Download Shoulder overview

Shoulder overview
ROM
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Check (passive and active)
External rotation
Internal rotation
Flexion
Extension
Adduction
Abduction
Range of Motion
• External and
Internal Rotation
• Flexion and
Extension
Range of Motion
• ADduction
• ABduction
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
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
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)
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
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
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
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
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
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.
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
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.
Shoulder Region Techniques
• Scapular Release
– Lateral recumbant – direct method – stretching,
Kimberly, 4914.11A pg 47 – 48
Scapular Release
1. Patient in lateral recumbent position with
physician at side of table
2. 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)
3. Carry scapula inferiorly and laterally to muscular
restrictive barrier
4. Apply sufficient force to feel muscles relax
5. Force is slowly relaxed
6. Stretching repeated rhythmically until max
response obtained
7. Move fingers to medial scapular margin (2)
8. Carry scapula laterally and repeat #4-#6
9. Move fingers to inferior angle (3)
10. Carry scapula superiorly and laterally, repeating
#4-#6
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Glenohumeral Joint Techniques
• Humeral Head Anterior and superior
– Seated, indirect method, patient cooperation, respiratory
force, Kimberly (4731.11A), pg 236
– Supine, direct method, HVLA, Kimberly (4731.11B) Page
237
• Muscular Restrictions
– Lateral recumbent, direct method, articulatory, ME (Seven
Stages of Spencer) Kimberly (4732.11A) Page 237 - 240
Glenohumeral Joint Techniques –
Humeral Head Anterior and superior
Seated, indirect method, patient cooperation, respiratory
force, Kimberly (4731.11A), p. 236
Glenohumeral Joint Techniques
Humeral Head Anterior and superior
Supine, direct method, HVLA, Kimberly
(4731.11B) Page 237
Glenohumeral Joint Techniques
Muscular Restrictions
Lateral recumbent, direct method, articulatory,
ME (Seven Stages of Spencer) Kimberly
(4732.11A) Page 237 - 240
• Extension
• Flexion
• Circumduction with compression
• Circumduction with traction
• Abduction
• Internal Rotation
• Joint Pump (Pulse)
Elephants fart constantly to annoy intelligent people
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
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4. Circumduction with
traction on straight arm
• Start small circles, then
gradually increase size
• Clockwise and
counterclockwise
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5. Engage abduction barrier
6. Adduction/IR with elbow
flexed
7. GH pump with distraction
and compression along 6
straight arm
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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 (4711.11B) Page 232
How to diagnose the SC joint
Sternoclavicular Dysfunction Assessment
• ABduction (IG)/ADduction (SG)
1. Physician stands at head of table
2. Patient is supine
3. Place tips of your fingers on the
superior edges of the medial ends
of the patient’s clavicle
4. Ask your patient to shrug their
shoulders. Both clavicles should
move into ABduction, and the
medial clavicles should move
inferiorly (inferior glide)
5. In the absence of trauma, the
dysfunctional (restricted) clavicle
stays superior at the SC
jointNamed an ADduction
somatic dysfunction (superior glide)
How to diagnose the SC joint
Sternoclavicular Dysfunction Assessment
• Horizontal Flex (PG)/Horizontal Ext (AG)
1. Physician stands at head of table
2. Patient is supine
3. Place tips of your fingers on the anterior
edges of the medial ends of the patient’s
clavicle
4. 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)
5. In the absence of trauma, the dysfunctional
(restricted) clavicle stays anterior at the SC
jointNamed a horizontal extension
(anterior glide) somatic dysfunction
Sternoclavicular Techniques - Seated, indirect method,
patient cooperation, respiratory force
Kimberly (4711.11B) Page 232
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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.
Acromioclavicular Joint Techniques
• Elevated AC Joint, Nicholas Atlas p. 436
• Seated, direct method, articulatory
Kimberly (4721.11A) Page 233
• Seated, indirect method, respiratory force
Kimberly (4721.11C) page 235
Acromioclavicular Joint Techniques - Treat
elevated AC joint for PROXIMAL CLAVICLE
Nicholas Atlas p. 436
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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
Elevated AC joint Nicholas Atlas p. 436
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Acromioclavicular Joint Techniques - Seated, direct
method, articulatory
Kimberly (4721.11A) 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
Acromioclavicular Joint Techniques –
Seated, indirect method, respiratory force
Kimberly (4721.11C) page 235
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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.