Shoulder OSCE

Question 1

Scapulothoracic Motion Testing ● Downward Rotation:

Answer 1

Turning on an anterior/posterior axis so that the scapula rotates in the frontal/coronal plane to tilt the glenoid fossa downward

Question 2

Scapulothoracic Motion Testing ● Upward Rotation:

Answer 2

Turning on an anterior/posterior axis so that the scapula rotates in the frontal/coronal plane to tilt the glenoid fossa upward

Question 3

Scapulothoracic Motion Testing ● Elevation:

Answer 3

Superior/Cephalad glide in vertical direction along the frontal/coronal plane o Upper Trapezius and Levator Scapula

Question 4

Scapulothoracic Motion Testing ● Forward Tilt:

Answer 4

Turning on a horizontal axis so that the posterior surface faces upward and the inferior angle protrudes posteriorly

Question 5

Scapulothoracic Motion Testing ● Backward Tilt:

Answer 5

Turning on a horizontal axis so that the posterior surface faces downward and the inferior angle is anterior

Question 6

Scapulothoracic Motion Testing ● Adduction (Retraction):

Answer 6

Scapula moves closer toward the spine o Rhomboids and Middle Trapezius

Question 7

Scapulothoracic Motion Testing ● Abduction (Protraction):

Answer 7

Scapula moves away from the spine, combined with lateral tilt around thorax o Serratus Anterior

Question 8

Scapulothoracic Motion Testing ● Depression:

Answer 8

Inferior/Caudal glide in vertical direction along the frontal/coronal plane o Lower Trapezius and Lower Rhomboids

Question 9

Muscle Energy Basics

Answer 9

• Physician positions the bone, joint, or muscle to be treated at the feather’s edge of the restrictive barrier (point of initial resistance) in all three planes of motion. • Instruct the patient to contract a specific muscle in a specific direction against the physician’s unyielding counterforce for 3 to 5 seconds. • Physician instructs the patient to relax, the patient stops contracting, simultaneously the physician also stops their counterforce • After sensing that the patient is not guarding and is completely relaxed (may take 1 to 2 seconds), the physician slowly repositions the patient to the feather’s edge of the new restrictive barrier. • Steps 1 to 4 are repeated until the best possible increase in motion is obtained. (usually requires three to seven repetitions, depending on the affected body region and tolerance of the patient) • Physician reevaluates the diagnostic parameters of the original dysfunction to determine the effectiveness of the technique.

Question 10

Glenohumeral Joint MET Treatment Flexion/Extension SD MET

Answer 10

1. Stabilize shoulder girdle with one hand, contact elbow with the other. 2. Engage restrictive barrier in flexion/extension based on diagnosis. 3. Apply principles and steps of MET to the motions of the GH joint. 4. Reassess.

Question 11

IR/ER SD MET

Answer 11

1. Stabilize shoulder girdle with one hand, contact wrist with the other. 2. Engage restrictive barrier in internal/external rotation based on diagnosis. 3. Apply principles and steps of MET to the motions of the GH joint. 4. Reassess.

Question 12

AB/ADduction SD MET

Answer 12

1. Stabilize shoulder girdle with one hand, contact elbow with the other. 2. Engage restrictive barrier in AB/ADduction based on diagnosis. 3. Apply principles and steps of MET to the motions of the GH joint. 4. Reassess.

Question 13

Spencer’s Technique

Answer 13

Series 7 stages of articulatory movement of the shoulder Patient: Lateral recumbent, involved shoulder up. Physician: Standing at side of table facing patient Dysfunctions are named for where they live and are restricted to the opposite motion

Question 14

Spencers Stage 1: Extension

Answer 14

1. Cephalad hand stabilizes shoulder girdle, caudal hand grasps patient’s flexed elbow. 2. Move shoulder into extension until restrictive barrier is engaged. With gentle but firm force, move a short distance through the restrictive barrier for 1-2 seconds and release. 3. Repeat rhythmically until no further progress in extension can be appreciated. 4. Reassess. MET Modification: Once restrictive barrier is engaged, have patient perform flexion against physician resistance and follow rules of MET

Question 15

Spencers Stage 2: Flexion

Answer 15

1. Cephalad hand stabilizes shoulder girdle, caudal hand grasps patient’s hand/wrist or elbow. 2. Move shoulder into flexion until restrictive barrier is engaged. With gentle but firm force, move a short distance through restrictive barrier for 1-2 seconds and release. 3. Repeat rhythmically until no further progress in flexion can be appreciated. 4. Reassess. MET Modification: Once restrictive barrier is engaged, have patient perform extension against physician resistance and follow principles of MET

Question 16

Spencers Stage 3: Compression Circumduction

Answer 16

1. Cephalad hand stabilizes shoulder girdle, caudal hand grasps flexed elbow. 2. Abduct patient’s shoulder to 90° and gently compress elbow toward glenoid fossa. 3. Make small clockwise circles, gradually increasing size of concentric circle for 15-30 sec. 4. Reverse direction of circle to counterclockwise and continue for 15-30 seconds. 5. Reassess.

