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Shoulder Problem Evaluation
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Shoulder assessment Second most common musculoskeletal complaint
Difficult joint to examine Multidirectional range of motion- UNIQUE! Shoulder injury can affect nearly every sport and many daily activities
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Bony Anatomy Anterior
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Bony Anatomy Anterior and Posterior
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Bones Scapula & clavicle Move as a unit
Clavicle’s articulation with sternum is only bony link to axial skeleton The Shoulder Girdle Manual of Structural Kinesiology
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Bones Key bony landmarks Manubrium Clavicle Coracoid process
Acromion process Glenoid fossa Lateral border Inferior angle Medial border The Shoulder Girdle Manual of Structural Kinesiology
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Bones Key bony landmarks Acromion process Glenoid fossa Lateral border
Inferior angle Medial border Superior angle Spine of the scapula The Shoulder Girdle Manual of Structural Kinesiology
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Radiographic Anatomy 9
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6 Articulations or Joints
Coraco Clavicular Sterno Clavicular Acromio Clavicular Gleno Humeral Scapulo Thoracic Sub Acromial Space
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Coraco Clavicular
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Sterno Clavicular
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Acromio Clavicular
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A/C Joint Grade 1+ A/C Separation
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Gleno Humeral
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Scapulo Thoracic
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Sub Acromial
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Where do things go wrong?? Fractures
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Where do things go wrong?? Dislocations and Separations
Dislocations and separations are protected by both “static” and “dynamic” stabilizers…
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Where do things go wrong?? Dislocations and Separations
Oh, yeah…Arthritis can happen at these joints, too…
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Voluntary Posterior Subluxation
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Glenohumeral Joint Shallow (“golf ball sitting on a tee”)
Inherently unstable (maximizes ROM) Static stabilizers glenohumeral ligaments, glenoid labrum and capsule Dynamic stabilizers Predominantly rotator cuff muscles Also scapular stabilizers Trapezius, leavator scapulae, serratus anterior, rhomboids
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Bony Anatomy “Static Stabilizers”
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What goes wrong… Besides separations and dislocations??
Instability!!! 24
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LABRUM
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What goes wrong? Tears and tendonopathies
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The Rotator Cuff Muscles
Supraspinatus Infraspinatus Teres minor Supscapularis
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The Rotator Cuff Muscles: SITS
Teres minor ER Supscapularis IR Supraspinatus ABD Infraspinatus ER Depress humeral head against glenoid to allow full abduction
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Finally…the subacromial space
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What can go wrong??? Impingement!!!!!!!
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Impingement 31
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Picture 6: Rotator Cuff MRI
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Shoulder Complex Muscles
Scapular Muscles
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Levator Scapulae O – Transverse processes of C1-C4
I – Medial border of scapula between superior angle and root of spine of scapula N – Nerve root C3-5 F scapular elevation retraction
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Rhomboid Major O – I – N – Dorsal Scapular
Major – T2-T5 spinous processes Minor – Ligamentum nuchae, C7-T1 spinour processes I – Major – Medial borde of scapula between spine and inferior angle Minor – medial border at root of spine of scapula N – Dorsal Scapular
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Upper Trapezius O – I – N – spinal accessory F – Occiptal protuberance
Medial 1/3 of nuchal line Upper part of ligamentum nuchae C7 spinous process I – Posterior border of lateral 1/3 of clavicle Acromion process N – spinal accessory F – Scapular elevation, retraction Rotation of head to opp. Side Lateral flexion of head to opp. side
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Middle Trapezius O – I – N – Spinal accessory F –
