Shoulder Complex Evaluation

Question 1

Red flags for shoulder complex in the history

Answer 1

• no incident or accident
• glove like numbness
• are the symptoms constant/unrelenting
• radiating symptoms across multiple dermatomes
• sudden onset of severe pain
• interrupting sleep/worse at night
• symptoms are constant

Question 2

Patient history that would make you think impingement

Answer 2

• Stage 1: intermittent mild pain with overhead activities
• Stage 2: mild to moderate pain with overhead activities
• Stage 3: pain at rest or activities, night pain, & weakness

Question 3

Patient history that would make you think rotator cuff tear (RCT)

Answer 3

• night pain
• weakness in abduction & external rotation
• loss of AROM

Question 4

Patient history that would make you think frozen shoulder

Answer 4

• inability to perform ADLs due to loss of motion

Question 5

Patient history that would make you think instability

Answer 5

• apprehension with abduction & external rotation
• popping

Question 6

Patient history that would make you think labral tear

Answer 6

• clonking with overhead motion

Question 7

Patient history that would make you think AC separation or arthritis

Answer 7

• localized pain
• swelling/deformity over AC joint

Question 8

Patient history that would make you think cervical spine

Answer 8

• pain/numbness below elbow in dermatomal distribution

Question 9

Self assessments for shoulder injuries

Answer 9

• DASH (disabilities of the arm, shoulder, and hand)
• Oxford shoulder score (catches the more active patient)

Question 10

What might you see in a scapular assessment

Answer 10

• bilateral with 1-3 lb weights to bring out impairments better
• Normal
• Subtle dyskinesia
• Obvious dyskinesia
• look for winging, hitching (on the way up one scapula stops & quickly catches up), & dumping (on the way down one scapula stops & quickly catches up)

Question 11

Describe scapular reposition test (McClure)

Answer 11

• manually reposition scapula with elevation
• look for decreased pain, improved motion, or improved strength

Question 12

Describe scapular assist test

Answer 12

• assist with upward rotation through facilitation of lower trapezius (try to cue lower trap)

Question 13

Describe scapular flip test

Answer 13

• resist glenohumeral external rotation while feeling for medial scapular border to wing

Question 14

Describe scapulohumeral rhythm

Answer 14

• 0-30 degrees elevation is GH motion
• 30-90 degrees elevation 2:1 ratio of GH movement (60 degrees & snap protraction and 30 degrees external rotation)
• 90-170 degrees elevation is a 1:1 ratio
• 170-180 degrees is TS extension

Question 15

Common painful ranges

Answer 15

• pain & limited between 70-110 degrees scaption: rotator cuff impingement, RCT, subacromial bursitis
• painful arc between 70-110 degrees scaption with full ROM: subacromial bursitis, impingement

Question 16

General guidelines for resisted movements

Answer 16

• IR is stronger than ER 3:2 ratio
• adduction is stronger than abduction 2:1 ratio
• extension is stronger than flexion 5:4 ratio
• increasing weakness with reps = cervical nerve injury
• consistent weakness with reps = muscular

Question 17

Peripheral nerve tests

Answer 17

• Spinal accessory nerve (SCM & upper traps): inability to abduct arm greater than 90 degrees
• Musculocutaneous nerve (biceps, brachialis, & coracobrachialis): weak elbow flexion with forearm supination
• Long thoracic nerve (serratus anterior): inability to flex fully extended arm (scapular winging)
• Suprascapular nerve (supraspinatus & infraspinatus): pain with shoulder flexion and/or abduction
• Axillary nerve (teres minor & deltoid): inability to abduct arm

Question 18

Open pack & closed pack position for shoulder joint mobilizations

Answer 18

• Open pack: 55 degrees abduction with 30 degrees horizontal ABD & slight ER (scaption plane)
• Closed pack: max abduction & ER

Question 19

What is the capsular pattern of the shoulder

Answer 19

• more ER than ABD and more ABD than IR
• ER > ABD > IR

Question 20

What motions do the different glenohumeral joint mobilizations improve

Answer 20

• Lateral distraction: all motions
• Inferior glide: abduction
• Anterior glide: ER and horizontal abduction
• Posterior glide: flexion and horizontal adduction

Question 21

What motions do the the different SC joint (sternoclavicular) mobilizations improve

Answer 21

• Posterior glide: retraction
• Anterior glide: protraction
• Inferior glide: elevation
• Superior glide: depression

Question 22

History for instability

Answer 22

• multiple recurrent subluxations
• injury to the shoulder
• dislocation
• sensation of something slipping/unstable or anxiety in certain positions

Question 23

Special tests for instability

Answer 23

• Sulcus sign
• Palpation of subacromial space
• Load and shift
• Apprehension/Relocation/Release

Question 24

History for labral tear

Answer 24

• FOOSH
• brace oneself with an outstretched arm in MVA
• lifting heavy objects repeatedly
• overhead activities

Question 25

Symptoms of a labral tear

Answer 25

- popping, clicking, or catching in the shoulder - pain when you move your arm over your head or throw a ball - a feeling of weakness or instability in the shoulder - aching pain of vague location

Question 26

Special tests for labral tear

Answer 26

- Anterior slide test - Crank test - Compression rotation test - Active compression test - Bicep load test - Kim test

Question 27

History & symptoms for subacromial impingement

Answer 27

- overhead activities - difficulty reaching up behind the back - pain with overhead use of the arm - weakness of shoulder muscles

Question 28

Test item cluster for subacromial impingement

Answer 28

- Hawkins and Kennedy impingement sign - Painful arc sign - Infraspinatus muscle test

Question 29

History and symptoms for rotator cuff pathology

Answer 29

- age >40 - overhead sports - overhead occupations - dull ache deep in the shoulder - disturb sleep, particularly win lay on affected side - painful to reach behind back - weakness

Question 30

Test item cluster for full thickness RCT (rotator cuff tear)

Answer 30

- Drop arm test - Painful arc sign - Infraspinatus muscle test

Question 31

Special tests for supraspinatus tear

Answer 31

- Drop arm test - Drop sign - Full can - Empty can - Scapular retraction test - ER lag sign - Subacromial grind test

Question 32

Special test for infraspinatus tear

Answer 32

- Dropping sign

Question 33

Special test for teres minor tear

Answer 33

- passively place patient in 90 degrees scaption and have them ER against resistance - Hornblowers

Question 34

Special tests for subscapularis tear

Answer 34

- IR lag sign - Napoleon test

Question 35

History for AC joint separation

Answer 35

- FOOSH - cradling arm decreases pain - pain directly over AC joint - horizontal adduction painful - positive active compression test

Question 36

3 types of AC joint separation

Answer 36

- Type I: AC ligament disruption but coracoclavicular ligaments intact - Type II: AC joint ligaments torn and coraocclavicular ligaments disrupted - Type III: all ligaments torn and complete AC joint separation

Question 37

History for adhesive capsulitis (AKA frozen shoulder)

Answer 37

- gradual onset of loss of ROM in a capsular pattern (ER>ABD>IR) - may be accompanied with a history of shoulder pain however generally idiopathic - pain with movement - pain when sleeping on involved side - difficulty with ADLs - Freezing, Frozen, and Thawing (18 months to 2 years for natural progression to self resolve)