap and the shoulder relaxed.The examiner stands behind the patient.One of the examiners hands stabilizes theshoulder girdle (scapula and clavicle) while theother grasps the proximal humerus.These tests are performed with(1) a minimal compressive load (just enough tocenter the head in the glenoid) and(2) with a substantial compressive load (to gain afeeling for the effectiveness of the glenoidconcavity).
  50. 50. Drawer TestStarting from the centered position with aminimal compressive load, the humerus is firstpushed forward to determine the amount ofanterior displacement relative to the scapula.The anterior translation of a normal shoulderreaches a firm end-point with no clunking, no painand no apprehension. A clunk or snap on anterior subluxation orreduction may suggest a labral tear or Bankartlesion.
  51. 51. Drawer TestThe test is then repeated with a substantialcompressive load applied before translation isattempted to gain an appreciation of thecompetency of the anterior glenoid lip.The humerus is returned to the neutral positionand the posterior drawer test is performed, withlight and again with substantial compressive loadsto judge the amount of translation and theeffectiveness of the posterior glenoid lip,respectively.(Silliman and Hawkins, 1993)
  52. 52. InstabilityInstabilityApprehensionApprehensionSulcusSulcusRelocationRelocationLoad and shiftLoad and shift
  53. 53. Apprehension TestHave the patient in thesupine position, withthe arm abducted 90degrees.Rotate the shoulderexternally by pushingthe forearmposteriorly.If patient feelsinstability, theytypically will balk whenthe test is performed.
  54. 54. ApprehensionTestThe anterior apprehensiontest is performed with thepatient supine or seated andthe shoulder in a neutralposition at 90 degrees ofabduction.apply slight anteriorpressure to the humerus(too much force candislocate the humerus) andexternally rotates the arm.Pain or apprehension about the feeling of impendingsubluxation or dislocation indicates anteriorglenohumeral instability.
  55. 55. Relocation TestThe relocation test is performedimmediately after a positive result on theanterior apprehension test.With the patient supine, the examinerapplies posterior force on the proximalhumerus while externally rotating thepatients arm.A decrease in pain or apprehensionsuggests anterior glenohumeral instability.
  56. 56. Sulcus SignWith the patients arm in aneutral position, pull downwardon the elbow or wrist whileobserving the shoulder area fora sulcus or depression lateral orinferior to the acromion.The presence of a depressionindicates inferior translation ofthe humerus and suggestsinferior glenohumeral instabilityremember that manyasymptomatic patients,especially adolescents, normallyhave some degree of instability.
  57. 57. Rotator CuffRotator CuffLift-offLift-offNapoleon (belly push)Napoleon (belly push)Whipple (resisted elevation with cross bodyWhipple (resisted elevation with cross bodyadduction)adduction)External rotation arm at sideExternal rotation arm at side(infraspinatus)(infraspinatus)Empty can (supraspinatus)Empty can (supraspinatus)
  58. 58. Rotator cuff tears
  59. 59. Drop-Arm TestA possible rotator cuff tear can be evaluated withthe drop-arm test.This test is performed by passively abducting thepatients shoulder, then observing as the patientslowly lowers the arm to the waist.Often, the arm will drop to the side if the patienthas a rotator cuff tear or supraspinatusdysfunction.The patient may be able to lower the arm slowly to90 degrees (because this is a function mostly of thedeltoid muscle) but will be unable to continue themaneuver as far as the waist.
  60. 60. Rotator cuff strength testingSupraspinatus“Pour out a Coke”Infraspinatus and teres minor“Act like a penguin”Subscapularis“Scratch your back”
  61. 61. Strength TestsPosition the patient sitting,with his arms at his sidesand elbows at 90 degrees.It is important to maintainthe elbow positioning at thesides while the externalrotation is attempted by thepatient (the examiner appliesinternal resistance).External Rotator Cuff (RC) Strength
  62. 62. Internal RC StrengthSame as above,but the patient isattempting torotate internally(and examinerresistingexternally).
  63. 63. Supraspinatus StrengthThe patient ispositioned sitting witharms straight out,elbows locked, thumbsdown, and arm at 30degrees (in scapularplane).The patient shouldattempt to abduct hisarms against theexaminers resistance.
  64. 64. Acromioclavicular (AC) Joint TestingPalpation of AC JointThe patients arm is kept at his side and theexaminer palpates the AC joint fordiscomfort/pain and gapping.
  65. 65. Cross-Arm Horizontal Adduction TestThe patient places his hand on the oppositeshoulder, while the examiner exerts forcehorizontally. Again, the presence of painindicates possible pathology.
  66. 66. Cross-Arm TestPatients with acromioclavicular joint dysfunctionoften have shoulder pain that is mistaken forimpingement syndrome.The cross-arm test isolates the acromioclavicularjoint.The patient raises the affected arm to 90 degrees.Active adduction of the arm forces the acromioninto the distal end of the clavicle .Pain in the area of the acromioclavicular jointsuggests a disorder in this region.
  67. 67. Cervical Spine and Neurologic ExamCervical Spine and Neurologic ExamCervical spine range of motionCervical spine range of motionHyperextension of cervical spineHyperextension of cervical spineComparison of bilateral upper extremityComparison of bilateral upper extremitystrength, sensation, and reflexesstrength, sensation, and reflexesSpurling’s maneuverSpurling’s maneuver
  68. 68. Spurlings TestIn a patient with neckpain or pain thatradiates below the elbow,a useful maneuver tofurther evaluate thecervical spine isSpurlings test.
  69. 69. Spurlings TestThe patients cervical spine is placed inextension and the head rotated toward theaffected shoulder.An axial load is then placed on the spineReproduction of the patients shoulder orarm pain indicates possible cervical nerveroot compression and warrants furtherevaluation of the bony and soft tissuestructures of the cervical spine.