Clinical Examination of the Shoulder Joint Complex Mike Reinold, DPT, SCS, CSCS MikeReinold.com Champion PT and Performance Boston, MA I. Introduction A. Clinical Examination 1. Vital to successful treatment of shoulder patients 2. Must be thorough and systematic a. Rule out & rule in 3. Main purpose is to establish underlying cause of symptoms 4. Also determines where to start with patient a. Tolerance level ßà aggressiveness of program B. Components of clinical exam 1. Subjective history 2. Inspection / observation 3. Clearing the cervical spine 3. Active range of motion 4. Passive range of motion 5. Manual muscle testing 6. Accessory motion assessment 7. Laxity testing 8. Special tests 9. Palpation 10. Neurovascular assessment 11. Functional assessments 12. Imaging studies / radiographs
Transcript
Clinical Examination of the Shoulder
Joint Complex
Mike Reinold, DPT, SCS, CSCS
MikeReinold.com Champion PT and Performance
Boston, MA
I. Introduction A. Clinical Examination 1. Vital to successful treatment of shoulder patients 2. Must be thorough and systematic a. Rule out & rule in
3. Main purpose is to establish underlying cause of symptoms 4. Also determines where to start with patient
a. Tolerance level ßà aggressiveness of program
B. Components of clinical exam 1. Subjective history 2. Inspection / observation 3. Clearing the cervical spine 3. Active range of motion 4. Passive range of motion 5. Manual muscle testing 6. Accessory motion assessment 7. Laxity testing 8. Special tests 9. Palpation 10. Neurovascular assessment 11. Functional assessments 12. Imaging studies / radiographs
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II. Subjective Examination A. Most important part of the clinical exam B. Will direct the approach to the objective examination
C. History of symptoms
1. What brings you here today? a. Pain, weakness, instability, sensations, etc. 2. When did the symptoms begin? a. Acute traumatic incident b. Insidious onset 3. Where, when, & how? 4. What alleviates symptoms? 5. What reproduces symptoms? 6. Chief complaint a. Limitations in functional activities b. Limitations in work activities c. Limitations in recreational/athletic activities Looking for “pattern recognition” of symptoms III. Observation A. Symmetry B. Posture 1. Head position 2. Shoulder position 3. Pectoralis position 3. Scapular position 4. Spine position C. Atrophy of muscle tissue D. Visible defects 1. Ecchymosis, edema, inflammation, deformities
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IV. Clearing the cervical spine A. Dermatomes, myotomes, reflexes
B. Active ROM (w/ overpressure), quadrant test, compression/distraction
V. Range of motion
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A. Active range of motion 1. Ability to raise arm 2. Functional ER/IR 3. Assess several factors a. Painful arc b. Quality of motion c. Quantity of motion 4. Scapulohumeral rhythm a. 0-30° = setting phase; mostly GH movement b. 30-90° = 2.0-2.75:1 ratio of GH:ST movement c. 90-160° = 1:1 ratio of scapulohumeral movement 5. Scapula movement & winging B. Passive range of motion
Motion AAOS AMA Boone JBJS 79 End Feel
Flexion 180 150 166.7 Firm Extension 60 50 62.3 IR 70 90 68.8 Firm-hard ER 90 90 103.7 Capsular Abduction 180 180 184.0 Motion 10-20 years
Boone JBJS 79 20-40 years Boone JBJS 79
40-54 years Boone JBJS 79
60-85 years Walker Phys Ther 84
61-93 years Downey Phys Ther 91
FLX 167.4 165 165.1 160 165 EXT 64 58 56.1 38 - IR 70.3 66.5 68.3 59 65 ER 106.3 101 97.5 76 80.6 ABD 185.1 182.7 182.6 155 157.9
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C. PROM in the athletic population Motion Baseball Players PROM
ER 129.9 103.2 103.7 IR 62.6 42.4 45.4 D. Assess several factors during PROM 1. Quality & quantity of motion 2. Crepitus 3. End feel (overpressure) VI. Neuromuscular system A. Resisted manual muscle testing
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B. Rotator cuff integrity 1. Empty can test Jobe: AJSM ‘82 2. Drop arm test 3. Lag Signs Hertel: JSES ‘96
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4. Push-pull test Matsen: ‘90 VIII. SLAP tests A. Speed’s tests
B. Grind test “Compression-Rotation”
Snyder: Arthroscopy ‘90
C. Clunk test / Crank Test
Andrews: Inj. Baseball ‘85 Liu: AJSM ‘96
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E. Anterior slide Kibler: Arthroscopy ‘95
F. Active compression test – O’Brien: AJSM ‘98 G. Biceps Load I & II – Kim: AJSM ’99 & Arthroscopy ‘01 H. Pain Provocation – Mimori: AJSM ’99 – Increased pain in pronation
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IX. Acromioclavicular joint A. Spring sign B. Shear test Davies: Phys Sports Med ‘81
C. Horizontal adduction
D. O’Brien’s test O’Brien: AJSM ‘98
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X. Neurovascular A. Neurological function 1. Upper limb tension test (ULTT) – Magee ‘97
2. Tinel’s sign – Landi ‘79
3. Dermatomes & Reflexes
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C. Thoracic outlet 1. Roos (EAST) test –
Generalized compression Roos: J Surg ‘76