Inferior part of ligamentum nuchea T1-T5 spinous processes I – Medial margin of acromion process Superior lip of spine of scapula N – Spinal accessory F – Scapular retraction
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Lower Trapezius O – I – N – spinal accessory F –
T6-T12 spinous processes I – Tubercle at apex of root of spine of scapula N – spinal accessory F – Scapular depression, retraction and upward rotation
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Serratus Anterior O – I – N – F –
Outer surfaces and superior border of ribs 1-8 I – Ventral scapular surface on medial border from superior angle to inferior angle N – Long Thoracic F – Scapular protraction, upward rotation Scapular depression (lower fibers) Scapular elevation (upper fibers
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Pectoralis Minor O – I – N – F –
Superior margins and outer surface ribs 3-5 near cartilages Fascia overlying corresponding intercostal muscles I – Medial border, superior surface of coracoid process N – Medial Pectoral F – Scapular depression, downward rotation, protraction
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Glenohumeral Muscles
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Biceps Brachii O I – N – Musculocutaneous F –
Short head – coracoid process Long head – supraglenoid tubercle of scapula I – Radial tuberosity Biceps brachii aponeurosis N – Musculocutaneous F – Shoulder – flexion Elbow – flexion, forearm supination
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Coracobrachialis O – I – N –Musculocutaneous F – Coracoid process
Medial surface of mid-humerus, opposite to deltoid tuberosity N –Musculocutaneous F – GH flexion, adduction, Hor. Adduction
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Pectoralis Major O – I – N – F –
Sternal – anterior surface of sternum, cartilages of ribs 1-6 or7 Clavicular – anterior surface of sternal ½ clavicle I – crest of humerus’s greater tuberosity N – Sternal – medial pectoral Clavicular – lateral pectora F – GH ADD, H. ADD and IR
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Anterior Deltoid O – I – N – Axillary F –
Anterior border, superior surface of lateral third of clavicle I – Deltoid tuberosity N – Axillary F – GH H. ADD, flexion IR when in supine position
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Middle Deltoid O – I – N – F –
Lateral margin and superior surface of acromion I – Deltoid Tuberosity N – Axillary F – GH ABD
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Posterior Deltoid O – I – N – Axillary F –
Inferior lip of posterior border of spine of scapula I – Deltoid tuberosity N – Axillary F – GH extension, H. ABD, ER when in prone position
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Triceps Brachii O – I – N – Radial F –
Long Head – infraglenoid tubercle Lateral Head – lateral and posterior surface of proximal ½ of body of humerus Medial Head – distal 2/3 of medial and posterior surfaces of humerus below radial groove I – Posterior surface of olecranon proess N – Radial F – Shoulder – long head – Ext and ADD Elbow -- extension
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Latissimus Dorsi O – I – N – Thoracodorsal F –
Posterior layer of lumbodorsal fascia, then attaching to the T6-T12, lumbar and sacral vertabrae External lip of iliace creast lateral to erector spinae Ribs 9-12 Slip from inferior angle of scapula I – Intertubercular groove (distal aspect) N – Thoracodorsal F – GH IR, ADD, Ext,
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Teres Major (Lat’s Little Helper)
Dorsal surface of inferior angle Lower 1/3 of scapula lateral border I – Crest of lesser tuberosity N – Lower Subscapular F – GH IR, ADD, Ext
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Rotator Cuff
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Suprspinatus O – I – N – Suprascapular F –
Medial 2/3 supraspinatus fossa I – Superior portion of greater tuberosity N – Suprascapular F – Intiates shoulder ABD Humeral head stabilization
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Infraspinatus O – I – N – Suprascapular F –
Medial 2/3 infraspinatus fossa I – Middle portion of greater tuberosity N – Suprascapular F – GH ER Humeral head stabilization
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Teres Minor O – Upper 2/3 dorsal surface of lateral border of scapula I -- Lowest portion of greater tuberosity N – Axillary F – GH ER Humeral head stabilization
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Subscapularis O – I – N – F – Subscapular Fossa Lesser tuberosity
Anterior capsule of GH joint N – Upper and lower subscapular F – GH IR Humeral head stabilization
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Basic Shoulder Complex Mechanics
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Performing Abduction Initiation Scapulohumeral Ryhthm Clavicle
First 30 degrees > 30 degrees Clavicle
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So…what causes shoulder pain?
