1. Shoulder overview

2. ROM Check (passive and active) External rotation Internal rotation
Flexion
Extension
Adduction
Abduction

3. Range of Motion
External and Internal Rotation
Flexion and Extension

4. Range of Motion
ADduction
ABduction

5. Special Tests to know Spurling’s Tests
Strength Testing of the Rotator Cuff
Supraspinatius
Infraspinatus and teres minor
Subscapularis
Lift off test is better than against the belly
Impingement testing
Hawkins
Neer’s
Instability testing
Anterior apprehension Test
Relocation Test
Anterior Release Test

6. Spurling’s Test Region of Body you are testing
Cervical/neck
What you are testing for
Cervical radiculopathy
How to do it
3 Stages: The examiner passively hyperextends and laterally flexes the patient’s neck toward the involved side
What a + sign means
pain/parasthesias radiating from shoulder to the elbow ipsilateral to side of rotation (reproduction of pt’s symptoms). It could also originate pain from the trapezius and levator scapulae
Special Notes
Use Axial Compression (Modified Spurling’s – no compression).
Has low sensitivity but high specificity (can rule cervical radiculopathy out but not confirm it)
If the patient feels better, think anterior/middle scalene issue

7. Strength Testing - Supraspinatus
Region of the body you are testing
Shoulder Supraspinatus
What you are testing for
Strength of supraspinatus – abduction initiator
How to do it
Have the pt stand with the arms held in scaption, full can or empty can, at 45 degrees abduction and 45 degrees to 90 degrees forward flexion. The pt’s resists a downward force applied by the examiner on the pt’s arm.
What a + sign means
pain or weakness
Special Notes (see below slide)
Indicates supraspinatus tendinitis, or muscle or tendon tear
Scaption – is the position where the arm is approximately the same plane as the scapula.
Thumb up or “the full can” test - moves the greater tuberosity of the humerus away from the acromion, lessening the contribution of impingement to pain or weakness during the exam. The empty can test or “thumbs down” position - places the greater tuberosity closer to the acromion and increases the contribution of impingement to the test. Avoiding impingement - painful impingement may cause a patient to make less of an effort due to pain  mistakenly interpret as weakness.

8. Strength Testing Infraspinatus and teres minor
Region of the body you are testing
Shoulder
What you are testing for
Infraspinatus and teres minor-ext rot
How to do it
Stabilize the arm at the elbow to prevent abduction
Patient externally rotates, doctor internally rotates
What a + sign means
pain or weakness
Special Notes
Tests external rotation strength difficult to separately test Infraspinatus and teres minor

9. Strength Testing – Subscapularis “Lift off Test”
Region of the body you are testing
Shoulder
What you are testing for
Subscapularis – allows for internal rotation
How to do it
Have pt hold elbow at 90o posteriorly; patient lifts arm off of waist line against resistance
What a + sign means
pain or weakness
Special Notes
Best Test for subscaularis. Hard for patients with impingement Patients can “cheat” and use triceps

10. Strength Testing – Subscapularis Testing Against Belly
Region of the body you are testing
shoulder
What you are testing for
Subscapularis – allows for internal rotation
How to do it
Patient holds arm against abdomen as shown; resists examiner attempt to externally rotate arm off of abdomen
What a + sign means
pain or weakness
Special Notes
Close; less precise than “lift off.” Can be easier for patients with impingement

11. Impingement Testing – Hawkins Test
Region of the body you are testing
Shoulder Bursa
What you are testing for
Bursitis
How to do it
Examiner exerts internal rotation of patient’s humerus with 90º of forward flexion and 90º of elbow flexion
What a + sign means
reproduction of pain
Special Notes
Note that the joint is stable with bursitis

12. Impingement Testing – Neer’s Test
Region of the body you are testing
Shoulder bursa
What you are testing for
Bursitis
How to do it
Examiner exerts extreme forward flexion on a patient’s arm with the arm pronated. Thumb should be down.
What a + sign means
pain
Special Notes
Note that the joint is stable with bursitis

13. Instability Testing – Anterior Apprehension Test
Region of the body you are testing
Shoulder
What you are testing for
To assess Glenohumeral joint instability/ dislocation
How to do it
doctor gives anterior pressure to patient’s humerus and externally rotates arm at 90 deg
What a + sign means
unpleasant sensation of the shoulder coming out of the joint. Positive=apprehension of patient that shoulder will dislocate indicating anterior glenohumeral instability
Special Notes
Simple pain from these tests can be from rotator cuff or labrum injury rather than instability.
The vast majority of shoulder instability is anterior.
If positive test, shoulder will dislocate indicating anterior instability at glenohumeral.

