Shoulder

SHOULDER ASSESSMENT
BY : TRIPTI
INTRODUCTION
• The shoulder complex is difficult to assess

because of its many structures ( most of
which are located in a small area ) , It’s
many movements , and the lesion that can
occur either inside or outside of the joints.
• Assessment of the shoulder region often
necessitates an evaluation of the cervical
spine and thoracic spine, especially the ribs
to rule out referred symptoms.
SUBJECTIVE EXAMINATION
• DEMOGRAPHIC DATA:
1. Age
• Rotator cuff Degeneration (40 – 60 years of age)
• Rotator cuff tears ( occur at any age)
• Calcium deposits ( 20 – 40 years of age)
• Chondrosarcomas ( older than 30years of age)
• PA ( 45- 60 years of age , PA due to trauma can occur at any age)
• Fractures ( occur at any age)
2. Occupation
• Work? Working environment? Postures assumed?
• CHIEF COMPLAINTS
• Describe in patients words
• HISTORY OF PRESENT ILLNESS :
• A) ONSET:
1. Duration
2. Mode - Acute ( Does the patient support the upper limb in a Protracted position or hesitate to move it? )
- Gradual
B) PAIN / SYMPTOMS :
1. Location : should be specific
2. Quality : - night pain + resting pain = Rotator cuff tears ,. Tumous
. - activity related = Tendinitis
. - at least initially and at extreme of motion = Arthritis
- Deep boring pain = TOS / Acute brachial neuropathy
. - Hot burning pain = Acute calcific Tendinitis
. - Dull and aching pain = PA
. - Deep pain with movement within a particular range = rotator cuff injury
3. Intensity : VAS 0 – 10
4. AF : -MOVEMENT , ANY ACTIVITY , OVERHEAD ACTIVITY

• 5. RF : - Rest , hot pack, cold pack , supported arm
• - any position ( Patient with nerve root pain may find the elevating the
• arm overhead relives the symptoms).
• C. INJURY
1. Date
2. Mechanism of injury : - Fall on outstretched hand ( fracture/ Dislocation of GH jt.)
. - Fall on receive a blow to the tip of shoulder ( fracture of GT)
- Land on elbow, driving the humerus up against the acromion ( Ac dislocation/ subluxation)
- Shoulder feel unstable / coming out during movement
. - overuse injuries ( evident immediately after the patient does repeated activity)
3. Swelling at the time of injury : present/ absent
4. Initial treatment / Diagnosis

Additional Points:
1. Recurrent Dislocation/ any instability
• How many episodes have there been in last year?
• Was there an injury that precipitated this?
• What direction does the shoulder “ go out” most times?
• Have you ever needed the help getting the shoulder back into proper position within the joint?
2. Patient with instability may appear normal on clinical examination especially when muscles are not fatigue.
3. Does the patient complaints of weakness and heaviness in the limb after activity? ( VASCULAR INVOLVEMENT , coolness and pallor?)
4 Is patient Able to talk/ swallow ? Is patient hoarse ? ( SC JOINT INJURY)
. HISTORY OF PAST ILLNESS
OBJECTIVE EXAMINATION
• CLINICAL EXAMINATION :
• A ) OBSERVATION
1. Gait : loss of swinging of arms
2. Posture : pelvis should be in neutral
a) Anterior view : look for the dominance
- Step deformity : AC dislocation with distal end of clavicle lying superior to acromion process ( AC and coracoclavicular ligament torn)
- sulcus deformity
- flattening of normally round deltoid muscle area may indicate anterior dislocation of GH joint / paralysis of deltoid muscle.
b) Posterior view
- Scapular position = T2 – T3 to T7 – T 9
- Upper trapezius atrophy ( spinal accessory nerve paralysis )

- Atrophy of supraspinatus and infraspinatus ( supraspinous nerve palsy )
- Spine of Scapula begin at T3 = Should be at same angle.
- Sprengel’s deformity
- Scapular dyskinesia / dysfunction
1. Inferior medial border being prominent at rest. Scapular tilt , inferior angle tilt dorsally with movement, while the acromion
tilts anteriorly over the top of thorax. ( weakness of lower trapz + LD + SA , tightness of P.major).
2. Winging of Scapula = due to weakness of SA , Rhomboids, Trapz, long thoracic nerve.
3. Superior border of Scapula being elevated at rest and during movement . ( When shoulder shrug initiate the movement.
4. Both the Scapula are symmetrical at rest and during movement. Rotatory winging ( inferior angles rotating laterally
away)
• C. Lateral view : FHP
• B) INSPECTION :
• Alignment in standing
• Soft tissue inspection
1. Muscle tone
2. Muscle contour
3. Swelling
• Skin inspection
1. Colour
2. Scar
3. Tenderness
4. Texture
C ) FLEXIBILITY TESTING ( MUSCLE SPECIFIC)
D) ROM :
1. Active ROM : painful movement perform at last
• Painful arc = 60° - 120°
• Pain within = 170°- 180° Ac joint involvement
• Reverse scapulo-humeral rhythm = as in PA
• Abrasion sign = rotation testing in 90° abduction ( crepitus present – indicate abrasion of torn tendon margins against the
coracoacromial arch.
• IR is diminished = contracture of posterio inferior capsule Which can lead to SLAP.
2. Passive ROM
3. Resisted isometrics movements
4. Joint play
1. End feel
5. Crepitus
6. Laxity
7. Pain
E ). MMT : perform on both limbs.

