SHOULDER

• What is the patient’s age?

• Many problems of the shoulder can be age-related. For example, rotator cuff
degeneration usually occurs in patients who are between 40 and 60 years of age.
• Rotator cuff tears, though, can occur at any age 19 suggested that external
rotation weakness, night pain, and age over 65 are indicative of rotator cuff tears.
• Primary impingement due to degeneration and weakness is usually seen in
patients older than 35, whereas secondary impingement due to instability caused
by weakness in the scapular or humeral control muscles is more common in
people in their late teens or twenties, especially those involved in vigorous
overhead activities, such as swimmers or pitchers in baseball.
• Calcium deposits may occur between the ages of 20 and 40.
• Does the patient support the upper limb in a protected position or hesitate to move it?
• If there was an injury, what exactly was the mechanism of injury?
• Did the patient injure themself with a fall on out-stretched hand (FOOSH), which could
indicate a fracture or dislocation of the glenohumeral joint?
• Did the patient fall on or receive a blow to the tip of the shoulder, or did the patient
land on the elbow, driving the humerus up against the acromion?
• This finding may indicate an acromioclavicular dislocation or subluxation. Does the
shoulder feel unstable or feel like it is “coming out” during movement? Does the arm
“go dead” when doing activity? “Going dead” implies the patient cannot use the arm
functionally because of pain and a subjective feeling of unease when using the arm.
• Patients with instability may appear normal on clinical examination, especially if
shoulder muscles are not fatigued. Many overuse injuries are more evident
• Are there any movements or positions that cause the patient pain or symptoms? If so,
which ones?
• The examiner must keep in mind that cervical spine movements may cause pain in the
shoulder. Persons who have had recurrent dislocations/instability of the shoulder may
find that any movement involving lateral rotation bothers them, because this
movement is involved in anterior dislocations of the shoulder.
• Questions related to instability should include:
• a. How many episodes have there been in the last year?
• b. Was there an injury that precipitated this?
• c. What direction does the shoulder “go out” most times?
• d. Have you ever needed help getting the shoulder back into proper position within
the joint?
Causes of Shoulder Primary and Secondary
Impingement Syndrome

•Abnormal glenohumeral arthrokinematics (secondary)

