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Shoulder Problem Evaluation PowerPoint Presentation

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Slide 1-

Shoulder Problem Evaluation
Slide 2-

Shoulder assessment Second most common musculoskeletal complaint Difficult joint to examine Multidirectional range of motion- UNIQUE! Shoulder injury can affect nearly every sport and many daily activities
Slide 3-

Bony AnatomyAnterior
Slide 4-

Bony AnatomyAnterior and Posterior
Slide 5-

ppt slide no 5 content not found
Slide 6-

Manual of Structural Kinesiology The Shoulder Girdle 4-6 Bones Scapula & clavicle Move as a unit Clavicle’s articulation with sternum is only bony link to axial skeleton
Slide 7-

Manual of Structural Kinesiology The Shoulder Girdle 4-7 Bones Key bony landmarks Manubrium Clavicle Coracoid process Acromion process Glenoid fossa Lateral border Inferior angle Medial border
Slide 8-

Manual of Structural Kinesiology The Shoulder Girdle 4-8 Bones Key bony landmarks Acromion process Glenoid fossa Lateral border Inferior angle Medial border Superior angle Spine of the scapula
Slide 9-

Radiographic Anatomy
Slide 10-

6 Articulations or Joints Coraco Clavicular Sterno Clavicular Acromio Clavicular Gleno Humeral Scapulo Thoracic Sub Acromial Space
Slide 11-

Coraco Clavicular
Slide 12-

Sterno Clavicular
Slide 13-

Acromio Clavicular
Slide 14-

A/C Joint Grade 1+ A/C Separation
Slide 15-

Gleno Humeral
Slide 16-

Scapulo Thoracic
Slide 17-

Sub Acromial
Slide 18-

Where do things go wrong??Fractures
Slide 19-

Where do things go wrong??Dislocations and Separations Dislocations and separations are protected by both “static” and “dynamic” stabilizers…
Slide 20-

Where do things go wrong??Dislocations and Separations Oh, yeah…Arthritis can happen at these joints, too…
Slide 21-

Voluntary Posterior Subluxation
Slide 22-

Glenohumeral Joint Shallow (“golf ball sitting on a tee”) Inherently unstable (maximizes ROM) Static stabilizers glenohumeral ligaments, glenoid labrum and capsule Dynamic stabilizers Predominantly rotator cuff muscles Also scapular stabilizers Trapezius, leavator scapulae, serratus anterior, rhomboids
Slide 23-

Bony Anatomy“Static Stabilizers”
Slide 24-

What goes wrong…Besides separations and dislocations?? Instability!!!
Slide 25-

LABRUM
Slide 26-

What goes wrong?Tears and tendonopathies
Slide 27-

The Rotator Cuff Muscles Supraspinatus Infraspinatus Teres minor Supscapularis
Slide 28-

The Rotator Cuff Muscles: SITS Supraspinatus ABD Infraspinatus ER Teres minor ER Supscapularis IR Depress humeral head against glenoid to allow full abduction
Slide 29-

Finally…the subacromial space
Slide 30-

What can go wrong??? Impingement!!!!!!!
Slide 31-

Impingement
Slide 32-

Picture 6: Rotator Cuff MRI
Slide 33-

Shoulder Complex Muscles Scapular Muscles
Slide 34-

Levator Scapulae O – Transverse processes of C1-C4 I – Medial border of scapula between superior angle and root of spine of scapula N – Nerve root C3-5 F scapular elevation retraction
Slide 35-

Rhomboid Major O – Major – T2-T5 spinous processes Minor – Ligamentum nuchae, C7-T1 spinour processes I – Major – Medial borde of scapula between spine and inferior angle Minor – medial border at root of spine of scapula N – Dorsal Scapular
Slide 36-

Upper Trapezius O – Occiptal protuberance Medial 1/3 of nuchal line Upper part of ligamentum nuchae C7 spinous process I – Posterior border of lateral 1/3 of clavicle Acromion process N – spinal accessory F – Scapular elevation, retraction Rotation of head to opp. Side Lateral flexion of head to opp. side
Slide 37-

Middle Trapezius O – Inferior part of ligamentum nuchea T1-T5 spinous processes I – Medial margin of acromion process Superior lip of spine of scapula N – Spinal accessory F – Scapular retraction
Slide 38-

Lower Trapezius O – T6-T12 spinous processes I – Tubercle at apex of root of spine of scapula N – spinal accessory F – Scapular depression, retraction and upward rotation
Slide 39-

Serratus Anterior O – Outer surfaces and superior border of ribs 1-8 I – Ventral scapular surface on medial border from superior angle to inferior angle N – Long Thoracic F – Scapular protraction, upward rotation Scapular depression (lower fibers) Scapular elevation (upper fibers
Slide 40-

Pectoralis Minor O – Superior margins and outer surface ribs 3-5 near cartilages Fascia overlying corresponding intercostal muscles I – Medial border, superior surface of coracoid process N – Medial Pectoral F – Scapular depression, downward rotation, protraction
Slide 41-

