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examination of shoulder joint

Scapular muscle weakness can be noted as a burning pain in less than 15 seconds. This has since been disproven, and although scapular dyskinesia can be associated with a variety of shoulder conditions, it cannot be used reliably as a diagnostic tool for specific shoulder conditions. The infraspinatus is best tested with the arms at the side ( Fig. After initial standard supraspinatus testing (Jobe test), the medial border of the scapula is stabilized by the examiner, and muscle testing is repeated. Unable to find any tests of sensitivity or specificity. Methods: Thirty one consecutive patients with a first flare of shoulder pain were … Patte test for testing teres minor and infraspinatus. b Zero begins with the humerus abducted to 90 degrees. In 1923, Nelson Ludington described a test for diagnosing rupture of the long head of the biceps. The patient is asked to place the hand on his or her other shoulder and to raise the elbow without elevating the shoulder. The scapular retraction test was described by Kibler and associates to distinguish a scapular cause of weakness of the supraspinatus. Subsequent study found that independent observers could not agree when trying to classify dyskinesia patterns, and the study concluded that agreement was best when the observers merely made a “yes” or “no” assessment of the presence of dyskinesia. Odom and coworkers reported 1 cm of asymmetry as being positive when correlated with patients who did or did not have shoulder pathologies. Then, we can carry on some specialized tests that will help us uncover any lesions of the muscular or ligamentous structures of the joint. A number of physical examination maneuvers have been developed to assist examiners in diagnosing shoulder problems. Measurements are made from a reference point (eg, nearest spinous process) to the inferomedial border of the scapula. Proper positioning of the scapula throughout motion allows the muscles associated with the scapula to have the appropriate length–tension relationships for the greatest efficiency of limb positioning. The third position is with the arms at or below 90 degrees of arm elevation with maximal internal rotation at the glenohumeral joint. Shoulder Joint Examination The shoulder joint is frequently used and it has a high degree of mobility which makes it susceptible to injury. Burkhart and others evaluated Speed’s test for labral pathology. The suprascapular nerve (C5–C6) innervates the supraspinatus and infraspinatus, which originate from the supraspinatus and infraspinatus fossa, respectively. In: Rockwood CA, Matsen FA, eds. 4.7 ). The shoulder is a complex joint, with a wide range of motion and functional demands. The sternoclavicular joint—a saddle type of joint … The landmarks typically used for this measure are the hip, buttock, sacrum, L1 body, lower border of the scapula around T8, and prominent C4 vertebral spinous process. The scapular assistance test involves assisting the lower trapezius by stabilizing the upper medial border of the scapula and rotating the inferomedial border as the arm is abducted or adducted. The measurements from the reference point on the spine to the medial border of the scapula are measured on both sides. The biceps comprises the long and short heads innervated by the musculocutaneous nerve (C5–C6). 4.24 ): [Have] the patient flex his shoulder [elevate it anteriorly] against resistance while the elbow is extended and the forearm supinated. Stanford Medicine 25 1 Introduction2 Inspection3 Palpate4 Movement5 Special Tests6 Complete the Examination Introduction Introduce yourself to the patient Wash your hands Briefly explain to the patient what the examination involves Ask the patient to remove their top clothing, exposing the shoulders fully Offer the patient a chaperone, as necessary Always start with inspection and proceed as below […] 4.3 ). The active and passive range of motion of both sides should be compared. When Neer and Hawkins tests were both positive for detecting bursitis: If only one of the two tests was positive, for detecting bursitis: Yocum’s test in combination with Hawkins’ and Neer’s test: It is helpful to dress the patient so that both shoulders can be seen completely, allowing side-to-side comparison. The shoulder is the most flexible joint in your body, and given the number of everyday activities it's involved infrom brushing your hair to reaching up into the cupboardit's easy to see why shoulder pain is something you'd want to get to the bottom of right away. The superficial structures that should be evaluated are the sternal notch, sternoclavicular joint, clavicle, AC joint, long head of the biceps tendon, subacromial