Question 17

Spencers Stage 4: Traction Circumduction

Answer 17

1. Cephalad hand stabilizes shoulder girdle, caudal hand grasps patient’s wrist or elbow. 2. Abduct patient’s shoulder to 90° and add gentle traction toward ceiling. 3. Make small clockwise circles, gradually increasing size of concentric circle for 15-30 sec. 4. Reverse direction of circle to counterclockwise and continue for 15-30 seconds. 5. Reassess.

Question 18

Spencers Stage 5A: Adduction and ER

Answer 18

1. Cephalad hand stabilizes shoulder girdle, and have patient grasp physician’s forearm. 2. Slightly flex patient’s shoulder so arm may pass just in front of their body. 3. With caudal hand, adduct shoulder to restrictive barrier. With gentle but firm force, move a short distance through restrictive barrier for 1-2 seconds and release. 4. Repeat rhythmically until no further progress in adduction can be appreciated. 5. Reassess. MET Modification: Once restrictive barrier is engaged, have patient perform abduction against physician resistance and follow principles of MET

Question 19

Spencers Stage 5B: Abduction

Answer 19

1. Return to starting position used in stage 5A. 2. With caudal hand, abduct shoulder to restrictive barrier. With gentle but firm force, move a short distance through restrictive barrier for 1-2 seconds and release. 3. Repeat rhythmically until no further progress in abduction can be appreciated. 4. Reassess. MET Modification: Once restrictive barrier is engaged, have patient perform adduction against physician resistance and follow principles of MET

Question 20

Spencers Stage 6: Internal Rotation

Answer 20

1. Abduct patient’s shoulder 45°and internally rotate shoulder, placing dorsum of patient’s hand in the small of the back. 2. Reinforce anterior shoulder with cephalad hand. 3. With caudal hand gently pull elbow forward into internal rotation restrictive barrier. With gentle but firm force, move a short distance through restrictive barrier for 1-2 seconds and release. 4. Repeat rhythmically until no further progress in adduction can be appreciated. 5. Reassess. MET Modification: Once restrictive barrier is engaged, have patient perform external rotation against physician resistance and follow principles of MET

Question 21

Spencers Stage 7: Traction with Inferior Glide

Answer 21

1. Abducts the patient’s arm. The patient’s hand and wrist are placed on the physician’s shoulder that is closest to the patient. 2. With fingers interlaced, the physician’s hands are placed just distal to the glenohumeral joint. 3. Scoops the patient’s humeral head in a caudad direction, parallel to the table, creating a translatory motion toward the inferior edge of the glenoid fossa. 4. Repeat rhythmically until no further progress in shoulder abduction can be appreciated. 5. Reassess. MET Modification: While the physician maintains caudad traction on the patient’s arm, the patient’s hand is pressed down against the physician’s shoulder

Question 22

SC Joint Abduction & Adduction Diagnosis

Answer 22

1. Patient is supine; examiner places index finger on clavicular head next to the sternum. 2. Patient then shrugs (ABduction) 3. An inferior/caudal movement should be palpated with normal motion at the sternoclavicular joint. 4. Patient then lowers shoulders downward (ADduction). 5. A superior/cephalad movement should be palpated with normal motion at the sternoclavicular joint.

Question 23

SC Joint Flexion & Extension Diagnosis

Answer 23

1. Patient is supine; examiner places index finger on the clavicular head next to the sternum; patient flexes shoulder to 90° and reaches for ceiling forcefully (Flexion). 2. A posterior movement of the clavicular head should be palpated with normal motion at the sternoclavicular joint. 3. Patient then lowers arms back toward the table (Extension). 4. An anterior movement of the clavicular head should be palpated with normal motion of the sternoclavicular joint.

Question 24

Elevated/ADducted SD Articulatory Treatment

Answer 24

1. Patient lying supine with neck fully flexed by physician. 2. Physician places thumb over sternal end of the clavicle, exerting a downward/caudal pressure on the clavicle. 3. Patient instructed to inhale and exhale fully. During exhalation, the physician springs the clavicle inferiorly/caudally to release restriction.

Question 25

Elevated/ADducted SD MET

Answer 25

1. Patient lying supine, examiner on side of affected shoulder. 2. Physician places one hand on the sternal/proximal clavicular head. With the other hand, grasp the patient's wrist and hold arm extended and internally rotated. 3. Patient is instructed to raise arm against physician’s hand toward ceiling (flexion at the shoulder) for 3-5 seconds, then relax. 4. Bring joint into new barrier, repeating until no new barriers reached or full ROM restored.

