Mtg08 Sports Shoulder

7/29/2019 Mtg08 Sports Shoulder

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The Shoulder ExamThe Shoulder Exam

J. Todd Davis, MDJ. Todd Davis, MD Arizona State University,Arizona State University,

Team PhysicianTeam Physician

Arizona Diamondbacks,Arizona Diamondbacks,Team PhysicianTeam Physician

St. JosephSt. Josephs Familys FamilyMedicine/ASU SportsMedicine/ASU Sports

Medicine Fellowship,Medicine Fellowship,FacultyFaculty

Owner, Sonoran Sports &Owner, Sonoran Sports &Family MedicineFamily Medicine


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Shoulder ExamShoulder Exam

HistoryHistory

InspectionInspection

PalpationPalpation

Range of MotionRange of Motion Muscle TestingMuscle Testing

Tests for Joint StabilityTests for Joint Stability Special TestsSpecial Tests


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HistoryHistory

Type of activityType of activity

Insidious onset orInsidious onset oracuteacute

PainPain

LocationLocation When it occursWhen it occurs

Instability sensationsInstability sensations

Numbness or tinglingNumbness or tingling

WeaknessWeakness


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InspectionInspection

Symmetry?Symmetry?

AC, clavicle, SC jointAC, clavicle, SC joint Ecchymosis?Ecchymosis?

Swelling?Swelling?

Muscle Atrophy?Muscle Atrophy?

Nerve entrapmentNerve entrapment

Winging of scapula?Winging of scapula?


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PalpationPalpation

SC jointSC joint

ClavicleClavicle AC jointAC joint

Coracoid processCoracoid process

Short head of bicepsShort head of bicepsand Pectoralis minorand Pectoralis minor

AcromionAcromion

Spine of scapulaSpine of scapula Long Head of theLong Head of the

Biceps TendonBiceps Tendon


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Range of MotionRange of Motion

AbductionAbduction

Normal ROM 0Normal ROM 0--160/180160/180 Watch from posterior view: evaulate forWatch from posterior view: evaulate for

scapular winging, dyskinesisscapular winging, dyskinesis

Forward FlexionForward Flexion

Normal ROM 0Normal ROM 0--160/180160/180


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External RotationExternal Rotation

If assessing with the arms at the side, need toIf assessing with the arms at the side, need tokeep the elbows next to the bodykeep the elbows next to the body

Normal ROM 45Normal ROM 45--90 degrees90 degrees

Assess in 90 degrees of abductionAssess in 90 degrees of abduction

Normal ROM 90 degreesNormal ROM 90 degrees

Up to 20 degrees of increased external rotation onUp to 20 degrees of increased external rotation onthe dominant side is normalthe dominant side is normal

More functional testMore functional test

Mirrors throwing or overhead motionsMirrors throwing or overhead motions


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Internal RotationInternal Rotation

If done at the side you ask the patient to seeIf done at the side you ask the patient to seehow far they can reach up their backhow far they can reach up their back

Apley Scratch TestApley Scratch Test

Normal ROM T7 for women, T9 for menNormal ROM T7 for women, T9 for men

More functional testMore functional test

Needed in activities of daily livingNeeded in activities of daily living

Assess in 90 degrees of abductionAssess in 90 degrees of abduction



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AdductionAdduction

Adduct arm across body at 90 degrees ofAdduct arm across body at 90 degrees offlexionflexion

Cross arm test for AC joint pathologyCross arm test for AC joint pathology

ExtensionExtension

Swing upper limb posteriorlySwing upper limb posteriorly



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Muscle TestingMuscle Testing

Scapular StabilizersScapular Stabilizers

Serratus AnteriorSerratus Anterior Origin: anterior ribs, Insertion: medial borderOrigin: anterior ribs, Insertion: medial border

scapulascapula

Innervation: Long Thoracic NerveInnervation: Long Thoracic Nerve

Action: Scapular RetractionAction: Scapular Retraction

To evaluate: Patient performs a modified push upTo evaluate: Patient performs a modified push up

against the wallagainst the wall

Winging of scapula noted with weaknessWinging of scapula noted with weakness


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Muscle Testing Scapular StabilizersMuscle Testing Scapular Stabilizers