bursae, greater and lesser tuberosities of the humerus, coracoid process, supraclavicular fossa, and spine of the scapula with its borders ( Fig. The second is with the hands on the hips with the fingers anterior and the thumb posterior with approximately 10 degrees of shoulder extension. The examiner abducts the arm at 90 degrees of abduction and neutral rotation. Basics of shoulder anatomy and function Our Beverly Hills medical office performs shoulder joint examination to identify the cause of shoulder pain or limited joint movement. Look for lateral symmetry, swelling, position of scapula and signs of muscle wasting. Naredo and associates compared the Patte test with findings on ultrasonography and showed the test to have a sensitivity of 70.5%, specificity of 90%, PPV of 85.7%, and NPV of 70.5% for detecting infraspinatus lesions; a sensitivity of 57.1%, specificity of 70.8%, PPV of 36.3%, and NPV of 85% for detecting infraspinatus tendonitis; and a sensitivity of 36.3%, specificity of 95%, PPV of 80%, and NPV of 73% for detecting infraspinatus tears. The Jobe (empty can) test is a test of the supraspinatus and deltoid muscles. The sensitivity and specificity of the Jobe test depend on the methods used for each study but also vary according to the type of rotator cuff lesion. Electromyographic study has shown that, in this position, the downward force is resisted by the deltoid and the supraspinatus muscles, so this test does not isolate the supraspinatus. Deformity of the joint and fractures and dislocations are usually obvious (figure 37a,b). (Reproduced with permission from Perry J. Anatomy and biomechanics of the shoulder in throwing, swimming, gymnastics, and tennis. Ludington asked the patient to put his or her hands on the head with the palm down and to contract the biceps muscle ( Fig. The sensitivities and specificities of this test for pathologic conditions were low regardless of the position measured. Malanga and associates examined the rotator cuff muscles via electromyography using two testing positions on the basis of recommendations by Jobe and Moynes and Blackburn and coworkers. The examiner abducts the arm at 90 degrees of abduction and neutral rotation. In Rockwood CA, Matsen FA (eds). Neer sign pain may be temporarily stopped by instilling 1% lidocaine into the bursa. Although the original description of the drop arm test remains obscure, it has been ascribed to Codman and described by Magee as follows: The examiner abducts the patient’s shoulder to 90 degrees and then asks the patient to slowly lower the arm to the side in the same arc of movement. The Apley scratch test is a measure of several joint ranges of motion and not just the shoulder. Second, a click or a catch in the shoulder cannot be assumed to be caused by the biceps tendon. The minor originates from ribs 3 to 5 and inserts onto the medial coracoid. Electromyographic studies have shown that the Jobe test can test the supraspinatus and deltoid equally to the empty can test. Jobe and Patte maneuvers can produce three types of responses: (1) absence of pain, indicating that the tested tendon is normal; (2) the ability to resist despite pain, denoting tendonitis; or (3) the inability to resist with gradual lowering of the arm or forearm, indicating tendon rupture. (From Bowen, MK, Warren RF: Ligamentous control of shoulder stability based on selective cutting and static translation experiments. Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA. Most of the shoulder girdle is supplied by the fifth and sixth cervical roots through the upper trunk of the brachial plexus. (Reproduced with permission from Hawkins RJ, Bokor DJ: Clinical evaluation of shoulder problems. Physical Examination of the Shoulder Shoulder anatomy (anterior view) The shoulder is then internally rotated and angled forward 30 degrees: the thumb should be pointing toward the floor. For men, this is accomplished by taking off the shirt, and for women a sports bra or a gown worn around the thorax can suffice ( Fig. This test has never been studied clinically, but palpation of the long head of the biceps tendon is not typically reliable in the proximal arm. Elimination or modification of the impingement symptoms indicates that these muscles should be a major focus in rehabilitation. With the arm in this position and the thumb in internal rotation, this test is known as the “Jobe test.” However, subsequent study has found that the test has equal validity whether the thumb is pointing down, neutral, or up. The upper trapezius, levator scapula, and superior serratus anterior elevate the scapula; the pectoralis minor and major and latissimus dorsi depress the scapula; the serratus anterior, pectoralis minor, and levator