Doing the basic aspects of a musculoskeletal examination is especially important in the shoulder: The key to performing a good shoulder examination is to develop a system in which the patient is prepped so you can (1) see the shoulders; (2) compare both sides; (3) do a neurovascular examination; and (4) consider the joint above, which in this case is the cervical spine. The long thoracic nerve (C5–C7) innervates the serratus anterior. 4.6B ) and internal rotation ( Fig. Range of motion is noted by degrees from a reference position; usually the anatomic position is used without scapular fixation unless otherwise specified. erythema that may indicate septic arthritis*), Swelling (suggesting potential joint effusion*), Especially the deltoid, supraspinatous, and infraspinatous. Shoulder pain leads many patients to see a primary care physician. In Rockwood CA, Matsen FA (eds). This method of measurement can be reproducible for one individual, but the relationship of the thumb tip to various vertebral levels has not been shown to be accurate or reproducible. The final position presents a challenge to the muscles in the position of most common function at 90 degrees of shoulder elevation …. Observing the shoulder girdle from the back of the patient during arm flexion and abduction may reveal altered movement of the scapula secondary to muscle weakness or imbalances in flexibilities. The long head of the biceps is anterior, between the lesser and greater humeral tuberosities, and is difficult to palpate because of the large deltoid muscle. The lift-off test is performed by having the patient lift the hand off the lower back as shown, The bear hug test is performed by having the patient place the hand of the affected shoulder on the opposite shoulder. Internal rotation of the shoulder can be performed by asking the patient to place the arms up the back with the thumbs up ( Fig. 4.21 ) described by Kibler and McMullen in 2003. By visiting this site you agree to the foregoing terms and conditions. There has been no independent verification of this study, and its clinical usefulness has not been adequately studied. They found the drop arm test to have a 100% PPV (ie, if present, the patient has a tear) and 10% sensitivity (ie, if negative, the patient could still have a tear). The distances once again are calculated on both sides. The examiner abducts the arm at 90 degrees of abduction and neutral rotation. Elimination or modification of the impingement symptoms indicates that these muscles should be a major focus in rehabilitation. They originate from the ligamentum nuchae and spinous processes from C7 to T5 and insert onto the medial border of the scapula from the scapular spine to the inferior angle. In the second position, the new position of the inferomedial border of the scapula is marked, and the reference point on the spine is maintained. 1 Introduction2 Inspection3 Palpate4 Movement5 Special Tests6 Complete the Examination Introduction Introduce yourself to the patient Wash your hands Briefly explain to the patient what the examination involves Ask the patient to remove their top clothing, exposing the shoulders fully Offer the patient a chaperone, as necessary Always start with inspection and proceed as below […] In a positive test result, the patient will experience pain from approximately 70 to 120 degrees, and pain will diminish after that level of elevation. The AC joint is examined using the ‘cross body’ or ‘scarf’ test. The examiner then asks the patient to try to keep the hand on the shoulder while the examiner attempts to pull it off the opposite shoulder. 4.12 ). 4.6C ) at this elevation typically include not only motion of the ST articulation but also the glenohumeral joint. A positive test result is when the patient cannot lift the hand off of the back. They noted the supraspinatus was sufficiently activated in both positions ( Figs. The Apley scratch test is a measure of several joint ranges of motion and not just the shoulder. SHOULDER EXAMINATION Introduction Shoulder disorders are can be broadly classified into the following types: 1. The many possibilities are owed to the anatomy involved in allowing your shoul… I think that the most daunting aspect of the shoulder exam is appreciating the functional anatomy of this incredibly mobile joint. The shoulder is then externally rotated with thumb pointing toward the roof. Naredo and coworkers reported a test described by Patte in 1995 for assessing tears of the infraspinatus and teres minor (see Fig. Jobe described the empty can test—also known as the supraspinatus test—to help in evaluating the strength of the supraspinatus muscle ( Fig. Background: High frequency ultrasonography is an accurate non-invasive imaging technique for evaluating patients with painful shoulder. Inspection; Palpation of sternoclavicular joint, clavicle, acromioclavicular joint, subacromial bursa, bicipital tendon. The reference point on the spine is the nearest spinous process, which is then marked with an X . Acromioclavicular Joint Examination. Elements of the shoulder exam. The shoulder is the most flexible joint in your body, and given the number of everyday activities it's involved infrom brushing your hair to reaching up into the cupboardit's easy to see why shoulder pain is something you'd want to get to the bottom of right away. 4.15 ). *As the shoulder is a deep structure, both skin changes from erythema and joint swelling from effusions are not always apparent. Calis and associates noted the Speed’s test to have a sensitivity of 68.5% and a specificity of 55.5%. Kibler defined 1.5 cm of asymmetry as positive for ST motion abnormality. Tests of Rotator Cuff Strength and Integrity. The superior glenohumeral ligament (SGHL) is the primary restraint to inferior translation. 