Impingement Labrum and biceps pathology A-C joint pathology Rotator Cuff Injury Instability Among other things…
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Clinical Exam History Pain Acute Chronic Weakness Deformity
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Clinical Exam History Single event Repetitive overload Instability
Does it feel like it’s going to come out? Catching/Locking
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Clinical Exam History Sport / Occupation Previous injury
Previous treatment Other joints involved Disability
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Physical Exam: Big 6 Inspection Palpation Range of Motion Strength
Neurovascular Special Tests
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Special Tests Impingement Rotator Cuff Integrity Labrum and Biceps
AC (SC) Joints Instability 63
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Throwing Mechanics Arm Cocking Phase Begins Ends
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Throwing Mechanics Arm Acceleration Begins Ends
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Throwing Mechanics Follow-through Begins Ends
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Pathomechanics of Throwing
Shoulder Rotator Cuff Labrum Impingement SLAP Lesion
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Common problems of the Shoulder
Arthritis, tendinitis, Dislocation- joint slips out of place ie, the bones move from their normal position. D/T: blow, fall, trauma Subluxation- incomplete or partial dislocation. D/T: same as above The Shoulder Girdle
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Case #1 22-year-old male rugby player falls onto his right shoulder while being tackled Severe pain on top of his right shoulder
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Case #1 Notable deformity over superior shoulder
Painful range of motion Unable to lift right arm above waist Special Tests?? Diagnosis???
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Acromioclavicular (A-C) Sprain
Special Tests Shear Test Cross Arm Test A-C Palpation Resisted Extension Active compression test
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Acromioclavicular (A-C) Sprain
Damage to A-C joint ligaments Pain and/or deformity over A-C joint Graded I-VI I-III usually treated non-operatively IV-VI referred to orthopedic surgery
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AC Joint Sprain Treatment
Analgesics, ice prn Sling for as long as needed Physical Therapy ROM restoration Gradual strength exercise Return to sport activity as tolerated
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Case #2 24-year-old male handball player
Fell onto his shoulder after being pushed Intense pain Hand is tingling and arm feels like it’s hanging X-rays
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X RAYS
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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
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Shoulder Dislocation/Anterior Instability
Treatment Reduction of dislocation Protection & rehab, rehab, rehab Most will have future dislocations and/or instability At least 70%!!! (young) May require surgical tightening/repair of the capsule/labrum complex
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Special Tests Glenoid Labrum and Instability
Biceps Load I and II Kim Test Jerk Test Active-Compression Test (O’Brien) Crank Test Apprehension Test Relocation Test Load and Shift Sulcas Sign
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Which of the following structures can be “impinged”?
Biceps tendon Subacromial Bursa Rotator Cuff Tendons All of the above 30 10
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Case #3 35-year-old male tennis player
Shoulder pain exacerbated by practicing serves Develops dull, aching pain in right shoulder
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SHOULDER PAIN Physical Exam
Tenderness to palpation anterior shoulder Pain with abduction starting around 90 degrees Unable to lift arm past 120 degrees Pain with forward flexion at degrees Special Tests??? Diagnosis???
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Shoulder Pain Physical Exam
Hawkin’s positive Neer’s positive IMPINGEMENT??? 82
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Impingement as a Clinical Sign
Repetitive overhead activities Subacromial bursa and/or rotator cuff impinged between acromion & humerus Physical therapy, activity modification +/- medications
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Diagnoses associated with clinical sign of Rotator Cuff Impingement:
Subacromial bone spurs and / or bursal hypertrophy AC joint arthrosis and /or bone spurs Rotator cuff disease Superior labral injury Glenohumeral instability Scapular dyskinesis Biceps tendinopathy A diagnostic injection sometimes helps to clarify the diagnosis
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Case #4 45-year-old weight lifter
Caught bar as it was falling off his shoulder Sudden pain Severe weakness left shoulder Worse with overhead activities; while sleeping at night Pain in anterior lateral shoulder Special tests?
