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1. SHOULDER PHYSCICAL EXAMINATION
& SURGICAL APPROACH

2. PHYSICAL EXAMINATION
• LOOK
• FEEL
• MOVE
• Special Test :
• Rotator cuff disease & impingement
• Instability & Laxity
• Biceps tendon & SLAP
• AC & SC joint

3. LOOK
• Anterior side
• Posterior
side
• Lateral
• Overhead
• Axillary

4. LOOK
• Anterior Side
– Deltoid
– Atrophy  Axillary Nerve
Palsy
– Loss of deltoid contour 
Dislocation
– Bony Prominent

5. LOOK
• Sub Acromial region
– Swelling bursitis
• Biceps tendon
– Proximal Rupture  Popeye bulge
– Distal Rupture  Hook Test/Sign
HOOK
SIGN/TEST
POPEYE BULGE

6. LOOK
• Posterior side
•Scapula
– Position  High 
Sprengel’s Shoulder
– Spine
– Fossae 
supraspinatus &
infraspinatus atrophy

7. LOOK
•Borders of scapula
–lateral; prominent in
Latisimus dorsi atrophy
– superior; prominent
in supraspinatus &
trapezius atrophy
– Vertebral; prominent
in serratus ant
weakness/winging

8. FEEL
• Tenderness
• Swelling
• Palpable gap
in muscles
Acromioclavic
ular joint
Coracoid
process
Subacromial

9. FEEL
Muscle Pain Referral Patterns

10. MOVE
Forward Flexion
0 – 160/180
Extension
0 – 45
External Rotation
(Adduction)
0 – 60
Internal Rotation
(Adduction)
0 – 70
Abduction
0 – 180
Adduction
0 – 20/40
External Rotation
(Abduction) 0 – 90
External Rotation
(Abduction) 0 – 70

11. MOVE
• Muscle Strength Test
Pectorali
s major
Latissimu
s Dorsi
Deltoid

12. MOVE
Trapeziu
s
Serratu
s
Rhomboid
s
• Muscle Strength Test

14. INSTABILITY
• Sulcus sign
• Anterior and posterior draw
• Anterior apprehension test
• Relocation test

15. SULCUS TEST
Detect inferior instability of the gleno-
humeral joint
“+” if dimpling of the skin below the
acromion or widening of the subacromial
space on palpation; >2cm translation

16. Anterior and Posterior Drawer
• Detect anterior and posterior instability
of the gleno-humeral joint
• Observe any movement, clicks and
patient apprehension.
• + if pain or apprehension by the client to
assume this position for fear of shoulder
dislocation

17. APPREHENSION TEST
• Detect instability of the gleno-humeral
joint
• Shoulder abducted to 90°, Slight stress to
humeral head directed in anterior
direction while externally rotating
shoulder
• + if pain or apprehension by the client to
assume this position for fear of shoulder
dislocation

18. RELOCATION TEST
• Detect Anterior instability
• After a positive apprehension Apply
posteriorly directed force over
externally rotated humeral head
• Positive test is relief of
apprehension

19. IMPINGEMENT
• Neer’s Test
• Hawkin’s Test
• Jobes Test

20. NEER’S TEST
• Test for impingement
• Passively take UE into full shoulder flexion
with humerus in Internal Rotation
• “+” if Pain located to the subacromial space
or anterior edge of acromion
• pain may be indicative of impingement of the
supraspinatus or long head of the biceps

21. HAWKINS/KENNEDY TEST
• Test for impingement
• place shoulder in 90° of flexion, slight
horizontal adduction, & maximal IR
• “+” if Pain located to the subacromial
space or anterior edge of acromion
• + test = shoulder pain due to
impingement of supraspinatus
between greater tuberosity against
coracoacromial arch

22. JOBES TEST
• Test supraspinatus muscle
• Elevate Upper Extrimity 30°–45° in
plane of the scapula with Internal
Rotation, resist elevation
• + test = reproduction of pain &/or
• weakness

23. ROTATOR CUFF
• External rotation lag sign (ERLS)
• Hornblowers sign
• Internal rotation lag sign (IRLS)
• Belly Press Test
• Bear Hug Test

24. External Rotation Lag Sign (ERLS)
• Test for infraspinatus tear.
• The clinician grasps the patient’s wrist and then
places the elbow at 90 degrees of flexion and the
shoulder at 20 degrees of elevation in the scapular
plane. Passively externally rotates the shoulder and,
at the end range, asks the patient to maintain this
position as the patient’s wrist is released
• A positive test, which is indicated by lag that occurs
with the inability of the patient to maintain his or her
arm near full External Rotation