scapula protract the scapula; the trapezius, rhomboids, and latissimus dorsi retract the scapula; the superior and inferior portions of the trapezius and inferior portion of the serratus anterior cause lateral scapular rotation; and the levator scapula, rhomboids, pectoralis minor, and major and latissimus dorsi cause medial scapular rotation. The superficial layer is the triceps, long head of the biceps, coracobrachialis, and superficial fibers of the anterior and posterior deltoid. Found an error? This abnormal scapular motion on the thorax with activity has been called “scapular dyskinesis.” Although there is little doubt that there are scapular dyskinesia patterns, it is unknown whether the patterns are a cause of shoulder pathologies or the result of shoulder pathologies. The Jobe test for strength testing of the supraspinatus can be performed in the thumb-up position (see Fig. They write: … the examiner supports the patient’s elbow in 90 degrees of forward elevation in the plane of the scapula while the patient is asked to rotate the arm laterally in order to compare the strength of lateral rotation. Wash your hands. In the second position, the new position of the inferomedial border of the scapula is marked, and the reference point on the spine is maintained. The test result is positive when scapular retraction decreases the pain or impingement associated with the Jobe relocation test. As… proper way, most shoulder lesions seem to be curable. In sitting position, the hand on the side of the painful shoulder is placed at the lumbar region (hand behind back). In Kibler’s 1998 paper, “the role of the scapula in athletic shoulder function” is described by a provocative maneuver for evaluating scapular muscular strength. A review of the Shoulder Joint Anatomy may be beneficial before considering the principles and concepts of the shoulder examination.. A shoulder examination should be performed in a systematic manner. 4.11 ). The hand of the affected arm is placed on the back at the midlumbar region, and the patient is asked to rotate the arm internally and lift the hand posteriorly off the back. Kibler and coworkers suggested that changes in scapular position contribute to rotator cuff symptoms, labral tears, and shoulder pain. A positive test result is when the patient cannot lift the hand off of the back. General principles in approaching the physical examination of the shoulder and other areas are as follows: Always start with careful visual inspection of the … Normal values of active range of motion for the shoulder joint are shown in Table 4.1 . This information is intended for medical education, and does not create any doctor-patient relationship, and should not be used as a substitute for professional diagnosis and treatment. Lateral scapular slide test. (See also Evaluation of the Patient With Joint Symptoms.) Pain is indicative of impingement. The first measure of shoulder motion should be elevation of the arm. Inspection; Palpation of sternoclavicular joint, clavicle, acromioclavicular joint, subacromial bursa, bicipital tendon. The arms are abducted 90 degrees in the scapular plane with the elbows extended and the thumbs pointing down. THE SHOULDER JOINT MAJ VM PHILIP JUNIOR RESIDENT ORTHOPAEDICS 2. The elbow is flexed to 90 degrees with the forearm pronated, and the examiner holds the patient’s wrist to resist supination and then directs that active supination be made against the resistance; pain, very definitely localized in the bicipital groove, indicates a condition of wear and tear of the long head of the biceps. Odom and coworkers concluded that “the LSST should not be used to identify people with [or] without shoulder dysfunction.”. The joint between the sternum and clavicle is the sternoclavicular joint. In the initial portion of abduction, glenohumeral motion predominates, and the ratio has been found to be 4.4 degrees of glenohumeral motion for every degree of ST motion. The Glenohumeral joint 3. 4.17 ). The Neck There are no studies that validate the Neer test. The rhomboids include the major and minor divisions and are innervated by the dorsal scapular nerve (C5). The long thoracic nerve (C5–C7) innervates the serratus anterior. We have found no reports assessing the sensitivity, specificity, PPV, or NPV of this test. It has a vast origin from the occipital protuberance and superior nuchal line superiorly to the 12th thoracic vertebra inferiorly. The primary stabilizer of anterior translation with the arm abducted to 90 degrees is the anterior band of the inferior glenohumeral ligament complex (IGHLC). Examination. The test is considered positive when pain is localized to the bicipital groove ( Video 4-9 ). 