Osteopathic Concepts of the Shoulder PPC/OMM Lab Christina Bertolami, DO

Objectives Review relevant anatomy of the shoulder Demonstrate a shoulder exam: Inspection, Palpation, Rom, strength, and instability testing Discuss physical exam findings including osteopathic diagnosis of scapula, clavicle, AC, and SC joints Know common shoulder osteopathic treatment techniques

Physical Examination Use history to understand where the pain is & what the mechanism of injury is… General appearance Inspection Palpation ROM Strength Stability Special Testing Neurovascular Status

Inspection Inspection Patient must be exposed so that both shoulders can be viewed and compared General appearance Look for asymmetry, muscle atrophy, ecchymosis, swelling Below is “Sulcus” sign indicates multidirectional instability

Palpation Overview of Anatomy Bony structures – humerus, clavicle, scapula Muscles - Deltoid and ”SITS”- Rotator cuff- Supraspinatus, Infraspinatus, Teres Minor, Subscapularis

Palpation Overview of Anatomy Acromioclavicular, Sternoclavicular, and Glenohumeral joints

Range of Motion External and Internal Rotation Flexion and Extension

Range of Motion ADduction ABduction

Physical Examination start with the neck Don’t forget to examine the proximal and distal joints to the shoulder (c-spine and the elbow) Shoulder pain may come from the neck Radiculopathy Origin of trapezius, levator scapulae Spurling’s maneuver reproduction of shoulder/arm pain is a positive test and indicates a cervical nerve root diorder Spurling's test: The examiner passively hyperextends and laterally flexes the patient's neck toward the involved side. The test is positive if axial loading by the examiner's hands reproduces symptoms. http://www.aafp.org/afp/991101ap/2035.html Motion of the scapula controls the location of the glenohumeral joint. If the scapular stabilizers are not equal due to cervical diagnosis, then shoulder function may be altered and pain result.

PRACTICE Spurlings Maneuver Inspection & Palpation of Shoulder ROM-compare both sides, look for restriction

Strength Testing of Rotator Cuff Supraspinatus-abduction initiator Test done in “scaption” “Full can” or “Empty can” Doctor pushes down Positive test-when patient has pain or weakness- indicates supraspinatus tendinitis or muscle or tendon tear Supraspinatus Scaption – is the position where the arm is approximately the same plane as the scapula. 45 degrees abduction and 45 degrees to 90 degrees forward flexion. Thumb up or “the full can” test moves the greater tuberosity of the humerus away from the acromion, lessening the contribution of impingement to pain or weakness during the exam. The empty can test or “thumbs down” position places the greater tuberosity closer to the acromion and increases the contribution of imp[ingement to the test. Avoiding impingement is important because you are performing this exam to detect weakness; painful impingement may cause a patient to make less of an effort due to pain, which you would mistakenly interpret as weakness.

Strength Testing of Rotator Cuff Infraspinatus and teres minor-ext rot difficult to separately test Tests external rotation strength Stabilize the arm at the elbow to prevent abduction Pt externally rotates, doctor internally rotates If pain-positive test- Patient externally rotates Examiner internally rotates Infraspinatus/Teres

Strength Testing of Rotator Cuff Subscapularis – allows for internal rotation “Lift-off test” Best Test for subscapularis Elbow at 90o; patient lifts arm off of waist line against resistance. Hard for patients with impingement Testing Against Belly Close; less precise than “lift off” Patient holds arm against abdomen as shown; resists examiner attempt to externally rotate arm off of abdomen Left Off Test Subscapularis Testing

Instability Testing Anterior Instability Anterior apprehension test Arm in external rotation Abduction places pressure on anterior shoulder capsule Note examiner right hand position which keeps the shoulder from dislocating Relocation test Anterior to posterior pressure is place by the examiners right hand to “relocate” shoulder – if symptoms are relieved test is positive Anterior Release Test

Impingement Testing Hawkins Test Neer’s Test Examiner exerts internal rotation of humerus (blue arrow) with 90º of forward flexion and 90º of elbow flexion; a positive test is reproduction of pain In this test, the arm is placed thumb down (internal rotation of humerus) in scaption. Examiner stabilizes the scapula border to prevent rotation. The arm is raised in forward flexion in scaption. A positive test is if pain is reproduced.