RhomboidsRhomboids

Action: Retraction of scapulaAction: Retraction of scapula Origin: Spinous processOrigin: Spinous process

Insertion: medial border of the scapulaInsertion: medial border of the scapula

Innervation: Dorsal scapular nerveInnervation: Dorsal scapular nerve To evaluate: Have patient retract the shouldersTo evaluate: Have patient retract the shoulders

backback

Isolated palsy of this nerve occurs rarelyIsolated palsy of this nerve occurs rarely


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Muscle Testing Scapular StabilizersMuscle Testing Scapular Stabilizers

TrapeziusTrapezius

Origin: Occiput of head and spinous processOrigin: Occiput of head and spinous process

Insertion: superior spine of scapula and clavicleInsertion: superior spine of scapula and clavicle

Innervation: Spinal Accessory Nerve (CN XI)Innervation: Spinal Accessory Nerve (CN XI)

To evaluate: patient shrugs their shoulders withTo evaluate: patient shrugs their shoulders withyou adding resistance downwardyou adding resistance downward


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Muscle Testing Rotator CuffMuscle Testing Rotator Cuff

SupraspinatusSupraspinatus Origin: Supraspinatus fossa of theOrigin: Supraspinatus fossa of the

scapulascapula Insertion: Greater tubercle of theInsertion: Greater tubercle of the

humerushumerus

Innervation: Suprascapular NerveInnervation: Suprascapular Nerve

Impingement of nerve at theImpingement of nerve at thesuperior scapular notchsuperior scapular notch

Atrophy of both supraspinatus andAtrophy of both supraspinatus andinfraspinatus or isolatedinfraspinatus or isolated

infraspinatus.infraspinatus. Action: Abduction of the shoulderAction: Abduction of the shoulder

To evaluate:To evaluate:

Supraspinatus or Empty Can TestSupraspinatus or Empty Can Test


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InfraspinatusInfraspinatus

Origin: Infraspinatus fossa of the posterior scapulaOrigin: Infraspinatus fossa of the posterior scapula

Insertion: Greater tubercle of the humerus justInsertion: Greater tubercle of the humerus just

inferior to the supraspinatusinferior to the supraspinatus

Innervation: Suprascapular NerveInnervation: Suprascapular Nerve Impingement at the Spinoglenoid notchImpingement at the Spinoglenoid notch

Action: External Rotation of the ShoulderAction: External Rotation of the Shoulder

To Evaluate: Resisted external rotationTo Evaluate: Resisted external rotation


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Teres MinorTeres Minor

Origin: Lateral Border of the Posterior ScapulaOrigin: Lateral Border of the Posterior Scapula

Insertion: Posterior humerus inferior to the greaterInsertion: Posterior humerus inferior to the greater

tubercletubercle

Innervation: Axillary NerveInnervation: Axillary NerveAction: External Rotation of the ShoulderAction: External Rotation of the Shoulder

To Evaluate: Resisted external rotationTo Evaluate: Resisted external rotation


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SubscapularisSubscapularis

Origin: Subscapular fossa on the anterior scapulaOrigin: Subscapular fossa on the anterior scapula

Insertion: Lesser tubercle of the humerusInsertion: Lesser tubercle of the humerus

Innervation: Upper and Lower subscapular nervesInnervation: Upper and Lower subscapular nerves

Action: Internal Rotation of the ShoulderAction: Internal Rotation of the Shoulder To Evaluate: Resisted Internal rotation using theTo Evaluate: Resisted Internal rotation using the

subscapularis lift off test or the belly press testsubscapularis lift off test or the belly press test


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Pectoralis MajorPectoralis Major

Origin: Sternum and inferior clavicle Insertion:Origin: Sternum and inferior clavicle Insertion:Crest of the greater tubercle of the humerusCrest of the greater tubercle of the humerus

Innervation: Medial and Lateral Pectoral NervesInnervation: Medial and Lateral Pectoral Nerves

Action: Internal Rotation and Adduction of theAction: Internal Rotation and Adduction of theShoulderShoulder