Glenohumeral Muscles
Slide 42-

Biceps Brachii O Short head – coracoid process Long head – supraglenoid tubercle of scapula I – Radial tuberosity Biceps brachii aponeurosis N – Musculocutaneous F – Shoulder – flexion Elbow – flexion, forearm supination
Slide 43-

Coracobrachialis O – Coracoid process I – Medial surface of mid-humerus, opposite to deltoid tuberosity N –Musculocutaneous F – GH flexion, adduction, Hor. Adduction
Slide 44-

Pectoralis Major O – Sternal – anterior surface of sternum, cartilages of ribs 1-6 or7 Clavicular – anterior surface of sternal ½ clavicle I – crest of humerus’s greater tuberosity N – Sternal – medial pectoral Clavicular – lateral pectora F – GH ADD, H. ADD and IR
Slide 45-

Anterior Deltoid O – Anterior border, superior surface of lateral third of clavicle I – Deltoid tuberosity N – Axillary F – GH H. ADD, flexion IR when in supine position
Slide 46-

Middle Deltoid O – Lateral margin and superior surface of acromion I – Deltoid Tuberosity N – Axillary F – GH ABD
Slide 47-

Posterior Deltoid O – Inferior lip of posterior border of spine of scapula I – Deltoid tuberosity N – Axillary F – GH extension, H. ABD, ER when in prone position
Slide 48-

Triceps Brachii O – Long Head – infraglenoid tubercle Lateral Head – lateral and posterior surface of proximal ½ of body of humerus Medial Head – distal 2/3 of medial and posterior surfaces of humerus below radial groove I – Posterior surface of olecranon proess N – Radial F – Shoulder – long head – Ext and ADD Elbow -- extension
Slide 49-

Latissimus Dorsi O – Posterior layer of lumbodorsal fascia, then attaching to the T6-T12, lumbar and sacral vertabrae External lip of iliace creast lateral to erector spinae Ribs 9-12 Slip from inferior angle of scapula I – Intertubercular groove (distal aspect) N – Thoracodorsal F – GH IR, ADD, Ext,
Slide 50-

Teres Major (Lat’s Little Helper) O – Dorsal surface of inferior angle Lower 1/3 of scapula lateral border I – Crest of lesser tuberosity N – Lower Subscapular F – GH IR, ADD, Ext
Slide 51-

Rotator Cuff
Slide 52-

Suprspinatus O – Medial 2/3 supraspinatus fossa I – Superior portion of greater tuberosity N – Suprascapular F – Intiates shoulder ABD Humeral head stabilization
Slide 53-

Infraspinatus O – Medial 2/3 infraspinatus fossa I – Middle portion of greater tuberosity N – Suprascapular F – GH ER Humeral head stabilization
Slide 54-

Teres Minor O – Upper 2/3 dorsal surface of lateral border of scapula I -- Lowest portion of greater tuberosity N – Axillary F – GH ER Humeral head stabilization
Slide 55-

Subscapularis O – Subscapular Fossa I – Lesser tuberosity Anterior capsule of GH joint N – Upper and lower subscapular F – GH IR Humeral head stabilization
Slide 56-

Basic Shoulder Complex Mechanics
Slide 57-

Performing Abduction Initiation Scapulohumeral Ryhthm First 30 degrees > 30 degrees Clavicle
Slide 58-

So…what causes shoulder pain? Impingement Labrum and biceps pathology A-C joint pathology Rotator Cuff Injury Instability Among other things…
Slide 59-

Clinical ExamHistory Pain Acute Chronic Weakness Deformity
Slide 60-

Clinical ExamHistory Single event Repetitive overload Instability Does it feel like it’s going to come out? Catching/Locking
Slide 61-

Clinical ExamHistory Sport / Occupation Previous injury Previous treatment Other joints involved Disability
Slide 62-

Physical Exam: Big 6 Inspection Palpation Range of Motion Strength Neurovascular Special Tests
Slide 63-

Special Tests Impingement Rotator Cuff Integrity Labrum and Biceps AC (SC) Joints Instability
Slide 64-

Throwing Mechanics Arm Cocking Phase Begins Ends
Slide 65-

Throwing Mechanics Arm Acceleration Begins Ends
Slide 66-

Throwing Mechanics Follow-through Begins Ends
Slide 67-

Pathomechanics of Throwing Shoulder Rotator Cuff Labrum Impingement SLAP Lesion
Slide 68-

The Shoulder Girdle Common problems of the Shoulder Arthritis, tendinitis, Dislocation- joint slips out of place ie, the bones move from their normal position. D/T: blow, fall, trauma Subluxation- incomplete or partial dislocation. D/T: same as above
Slide 69-

Case #1 22-year-old male rugby player falls onto his right shoulder while being tackled Severe pain on top of his right shoulder
Slide 70-

Case #1 Notable deformity over superior shoulder Painful range of motion Unable to lift right arm above waist Special Tests?? Diagnosis???
Slide 71-

Acromioclavicular (A-C) Sprain Special Tests Shear Test Cross Arm Test A-C Palpation Resisted Extension Active compression test
Slide 72-

Acromioclavicular (A-C) Sprain Damage to A-C joint ligaments Pain and/or deformity over A-C joint Graded I-VI I-III usually treated non-operatively IV-VI referred to orthopedic surgery
Slide 73-

