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Shoulder Problem Evaluation

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Presentation on theme: "Shoulder Problem Evaluation"— Presentation transcript:

1 Shoulder Problem Evaluation

2 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

3 Bony Anatomy Anterior

4 Bony Anatomy Anterior and Posterior
4

5

6 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

7 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

8 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

9 Radiographic Anatomy 9

10 6 Articulations or Joints
Coraco Clavicular Sterno Clavicular Acromio Clavicular Gleno Humeral Scapulo Thoracic Sub Acromial Space

11 Coraco Clavicular

12 Sterno Clavicular

13 Acromio Clavicular

14 A/C Joint Grade 1+ A/C Separation

15 Gleno Humeral

16 Scapulo Thoracic

17 Sub Acromial

18 Where do things go wrong?? Fractures

19 Where do things go wrong?? Dislocations and Separations
Dislocations and separations are protected by both “static” and “dynamic” stabilizers…

20 Where do things go wrong?? Dislocations and Separations
Oh, yeah…Arthritis can happen at these joints, too…

21 Voluntary Posterior Subluxation

22 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

23 Bony Anatomy “Static Stabilizers”

24 What goes wrong… Besides separations and dislocations??
Instability!!! 24

25 LABRUM

26 What goes wrong? Tears and tendonopathies

27 The Rotator Cuff Muscles
Supraspinatus Infraspinatus Teres minor Supscapularis

28 The Rotator Cuff Muscles: SITS
Teres minor ER Supscapularis IR Supraspinatus ABD Infraspinatus ER Depress humeral head against glenoid to allow full abduction

29 Finally…the subacromial space

30 What can go wrong??? Impingement!!!!!!!

31 Impingement 31

32 Picture 6: Rotator Cuff MRI

33 Shoulder Complex Muscles
Scapular Muscles

34 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

35 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

36 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

37 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

38 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

39 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

40 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

41 Glenohumeral Muscles

42 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

43 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

44 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

45 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

46 Middle Deltoid O – I – N – F –
Lateral margin and superior surface of acromion I – Deltoid Tuberosity N – Axillary F – GH ABD

47 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

48 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

49 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,

50 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

51 Rotator Cuff

52 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

53 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

54 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

55 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

56 Basic Shoulder Complex Mechanics

57 Performing Abduction Initiation Scapulohumeral Ryhthm Clavicle
First 30 degrees > 30 degrees Clavicle

58 So…what causes shoulder pain?
Impingement Labrum and biceps pathology A-C joint pathology Rotator Cuff Injury Instability Among other things…

59 Clinical Exam History Pain Acute Chronic Weakness Deformity

60 Clinical Exam History Single event Repetitive overload Instability
Does it feel like it’s going to come out? Catching/Locking

61 Clinical Exam History Sport / Occupation Previous injury
Previous treatment Other joints involved Disability

62 Physical Exam: Big 6 Inspection Palpation Range of Motion Strength
Neurovascular Special Tests

63 Special Tests Impingement Rotator Cuff Integrity Labrum and Biceps
AC (SC) Joints Instability 63

64 Throwing Mechanics Arm Cocking Phase Begins Ends

65 Throwing Mechanics Arm Acceleration Begins Ends

66 Throwing Mechanics Follow-through Begins Ends

67 Pathomechanics of Throwing
Shoulder Rotator Cuff Labrum Impingement SLAP Lesion

68 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

69 Case #1 22-year-old male rugby player falls onto his right shoulder while being tackled Severe pain on top of his right shoulder

70 Case #1 Notable deformity over superior shoulder
Painful range of motion Unable to lift right arm above waist Special Tests?? Diagnosis???

71 Acromioclavicular (A-C) Sprain
Special Tests Shear Test Cross Arm Test A-C Palpation Resisted Extension Active compression test

72 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

73 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

74 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

75 X RAYS

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

77 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

78 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

79 Which of the following structures can be “impinged”?
Biceps tendon Subacromial Bursa Rotator Cuff Tendons All of the above 30 10

80 Case #3 35-year-old male tennis player
Shoulder pain exacerbated by practicing serves Develops dull, aching pain in right shoulder

81 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???

82 Shoulder Pain Physical Exam
Hawkin’s positive Neer’s positive IMPINGEMENT??? 82

83 Impingement as a Clinical Sign
Repetitive overhead activities Subacromial bursa and/or rotator cuff impinged between acromion & humerus Physical therapy, activity modification +/- medications

84 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

85 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?

86 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

87 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

88 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

89 Physical Exam Obese, pleasant female Diffuse pain Normal shoulder exam
Not able to reproduce pain during exam What else do you want to do???

90 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

91 In the human body, which is the most incredible joint?
PIP Knee Ankle Shoulder None of the above

92 Case #6 40-year-old male Recently shoveled 16” of snow
Can hardly lift left arm due to pain Special Tests? Diagnosis?

93 Biceps Tendonopathy Speed Test Yergason Test Direct palpation

94 Biceps Tendonopathies
Repetitive overhead activity Repetitive forearm flexion/supination Difficult to discern from rotator cuff tendinopathy or impingement 94

95 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.

96 QUESTIONS?

97 Physical Exam Inspection
Front & back Height of shoulder and scapulae Muscle atrophy, asymmetry 97

98 Physical Exam Range of Motion
Abduction 0-180o 98

99 Physical Exam Range of Motion
Forward flexion: 0o – 180o 99

100 Physical Exam Range of Motion
Extension 0o – 40 to 60o 100

101 Physical Exam Range of Motion
Internal rotation T5 segment External rotation 80-90o 101

102 Physical Exam Strength
Empty can test 30o angle Steady downward pressure Tests supraspinatus strength and pain 102

103 Physical Exam Strength
Resisted external rotation Tests infraspinatus, teres minor strength 103

104 Physical Exam Strength of Subscapularis
Liftoff test Belly press test 104

105 Cross-Arm Adduction Test
AC joint pathology Arm flexed to 90° Hyperadduct arm across body as far as possible Pain in AC = (+) test 105

106 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

107 Sulcus Sign Inferior instability
Arm relaxed in neutral position, pull downward at elbow (+) test = sulcus at infra-acromial area compare to unaffected side 107

108 Apprehension Test Anterior instability
Shoulder at 90° abducted, slight anterior pressure & External rotation (+) test = dislocation apprehension some false (+) 108

109 Relocation Test Perform after positive apprehension test
Apply post force over humeral head during external rotation (ER) (+) test = increased ER tolerance 109

110 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

111 Impingement Signs Hawkins Neer 111

112 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

113 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

114 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

115 O’Brien’s Active Compression SLAP lesion
Supination should be pain free (decreased pain) 115

116 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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