Shoulder Examination


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Shoulder Examination

  1. 1. Shoulder Examination Mr Penna
  2. 2. Shoulder Anatomy Sreeram Penna
  3. 3. Shoulder Anatomy Sreeram Penna
  4. 4. Sreeram Penna
  5. 5. History taking <ul><li>Age, Dominant hand </li></ul><ul><li>Presenting complaints (duration, onset) </li></ul><ul><li>Pain (location, diurnal variation, duration, onset, aggravating factors, relieving factors, radiation ) </li></ul><ul><li>Laxity, Instability, subluxation, dislocation ( h/o trauma, other lax joints ) </li></ul><ul><li>Stiffness </li></ul><ul><li>Past medical history : diabetes, epilepsy, </li></ul><ul><li>Occupation and Hobbies </li></ul>Sreeram Penna
  6. 6. Examination <ul><li>Inspection </li></ul><ul><li>Palpation </li></ul><ul><li>Range of movements </li></ul><ul><li>Rotator cuff assessment </li></ul><ul><li>Special tests </li></ul><ul><li>Distal neurovascular examination </li></ul><ul><li>Neck examination </li></ul><ul><li>Examination of other joints </li></ul>Sreeram Penna
  7. 7. Inspection <ul><li>Anterior, Lateral, Posterior </li></ul>Sreeram Penna
  8. 8. Inspection <ul><li>Inspect for swelling, deformity, asymmetry, scars, echymosis, venous distension, muscular atrophy. </li></ul><ul><li>Winging of scapula, Rupture of long head of biceps. </li></ul>Sreeram Penna
  9. 9. AC Joint dislocation Sreeram Penna
  10. 10. Sreeram Penna
  11. 11. Sreeram Penna
  12. 12. Sreeram Penna
  13. 13. Palpation <ul><li>AC joint </li></ul><ul><li>SC joint </li></ul><ul><li>Greater Tuberosity </li></ul><ul><li>Biceps groove </li></ul><ul><li>Ant/Post Capsule </li></ul><ul><li>Coracoid process </li></ul>Sreeram Penna
  14. 14. Palpation of AC Joint Palpation of Bicipital Groove Sreeram Penna
  15. 15. Range of Movements <ul><li>Flexion </li></ul><ul><li>Abduction </li></ul><ul><li>External Rotation </li></ul><ul><li>Internal Rotation </li></ul><ul><li>Both Active and Passive </li></ul><ul><li>Imp to see patients face during this to see if they are in any pain </li></ul><ul><li>Check for painful arc </li></ul><ul><li>Scapular diskinesia </li></ul>Sreeram Penna
  16. 16. Sreeram Penna
  17. 17. Frozen Shoulder Sreeram Penna
  18. 18. Testing for Rotator Cuff <ul><li>Supraspinatus : Empty can test </li></ul><ul><li>Infraspinatus : External rotation lag sign </li></ul><ul><li>Subscapularis: Internal rotation lag sign test, Gerbers lift off test, Belly press sign </li></ul>Sreeram Penna
  19. 19. Test for Supra Spinatus <ul><li>Empty can test: The patient is tested at 90° elevation in the scapula plane and full internal rotation (empty can) or 45°external rotation (full can). Patient resists downward pressure exerted by examiner at patients elbow or wrist. </li></ul>Sreeram Penna
  20. 20. External and Internal Rotation lag Signs Sreeram Penna
  21. 21. Tests for Subscapularis <ul><li>Belly Press / Napoleon Sign While in the standing position the patient puts a hand on the stomach and pushes as hard as possible. The effect is an isometric contraction with the shoulder in a position of internal rotation. At the same time the patient moves the elbow forward, which puts the shoulder in even more rotation. The test is positive for a tear in the subscapularis muscle if the patient can't press against the belly while rotating the shoulder. </li></ul>Sreeram Penna
  22. 22. Tests for Subscapularis <ul><li>Gerber’s Lift-Off Test: The patient is examined in standing and is asked to place their hand behind Their back with the dorsum of the hand resting in the region of the mid- lumbar spine. The dorsum of the hand is raised off the back by maintaining or increasing internal rotation of the humerus and extension at the shoulder. To perform this test the patient must have full passive internal rotation so that it is physically possible to place the arm in the desired position and pain cannot be a limiting factor during the manoeuvre. </li></ul>Sreeram Penna
  23. 23. Tests for Impingement <ul><li>Neer’s sign: pain with passive abduction in scapula plane, shoulder internally rotated. </li></ul>Sreeram Penna