14. Instability Testing – Relocation Test
Region of the body you are testing
Shoulder
What you are testing for
To assess Glenohumeral joint instability/dislocation
How to do it
Lying on the back, the patient's arm is extended 90o from the side and rotated clockwise ("externally rotated"). When shoulder feels like it is going to pop out of place, examiner applies anterior to posterior pressure to alleviate this and “relocates” shoulder
What a + sign means
if symptoms are relieved test is positive indicating anterior instability

15. Instability Testing – Anterior Release Test
Region of the body you are testing
Shoulder
What you are testing for
To assess Glenohumeral joint instability /dislocation
How to do it
While examiner has patient in the Relocation test, the examiner lets go of the relocation position and “dislocates” the shoulder again
What a + sign means
Symptoms of dislocation and instability reappear
Special Notes
You’re a mean doctor for doing this  However, it has the highest sensitivity and specificity of all the instability tests.

16. Shoulder Region Techniques
Scapular Release
Lateral recumbant – direct method – stretching, Kimberly, A pg 47 – 48

17. Scapular Release
Patient in lateral recumbent position with physician at side of table
Hook fingers of cephalad hand over superior angle of scapula. Grasp elbow with opposite hand, resting patient’s arm on physician’s cephalad forearm (1)
Carry scapula inferiorly and laterally to muscular restrictive barrier
Apply sufficient force to feel muscles relax
Force is slowly relaxed
Stretching repeated rhythmically until max response obtained
Move fingers to medial scapular margin (2)
Carry scapula laterally and repeat #4-#6
Move fingers to inferior angle (3)
Carry scapula superiorly and laterally, repeating #4-#6 1 2 3
Kimberly Manual p , direct soft tissue method

18. Glenohumeral Joint Techniques
Humeral Head Anterior and superior
Seated, indirect method, patient cooperation, respiratory force, Kimberly ( A), pg 236
Supine, direct method, HVLA, Kimberly ( B) Page 237
Muscular Restrictions
Lateral recumbent, direct method, articulatory, ME (Seven Stages of Spencer) Kimberly ( A) Page 237  - 240

19. Glenohumeral Joint Techniques – Humeral Head Anterior and superior Seated, indirect method, patient cooperation, respiratory force, Kimberly ( A), p. 236

20. Glenohumeral Joint Techniques Humeral Head Anterior and superior Supine, direct method, HVLA, Kimberly ( B) Page 237

21. Glenohumeral Joint Techniques Muscular Restrictions Lateral recumbent, direct method, articulatory, ME (Seven Stages of Spencer) Kimberly ( A) Page 237 - 240
Extension
Flexion
Circumduction with compression
Circumduction with traction
Abduction
Internal Rotation
Joint Pump (Pulse)
Elephants fart constantly to annoy intelligent people

22. Spencer Technique The seven stages of motions are:
1. Engage GH extension barrier with elbow flexed
2. Engage GH flexion barrier with the elbow flexed
3. Circumduction with compression
Start small circles, then gradually increase size
Clockwise and counterclockwise
May also do ME of IR/ER barriers 1 2
Kimberly Manual, p
Direct articulatory/ME 3

23. 4. Circumduction with traction on straight arm
Start small circles, then gradually increase size
Clockwise and counterclockwise
5. Engage abduction barrier
6. Adduction/IR with elbow flexed
7. GH pump with distraction and compression along straight arm 4 5 6 7

24. Sternoclavicular Techniques
Know how to diagnose the SC joint
Abduction/Adduction
Horizontal Flex (posterior glide) / Horizontal Extension (anterior glide)
Seated, indirect method, patient cooperation, respiratory force Kimberly ( B) Page 232