F ) Other related joints :. Cervical, thoracic , elbow
1. Alignment
2. ROM
3. Stability
4. Strength
.
G ) SPECIAL TESTS
1 . Tests for anterior instability

• crank test
• Relocation release test
• Anterior drawer test
• Cross chest adduction test
• 2. Tests for Posterior instability
• Posterior apprehension test
• 3. Tests for inferior instability

• Sulcus sign
• 4. Tests for impingement syndrome

• Neer test Subacromial impingemen)
• Hawkines kennedy ( Subacromial impingement)

• Drop arm test ( rotator cuff tear)
• Enpty can test ( supraspinatus tendinitis)
• 5. Tests for bicepital tendinitis
• Yargarson Test
• Speed Test
• 6. Apley’s scratch test

• 7. Test for infraspinatus and teres minor tendinitis
• 8. Lift off test ( subscapularis tendinitis)
• H ) Involuntary movements ( neurological assessment)
1. Reflexes
• Biceps c5
• Triceps c7
• Brachioradialis c6
• 2. Dermatomes sensation C4 – Top of Shoulders
• C5 – Lateral Deltoid
• C6 – Tip of Thumb
• C7 – Distal middle Finger
• C8 – Distal 5th Finger
• T1 – Medial Forearm
• 3. Myotomes C4 – Shoulder Elevation/Shrug
• C5 – Shoulder Abduction
• C6 – Elbow Flexion, Wrist Extension
• C7 – Elbow Extension, Wrist Flexion
• C8 – Thumb Abduction/Extension
• T1 – Finger Abduction
• I ) SENSORY EXAMINATION
1. TOUCH
2. TEMPERATURE
3. PRESSURE
4. PROPRIOCEPTIVE
J ) COORDINATION.
• K ) MEASUREMENTS
1. Length of the limb
2. Muscle girth
3. Contracture/ tightness/ deformitt
L) INVESTIGATION
X RAY
MRI
OTHERS
M ) ASSOCIATED DEFICITS
1. speech
2. Hearing
3. Memory
N ) AIMS OF THE TREATMENT
O ) TREATMENT

Shoulder

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SHOULDER ASSESSMENT

• The shoulder complex is difficult to assess

• Describe in patients words

• HISTORY OF PRESENT ILLNESS :

1. Location : should be specific

2. Quality : - night pain + resting pain = Rotator cuff tears ,. Tumous

. - activity related = Tendinitis

. - at least initially and at extreme of motion = Arthritis

- Deep boring pain = TOS / Acute brachial neuropathy

. - Hot burning pain = Acute calcific Tendinitis

. - Dull and aching pain = PA

4. AF : -MOVEMENT , ANY ACTIVITY , OVERHEAD ACTIVITY

• arm overhead relives the symptoms).

2. Mechanism of injury : - Fall on outstretched hand ( fracture/ Dislocation of GH jt.)

. - Fall on receive a blow to the tip of shoulder ( fracture of GT)

- Shoulder feel unstable / coming out during movement

3. Swelling at the time of injury : present/ absent

4. Initial treatment / Diagnosis

1. Gait : loss of swinging of arms

2. Posture : pelvis should be in neutral

a) Anterior view : look for the dominance

- Upper trapezius atrophy ( spinal accessory nerve paralysis )

E ). MMT : perform on both limbs.

1 . Tests for anterior instability

• 3. Tests for inferior instability

• 4. Tests for impingement syndrome

• Hawkines kennedy ( Subacromial impingement)

• 6. Apley’s scratch test

• 2. Dermatomes sensation C4 – Top of Shoulders

• C7 – Distal middle Finger

• C8 – Distal 5th Finger

• C6 – Elbow Flexion, Wrist Extension

• C7 – Elbow Extension, Wrist Flexion

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