25. HORNBLOWERS SIGN
• Test teres minor muscle
• Shoulder in 90° abd & elbow flexed so that the
hand comes to the mouth (blowing a horn)
• + test = reproduction of pain &/or inability to
maintain Upper Extrimity in External Rotation

26. Internal Rotation Lag Sign (IRLS)
• Test for Subscapularis tear
• clinician grasps the patient’s shoulder with one
hand and the wrist with the other and then lifts
the patient’s arm off the back. The clinician then
asks the patient to maintain this position as the
wrist is released.
• A positive test, which is manifested with an
inability of the patient to maintain his or her arm
off of the back

27. BELLY PRESS TEST
• Test subscapularis muscle
• Press the hand into belly
• A positive test, which results in the elbow
dropping behind the body into extension,
indicates a subscapularis tear

28. BEAR HUG TEST
• Test subscapularis tear
• The patient place the hand of the involved arm on the
contralateral acromioclavicular joint with the hand flat
and fingers extended. The elbow of the involved arm
should be positioned anterior to the body at the same
height as the shoulders. The patient is asked to maintain
that position while the examiner applies an ER force to
the forear
• A positive test is weakness or inability to maintain that
position

29. BISCEPS
• Speed’s test
• Yergason’s test

30. SPEED’S TEST
• Assess for biceps tendonitis or labrum
problem
• Resist elevation
• + test = pain with biceps tendonitis & sense of
instability with labral px

31. YERGASON’S TEST
• Assess for Bisceps Tendon
• The patient sits or stands, and the upper arm
is positioned with the elbow at 90 degrees of
flexion and the forearm pronated. The patient
is asked to supinate his or her forearm against
the manual resistance of the clinician.
• + test = pain over the bicipital groove

32. SLAP (Superior Labrum Anterior to Posterior)
Lession
• O’Briens Test
• Pain Provocation test
• Crank Test
• Jerk Test
• Kim Test

33. O’BRIENS TEST
• Assess Assess for labrum or AC joint problem
• Resist elevation in Internal Rotation then
repeat in External Rotation
• + test = pain in IR > ER; pain “inside” shoulder
is labrum & pain “on top” of shoulder is AC

34. PAIN PROVOCATION TEST
• Assess Assess for labrum
• Traction the biceps by passively taking the forearm
into maximal pronation
• + test = biceps will tug on labrum & reproduces the
pain in the superior region of the joint line (superior
labrum)

35. CRANK TEST
• Assess Assess for labrum
• Their arm is elevated to 160 degrees in the scapular
plane of the body and is positioned in maximal
internal or ER. The clinician then applies an axial load
along the humerus.
• A positive test is indicated by the reproduction of a
painful click in the shoulder during the maneuver.

36. JERK TEST
• Detect a posteroinferior labral lesion
• The clinician grasps the patient’s elbow with one
hand and the scapula with the other, and then
positions the patient’s arm at 90 degrees of
abduction and IR. The clinician then provides an axial
compression-based load to the humerus through the
elbow while maintaining the horizontally abducted
arm.
• A positive test is indicated by sharp shoulder pain
with or without a clunk or click

37. KIM TEST
• Detect a posteroinferior labral lesion
• The clinician grasps the elbow with one hand and the
midhumeral region with the other hand, and then
elevates the patient’s arm to 90 degrees of
abduction. Simultaneously, the clinician provides an
axial load to the humerus and a 45-degree diagonal
elevation to the distal humerus concurrent with a
posteroinferior glide to the proximal humerus.
• A positive test is indicated by a sudden onset of
posterior shoulder pain.

38. AC JOINT
• Ac Shear Test
• Coracoclavicular Ligament Test
• Cross-body Adduction Test

39. AC SHEAR TEST
• Assess for AC sprain
• Clinician interlaces fingers & surrounds the AC joint;
squeezing the hands together compresses the AC
joint
• + test = pain or excessive move is indicative of
damage to the AC ligaments

40. CORACOCLAVICULAR LIGAMENT TEST
• Assess CC ligament
• Place affected Upper Extrimity behind back, palpate
CC ligament while stabilizing clavicle; pulling inferior
angle of scapula away from ribs to stress the conoid
portion; pulling medial border of scapula away from
the ribs stresses the trapezoid portion
• + test = pain

41. CROSS-BODY ADDUCTION
• Assess AC ligament
• Shoulder flexed to 90°, horizontally
• + test = pain @ AC joint

42. SHOULDER
SURGICAL APPROACH

43. • The anterior surgical approach offers good wide
exposure of the shoulder joint, allowing repairs to be
made of its anterior, inferior, and superior coverings.
• anterior approach permits the following :
– Reconstruction of recurrent dislocations
– Drainage of sepsis
– Biopsy and excision of tumors
– Repair or stabilization of the tendon of the long head of the biceps
– Shoulder arthroplasties, which usually are inserted through modified
anterior incisions
– Fixation of fractures of the proximal humerus
Anterior Approach

