RN(EC) ENC(C) GNC(C) MN ACNP *** MECHANISM OF INJURY.. MOST IMPORTANT ***

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1 HISTORY *** MECHANISM OF INJURY.. MOST IMPORTANT *** Age - Certain conditions are more prevalent in particular age groups (i.e. Full rotator cuff tears are more common over the age of 45, traumatic injuries are more common in youth) Sport / Occupation - Useful in determining mechanism of injury / overuse Level of Activity - Training schedule / repetitive use / injury healing time Training Errors - Technique / change in training intensity / nutrition / sleep / hydration / ergonomics Pain Characteristics - Onset / severity / duration / location (possible neck or upper back - referred from cardiac / abdomen source) / sleep quality / mechanical vs. constant pain Past History - Dislocations / overuse / Motor Vehicle Accident cervical origin of pain Past Treatment - Success / what treatments have been tried Aggravating / Relieving Factors Other Health Conditions - Cardiac / gallbladder / Degenerative Disk Disease of the C-spine etc. Copyright 2006 Page 1 of 5 mskeducation.com

2 PHYSICAL EXAMINATION Observation Posture Deformities Alignment - Guarding /, cranial / shoulder carriage / shoulder heights - Swelling / winging / bruising / bony deformities / atrophy - Scoliosis / kyphosis / scapular position / hips Range of Motion (ROM) Neck Neurological - Important to clear with Range of Motion (ROM) and passive over-pressure of ROM if active movements are pain-free - Deep Tendon Reflex s (DTR s) / dermatomes / myotomes - Important to assess if patient s pain radiates below the level of the elbow or if patient is experiencing numbness / weakness / paresthesias into the arm Shoulder - Abduction (180 ) - Supraspinatous (most active at 30 ) / Middle deltoid - Adduction (60 ) - Pectoralis Major / Latissimus Dorsi / Teres Major - Flexion (180 ) - Anterior Deltoid / Coracobrachialis - Extension (50 ) - Latissimus Dorsi / Teres Major / Posterior Deltoid - Internal Rotation (90 ) - External Rotation (90 ) - Subscapularis / Teres Major / Pectoralis Major / Latissimus Dorsi - Infraspinatous / Teres Minor Copyright 2006 Page 2 of 5 mskeducation.com

3 SPECIAL TESTS Impingement Painful Arc - Patient actively abducts extended arm from (Considered positive if pain is reproduced between ) Hawkins / Kennedy Test - Examiner passively flexes patient s elbow and shoulder to 90, then applies passive internal rotation (Considered positive with pain felt in the anterior aspect of Acromioclavicular Joint Impingement ( Cross-over Test / Scarf Test ) - Patient flexes arm to 90, then places the ipsilateral hand over the contralateral shoulder while examiner places gentle force on the posterior aspect of the flexed elbow in the direction of the contralateral shoulder (Motion simulates wrapping a scarf around the neck) - Examiner then tests strength by having patient maintain this position while applying a downward force over the elbow of the flexed arm (Considered positive if it reproduces pain over the Acromial Clavicular joint) Rotator Cuff Testing Supraspinatous Test - Patient actively abducts arms to 90, then internally rotates so thumbs are pointing to the floor - examiner brings extended arms forward into the plane of the scapulae (approximately 30 ) - patient attempts to resist downward force that the examiner is placing over the forearms (Considered positive if it reproduces pain in the anterior Copyright 2006 Page 3 of 5 mskeducation.com

4 Biceps Impingement (Speeds Test) - (* Not officially considered one of the rotator cuff muscles but, it is often involved in overuse injuries due to it s anatomic proximity to the Supraspinatous *) - Patient actively abducts arms to 90, then supinates arms so that palms are facing upwards - Examiner brings arms forward into the plane of the scapulae - Patient tries to resist downward force examiner is placing over forearms (Considered positive if it reproduces pain in the anterior Infraspinatous Test - Done with patient abducting shoulder and flexing the elbow to 90, then internally rotating shoulder so fingers are pointing to the floor - Patient then attempts to externally rotate shoulder while examiner resists this motion Subscapularis Test - Done with shoulder and elbow abducted and flexed to 90 - Patient attempts to internally rotate shoulder while examiner resists this motion Drop Arm Test - Patient abducts arm to 90 and attempts to resist downward force applied by examiner over forearm, or is unable to slowly lower arm back to the resting position Copyright 2006 Page 4 of 5 mskeducation.com

5 Stability Tests Anterior / Posterior Load-Shift Test - Examiner stabilizes scapula with one hand while attempting to shift the humeral head in an Anterior / Posterior plane with the other hand - This may be done with patient sitting or supine Sulcus Sign (Multidirectional Instability Test) - Patient is seated with arm relaxed at their side - Examiner grasps arm just proximal to the elbow and applies gentle downward traction (Considered positive if a hollow appears inferior to the acromium) Apprehension Test - With patient supine, examiner will hold patient s arm in 90 of abduction and elbow in 90 of flexion - Examiner then passively externally rotates arm (Considered positive if patient appears apprehensive and reports a fear of the shoulder dislocating) Relocation Test - With patient in same position as the Apprehension Test, the examiner applies a quick downward force over the proximal humeral shaft in the Anterior / Posterior plane to induce a whiplash type motion over the proximal humerus while monitoring for pain reproduction. - This test is also useful as an indicator that the humeral head is sitting more anteriorally in the joint due to a muscle imbalance. The examiner applies a passive gentle downward force over the proximal humerus while externally rotating the arm (Considered positive if patient feels less apprehensive with the above maneuver) Copyright 2006 Page 5 of 5 mskeducation.com