To Evaluate: Patient adducts the arm in about 20To Evaluate: Patient adducts the arm in about 20

degrees of flexion with the elbows slightly bentdegrees of flexion with the elbows slightly bent


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Latissimus DorsiLatissimus Dorsi

Origin: Inferior angle of the scapula Insertion:Origin: Inferior angle of the scapula Insertion:Crest of the lesser tubercle of the humerusCrest of the lesser tubercle of the humerus

Innervation: Thoracodorsal NerveInnervation: Thoracodorsal Nerve

Action: Internal Rotation and Extension of theAction: Internal Rotation and Extension of theShoulderShoulder

To Evaluate: Patient flexes the shoulder with theTo Evaluate: Patient flexes the shoulder with the

elbows flexed to 90 degrees, then asked toelbows flexed to 90 degrees, then asked tointernally rotate and extend the shoulder againstinternally rotate and extend the shoulder against

resistanceresistance


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DeltoidDeltoid Origin: Inferior boarder of clavicle and acromiumOrigin: Inferior boarder of clavicle and acromium

Insertion: Deltoid tuberosityInsertion: Deltoid tuberosity Innervation: Axillary NerveInnervation: Axillary Nerve

Most common nerve to be injured with shoulderMost common nerve to be injured with shoulderdislocations or surgerydislocations or surgery

Action: FlexionAction: Flexion--anterior deltoid, Abductionanterior deltoid, Abduction--middlemiddledeltoid, Extensiondeltoid, Extension--posterior deltoidposterior deltoid

To Evaluate:To Evaluate:Anterior deltoidAnterior deltoid--resisted flexionresisted flexion

Middle deltoidMiddle deltoid--Resisted abduction with the elbow in 90Resisted abduction with the elbow in 90degrees of flexiondegrees of flexion

Posterior deltoidPosterior deltoid--resisted extension of shoulder withresisted extension of shoulder withelbow flexed at 90 degreeselbow flexed at 90 degrees


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Rotator Cuff ImpingementRotator Cuff Impingement


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Special TestsSpecial Tests--Rotator CuffRotator Cuff

Neer ImpingementNeer ImpingementSignSign Passively flex thePassively flex the

shoulder toshoulder tomaximal forwardmaximal forward

flexion whileflexion whilestabilizing thestabilizing thescapula with thescapula with theother handother hand

Pain at maximalPain at maximalforward flexion isforward flexion isconsidered aconsidered a

positive testpositive test


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Subscapularis Lift OffSubscapularis Lift Off

TestTest Inability to lift the armInability to lift the arm

off the back isoff the back is

considered a positiveconsidered a positive

testtest


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HawkinHawkinss--KennedyKennedyTestTest Forward flex theForward flex the

patientpatients shoulders shoulderto 90 degrees withto 90 degrees with

the elbow bent atthe elbow bent at90 degrees and90 degrees andinternally rotate theinternally rotate theshouldershoulder

Pain with thePain with themotion ismotion isconsidered aconsidered a

positive testpositive test


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Special TestsSpecial Tests--Biceps TendonBiceps Tendon

SpeedSpeeds Tests Test The shoulder is placedThe shoulder is placed

in 90 degrees ofin 90 degrees offorward flexion, elbowforward flexion, elbowin full extension andin full extension andforearm supination aforearm supination a

downward force isdownward force isplaced and the patientplaced and the patientis asked to resist itis asked to resist it

A positive test is notedA positive test is notedwhen pain and difficultywhen pain and difficultyresisting is presentresisting is present


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Special TestsSpecial Tests--Biceps TendonBiceps Tendon

YergasonYergasons Tests Test Arm is at the side withArm is at the side with

the elbow flexed to 90the elbow flexed to 90degrees and thedegrees and theforearm pronated, theforearm pronated, thearm is then grasped byarm is then grasped by

the examiner and thethe examiner and thepatient forcefully flexespatient forcefully flexesand supinates theand supinates theforearmforearm

A positive test is notedA positive test is notedby pain over theby pain over theanterior shoulderanterior shoulder

R t t ff bi i it lRotator cuff or bicipital


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Rotator cuff or bicipitalRotator cuff or bicipital

tendinosistendinosis TreatmentTreatment

Physical therapyPhysical therapy +/+/-- injectioninjection-- diagnostic and/or therapeuticdiagnostic and/or therapeutic


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AC jointAC joint

HistoryHistory

Usually injuredUsually injuredfalling on shoulderfalling on shoulder

with arm at thewith arm at the

side.side.


