1. Occupation; Right or left handed, Age
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1 SHOULDER HISTORY 1. Occupation; Right or left handed, Age 2. Pain: Site. Any referred pain to the deltoid insertion Any localizing pain at Acromio-clavicular joint How long? Continuous or not Night pain How does it affect you? Work Sleep 3. ADL s Disabilities: Bra, hanging out clothes. Reach top shelf, carrying weight 4. Any weakness and tingly in the hand Previous treatment: medication, Steroid injections, History of injury Co-morbidities: Diabetes, Chronic renal failure, Coronary problem INSPECTION Front Sterno-Clavicular joint [SCJ], Clavicle, Supraclavicular region, Acromio-clavicular joint[acj], Deltoid contour Lateral Deltoid musculature Position of the humeral head Back Supraspinatus and Infraspinatus fossa for wasting Any Scar
2 Any deformity of biceps muscle Look for any elevation of the scapula: Sprengels s shoulder PALPATION Warmth, Tenderness (Impingement) Feel all bony prominence and SCJ and ACJ Acromion Greater tuberosity Biceps tendon in the bicipital sulcus: Shoulder in 15º of Internal rotation and 4 cm below the acromion RANGE OF MOVEMENT First perform the active movements and then the passive movements. If there is disparity between passive movement and active movement ie., passive more than active then a lag of movement is present. This means either tendon is tore or muscle is paralysed Fixed deformity: opposite movement is absent. Ie., when 30 of external rotation deformity of the shoulder means: no internal rotation is possible. But patient may further rotate externally. ABDUCTION OF THE SHOULDER Examiner stands behind the patient Patient actively abducts the arm Watch for the: Range of movement Rhythm [Glenohumeral or Scapulothoracic] Any pain on abduction range Look for any early winging as in Shoulder dyskinesia Normal: Abduction 180 º [Rhythm: 2:1] In frozen shoulder, abduction predominantly Scapulothoracic joint
![shoulder all movements are terminally limited In Frozen Shoulder all movements are severely limited particularly external rotation and abduction [Normal X rays] In massive cuff tear:](/docs-images/90/102660967/images/3-3.jpg "active abduction and flexion are grossly limited OTHER MOVEMENTS Normal Flexion 180 º External rotation 60 º Internal rotation 90º[up to T6] Extension 30 º Adduction 60 º MUSCLE")
3 How to isolate abduction at Glenohumeral joint? Examiner stands behind the patient Stabilize the inferior pole of the scapula Now ask to abduct actively All abduction now occurs at the Glenohumeral joint Note: In arthritis of shoulder all movements are terminally limited In Frozen Shoulder all movements are severely limited particularly external rotation and abduction [Normal X rays] In massive cuff tear: active abduction and flexion are grossly limited OTHER MOVEMENTS Normal Flexion 180 º External rotation 60 º Internal rotation 90º[up to T6] Extension 30 º Adduction 60 º MUSCLE STRENGTH SUPRASPINATUS 90º Flexion of the shoulder 30º abduction of the shoulder 0º at the elbow Thumbs down Resistance against the forearm Jobe s Test
4 INFRASPINATUS Arms close to the chest Elbow at 90º Examiner s hand against the forearm Patient is asked to external rotation forcefully Usually this causes pain in rotator cuff tear Lift Off SUBSCAPULARIS Lift off test Should be done only if internal rotation is possible Ask the patient take back of the hand first off the back Make sure arm is well adducted If he can: test the strength against resistance Belly press test [Napolean Sign] It is the test for Subscapularis, when internal rotation Belly Press is limited. Make sure elbow stays anterior and the wrist stays straight and forceful internal rotation against examiner s hand BICEPS Yargason s test Arm close to the chest; Elbow in 90º of flexion: Supination of the forearm; Examiner tries to pronate forearm against resistance Speed test Speed Test Elbow straight and shoulder 90º of flexion Examiner s resistance of upward pull of supinated forearm and extended elbow
5 Abbott s test This test is for instability of the long head biceps tendon in the Groove. The examiner grasps the patient s arm and brings into Abduction and external rotation. While palpating the bicipital groove, the examiner then internally rotates the shoulder. Subluxation or dislocation of the tendon produces a palpable or audible snap Painful Arc Syndrome Patient actively abduction Pain is precipitated between 60º to 120º Pain at terminal abduction is absent Pain can be abolished by local anaesthesia Positive in: Rotator cuff tear Impingement syndrome NEER S IMPINGEMENT SIGN Forward flexion of the shoulder by the examiner Shoulder in external rotation Note any pain due to impingement of the cuff HAWKINS SIGN Flexion of the shoulder to 90º with shoulder in 90º internal rotation Elbow is kept at 90º flexion Now examiner passively rotates internally This causes pain in cuff problems
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