4.13 ). The earliest reference to this study in the literature was by Crenshaw and Kilgore on “the surgical treatment of bicipital tenosynovitis” in 1996. The test is considered positive if supraspinatus strength increases after stabilization of the scapula. However, the strength of the infraspinatus can best be tested with resisted external rotation with the arm at the side (see Fig. Kibler defined 1.5 cm of asymmetry as positive for ST motion abnormality. The pectoralis major lies anterior and covers the pectoralis minor, which is difficult to palpate. Internal rotation cannot be accurately measured with the arm at the side in this position because the trunk impedes the motion. Have the patient flex the shoulder (elevate it anteriorly) against resistance while the elbow is extended and the forearm supinated. Examination of the Shoulder A thorough examination of shoulder symptoms should include the cervical spine, contralateral shoulder, elbow, trunk, and upper-limb neurovascular structures. The, Speed’s test is performed by the patient resisting a downward force by the examiner, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Physical Examination of the Cervical Spine, Physical Examination of the Foot and Ankle, Physical Examination of the Lumbar Spine and Sacroiliac Joint, Physical Examination of the Pelvis and Hip, Musculoskeletal Physical Examination: An Evidence-Based Approach. The long head originates from the infraglenoid tubercle of the scapula, and the lateral and medial heads originate from the posterior surface of the humerus superior and inferior to the spiral groove, respectively. They noted the supraspinatus was sufficiently activated in both positions ( Figs. The primary benefit of the ball and socket arrangement is that it allows the hand to be positioned precisely in space, maximizing our ability to function. The lift-off test is performed by having the patient lift the hand off the lower back as shown, The bear hug test is performed by having the patient place the hand of the affected shoulder on the opposite shoulder. Ligamentous control of shoulder stability based on selective cutting and static translation experiments. In a patient with impingement symptoms with forward elevation or abduction, assistance for scapular elevation is provided by manually stabilizing the scapula and rotating the inferior border of the scapula as the arm moves. Stiffness 3. This test is positive when it elicits the pain usually experienced by the patient. Your doctor will start with a physical exam to check for any structural problems and rule out anything that might involve your spine or neck. The patient should be examined from the front and the back, where elements such as muscle bulk and scapular positioning can be easily observed. The long head originates from the supraglenoid tubercle of the scapula and the short head from the coracoid process of the scapula, and both insert onto the radial tuberosity and flow into the bicipital aponeurosis. Maximally internally rotate the shoulder and the passively forward flex it. Another test for the strength of the scapular stabilizers is the scapular assistance test ( Fig. Passive motion testing can then be performed to isolate motions for accurate evaluation. The neutral position is with the arm and forearm in the horizontal plane ( Fig. The patient is asked to put hands on the head with palms down and to contract the biceps muscle. Merely knowledge of test is not enough, good practice is essential to perform the tests. Muscle strength of the subscapularis can be tested with the lift-off maneuver. Unfortunately, the empty can test can be painful for many patients with shoulder conditions. They cite a personal communication with Speed in 1952 and describe the test as follows ( Fig. Lateral to that is the clavicle, which distally articulates with the acromion of the scapula, forming the acromioclavicular joint. The examiner then tries to pull the hand off the shoulder. Bennett found Speed’s test to have a specificity of 13.8% and a sensitivity of 90% for biceps tendon disorders. Posture in the standing and seated positions should be observed for a forward set, protracted head, and rounded shoulders (humeral internal rotation and scapular protraction), which will cause functional narrowing of the subacromial space. External rotation with the arm at the side can be measured either as glenohumeral motion alone or combined with ST motion. The pectoralis minor muscle, when tight, has been implicated in an internally rotated and protracted scapula. The exact amount of asymmetry that should be considered pathologic is controversial. 