2. Adson maneuver – Compression between anterior & middle scalenes or between cervical rib and scalenes. Adson: Ann Surg ‘27
3. Costoclavicular (Military) test – Compression between 1st rib & clavicle in costoclavicular space. Magee ‘97
4. Allen test – Compression between pectoralis minor and ribs. Allen: AJ Med Sci ‘29
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XI. Palpation A. Specific structures 1. Greater tuberosity – rotator cuff insertion 2. Biceps brachii (proximal) 3. Coracoid process 4. Subacromial bursa 5. Anterior deltoid 6. Infraspinatus – internal impingement location 7. Quadralateral space 8. 1st rib 9. Acromioclavicular joint 10. Scapular mobility (crepitus, etc) during AROM XII. Functional Assessment A. Specific shoulder assessment forms 1. American Shoulder Elbow Surgeon Form 2. UCLA Shoulder Form 3. Jobe-Tobonie Athletic Shoulder Form 4. Modified Athletic Shoulder Form – Reinold, Wilk, Andrews
5. Mimori Scoring System XIII. Summary
A. Key Points 1. Systemic approach to shoulder exam 2. Logical progression 3. Knowledge of anatomy & biomechanics 4. Establish chief complaints 5. Correlate clinical findings to history
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References Adson AW, Coffey JR. Cervical rib: a method of anterior approach for relief of symptoms by division of scalenus anticus. Ann Surg. 1927; 85: 839-857. Allen EV. Thromboangitis obliterans: Methods of diagnosis of chronic occlusive arterial lesions distal to wrist with illustrative cases. Am J Med Sci. 1929; 178: 237-244. Andrews JR, Timmerman LA, Wilk KE. Baseball. In Pettrone FA, editor. Athletic injuries of the shoulder. New York: McGraw-Hill: 1995. Andrews JR, Gillogly S. Physical exam of the shoulder in throwing athletes. In Zarins B, Andrews JR, Carson WG, editors. Injuries to the throwing arm. Philadelphia: WB Saunders: 1985. Bell, R.H. and J.B. Noble: Biceps disorders, In Hawkins, R.J., and G.W. Misamore (eds.): Shoulder Injuries in the Athlete. New York, Churchill Livingstone, 1996. Davies GJ, Gould JA, Larson RL. Functional examination of shoulder girdle. Phys Sports Med. 1981; 9: 82-104. Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Joint Surg. 1991; 73B: 289-294. Guidi, E.J. and J.D. Suckerman: Glenoid labral lesions. In Andrews, J.R., and Wilk KE (eds.): The Athlete’s Shoulder. New York, Churchill Livingstone, 1994. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980; 8(3):151-8. Hawkins RJ, NG Mohtadi: Clinical evaluation of shoulder instability. Clin. J. Sports Medi. 1:59-64, 1991. Jobe FW, Kvitne RS. Shoulder pain in the overhead or throwing athlete. The relationship of anterior instability and rotator cuff impingement. Ortho Rev 1989; 18(9): 963-975. Jobe FW, Moynes DR. Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries. Am J Sports Med 1982;10(6):336-9. Kessel, L., and M Watson: The painful arc syndrome. J. Bone Joint Surg. Br. 59:166-72, 1977 Kibler WB. Specificity and sensitivity of the anterior slide test in throwing athletes with superior glenoid labral tears. Arthro 1995; 11(3): 296-300.
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Kim SH, Ha KI, Ahn JH, Kim SH, Choi HJ. Biceps load test II: Clinical test for SLAP lesions of the shoulder. Arthro 2001; 17(2): 160-164. Kim SH, Ha KI, Han KY. Biceps load test: a clinical test for superior labrum anterior and posterior lesions in shoulders with recurrent anterior dislocations. Am J Sports Med. 1999; 27(3):300-3. Landi A, Copeland S. Value of tinel sign in brachial plexus lesions. Ann R Coll Surg Engl. 1979; 61: 470-471. Liu SH, Henry MH, Nuccion SL. A prospective evaluation of a new physical examination in predicting glenoid labral tears. Am J Sports Med. 1996;24(6):721-5. Magee DJ. Cervical Spine. Orthopedic physical assessment. Philadelphia: WB Saunders: 1997. Matsen FA, Thomas SC, Rockwood CA. Glenohumeral instability. In Rockwood CA, Matsen FA, editors. The shoulder. Philadelphia: WB Saunders: 1990. Meister BR, Michael SP, Moyer RA, Kelly JD, Schneck CD. Anatomy and kinematics of the lateral collateral ligament of the knee. Am J Sports Med. 2000; 28(6):869-78. Mimori K, Muneta T, Nakagawa T, Shinomiya K. A new pain provocation test for superior labral tears of the shoulder. Am J Sports Med. 1999; 27(2):137-42. Mosely, H.F.: Disorders of the shoulder. Clin. Symp. 12:1-30, 1960 Neer CS 2nd, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am. 1980; 62(6):897-908. Neer CS 2nd, Welsh, RP. The shoulder in sports. Ortho Clin NA. 1977; 8(3): 583-592. Norwood LA, Terry GC. Shoulder posterior subluxation. Am J Sports Med. 1984; 12(1):25-30. O'Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998; 26(5):610-3. Roos DB. Congenital anomalies associated with thoracic outlet syndrome. J Surg; 1976: 771-778.
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Silliman JF, Hawkins RJ. Classification and physical diagnosis of instability of the shoulder. CORR 1993; 291: 7-19. Wilk KE, Andrews JR, Arrigo CA: The physical examination of the glenohumeral joint: Emphasis on the stabilizing structures. J Orthop Sports Phys Ther 25(6):380-389, 1997. Yergason RM. Supination sign. J Bone Joint Surg. 1931; 13: 160.
