Shoulder Evaluation

Overview Soft tissue palpation Muscular anatomy Evaluation Special tests

Soft Tissue Palpation Sterno-Clavicular (SC) ligament Acromio-Clavicular (AC) ligament Coraco-Clavicular (CC) ligament Coraco-Acromioclavicular (CA) ligament Glenohumeral joint Subacromial bursa Subdeltoid bursa

Muscular Anatomy Supraspinatus Infraspinatus Teres minor Subscapularis Pectoralis major Pectoralis minor Scalenes Teres major Latissimus dorsi Serratus anterior Biceps brachii Triceps brachii Rhomboid major & minor Deltoid

Intrinsic Musculature: Supraspinatus O: Supraspinous fossa I: Superior greater trochanter A:? N: Suprascapular nerve

Intrinsic Musculature: Infraspinatus O: Infraspinous fossa I: Posterior greater tubercle A: ? N: Suprascapular nerve

Intrinsic Musculature: Teres Minor O: Lateral scapula I: Posterior greater tubercle A: ? N: Axillary nerve

Intrinsic Musculature: Subscapularis O: Anterior surface of scapula (subscapular fossa) I: Lesser tubercle of humerus A: ? N: Subscapular

Pectoralis Major O: Clavicle, sternum, and ribs I: Intertubercular groove of humerus A: Int. rot, horiz. add, flex, add below 90, abd above 90 N: pectoral

Pectoralis Minor O: Anterior surfaces of ribs 3-5 I: Coracoid process A: Abd, Down rot, dep N: Medial pectoral

Scalenes O: Transverse processes of C2-C7 I: First & second ribs A: Rib elevation & head rotation (same side) I: Spinal nerves C3-C8

Teres Major O: Inferior 1/3 of lateral border of scapula I: Medial intertubercular groove of humerus A: Ext, add, IR N: Lower subscapular

Latissimus Dorsi O: Ilium, sacrum, lumbar vertebrae, and lower 6 thoracic vertebrae I: Anterior humerus A: Add, in rot, ext N: Thoracodorsal

Serratus Anterior O: Ribs 1-9 on lateral thorax I: Medial border of scapula A: Abduction, up rot I: Long thoracic nerve

Biceps Brachii O: LH-Superior glenoid ; SH-Coracoid I: Radial tuberosity A: Elbow flexion & supination, shoulder flexion N: Musculocutaneous

Triceps Brachii O: LoH- infraglenoid lip of scapula; LaH- posterior humerus; MH- medial posterior humerus I: Olecranon process A: Elbow extension, shoulder extension N: Radial

Rhomboids O: Spinous processes of C5-T5 I: Medial border of scapula A: Adduction, down rot, elev N: Dorsal scapular nerve

Deltoid O: Clavicle, acromion, & scapular spine I: Lateral humerus A: flex, ext, in rot, ex rot, add, abd, horiz add, horiz abd (everything!) N: Axillary

Evaluation Passive/Active ROM (Shoulder): Flexion Extension Abduction Adduction External rotation Internal rotation

Evaluation Passive/Active ROM (Scapula): Elevation Depression Abduction (protraction) Adduction (retraction) Internal rotation External rotation Circumduction Apley scratch test

Special Tests (31) Fracture/sprain test (1) Rotator cuff tests (6) Glenohumeral instability tests (11) Biceps tendon tests (6) Impingement tests (3) Thoracic outlet tests (4)

AC-SC Stress Test (fracture/sprain) The examiner palpates the patient’s clavicle and manipulates it inferiorly, superiorly, medially, and laterally Pain or crepitus indicates a positive test for possible clavicular fracture

Drop Arm Test (rotator cuff): Patient begins by abducting both arms to 90 degrees Examiner then pushes downward on both arms with equal force Test is positive for rotator cuff injury if patient experiences pain or pt’s arm(s) can be pushed down without springing back into position once the examiner suddenly stops applying the downward force

Empty Can Test (rotator cuff): Pt in standing, the examiner instructs pt to internally rotate the shoulder and point the thumb toward the floor Examiner then resists the pt’s movement into full abduction Examiner should perform the test in four different planes Abduction between 0 and 45 degrees in front of the body = supraspinatus Abduction/flexion greater than 45 degrees in front of the body but less than 90 degrees = infraspinatus Shoulder flexion in the empty can position straight out in front of the body = teres minor Test performed across the body = subscapularis Any pain or weakness in any of the movements is a positive test for strain of the affected rotator cuff muscle(s).

Arms Over Head (rotator cuff): Pt in standing, the examiner instructs the pt to externally rotate the shoulders and actively lift both arms overhead Test positive for rotator cuff strain if the pt notes pain and/or is unable to perform the movement 

High Five Test (rotator cuff): Pt begins standing with the arms abducted to 90 degrees and externally rotated, and the elbows flexed to 90 degrees From this position, pt’s hands will remain in the frontal plane, however, the palmar surface will be positioned anteriorly and the hands will be held overhead Examiner then uses both of his/her hands to forcefully push the pt’s hands posteriorly while pt resists Pain indicates a positive test for muscle strain to one or more of the rotator cuff muscles

Lift Off Sign (rotator cuff): The examiner prepositions the pt with dorsal surface of pt’s hand over the lumbar spine (end range shoulder internal rotation) Examiner applies resistance as pt attempts to lift the hand off the spine and push posteriorly Weakness indicates a positive test for subscapularis muscular injury

Resisted Pull Test (tendinitis vs. bursitis): Examiner stabilizes the pt’s involved upper arm and resists active shoulder external rotation and/or abduction Pt is asked to rate his/her pain Obvious pain is a positive sign for rotator cuff tendon pathology and/or subacromial bursitis Examiner then applies a caudal pull to the upper arm, resulting in a traction force at the glenohumeral joint During the pull, pt is instructed to repeat the resisted active shoulder external rotation and/or abduction If pain was present when the test was performed with no pull, reduced pain with a pull is indicative of subacromial bursitis, while no change or increased pain is indicative of rotator cuff pathology.