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AC jointAC joint

Inspection andInspection and

palpationpalpation

Special TestsSpecial Tests AC Joint InjuryAC Joint Injury


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Special TestsSpecial Tests--AC Joint InjuryAC Joint Injury

Separated shoulderSeparated shoulder Cross Over TestCross Over Test

Passive adduction ofPassive adduction of

the arm in 90 degreesthe arm in 90 degrees

of flexionof flexion

A positive test occursA positive test occurs

with reproduction ofwith reproduction of

the patientthe patients pain ats pain at

the AC jointthe AC joint


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AC jointAC joint--imagingimaging

XraysXrays

May showMay showseparation of ACseparation of AC

joint or elevation ofjoint or elevation of

clavicle aboveclavicle aboveacromionacromion


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AC joint injuriesAC joint injuries--6 types6 types

Type IType IAcromioclavicularAcromioclavicular

ligament sprain with theligament sprain with the

AC joint intactAC joint intact

Type IIType IIAcromioclavicularAcromioclavicular

ligament tear,ligament tear,

coracoclavicular ligamentcoracoclavicular ligamentintact; AC joint subluxedintact; AC joint subluxed

Type IIIType III

Acromioclavicular andAcromioclavicular andcoracoclavicular ligamentscoracoclavicular ligaments

torn; 100% dislocation intorn; 100% dislocation in

jointjoint


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AC JOINT INJURIESAC JOINT INJURIES--6 TYPES6 TYPES

Type IVType IVComplete dislocation with posterior displacement ofComplete dislocation with posterior displacement of

distal clavicle into or through the trapezius muscledistal clavicle into or through the trapezius muscle

Type VType VExaggerated superior dislocation of the joint of 100% toExaggerated superior dislocation of the joint of 100% to300%, increasing the coracoclavicular ligament distance two to300%, increasing the coracoclavicular ligament distance two to

three times, including disruption of the deltotrapezial fasciathree times, including disruption of the deltotrapezial fascia

Type VIType VIComplete dislocation with inferior displacement of distalComplete dislocation with inferior displacement of distal

clavicle into a subacromial or subcoracoid positionclavicle into a subacromial or subcoracoid position


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AC jointAC joint--treatmenttreatment

Type I and IIType I and II

NonsurgicalNonsurgical Pain controlPain control

? Injection? Injection

PTPT

Type IIIType III

Possibly surgicalPossibly surgical

Type IVType IV--VIVI--surgicalsurgical

Special TestsSpecial Tests InstabilityInstability


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Special TestsSpecial Tests--InstabilityInstability

Apprehension/Relocation/Surprise TestApprehension/Relocation/Surprise Test Lie the patient on their back, the shoulder isLie the patient on their back, the shoulder is

placed in 90 degrees or abduction and slightplaced in 90 degrees or abduction and slight

extension with the elbow flexed. The examinerextension with the elbow flexed. The examinerthen externally rotates the armthen externally rotates the arm

A positive test is when the patient experiencesA positive test is when the patient experiences

anxiety over the test or you dislocate the shoulderanxiety over the test or you dislocate the shoulder Continue the apprehension maneuver but then theContinue the apprehension maneuver but then the

examiner places posterior pressure on the anteriorexaminer places posterior pressure on the anteriorshoulder thus relieving the anxiety or instabilityshoulder thus relieving the anxiety or instability

sensationsensation Surprise: Subsequently letting go of the anteriorSurprise: Subsequently letting go of the anterior

pressure recreating the anxiety feeling orpressure recreating the anxiety feeling or

dislocationdislocation


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Drawer TestDrawer Test

Examiner places one hand on the scapular spineExaminer places one hand on the scapular spine