25. How to diagnose the SC joint Sternoclavicular Dysfunction Assessment
ABduction (IG)/ADduction (SG)
Physician stands at head of table
Patient is supine
Place tips of your fingers on the superior edges of the medial ends of the patient’s clavicle
Ask your patient to shrug their shoulders. Both clavicles should move into ABduction, and the medial clavicles should move inferiorly (inferior glide)
In the absence of trauma, the dysfunctional (restricted) clavicle stays superior at the SC jointNamed an ADduction somatic dysfunction (superior glide)

26. How to diagnose the SC joint Sternoclavicular Dysfunction Assessment
Horizontal Flex (PG)/Horizontal Ext (AG)
Physician stands at head of table
Patient is supine
Place tips of your fingers on the anterior edges of the medial ends of the patient’s clavicle
Ask your patient to reach toward the ceiling with their arms. Their scapulae should come off the table. Both clavicles should move into horizontal flexion, and the medial clavicles should move posterior (posterior glide)
In the absence of trauma, the dysfunctional (restricted) clavicle stays anterior at the SC jointNamed a horizontal extension (anterior glide) somatic dysfunction

27. Sternoclavicular Techniques - Seated, indirect method, patient cooperation, respiratory force Kimberly ( B) Page 232
Both seated.
Thumbs under junction of the medial and middle third of clavicle.
Fingers over each end of clavicle.
Patient rests forearm over D.O.’s forearm.
“Lean forward slightly toward me.”
“Slightly turn your body away from me.” (gaps SC joint!)
D.O. carries shoulder posteriorly to gap and balance AC joint.
Medial end of clavicle is elevated by rotating clavicle around pivot point formed by thumbs.
Clavicle is taken to a point of BLT (balanced ligamentous tension).
May need minor movement of the patient’s scapula and clavicle by moving the forearm & body to achieve BLT.
Respiratory phases are tested. Pt holds breath in phase giving best ligamentous balance.
Recheck.
Similar to doing the interosseous membrane in lower leg.
Anterior and superior glide

28. Acromioclavicular Joint Techniques
Elevated AC Joint, Nicholas Atlas p. 436
Seated, direct method, articulatory Kimberly ( A) Page 233
Seated, indirect method, respiratory force Kimberly ( C) page 235

29. Acromioclavicular Joint Techniques - Treat elevated AC joint for PROXIMAL CLAVICLE Nicholas Atlas p. 436
Pt. seated, physician stands behind the pt. toward the side being treated
Physician, using the closest hand to pt., places the second metacarpophalangeal joint over the distal third of clavicle being treated
Physician’s other hand grasps the Pt. arm on side to be treated below elbow
Pt arm is pulled down and then drawn backward into extension with a continuous motion similar to throwing a ball, circumducting the arm until it is once again in front of patient, finishing with arm across chest in adduction
The release may occur before barrier is met
The physician reevaluates the dysfunctional (TART) components
Note this is not the exact same thing the atlas says….read it
WE THINK THIS IS FOR SC….WHO KNOWS
WHEN YOU HAVE the distal clavicle elevated THAT is AC, and that is a forward stroke.

30. Elevated AC joint Nicholas Atlas p. 4362. 1. 3. 4.

31. Acromioclavicular Joint Techniques - Seated, direct method, articulatory Kimberly ( A) Page 233
Grasp elbow or forearm.
Pad of thumb with other hand applies Ant/Inf pressure to the restrictive barrier.
Flex elbow.
Extend and adduct humerus to gap AC joint.
Extend shoulder further and apply a circulatory sweep
elbow posterior, then superior, and finally anteromedially
must maintain capsular tension through out.
Recheck

32. Acromioclavicular Joint Techniques – Seated, indirect method, respiratory force Kimberly ( C) page 235
Thumbs under middle and medial third portion of clavicle.
Patient rests forearm on D.O. forearm.
“Lean slightly forward and toward me.”
Clavicle needs to be supported by D.O.’s thumbs.
“Slightly turn body away from me.” (gaps SC joint.)
Carry shoulder posteriorly to gap and balance the AC joint.
Elevate lateral end of clavicle by rotating the clavicle around the povot point formed by the DO thumbs.
May need minor movement of scapula and body position to obtain BLT.
Test resp phase to get best BLT
Recheck.