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Case #4 Drop Arm Test Positive External Rotation Lag Sign positive
Weakness with Empty Can Sign Normal bear hug and belly press tests… Diagnosis????? 86
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Rotator Cuff Tear Supraspinatus tendon most common
Acute trauma or chronic tendinopathy Treatment dependent upon age/activity Young, active usually require operative treatment Older, low-activity usually respond to non-operative treatment
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Case #5 42-year-old female with dull pain right shoulder
Pain is diffuse in nature Sometimes spreads to between shoulder blades Seems worse at night
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Physical Exam Obese, pleasant female Diffuse pain Normal shoulder exam
Not able to reproduce pain during exam What else do you want to do???
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Shoulder pain isn’t always the shoulder!! Get more history…
Gall bladder disease Peptic Ulcer Disease Cervical radiculopathy Cardiac ischemia Pulmonary conditions ie Pancoast’s tumor, Pneumonia
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In the human body, which is the most incredible joint?
PIP Knee Ankle Shoulder None of the above
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Case #6 40-year-old male Recently shoveled 16” of snow
Can hardly lift left arm due to pain Special Tests? Diagnosis?
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Biceps Tendonopathy Speed Test Yergason Test Direct palpation
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Biceps Tendonopathies
Repetitive overhead activity Repetitive forearm flexion/supination Difficult to discern from rotator cuff tendinopathy or impingement 94
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Conclusion Shoulder injuries are common.
Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis. Impingement is a clinical sign, not a diagnosis. Don’t forget about medical causes.
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QUESTIONS?
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Physical Exam Inspection
Front & back Height of shoulder and scapulae Muscle atrophy, asymmetry 97
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Physical Exam Range of Motion
Abduction 0-180o 98
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Physical Exam Range of Motion
Forward flexion: 0o – 180o 99
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Physical Exam Range of Motion
Extension 0o – 40 to 60o 100
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Physical Exam Range of Motion
Internal rotation T5 segment External rotation 80-90o 101
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Physical Exam Strength
Empty can test 30o angle Steady downward pressure Tests supraspinatus strength and pain 102
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Physical Exam Strength
Resisted external rotation Tests infraspinatus, teres minor strength 103
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Physical Exam Strength of Subscapularis
Liftoff test Belly press test 104
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Cross-Arm Adduction Test
AC joint pathology Arm flexed to 90° Hyperadduct arm across body as far as possible Pain in AC = (+) test 105
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A-C Shear Test Interlock fingers with hand on distal clavicle and spine of scapula Pain in A-C joint when hands squeezed together = (+) test 106
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Sulcus Sign Inferior instability
Arm relaxed in neutral position, pull downward at elbow (+) test = sulcus at infra-acromial area compare to unaffected side 107
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Apprehension Test Anterior instability
Shoulder at 90° abducted, slight anterior pressure & External rotation (+) test = dislocation apprehension some false (+) 108
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Relocation Test Perform after positive apprehension test
Apply post force over humeral head during external rotation (ER) (+) test = increased ER tolerance 109
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Load & Shift Test Test for multidirectional instability
Grasp humeral head, slide anteriorly and posteriorly while securing rest of shoulder (+) if greater than 50% displacement (graded 1-3) 110
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Impingement Signs Hawkins Neer 111
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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 112
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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 113
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O’Brien’s Active Compression SLAP lesion (Superior Labrum Antero-Posterior)
Labral/AC pathology Arm flexed to 90°, elbow extended, adduct 10-15°, resist downward force + if AC pain or internal pain/click 114
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O’Brien’s Active Compression SLAP lesion
Supination should be pain free (decreased pain) 115
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Crank Test Labral injury
Glenoid labrum tear Abduct arm to 160°, pt is supine or upright, elbow secured with one hand axial load at shoulder with other (+) if audible/painful catch/grind is noted 116
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