CLINICAL EXAMINATION OF THE SHOULDER JOINT 대한신경근골격연구회 분당제생병원재활의학과 박준성

CLINICAL EXAMINATION OF THE SHOULDER JOINT 대한신경근골격연구회 분당제생병원재활의학과 박준성

Clinical Examination of the Shoulder Good history, full clinical examination Detailed knowledge of the anatomy solve the majority of shoulder problem Complicated cases difficult to diagnosis Tendinitis and bursitis diagnostic infiltration can be helpful. first lesion : suprapinatus with infraspinatus tendinitis second lesion : subdeltoid bursitis

Pain Referred to the Shoulder Posterolateral cervical disc protrusion ( start in neck & interscapular area-> shifting pain) Posterocentral cervical disc lesion dural compression Cervical neuroma Visceral disorders ( diaphragm, heart ) Pulmonary tumors

Pain Referred from the Shoulder Mostly C5 dermatome : lateral arm pain, elbow pain Exception, A-C joint to the C4 origin. Acromioclavicular joint problems the is felt at the tip of the shoulder, with little spread.

History What is your age? Traumatic arthritis ; over 40 years of age Immobilizational arthritis ; over 60 Subdeltoid bursitis ; between 15 ~ 65 Tendinitis can occur at any adult age Where is the pain? Does it radiate? C4 only at the tip of the shoulder C5 from the deltoid area down to the wrist Pain at rest or only at use? Severity of the lesion : one of criteria for judging the stage of arthritis.

History Can you lie on affected side at night? Pain->more severe inflammation than just pain on exercise. In Bursitis, tendinitis, or arthritis How did the pain come on spontaneously, such as overuse or an injury? Overactivity may provoke tendinitis and arthritis Spontaneously: haemarthrosis in haemophilia (more common at knee joint)

Inspection Position of head, level of shoulders Redness, swelling, muscular wasting, Any deformity (scapular winging)? Local swelling Acute, haemorrhagic or chronic subdeltoid bursitis Acromioclavicular joint cysts Tumors

Preliminary Examination

Basic Functional Examination of the Shoulder

Elevation

Elevation Active elevation asked to raise both arms sideways above the head as far as possible. check pain and ranges onset of these movement is done by supraspinatus muscle. (0~30 degrees) Passive elevation Pain, range of motion and end-feel are noted. normal end-feel is elastic.

Painful Arc Ascending arc or descending arc : both are regareded as a real painful arc. Rotator cuff injury, subdeltoid bursitis, A-C joint lesion, subcoracoid bursitis.

3 tests of Glenohumeral Joint Passive scapulohumeral abduction (90 degree) Passive lateral rotation(90 degree) Passive medial rotation

Resisted movements Resisted adduction PM, LD, Tma, TMi Resisted abduction Deltoid, SS

Resisted movements Resisted lateral rotation IS, TMi Resisted medial rotation Subscapularis, PM, LD,TMa

Resisted movements Resisted elbow flexion Biceps brachii Resisted elbow extension Triceps brachii, impinging

Palpation heat and swelling Comparison between two sides is essential Palpation for tenderness in acute and chronic subdeltoid bursitis, in a sprained superior ligament of the AC joint

Accessory Tests

Passive Horizontal Adduction Sprain of the AC joint Subcoracoid bursitis Subscapularis tendinitis (lower half) Sternoclavicular joint problem Chronic subdeltoid bursitis

Passive Horizontal Lateral Rotation Subcoracoid bursitis Painful limitation Sprained coacoclavicular ligament.

Instability of the Shoulder Apprehension test for recurrent anterior dislocation Feel subluxation and Pain Apprehension test for recurrent posterior dislocation

Instability of the Shoulder Load and shift test Sulcus sign

Deltoid Muscle Lesion Resisted horizontal adduction Resisted horizontal extension

Yergason s Test Resisted shoulder external rotation & elbow flexion For subluxation of the tendon of the long head of the biceps

Resisted Flexion of the Arm Coracobrachial muscle (rare)

Clinical Examination of the Shoulder Girdle

Basic Functional Examination of the Shoulder Girdle If Negative or unclear : shoulder examination Or Active elevation of scapular is painful

Basic Functional Examination of the Shoulder Girdle Active movement of the shoulders Elevation, protraction, retraction of both shoulders Passive movement of the shoulders Elevation, protraction, retraction Resisted movement of the shoulders Elevation, protraction, retraction, depression,

Active movements elevation protraction retraction (shrugging) (scapular abd.)

Passive movements elevation protraction retraction

Resisted Movements Resisted elevation of the scapulae Levator scapulae, upper part of the trapezius Weakness: lesion of the C2-C4 nerve roots Resisted protraction of the scapulae Pectoralis major & minor(rare), serratus ant. Resisted retraction of the scapulae Rhomboid, middle and lower parts of the trapezius, latissimus dorsi Resisted depression of the scapulae Pectoralis minor, subclavius, latissimus dorsi

Resisted Movements

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