OPP Exam I

darodri6's version from 2016-09-13 12:36

Age vs. Common Dysfunctions

DysfunctionCommon Age
Rotator cuff degeneration40-60 y/o
Rotator cuff tearany age (but most common > 40 years due to chronic impingement)
Primary impingement from degeneration & weaknessover age 35
Secondary impingement due to instability from muscle weaknesslate teens or early 20s (usually vigorous swimmers or baseball pitchers)
Frozen shoulder (aka Adhesive Capsulitis)45-60 y/o (if cause other than trauma)
Atraumatic instability10-35 y/o
Calcium deposits20-40 y/o
Cervical spondylosisabove 50 y/o
Chondrosarcomaover age 30

Possible Peripheral Nerve Involvement

Spinal Accessory NerveInability to ABduct arm BEYOND 90 (b/c it innervates the Trapezius). Pain at shoulder on ABductionA&A = AB-duction issues
Long Thoracic NervePain on FLEXING fully extended arm. Inability to FLEX full extended arm. Winging starts at 90 degree forward FLEXION
Suprascapular NerveIncreased pain on forward shoulder FLEXION. Shoulder weakness (partial loss control). Pain increases with scapular ABduction. Pain increased with cervical rotation to OPPOSITE side
Axillary (Circumflex) NerveInability to ABduct arm with NEUTRAL rotation A&A = AB-duction issues
Musculocutaneous NerveWeak elbow FLEXION with forearm SUPINATED

Clinical Signs & Symptoms in Shoulder Pathology

FindingProbable Diagnosis
Scapular winging, trauma, recent viral illnessSerratus anterior or Trapezius dysfunction
Seizure and inability to passively or actively rotate affected arm externallyPosterior shoulder dislocation
Supraspinatus/Infraspinatus wastingRotator cuff tear; suprascapular nerve entrapment
Pain radiating below elbow; decreased cervical ROMCervical disc disease
Shoulder pain in throwing athletes; anterior Glenohumeral joint pain & impingementGlenohumeral joint instability
Pain or "clunking" sound with overhead motionLabral disorder
Nightime shoulder painImpingement
Generalized ligamentous laxityMultidirectional instability

Shoulder Special Tests

TestManeuverDiagnosis suggested by Positive Test
Apley scratch testPatient touches superior and inferior aspects of opposite scapulaLoss of ROM = Rotator Cuff problem
Drop-arm testpassively ABducting the patient's shoulder, then observing as patient slowly lowers the arm to the waist.Rotator cuff TEAR (if arm drops to the side)
Neer's signarm is fully pronated, then placed into forced flexionSubacromial IMPINGEMENT of S-I-T-S tendons (impingement of the rotator cuff tendons under the coracoacromial arch)
Hawkins' testForward flexion of the shoulder to 90 degrees, then forcible INTERNALLY rotatedSupraspinatus tendon IMPINGEMENT (subacromial impingement or rotator cuff tendonitis)
Full Can TestPatient's arms are held at 90 degrees of shoulder ABduction with thumbs up. Operator applies downward pressure against patient's resistance.Supraspinatus weakness
Empty Can TestThe patient's arms are held at 90 degrees of shoulder flexion, intenral rotation (thumbs down) and 30 degrees of horizontal adduction....operator applies a downward pressure against patient's resistancepain/weakness with Supraspinatus
Cross-arm testThe patient elevates (flexes) the affected shoulder to 90 degrees, then actively adducts itAcromioclavicular joint arthritis
Spurling's testSpine extended with head rotated to affected shoulder while axially loadedCervical nerve root disorder
Apprehension testThe patient's arm is ABducted to 90 degrees, while the examiner EXTERNALLY rotates the arm & applies anterior pressure to the humerusAnterior glenohumeral instability
Relocation testPosterior force on humerus while externally rotating the armAnterior glenohumeral instability (if a decrease in pain/apprehension following a positive Apprehension test)
Sulcus signPulling downward on elbow or wrist while observing the shoulder area for a depression lateral or inferior to the acromion.INFERIOR glenohumeral instability (if there is a presence of a depression upon testing)
Yergason testElbow flexed to 90 degrees with forearm pronated --> Examiner resists the patient's active attempts to supinate the arm and flex the elbowBiceps tendon instability or tendonitis
Speed's maneuverThe patient's elbow is flexed 20-30 degrees with the forearm in supination and the arm in about 60 degrees of flexion. The examiner resists forward flexion of the arm while palpating the patient's biceps tendon over the anterior aspect of the shoulder.Biceps tendon instability or tendonitis...used to examine the proximal tendon of the long head of the biceps
"Clunk" signRotation of loaded shoulder from extension through forward flexionLabral disorder
Load & Shift TestGrasp the humeral head & stabilize the shoulder. Seat the humerus on the glenoid fossa & push anterior and posteriorly to check for instabilityGlenohumeral Capsular Laxity/Instability (AC joint sprain & separation, aka Shoulder separation)

Muscles responsible for Shoulder Motions

MotionMuscles Involvedmnemonic
FlexionBiceps brachii, Pectoralis Major, Anterior Deltoid, CoracobrachialisP CAB
ExtensionPosterior Deltoid, Latissimus dorsi, Teres major, Teres minor, Pectoralis major (sternocostal fibers)m/m TIP PL
Lateral ABductionSupraspinatus (0-15 deg.), Middle Deltoid (15-90 deg.), Trapezius & Serratus anterior (>90 deg.), [Infraspinatus, Subscapularus, Teres minor, Long head of biceps (= trick movement)]
Trick movement (circumvent limitations of MSK paralysis in ABduction if arm is laterally/externally rotated first)Infraspinatus, Subscapularus, Teres minor & Long head of bicepsminor LIST
Horizontal ABductionPosterior deltoid, Teres major, Teres minor & Infraspinatusm/m TIP
ADductionPectoralis major, Latissimus dorsi, Teres major, Subscapularismajor T PSL
Medial (Internal) RotationSubscapularis (when arm is by the side), Pectoralis major, Latissimus dorsi, Teres major & Anterior deltoidmajor T PAL
Lateral (External) RotationInfraspinatus, Posterior deltoid, and Teres minorminor TIP

Spencer Technique for Shoulder Girdle

1Shoulder Extension with Elbow Flexed
2Shoulder Flexion with Elbow Extended
3Circumduction with Slight Compression & Elbow Flexed
4Circumduction and Traction with Elbow Extended
5aABduction with Elbow Flexed
5bADduction and External Rotation with Elbow Flexed
6Internal Rotation with Arm ABducted, Hand behind Back
7Distraction, Stretching Tissues, and Enhancing Fluid Drainage with Arm Extended