  24. 24. Tests for Impingement <ul><li>Hawkins – Kennedy test: </li></ul><ul><li>The patient is examined in sitting with their arm at 90° and their elbow flexed to 90°, supported by the examiner to ensure maximal relaxation. The examiner then stabilises proximal to the elbow with their outside hand and with the other holds just proximal to the patient's wrist. They then quickly move the arm into internal rotation. </li></ul>Sreeram Penna
  25. 25. Tests for Labral pathology <ul><li>O’Briens test: </li></ul><ul><li>SLAP lesion </li></ul><ul><li>False positive AC joint pain </li></ul>Sreeram Penna
  26. 26. Tests for Instability <ul><li>Anterior Apprehension test: Test for anterior labrum and anterior capsule </li></ul><ul><li>In supine the patient is positioned with the scapula supported by the edge of the examining table. The arm is positioned in 90 °abduction and external rotation. With increasing external rotation the examiner watches for apprehension on the part of the patient. This test is often performed in sitting in the clinic setting and the examiner exerts an anterior translatory force with their thumb placed posteriorly on the humerus. However their fingers are anterior to control any sudden instability episode that may occur. </li></ul>Sreeram Penna
  27. 27. Tests for Instability <ul><li>Jobe Relocation Test: </li></ul><ul><li>For anterior capsule and labrum, SLAP lesions </li></ul><ul><li>The examiner repeats the apprehension test and notes the amount of external rotation before the onset of apprehension. They then return to the start position and apply a posterior stress over the humeral head. They then repeat the external rotation manoeuvre and again note amount of external rotation at onset of apprehension. </li></ul>Sreeram Penna
  28. 28. Tests for Instability <ul><li>Anterior Drawer Test: Ideally this test should be performed with the patient in supine. The affected shoulder is held at 80-120° of abduction, 0-20° of forward Flexion and 0-30° of external rotation. The examiner holds the patients scapula spine forward with his index and middle fingers; the thumb exerts counter pressure on the coracoid. The scapula is fixed. The examiner uses his right hand to grasp the patient's relaxed upper arm and draws it anteriorly with a force comparable to that used in a Lachmann's test. </li></ul><ul><li>Gerber-Ganz Posterior Drawer Test - same as anterior drawer except with posterior force. </li></ul>Sreeram Penna
  29. 29. Test for Instability <ul><li>Sulcus Test: The patient is examined in sitting or standing and the shoulder is in a neutral position. It is important that the shoulder muscles are relaxed and that stress is applied above the elbow. (This eliminates the effect of the biceps and triceps brachii). With the arm grasped inferior traction is applied. The examiner watches for dimpling of the skin below the acromion. Palpation reveals widening of the subacromial space between the acromion and the humeral head. </li></ul>Sreeram Penna
  30. 30. Tests for Long Head of Biceps <ul><li>Yergasons Test: The patient's elbow is flexed and their forearm pronated. The examiner holds their arm at the wrist. Patient actively supinates against resistance. </li></ul>Speeds Test: The patient's elbow is extended, forearm supinated and the humerus elevated to 60°. The examiner resists humeral forward flexion. Sreeram Penna
  31. 31. Tests for AC Joint <ul><li>Cross chest Adduction (Scarf / Forced Adduction Test) - the 90 degrees flexed arm on the affected side is forcibly adducted across the chest. </li></ul>AC Distraction (Bad cop) Test - place the arm in maximal internal rotation and apply slight pressure upward. A positive test is pain at the top of the shoulder. Sreeram Penna
  32. 32. Neck and Other Joints <ul><li>Neck for range of movements and distal neurology </li></ul><ul><li>Examine opposite shoulder </li></ul><ul><li>Examine other joints for laxity </li></ul>Sreeram Penna
  33. 33. X – rays Sreeram Penna
  34. 34. X – rays Sreeram Penna
  35. 35. X – rays Sreeram Penna
  36. 36. X – rays Sreeram Penna
  37. 37. X – rays Sreeram Penna
  38. 38. Sreeram Penna
  39. 39. X – rays Sreeram Penna
  40. 40. X - rays Sreeram Penna
  41. 41. Thank You