44. Positioning
sandbag
• Reduce venous pressure
 decrease bleeding
• Allow the blood to drain
away from the operative
field during surgery

45. LANDMARKS AND INCISION
Two Skin Incision:
• Anterior Incision
• Axillary Incision
Anterior Incision AxiIlary incision Retract the axillary incision cephalad
to expose the cephalic vein and the
deltopectoral groove.

46. Superficial Surgical Dissection
Find the deltopectoral groove, with its cephalic vein.
Retract the pectoralis major medially and the deltoid laterally,
splitting the two muscles apart

47. DEEP DISECTION

48. DEEP DISECTION

49. DANGER
Nerves
• musculocutaneous nerve
– Enters the body of the coracobrachialis to
the muscle's origin at the coracoid process.
– nerve enters the muscle from its medial
side, all dissection must remain on the
lateral side
– Do not to retract the muscle inferiorly, to
avoid stretching the nerve and causing
paralysis of the elbow flexors
Vessel
• cephalic vein
– The cephalic vein should be preserved
– traumatized cephalic vein should be ligated
to prevent the slight danger of
thromboembolism

50. Lateral Approach
• The lateral approach provides limited access to
the head and surgical neck of the humerus.
• The uses of the lateral approach include the
following:
– Open reduction and internal fixation of displaced fractures of
the greater tuberosity of the humerus
– Open reduction and internal fixation of humeral neck fractures
– Removal of calcific deposits from the subacromial bursa
– Repair of the supraspinatus tendon
– Repair of the rotator cuff

51. POSITIONING
Position of the patient on the operating table for the
lateral approach to the shoulder. Elevate the table 45°.
Place a
SANDBAG

52. LANDMARK AND INCISION
LANDMARK
The acromion is rectangular. Its bony dorsum and lateral border
are easy to palpate on the outer aspect of the shoulder.
INCISION
Make a 5-cm longitudinal incision from the tip of the acromion
down the lateral aspect of the arm

53. • Superficial Surgical Dissection
Split the deltoid muscle in the line of its fibers from the
acromion downward for 5 cm. Insert a suture at the
inferior apex of the split to help prevent it from
extending accidentally, with consequent axillary nerve
damage, as the exposure is worked on

54. • Deep Surgical Dissection

55. DANGER
Nerves
• The axillary nerve leaves the posterior
wall of the axilla by penetrating the
quadrangular space. Then it winds
around the humerus with the posterior
circumflex humeral arteries

56. Posterior Approach
• The posterior approach offers access to the posterior and
inferior aspects of the shoulder joinIt rarely is needed, but
can be used in the following instances :
– Repairs in cases of recurrent posterior dislocation or subluxation of the shoulder
– Glenoid osteotomy
– Biopsy and excision of tumors
– Removal of loose bodies in the posterior recess of the shoulder
– Drainage of sepsis (the approach allows dependent drainage with the patient in the normal
position in bed)
– Treatment of fractures of the scapula neck, particularly those in association with fractured
clavicles (floating shoulder)
– Treatment of posterior fracture dislocations of the proximal humerus

57. POSITIONING
Place the patient in a lateral position on the edge of
the operating table with the affected side uppermost.
Drape him or her to allow independent movement of
the arm. Stand behind the patient and take care that
the ear is not folded accidentally under the head

58. LANDMARK AND INCISION
Landmarks
The acromion and the spine of the scapula form one
continuous arch. The spine of the scapula extends
obliquely across the upper four fifths of the dorsum of
the scapula and ends in a flat, smooth triangle at the
medial border of the scapula. It is easy to palpate.
Incision
Make a linear incision along the entire length of the
scapular spine, extending to the posterior corner of the
acromion

61. DANGER
Nerves
• The axillary nerve runs through the
quadrangular space beneath the teres
minor.
• The suprascapular nerve passes
around the base of the spine of the
scapula as it runs from the
supraspinous fossa to the infraspinous
fossa.
Vessel
• The posterior circumflex humeral
artery runs with the axillary nerve in
the quadrangular space beneath the
inferior border of the teres minor
muscle. Damage to this artery leads to
hemorrhaging that is difficult to
control. This danger can be avoided by
staying in the correct intermuscular
plane

62. (Syukron Jazakalloh
Khoir)
HATUR
NUHUN