Shoulder Examination

Shoulder
“EVAL and TREAT”

For the typical shoulder referral with a prescription as “Eval and treat”, an exact shoulder diagnosis can be very difficult to find.  What we must understand is that most shoulder pathologies lie within a continuum of sxs, starting benign and progressing to more severe dysfunctions/pathologies.  In many cases patients sxs may begin with scapula dyskinesia, secondary to muscle imbalances, eventually causing repetitive stress injuries as tendonitis or impingement, that eventually can lead to rotator cuff pathology or structural damage.  Recognizing that a patient may fall anywhere within this progression is a difficult challenge.  There are very few definitive special tests that rule in or out a SLAP lesion versus an anterior impingement.   Let’s begin with an examination screening process that will begin to first rule in the shoulder, and second focus our direction.

History:
How did the symptoms begin?
 -Insidious onset, or trauma?
 -What brings on the sxs?
  -Repetitive overhead activity
  -Sitting Statically
  -Elbow hand Motion?

Where are the sxs located?
 -Anterior shoulder?
 -Posterior?
 -Scapular region?

What other complaints do they demonstrate?
 -Looseness or instability, may indicate GH instability or labral activity
 -Global pain with tightness, may indicate Adhesive capsulitis
 -Weakness, may be indicative or subacromial impingement, rotator cuff pathology

What is the patient’s profession?
 -Laborer
 -Desk work
Outcomes:
Outcomes can and should be performed to establish initial disability and to track progress
-Dash
-Shoulder pain and disability index
-Upper limb Lift and carry 
Screening Red Flags:
Left shoulder referred pain:
-Myocardial infarction
-Ruptured spleen

Right shoulder referred pain:
-Liver disease
-Pancreatic disease
-Gallbladder 

Both shoulder referred pain:
-Pancoast tumor
Yellow flags:
-Fear and avoidance
-Psychological illness
-Workman’s comp or attorney involvement
-Depression
Cervical Spine clearing:
-AROM in all directions
-PROM with over pressure
-Distraction/compression
Any reproduction of sxs may indicate further investigation of cervical spine
-Accessory motion assessment
-ULTT
-Repeated movement examination
-Traction

-Dermatome: 
 -C4 - Top of shoulder
 -C5 – Lateral shoulder
 -C6 – Tip of thumb
 -C7 – Tip of Middle 3rd digit
 -C8 – Tip fifth digit
 -T1 -  Medial Forearm

-Myotome:
-C4 – Shoulder shrug
 -C5 – Abduction
 -C6 – Elbow flexion, wrist extension
 -C7 – Elbow extension, Wrist flexion
 -C8 – Thumb abduction
 -T1 -  Finger abduction

-DTR:
 C5- Biceps
 C6- Brachioradialis
 C7- Triceps
Observation
Static:
 -Scapula position
  -Winging, rounded, tilted
 -Humeral Position
  -IR
 -Head position
  -Forward
 -AC joint
 -SC joint
Dynamic:
 -Scapulae rhythm
 -Shoulder Hiking
 -Shaking, juttering, quivering
PROM with overpressure
Flexion
Abduction
IR
ER
Horizontal Abduction
Horizontal adduction
MMT
Shoulder Flexion- Anterior Deltioid, Biceps, pec
Shoulder extension- Mid and lower trap
Shoulder Abduction- Deltoid, Supraspinatus
Internal Rotation- Subscapularis, Teres major
External Rotation- teres minor, infraspinatus
Other Resistive testing to consider:
-Serratus Anterior
-Lower and Middle Trap
-Rhomboid
Joint Accessory Motion
GH: Anterior, posterior, inferior, lateral distraction
AC: Posterior, anterior
SC: Posterior, Inferior and superior
Scapulothoracic
-Medial mobility
-Lateral mobility
-Superior and inferior
-Upward and downward rotation
Special tests
-See special test in additional sections
OK, so there are your typical screening options.  Let me know in the comments if you have any other questions or suggestions for the screening process.  We will discuss special tests in another section along with specific pathologies and treatment strategies.  Resources include Current concepts of orthopedic physical therapy, eMed, Physiopedia. 

 

 

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