and the coracoid process the second hand graspsand the coracoid process the second hand grasps

the humeral headthe humeral head--alternating anterior andalternating anterior and

posterior pressure on the humeral headposterior pressure on the humeral head

Up to 25% anterior translation and 50% posteriorUp to 25% anterior translation and 50% posterior

translation can be considered normaltranslation can be considered normal

Grinding can be a sign of glenohumeralGrinding can be a sign of glenohumeral

degenerationdegeneration


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Load and Shift TestsLoad and Shift Tests The patient lies supine on the table and the arm isThe patient lies supine on the table and the arm is

slightly abducted, one hand is placed on theslightly abducted, one hand is placed on thepatientpatients wrist, the second hand grasps thes wrist, the second hand grasps the

humeral head and the AP translation test ishumeral head and the AP translation test isrepeatedrepeated


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Sulcus SignSulcus Sign

Tests inferior laxity of the shoulderTests inferior laxity of the shoulder

The patient relaxes the arm at their side andThe patient relaxes the arm at their side and

inferior traction is placed on the arm, a visibleinferior traction is placed on the arm, a visible

sulcus is noted under the acromiumsulcus is noted under the acromium


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Jerk TestJerk Test

Evaluating posterior instabilityEvaluating posterior instability

The patient is placed spine on the table, theThe patient is placed spine on the table, the

shoulder is flexed to 90 degrees with the elbowshoulder is flexed to 90 degrees with the elbow

flexed, a posterior force is then applied to the armflexed, a posterior force is then applied to the arm

a jerk is felt as the should subluxes posteriorlya jerk is felt as the should subluxes posteriorly

In less severe cases one may complain of apprehensionIn less severe cases one may complain of apprehension

or painor pain

h ld d l


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Shoulder dislocationsShoulder dislocations

Fall onFall on

outstretched armoutstretched arm Forced ER at 90Forced ER at 90

degrees abductiondegrees abduction

95% anterior95% anterior

5% posterior5% posterior

SeizuresSeizures

h ld d lSh ld di l i


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Shoulder dislocationShoulder dislocation

Imaging to r/oImaging to r/o

fracturefracture ReductionReduction

ImmobilizationImmobilization Physical therapy toPhysical therapy to

advance strengthadvance strength

and ROMand ROM

Monitor forMonitor for

instabilityinstability

Sh ld di l iSh ld di l ti


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Shoulder dislocationShoulder dislocation

MRI arthrogramMRI arthrogram

Labral tearsLabral tears Hill sachs lesionHill sachs lesion

Bankart lesionBankart lesion

S i l T tS i l T t SLAPSLAP


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Special TestsSpecial Tests--SLAPSLAP

OOBrien TestBrien Test

Forward flex the patientForward flex the patients shoulder 90 degrees ands shoulder 90 degrees and

adduct approximately 15 degrees. The patientadduct approximately 15 degrees. The patient

then maximally internally rotates the arm. Thethen maximally internally rotates the arm. The

examiner then places downward resistance on theexaminer then places downward resistance on the

arm and asks the patient to resist the force. Thearm and asks the patient to resist the force. Themaneuver is then repeated with the arm externallymaneuver is then repeated with the arm externally

rotated.rotated.

A positive test is noted if there is pain only in theA positive test is noted if there is pain only in thethumbs down position and deep in the shoulder.thumbs down position and deep in the shoulder.

L b l t tL b l t t


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Labral testsLabral tests

Crank and loadCrank and load

MimoriMimorissAA--P shiftP shift

Biceps loadBiceps load

Di l ti /l b l tDi l ti /l b l t t t tt t t


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Dislocation/labral tearDislocation/labral tear--treatmenttreatment

If instability, chronic pain with activityIf instability, chronic pain with activity

surgical correction may be necessarysurgical correction may be necessary Capsulorrhaphy, labral repair, RTC tear,Capsulorrhaphy, labral repair, RTC tear,

bankartbankart lesion, other pathologylesion, other pathology

Controversy about first timeControversy about first time dislocatorsdislocators

To repair or not to repairTo repair or not to repair

Documents

Mtg08 Sports Shoulder