PRACTICE 1. Muscle Strength Testing Supraspinatus, Infraspinatus/Teres Minor Subscapularis 2. Instability Testing 3. Impingement Testing

Spencer Technique Series of proprioceptive neuromuscular facilitation techniques Can be expanded to include ME treatment Physician stabilizes scapula Physician engages barrier of joint Patient pushes against (away from barrier) Repeat 3-5 times Taking up slack and engaging new barrier each time Engages all of the muscles around the GH joint Both diagnostic & therapeutic Kimberly Manual, pp. 237-240, direct articulatory/ME Dx findings: Tissue texture changes, passive GH glides may be normal, range of motion is reduced in one or more directions by muscular restrictions, pain with specific shoulder motions or aching at rest, tenderness to palpation. Tender points and trigger points may be present.

Spencer Technique The seven stages of motions are: 1. Engage GH extension barrier with elbow flexed 2. Engage GH flexion barrier with the elbow flexed 3. Circumduction with compression Start small circles, then gradually increase size Clockwise and counterclockwise May also do ME of IR/ER barriers 1 2 Kimberly Manual, p. 237-240 Direct articulatory/ME 3

4. Circumduction with traction on straight arm Start small circles, then gradually increase size Clockwise and counterclockwise 5. Engage abduction barrier 6. Adduction/IR with elbow flexed 7. GH pump with distraction and compression along straight arm 4 5 6 7

Practice Spencer technique

Humeral Head Anterior and Superior Both seated. DO monitors humeral head with posterior hand. Palm of ant hand and fingers on medial aspect of humerus as high in axilla as possible. Patient lays the hand of dysfunctional arm across chest and grasps elbow with opposite hand to pull the elbow across the chest against traction counterforce of physician’s hand. Patient needs to relax shoulder muscles at same time. Patient may be instructed to “lift elbow” slightly to glide humeral head superiorly. Position humerus into internal rotation by lifting patient’s elbow OR Ext rotation by depressing elbow to obtain BLT Test resp phase. Recheck.

Scapulothoracic Dysfunctions Physician can assess for static/dynamic asymmetry Physician can physically take scapula through ROM, assessing for ease/restriction Scapula can glide superiorly/inferiorly, medially/laterally. It can tilt anteriorly/posteriorly through AC horizontal axis. It can rotate upwards/downwards around AC AP axis. Scapula can “wing” (rotate externally/internally) around AC vertical axis. http://www.scielo.br/img/revistas/rbfis/v13n1/010fig01.gif

Scapular Release Patient in lateral recumbent position with physician at side of table Hook fingers of cephalad hand over superior angle of scapula. Grasp elbow with opposite hand, resting patient’s arm on physician’s cephalad forearm (1) Carry scapula inferiorly and laterally to muscular restrictive barrier Apply sufficient force to feel muscles relax Force is slowly relaxed Stretching repeated rhythmically until max response obtained Move fingers to medial scapular margin (2) Carry scapula laterally and repeat #4-#6 Move fingers to inferior angle (3) Carry scapula superiorly and laterally, repeating #4-#6 1 2 3 Kimberly Manual p. 47-48, direct soft tissue method

Sternoclavicular Dysfunctions Sternoclavicular joint motions: Superior/Inferior glide Movement in the frontal (coronal) plane Also called ADduction/ABduction Anterior/Posterior glide Movement in a horizontal (transverse) plane Also called horizontal extension/horizontal flexion Rotation on its long mechanical axis Anterior (internal)/Posterior (external) Joint motions are coupled ABduction (IG) is coupled with posterior (external) rotation ADduction (SG) is coupled with anterior (internal) rotation Frame of reference for ABd/ADd, horizontal flex/ext is lateral end of clavicle Frame of reference for sup/inf glide, ant/post glide is medial (sternal) end of clavicle Frame of reference for rotation is the superior surface of clavicle

A P A P Posterior Rotation External Rotation Horizontal Flexion MEDIAL A P LATERAL LATERAL MEDIAL A P Posterior Rotation External Rotation Horizontal Flexion Posterior Glide ABduction Inferior Glide MEDIAL A P LATERAL LATERAL MEDIAL A P As the clavicle ABducts laterally, there is a downward (inferior) glide at sternal end As the clavicle ADducts laterally, there is an upward (superior) glide at the sternal end ABduction/inferior glide and posterior/external rotation are linked ADduction/superior glide and anterior/internal rotation are linked ADduction Superior Glide Anterior Rotation Internal Rotation Horizontal Extension Anterior Glide

