بسم الله الرحمن الرحيم 1

The shoulder 'joint' in fact comprises three components- the gleno-humeral joint or shoulder joint proper, acromio-clavicular joint, and the sterno-clavicular 2

SYMPTOMS Pain Stiffness Deformity Swelling 3

How to Start IPEEP INTRODUCE. PERMISSION. EXPLANTION. EXPOSURE. POSITION. 4

The Apley System All joint examinations follow this system: Look Feel Move : Active then Passive Special Tests Radiograpgy. 5

Radiographic Anatomy 6

Inspection Bone contours and alignment Soft-tissue contours Colour and texture of skin Scars or sin uses 7

Inspection(look) Front & back Height of shoulder and scapulae Muscle atrophy, asymmetry 8

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Palpation Skin temperature Bone contours Soft-tissue contours Local tenderness 13

Palpation Surface Anatomy (Anterior) Clavicle SC Joint Acromion process AC Joint Deltoid Coracoid process Pectoralis major Trapezius Biceps (long head) AC joint SC joint biceps 14

Palpation Surface Anatomy (Posterior) Scapular spine Acromion process Supraspinatus Infraspinatus Deltoid Trapezius Latissumus dorsi Scapula Inferior angle Medial border Supraspinatus Infraspinatus Inferior angle of scapula 15

Movements Distinguish between gleno-humeral Movement and Scapular movement during 16

abduction, flexion, extension, lateral rotation, and medial rotation 17

Pain on movement ? Muscle spasm ? Crepitation on movement 18

Range of Motion Forward flexion: ° Extension: ° Abduction: 180 ◦ Adduction: 45 ° Internal rotation: ° External rotation: ° Apley Scratch Test 19

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Power Cervico-scapular and thoraco-scapular muscles (controlling scapular movement)- Elevation of scapula, retraction of scapula, abduction- rotation of scapula. 22

Scapular dyskinesis (Scapulothoracic dysfuntion) Compare scapular motion through ROM on both sides Wall push-ups Symmetrical Smooth No or minimal winging 23

S capulo-humeral muscles (controlling movement at gleno-humeral joint) -Abduction, adduction, flexion, extension, lateral rotation, medial rotation 24

Acromio-clavicular joint Examine for swelling, increased warmth, tenderness, movement, and stability 25

Sterno-clavicular joint Examine for swelling, increased warmth, tenderness, Movement. and stability 26

Grade strength on 0 → 5 scale 0: no contraction 1: muscle flicker; no movement 2: motion, but not against gravity 3: motion against gravity, but not resistance 4: motion against resistance 5: normal strength 27

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 28

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 29

Strength Testing Supraspinatus “Empty can" test Jobe’s Test Tests Supraspinatus Attempt to isolate from deltoid Positioned sitting Arms straight out Elbows locked straight Thumbs down Arm at 30 degrees (in scapular plane) Attempts to elevate arms against resistance 30

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Impingement Signs Hawkins Neer 33

Speed’s Test Biceps Tendinopathy Long head of biceps tendonitis Fwd flex to 90°, abd 10°, full supination Apply downward force to distal arm Pain = (+) test weakness w/o pain = muscle weakness or rupture 34

Sulcus Sign Inferior instability Arm relaxed in neutral position, pull downward at elbow (+) test = sulcus at infra- acromial area compare to unaffected side 35

Instability: Apprehension Test Anterior instability Shoulder abducted to 90° Slight stress to humeral head directed in anterior direction While externally rotating shoulder Positive test is apprehension due to feeling of instability or impending dislocation Beware if false positives 36

Drop Arm Test Suggestive of Rotator Cuff Tear Passive abduction to 90° Instruct patient to slowly lower arm At 90° abducted arm will suddenly drop, may need to add slight pressure (+) drop = (+) test 37

Cross-Arm Adduction Test AC joint pathology Arm flexed to 90° Hyperadduct arm across body as far as possible Pain in AC = (+) test 38

EXAMINATION OF POTENTIAL EXTRINSIC SOURCES OF SHOULDER SYMPTOMS The investigation should include: I) the neck,with the brachial plexus; 2) the thorax, with special reference to the heart and pleura; and 3) the abdomen, for subdiaphragmatic lesions. 39

GENERAL EXAMINATION 3. General survey of other parts of the body. Referred pain in the shoulder region. The pain referred from an irritative lesion of the brachial plexus often extends from the base of the neck, over the top of the shoulder, and thence into the arm. 40

CLASSIFICATION OF DISORDERS OF THE SHOULDER REGION DISORDERS OF THE SHOULDER (GLENO-HUMERAL) JOINT 41

ARTHRITIS Pyogenic arthritis Rheumatoid arthritis Tuberculous arthritis Osteoarthritis 42

MECHANICAL DERANGEMENTS Recurrent dislocation Complete tear of the tendinous cuff Painful arc syndrome (including calcified deposit in tendon) Rupture of the long tendon of biceps 43

MISCELLANEOUS Tenosynovitis of the long tendon of biceps. 'Frozen' shoulder 44

DISORDERS OF THE ACROMIO- CLAVICULAR j01NT Osteoarthritis Persistent dislocation or subluxation 45

DISORDERS OF THE STERNO-CLAVICULAR JOINT Arthritis Persistent or recurrent dislocation 46

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Shoulder Dislocation/Anterior Instability Humeral head dislocates from glenoid fossa Almost always anterior (95%) Usually traumatic with injury to capsule-labrum complex 48

X RAYS DIAGNOSIS??? 49

Impingement Signs Neer’s Sign –Arm fully pronated and placed in forced flexion –Trying to impinge subacromial structures with humeral head –Pain is positive test 50

Impingement Signs Hawkin’s Sign –Arm is forward elevated to 90 degrees, then forcibly internally rotated –Trying to impinge subacromial structures with humeral head –Pain is positive test 51

Rotator Cuff Tear Partial thickness tear Full (Complete) thickness tear May be due to: Impingement Degeneration Overuse Trauma Partial tears Conservative Complete tears Surgery 52