• Abnormal scapulothoracic arthrokinematics (secondary)
• “Slouched” (chin poking) posture (secondary)
• Muscle weakness or fatigue (secondary)
• Muscle hypomobility (secondary)
• Capsule tightness especially posterior (secondary)
• Inflammation in subacromial space (primary)
• Rotator cuff tendon degeneration (primary)
• Adhesions especially inferiorly (secondary)
• Osteophytes under acromioclavicular joint (primary)
• Hooked acromion (primary)
• Glenohumeral joint hypermobility (primary)
• What is the extent and behavior of the patient’s pain? For example,
deep, boring, toothache-like pain in the neck, shoulder region, or both
may indicate thoracic outlet syndrome
• Are there any activities that cause or increase the pain? For example,
bicipital paratenonitis or tendinosis are often seen in skiers and may
result from holding on to a ski tow; in cross-country skiing, it may result
from poling (using the pole for propulsion).
• Paratenonitis is inflammation of the paratenon of the tendon. The
paratenon is the outer covering of the tendon whether or not it is lined
with synovium. Tendinosis is actual degeneration of the tendon itself.
With chronic overuse, tendinosis is more likely than paratenonitis
• Do any positions relieve the pain?
• Patients with nerve root pain may find that elevating the arm over the
head relieves symptoms. For a patient with instability or inflammatory
conditions, lifting the arm over the head usually exacerbates shoulder
problems.
• What is the patient unable to do functionally? Is the patient able to
talk or swallow? Is the patient hoarse?
• These signs could indicate an injury to the sternoclavicular joint (if there is swelling) or a posterior
dislocation of the joint because pressure is being applied to the trachea. In addition, determining whether
the shoulder has been overstressed or overused is important. For example, in swimmers and baseball
pitchers, it is important to determine
• a. The age when the patient first began the activity
• b. The total years throwing/swimming
• c. The number of pitches thrown per outing
• d. The number of games/innings pitched per year
• e. The distances swam per week
• f. The strokes used/types of pitches thrown
• g. The amount of rest between outings
• h. Whether there was any complete rest from activity during year
• i. Whether there was any previous injury related to the activity
• j. The phase of activity that produces the symptoms
• How long has the problem bothered the patient?
• For example, an idiopathic frozen shoulder goes through three stages: the
condition becomes progressively worse, plateaus, and then progressively
improves, with each stage lasting 3 to 5 months
• Is there any indication of muscle spasm, deformity, bruising, wasting,
paresthesia, or numbness?
• These findings can help the examiner determine the acuteness of the
condition and, potentially, the structures injured.
• Does the patient complain of weakness and heaviness in the limb after
activity?
• Is there any indication of nerve injury?
OBSERVATION
• As part of the observation, noting whether the patient can assume a “neutral pelvis” position
is important, because an abnormal pelvic position can lead to an abnormal scapulothoracic,
glenohumeral, and cervical spine position and abnormal kinematics in these joints.
• In addition, kinematics plays a role in how much force can be generated by the lower quadrant
that contributes to an activity.
• For example, about 50% of the force of throwing is normally generated by the lower quadrant.
Three questions must be asked by the examiner related to the “neutral pelvic” position:
• 1. Can the patient get into the “neutral pelvis” position?
• 2. Can the patient hold the static “neutral pelvis” position while doing distal dynamic
movement (e.g., shoulder movements)?
• 3. Can the patient control a dynamic “neutral pelvis” while doing dynamic shoulder
movements? If the answer to any of the questions is negative, the examiner has to consider
including the pelvis in the treatment plan for the shoulder.
• Anterior View
• Posterior View
• Causes of Scapular Dyskinesia
• BONY • Thoracic kyphosis • Clavicular fracture nonunion • Clavicular fracture
malunion
• JOINT • Acromioclavicular instability • Acromioclavicular arthrosis • Glenohumeral
internal derangement
• NEUROLOGICAL • Cervical radiculopathy • Long thoracic nerve palsy • Spinal
accessory nerve palsy
• SOFT TISSUE • Intrinsic muscle pathology (1°, 2°, or 3° strain) • Hypomobility (e.g.,
short head of biceps, pectoralis minor) • Glenohumeral internal rotation deficit (GIRD)
• Altered muscle activation patterns • Altered muscle force-couple action
EXAMINATION
• Active Movements
• Active Movements of the Shoulder Complex
• Elevation through abduction (170° to 180°)
• Elevation through forward flexion (160° to 180°)
• Elevation through the plane of the scapula (170° to 180°)
• Lateral (external) rotation (80° to 90°)
• Medial (internal) rotation (60° to 100°)
• Extension (50° to 60°)
• Adduction (50° to 75°)
• Horizontal adduction/abduction (cross-flexion/cross-extension; 130°)
• Circumduction (200°)
• Scapular protraction
• Scapular retraction
• Combined movements (if necessary)
• Repetitive movements (if necessary)
• Sustained positions (if necessary)
Scapulohumeral Rhythm