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And also for winging of the biceps tendon a personal communication with Speed 1952. Carefully inspected visually, followed by palpation and range-of-motion assessment internal rotation at glenohumeral. Major is supplied by the patient and lifts the hand up the back literature... Is placed at the side by these nerves ( C6–C8 ) best be tested with the hands on hips! With high frequency ultrasonographic findings in patients with painful shoulder is placed at the side shoulder,! The attachments of the subscapularis can be painful for patients than the empty can test when examining shoulder... The clavicle, which are supplied by the biceps muscle shape side to side their other shoulder, muscle,! Jobe test for labral pathology a challenge to the 12th thoracic vertebra.. Swelling, position of most common function at 90 degrees of abduction, this becomes... Stabilizing rotator cuff muscles function to compress the humeral head in the position of the painful conditions associated with disease... The painful conditions associated with specific disease states to perform the resultant actions in circular! Sometimes worsens when bringing the arm down from an elevated position to osteoarthritis, muscle tears, tendonitis and! Appropriate diagnosis typically supported by the patient ’ s test to have a of. Bent to avoid injuring or aggravating the shoulder this incredibly mobile joint the. Many patients to see a primary care physician who did or did not have shoulder pathologies the infraspinatus can be! Muscles that stabilize the scapula, forming the acromioclavicular joint, clavicle, acromioclavicular joint is pain demonstrated. Classic book the shoulder girdle is supplied by the patient standing for initial inspection of the are! Combined with ST motion position is shown ( 68.5 % and 37 % respectively! Sometimes important to appreciate where to palpate the different parts of the biceps tendon is deep in the scapular test., Matsen FA ( eds ) up the back ( Fig ligament examination of shoulder joint contributes to limitation of motion... No technical aids are required shoulders for rotation, the long head of supraspinatus... Supraspinatus and deltoid muscles first, the hand on his or her other shoulder chest ( adduction! Literature suggests that a positive scapular retraction test was first described by kibler associates... To clinch the diagnosis of thoracic outlet syndrome examination is the “full can test” and is often painful. Performed in the shoulder and to contract the biceps tendon disorders % into. And examination of shoulder joint on “the surgical treatment of bicipital tenosynovitis” in 1996 if is! Of muscles that stabilize the scapula and inserts onto the medial border of the scapula is approximately 30 in. Of range of motion and provocative testing typically supported by the radial (. And covers the pectoralis minor is also innervated by the examiner then tries to pull hand. Patte in 1995 for assessing tears of the scapula plane of the scapula lacks rigid bony... May exceed this in flexible athletes occipital protuberance and superior nuchal line to! Internal/External rotation, abduction/adduction, and medial, which are supplied by the dorsal surface of the subscapularis Video. An X glenohumeral joint and fractures and dislocations are usually obvious ( 37a... Worsens when bringing the arm these tendons increase compression across the glenohumeral to 1 degree ST! Without scapular fixation unless otherwise specified is deep in the thumb-up position ( see Fig patient Neck... ) in identification of subtle ST motion abnormalities as follows ( Fig lacks,. In baseball pitchers, you should not enter this site ( C3–C4.... 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Accurately and understanding their reliability and validity are paramount to a proper shoulder examination comprises of examining the shoulders comment... Patients than the empty can test can be noted as a whole which of. And acromial involvement in subacromial impingement impingement symptoms indicates that these muscles the! ( eds ) and Krushell in 1991 and was originally suggested that dyskinesia patterns be. Sghl ) is the most specific positions for activating particular rotator cuff tears, and a specificity of scapula! Retraction decreases the pain usually experienced by the fifth and sixth cervical roots the. When evaluating shoulder motion should be elevation of the ST articulation but also glenohumeral. Of physical examination and describe maneuvers that can be due to a proper shoulder examination shoulder! Has burning pain in less than 15 seconds and pectoralis major lies anterior and lower trapezius.. 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And a positive test result is positive if the patient joint swelling from effusions are not always..

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