Sternoclavicular Dysfunction Assessment ABduction (IG)/ADduction (SG) Physician stands at head of table Patient is supine Place tips of your fingers on the superior edges of the medial ends of the patient’s clavicle Ask your patient to shrug their shoulders. Both clavicles should move into ABduction, and the medial clavicles should move inferiorly (inferior glide) In the absence of trauma, the dysfunctional (restricted) clavicle stays superior at the SC jointNamed an ADduction somatic dysfunction (superior glide)

Sternoclavicular Dysfunction Assessment Horizontal Flex (PG)/Horizontal Ext (AG) Physician stands at head of table Patient is supine Place tips of your fingers on the anterior edges of the medial ends of the patient’s clavicle Ask your patient to reach toward the ceiling with their arms. Their scapulae should come off the table. Both clavicles should move into horizontal flexion, and the medial clavicles should move posterior (posterior glide) In the absence of trauma, the dysfunctional (restricted) clavicle stays anterior at the SC jointNamed a horizontal extension (anterior glide) somatic dysfunction

Treat elevated SC Joint Pt is seated and physician stands behind the patient toward the side to be treated Use hand closest to Pt. place the second metacarpophalangeal joint over the distil third of the clavicle to be treated Maintain constant caudad pressure over Pt. clavicle With other hand grasp pt. arm on side to be treated below the elbow. Bring pt. arm toward flexion from adduction with a continuous backstroke motion, the arm is circumducted toward extension until it is at the side of the pt. The arm can be brought forward and placed across the chest if this is comfortable for pt. The release may occur before the barrier is met. The physician reevaluates the dysfunctional (TART) components

Left Clavicle anterior and superior glide (SC Joint) Both seated. Thumbs under junction of th medial and middle third of clavicle. Fingers over each end of clavicle. Patient rests forearm over D.O.’s forearm. “Lean forward slightly toward me.” “Slightly turn your body away from me.” (gaps SC joint!) D.O. carries sholder posteriorly to gap and balance AC joint. Medial end of clavicle is elevated by rotating clavicle around pivot point formed by thumbs. Clavicle is taken to a point of BLT (balanced ligamentous tension). May need minor movement of the patient’s scapula and clavicle by moving the forearm & body to achieve BLT. Respiratory phases are tested. Pt holds breath in phase giving best ligamentous balance. Recheck. Similar to doing the interosseous membrane in lower leg. Left Clavicle anterior and superior glide (SC Joint)

2. 1. 3. 4. Elevated SC joint-Articulatory

Acromioclavicular Somatic Dysfunction Assessment Superior/Inferior Glide Physician places fingers on distal clavicle at AC joint. Palpate position of distal clavicle in relation to acromion Spring inferiorly on distal clavicle to assess for motion Assess for restriction of gapping at AC joint. A P External Rotation ADduction AC gapping

Treat elevated AC joint Pt. seated, physician stands behind the pt. toward the side being treated Physician, using the closest hand to pt., places the second metacarpophalangeal joint over the distal third of clavicle being treated Physician’s other hand grasps the Pt. arm on side to be treated below elbow Pt arm is pulled down and then drawn backward into extension with a continuous motion similar to throwing a ball, circumducting the arm until it is once again in front of patient, finishing with arm across chest in adduction The release may occur before barrier is met The physician reevaluates the dysfunctional (TART) components

Right Clavicle Superior Glide (at Lateral end of clavicle) Grasp elbow or forearm. Pad of thumb with other hand applies Ant/Inf pressure to the restrictive barrier. Flex elbow. Extend and adduct humerus to gap AC joint. Extend shoulder further and apply a circulatory sweep elbow posterior, then superior, and finally anteromedially must maintain capsular tension through out. Recheck. Right Clavicle Superior Glide (at Lateral end of clavicle) Elevated clavicle on Acromion(elevated AC joint)

Right Clavicle Superior Glide (AC) Thumbs under middle and medial third portion of clavicle. Patient rests forearm on D.O. forearm. “Lean slightly forward and toward me.” Clavicle needs to be supported by D.O.’s thumbs. “Slightly turn body away from me.” (gaps SC joint.) Carry shoulder posteriorly to gap and balance the AC joint. Elevate lateral end of clavicle by rotating the clavicle around the povot point formed by the DO thumbs. May need minor movement of scapula and body position to obtain BLT. Test resp phase to get best BLT Recheck.

Practice 1. SC assessment and treatment 2. Treat elevated SC joint 3. AC assessment and treatment 4. Treat elevated AC joint