• Phase 1: Humerus 30° abduction Scapula Minimal movement (setting

phase) Clavicle 0° to 5° elevation
• Phase 2: Humerus 40° abduction Scapula 20° rotation, minimal
protraction or elevation Clavicle 15° elevation
• Phase 3: Humerus 60° abduction, 90° lateral rotation Scapula 30°
rotation Clavicle 30° to 50° posterior rotation, up to 15° elevation
Passive Movements
• Passive Movements of the Shoulder Complex and Normal End Feel
• Elevation through forward flexion of the arm (tissue stretch)
• Elevation through abduction of the arm (bone-to-bone or tissue stretch)
• Elevation through abduction of the glenohumeral joint only (bone-to-bone
or tissue stretch)
• Lateral rotation of the arm (tissue stretch)
• Medial rotation of the arm (tissue stretch)
• Extension of the arm (tissue stretch)
• Adduction of the arm (tissue approximation)
• Horizontal adduction (tissue stretch or approximation) and abduction of
the arm (tissue stretch)
• Quadrant test
Resisted Isometric Movements
• Resisted Isometric Movements of the Shoulder Complex
• Forward flexion of the shoulder
• Extension of the shoulder
• Adduction of the shoulder
• Abduction of the shoulder
• Medial rotation of the shoulder
• Lateral rotation of the shoulder
• Flexion of the elbow
• Extension of the elbow
Functional Assessment
Special Tests
• Tests for Anterior Shoulder Instability
• Andrews’ Anterior Instability Test.
• The patient lies supine with the shoulder abducted 130° and laterally
rotated 90°.
• The examiner stabilizes the elbow and distal humerus with one hand and
uses the other hand to grasp the humeral head and lift it forward .
• A reproduction of the patient’s symptoms gives a positive test for
anterior instability. If the examiner hears a clunk, an anterior labral tear
may be present.
• This test is a modification of the load and shift test
Apprehension (Crank) Test for
Anterior Shoulder Dislocation
 Load and Shift Test
• This test is designed to check primarily atraumatic instability problems
of the glenohumeral joint.
• The patient sits with no back support and with the hand of the test
arm resting on the thigh. Ideally, the patient should be sitting in a
properly aligned posture (i.e., ear lobe, tip of acromion, and high
point of iliac crest in a straight line).
• If the patient slouches forward, the scapula protracts, causing the
humeral head to translate anteriorly in the glenoid and narrows the
subacromial space
Tests for Posterior Shoulder
Instability
• Circumduction Test
• The patient is in the standing position.
• The examiner stands behind the patient grasping the patient’s forearm with the hand.
• The examiner begins circumduction by extending the patient’s arm while maintaining slight
abduction.
• As the circumduction continues into elevation, the arm is brought over the top and into the
flexed and adducted position.
• As the arm moves into forward flexion and adduction from above, it is vulnerable to
posterior subluxation if the patient is unstable posteriorly.
• If the examiner palpates the posterior aspect of the patient’s shoulder as the arm moves
downward in forward flexion and adduction, the humeral head will be felt to sublux
posteriorly in a positive test, and the patient will say, “That’s what it feels like when it
bothers me
Tests for Impingement
Hawkins-Kennedy Impingement Test
The patient stands while the examiner forward flexes the arm to 90°
and then forcibly medially rotates the shoulder
Tests for Labral Tears
• Injuries to the labrum are relatively common, especially in throwing
athletes where the labrum plays a key role
• in glenohumeral stability.31 In the young, the tensile strength of the
labrum is less than the capsule, so it is more prone to injury when
anterior stress (e.g., anterior dislocation) is applied to the
glenohumeral joint
• tear may be a Bankart lesion, in which the anteroinferior labrum is
torn, or the superior labrum may have been injured, causing a SLAP
lesion (to the biceps)
Drop-Arm (Codman’s) Test
Rhomboid Weaknes
• The patient is in a prone lying position or sitting with the test arm
behind the body so that the hand is on the opposite side (opposite
back pocket).
• The examiner places the index finger along and under the medial
border of the scapula while asking the patient to push the shoulder
Tests for Thoracic Outlet Syndrome
• Adson Maneuver.
Roos Test (Elevated Arm Stress Test
[EAST]
Reflexes and Cutaneous Distribution
Joint Play Movement
Joint Play Movements of the
Shoulder Complex
• Backward glide of the humerus
• Forward glide of the humerus
• Lateral distraction of the humerus
• Caudal glide of the humerus (long arm traction)
• Backward glide of the humerus in abduction
• Lateral distraction of the humerus in abduction
• Anteroposterior and cephalocaudal movements of the clavicle at the acromioclavicular joint
• Anteroposterior and cephalocaudal movements of the clavicle at the sternoclavicular joint
• General movement of the scapula to determine mobility
• Ribs
• Thoracic spine
Palpation
• Anterior Structures
• Posterior Structures
Case study
• A 47-year-old man comes to you complaining of pain in the left
shoulder. There is no history of overuse activity. The pain that occurs
when he elevates his shoulder is referred to his neck and sometimes
down the arm to his wrist. Describe your assessment plan for this
patient (cervical spondylosis versus subacromial bursitis).
Case study
• An 18-year-old woman recently had a Putti-Platt procedure for a
recurring dislocation of the left shoulder. When you see her, her arm
is still in a sling, but the surgeon wants you to begin treatment.
Describe your assessment for this patient