Question 26

Horizontal Extension SD MET

Answer 26

1. Patient lying supine, examiner on side of affected shoulder 2. Physician places one hand on the restricted clavicular head and the other hand placed behind axilla to cover the scapula. Patient holds physician’s shoulder with the hand of the affected shoulder. 3. Physician then flexes the clavicle toward the manubrium until movement is palpated in the SC joint by pulling scapula anteriorly. 4. Posterior force simultaneously applied to proximal clavicle from anterior to posterior to engage restrictive barrier. 5. Apply the principles of MET by having patient pulling their shoulder down toward the table.

Question 27

Articulatory Technique Diagnosis: Clavicle Anterior and Superior Glide

Answer 27

1. Pt lying supine, physician on contralateral side to somatic dysfunction. 2. The pt helps to gap the SC joint by aDducting the arm ipsilateral to the SD (using their contralateral hand to aid in the motion). The physician’s ipsilateral hand may be placed on the table under the patient’s axilla to create a fulcrum for the patient to adduct against. 3. Articulatory springing is applied laterally, posteriorly, and inferiorly over medial end of clavicle using the physician’s hypothenar eminence of the contralateral arm. 4. Reassess.

Question 28

AC Joint General Exam

Answer 28

Inspect for asymmetry: • Look for shifted clavicle: Superior/Inferior, “Step-off” Palpate: • Clavicle on Acromion for “Step-off” (Clavicle Superior) • Tenderness & Tissue texture changes Motion Screen: Cross-arm adduction test • Positive = pain or increased TTA. Assess glides springing inferiorly on distal clavicle (compare bilaterally): • Resistant to springing inferiorly (Clavicle Superior) • Presence of springing inferiorly (Clavicle Inferior) • (Ant./Post.) – springing ant/post.

Question 29

Cross-Arm/Adduction Test

Answer 29

Physician monitors the posterior aspect of the AC joint. • Patient is instructed to start with the arm flexed to 90° and add adduction across the body. • This motion should gap the joint posteriorly. Positive Finding: patient perceives pain at the AC joint and/or there is increased tissue texture abnormality ● A tight posterior glenohumeral capsule may produce pain in the posterior aspect of the shoulder.

Question 30

AC Joint: IR/ER

Answer 30

1. Patient seated, physician stands behind patient. 2. One hand contacts and stabilizes the clavicular side of the joint with index finger over the AC joint noting if patient has tenderness. 3. Note asymmetry of joint gap compared to opposite side. 4. Flex, abduct (approximately 45°) to maximally engage the AC component of GH rotation. 5. IR and ER to assess for 90° of motion each direction. 6. Note restriction of motion and ease of motion. 7. Name dysfunction based on the direction of ease of motion (IR or ER).

Question 31

AC Joint: Articulatory Technique Dx AC- Clavicle Superior

Answer 31

1. Patient supine with doctor on ipsilateral side. 2. Doctor’s index fingerpad monitoring AC joint and other fingers on superior aspect of clavicle; the other hand grasps the patient’s forearm proximal to the wrist. 3. Apply a traction force in a caudad direction to gap the AC joint. 1. Use enough force to register a change with the monitoring hand 4. While maintaining the traction force maximally flex the arm. 5. Reassess.

Question 32

AC Joint – Direct – Seated ART Diagnosis: Right Clavicle superior glide

Answer 32

1. Grasp elbow or forearm of dysfunctional side. 2. Grasp dysfunctional clavicle between thumb and fingers of free hand. (Thumb on posterior/superior surface of distal clavicle, and NOT on scapula). 3. Apply anterior/inferior pressure with thumb on lateral (or posterior) aspect of clavicle while flexing patients elbow, extending and adducting humerus (to gap AC joint). 4. Doctor holds clavicle antero-inferior (with thumb). Shoulder is extended into a circulatory sweep, posterior, superior, then anteromedial while maintaining adduction and capsular tension 5. Recheck.

Question 33

Internal Rotation SD MET

Answer 33

1. Patient seated, physician stands behind patient. 2. Physician places hand on clavicle just medial to AC joint while grasping wrist with the other hand. 3. Add compressive force (blocking linkage) to stabilize clavicle/AC joint while flexing, abducting (approximately 45 ) & Externally Rotate to restrictive barrier. 4. Apply the principles of MET by having the patient Internally Rotate against physician’s resistance for 3-5 seconds. 5. Repeat 3-5 times or until motion is fully restored 6. Reassess.

Question 34

External Rotation SD MET

Answer 34

1. Patient seated, physician stands behind patient. 2. Physician places hand on clavicle just medial to AC joint while grasping wrist with the other hand. 3. Add compressive force (blocking linkage) to stabilize clavicle/AC joint while flexing, abducting (approximately 45 ) & Internally Rotate to restrictive barrier. 4. Apply the principles of MET by having the patient Externally Rotate against physician’s resistance for 3-5 seconds. 5. Repeat 3-5 times or until motion is fully restored. 6. Reassess.