4.7 ). A test result is considered positive when the patient cannot keep the hand on the shoulder and it pulls away. The hand of the affected arm is placed on the back at the midlumbar region, and the patient is asked to rotate the arm internally and lift the hand posteriorly off the back. Posture should be observed in both the seated and standing positions and from different angles. In 1934, in his classic book The Shoulder, Codman1 was the first to specifically address conditions that affect the shoulder joint. Examination of shoulder joint 1. Although measurement of scapular position and movement had become very popular, these concepts have undergone increasing scrutiny. The subscapularis is innervated by the nerve to the subscapularis (upper and lower), composed of the cervical 5, 6, and 7 roots. Several studies have shown that Speed’s test does not actually help the clinician in making the diagnosis of biceps tendon disorders. As noted, previous electromyographic data have failed to differentiate the function of the infraspinatus and teres minor. With the arm in lesser degrees of abduction, the middle glenohumeral ligament restricts external rotation. The cervical spine and trapezius should be palpated if the patient has neck pain. The major originates from the medial portion of the clavicle, sternum, and second to sixth ribs and inserts onto the humeral lateral lip of the intertubercular groove. The drop arm test has been used to assess for rotator cuff tears, particularly of the supraspinatus. The middle layer comprises the teres major, pectoralis major, the latissimus dorsi, and the short fibers of the anterior and posterior deltoid. The sensitivities and specificities of this test for pathologic conditions were low regardless of the position measured. The scapular retraction test was described by Kibler and associates to distinguish a scapular cause of weakness of the supraspinatus. The examiner pushes down, and a positive test result is pain or weakness. The examiner stabilizes the scapula and elevates the arm. Have the patient flex the shoulder (elevate it anteriorly) against resistance while the elbow is extended and the forearm supinated. These positions offer a graded challenge to the functioning of the shoulder muscles to stabilize the scapula. Electromyographic studies have shown that the Jobe test can test the supraspinatus and deltoid equally to the empty can test. Scars, atrophy, swelling, ecchymosis, erythema, rashes, deformities, shoulder heights, and scapular positioning should be evaluated. The patient is asked to put hands on the head with palms down and to contract the biceps muscle. A number of physical examination maneuvers have been developed to assist examiners in diagnosing shoulder problems. By externally rotating the arm and flexing and extending the elbow, the examiner may be able to feel the tendon moving in the anterior shoulder. For men, this is accomplished by taking off the shirt, and for women a sports bra or a gown worn around the thorax can suffice ( Fig. The scapular assistance test is designed to determine if stabilizing the scapula improves shoulder pain. The sternoclavicular joint—a saddle type of joint … As… Prime movers about the shoulder girdle shown on magnetic resonance imaging (. The patient is asked not to let the arm or forearm fall to the buttocks; a test result is considered positive if the arm falls to the buttocks or toward the floor ( Fig. The, Yergason’s test is performed by the examiner resisting forearm supination by the patient with the elbow bent. Burkhart and others evaluated Speed’s test for labral pathology. Reproduced with permission from Moore KL. It originates from the lateral portions of the first eight ribs and inserts onto the anterior surface of the medial border of the scapula. Electromyographic study has shown that, in this position, the downward force is resisted by the deltoid and the supraspinatus muscles, so this test does not isolate the supraspinatus. Passive motion testing can then be performed to isolate motions for accurate evaluation. Shoulder pain, injuries, and stiffness are the third most common muscle and joint issue that bring people to the doctor. The tests are described below in detail, but the relationships between these findings and the pathophysiology of the clinical findings is being questioned. One study found that only 5% of patients with superior labral tears have a click, but 5% of a control group also had a click. The deltoid originates from the lateral third of the clavicle and scapular spine and includes the AC joint; it inserts onto the deltoid tuberosity of the humerus. Also, in most patients with a torn biceps tendon, a bulge is seen simply by asking the patient to contract the biceps muscle with the arm at the side. Jobe’s and Patte’s manoeuvres can produce three types of response: (a) absence of pain, indicating that the tested tendon is normal; (b) the ability to resist despite pain, denoting tendinitis; or (c) the inability to resist with gradual lowering of the arm or forearm, indicating tendon rupture. The planes of shoulder girdle motion include forward flexion, extension, internal/external rotation, abduction/adduction, and a combination called circumduction . The examiner abducts the patient’s shoulder to 90 degrees and then asks the patient to slowly lower the arm to the side in the same arc of movement. The teres minor is best tested with the arm abducted 90 degrees and externally rotated 90 degrees ( Fig. Introduce yourself to the patient including your name and role. The same protocol is done for the third position. The examiner supports the patient’s elbow in 90 degrees of forward elevation in the plane of the scapula while the patient is asked to rotate the arm laterally to compare the strength of lateral rotation. For example, Kibler and associates proposed that there were four patterns of scapular dyskinesia. Our Beverly Hills medical office performs shoulder joint examination to identify the cause of shoulder pain or limited joint movement. 4.2 ). Found an error? There are no reported studies assessing the sensitivity, specificity, PPV, or NPV of this maneuver. Methods: Thirty one consecutive patients with a first flare of shoulder pain were … Here, the patient’s hand is taken across their chest (horizontal adduction) and placed on top of their other shoulder. Jobe originally described the test as follows: The supraspinatus test is first performed by assessing the deltoid with the arm at 90 degrees of abduction and neutral rotation. 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