AC Joint Sprain Treatment Analgesics, ice prn Sling for as long as needed Physical Therapy ROM restoration Gradual strength exercise Return to sport activity as tolerated
Slide 74-

Case #2 24-year-old male handball player Fell onto his shoulder after being pushed Intense pain Hand is tingling and arm feels like it’s hanging X-rays
Slide 75-

X RAYS DIAGNOSIS???
Slide 76-

Shoulder Dislocation/Anterior Instability Humeral head dislocates from glenoid fossa Almost always anterior (95%) Usually traumatic with injury to capsule-labrum complex
Slide 77-

Shoulder Dislocation/Anterior Instability Treatment Reduction of dislocation Protection & rehab, rehab, rehab Most will have future dislocations and/or instability At least 70%!!! (young) May require surgical tightening/repair of the capsule/labrum complex
Slide 78-

Special TestsGlenoid Labrum and Instability Biceps Load I and II Kim Test Jerk Test Active-Compression Test (O’Brien) Crank Test Apprehension Test Relocation Test Load and Shift Sulcas Sign
Slide 79-

Which of the following structures can be “impinged”? 10 Biceps tendon Subacromial Bursa Rotator Cuff Tendons All of the above 0 0 30
Slide 80-

Case #3 35-year-old male tennis player Shoulder pain exacerbated by practicing serves Develops dull, aching pain in right shoulder
Slide 81-

SHOULDER PAINPhysical Exam Tenderness to palpation anterior shoulder Pain with abduction starting around 90 degrees Unable to lift arm past 120 degrees Pain with forward flexion at 90-120 degrees Special Tests??? Diagnosis???
Slide 82-

Shoulder PainPhysical Exam Hawkin’s positive Neer’s positive IMPINGEMENT???
Slide 83-

Impingement as a Clinical Sign Repetitive overhead activities Subacromial bursa and/or rotator cuff impinged between acromion & humerus Physical therapy, activity modification +/- medications
Slide 84-

Diagnoses associated with clinical sign of Rotator Cuff Impingement: Subacromial bone spurs and / or bursal hypertrophy AC joint arthrosis and /or bone spurs Rotator cuff disease Superior labral injury Glenohumeral instability Scapular dyskinesis Biceps tendinopathy A diagnostic injection sometimes helps to clarify the diagnosis
Slide 85-

Case #4 45-year-old weight lifter Caught bar as it was falling off his shoulder Sudden pain Severe weakness left shoulder Worse with overhead activities; while sleeping at night Pain in anterior lateral shoulder Special tests?
Slide 86-

Case #4 Drop Arm Test Positive External Rotation Lag Sign positive Weakness with Empty Can Sign Normal bear hug and belly press tests… Diagnosis?????
Slide 87-

Rotator Cuff Tear Supraspinatus tendon most common Acute trauma or chronic tendinopathy Treatment dependent upon age/activity Young, active usually require operative treatment Older, low-activity usually respond to non-operative treatment
Slide 88-

Case #5 42-year-old female with dull pain right shoulder Pain is diffuse in nature Sometimes spreads to between shoulder blades Seems worse at night
Slide 89-

Physical Exam Obese, pleasant female Diffuse pain Normal shoulder exam Not able to reproduce pain during exam What else do you want to do???
Slide 90-

Shoulder pain isn’t always the shoulder!!Get more history… Gall bladder disease Peptic Ulcer Disease Cervical radiculopathy Cardiac ischemia Pulmonary conditions ie Pancoast’s tumor, Pneumonia
Slide 91-

In the human body, which is the most incredible joint? PIP Knee Ankle Shoulder None of the above
Slide 92-

Case #6 40-year-old male Recently shoveled 16” of snow Can hardly lift left arm due to pain Special Tests? Diagnosis?
Slide 93-

Biceps Tendonopathy Speed Test Yergason Test Direct palpation
Slide 94-

Biceps Tendonopathies Repetitive overhead activity Repetitive forearm flexion/supination Difficult to discern from rotator cuff tendinopathy or impingement
Slide 95-

Conclusion Shoulder injuries are common. Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis. Impingement is a clinical sign, not a diagnosis. Don’t forget about medical causes.
Slide 96-

QUESTIONS?
Slide 97-

Physical ExamInspection Front & back Height of shoulder and scapulae Muscle atrophy, asymmetry
Slide 98-

Physical Exam Range of Motion Abduction 0-180o
Slide 99-

Physical Exam Range of Motion Forward flexion: 0o – 180o
Slide 100-

Physical Exam Range of Motion Extension 0o – 40 to 60o
Slide 101-

Physical Exam Range of Motion Internal rotation T5 segment External rotation 80-90o
Slide 102-

Physical Exam Strength Empty can test 30o angle Steady downward pressure Tests supraspinatus strength and pain
Slide 103-

Physical Exam Strength Resisted external rotation Tests infraspinatus, teres minor strength
Slide 104-

Physical Exam Strength of Subscapularis Liftoff test Belly press test
Slide 105-

Cross-Arm Adduction Test AC joint pathology Arm flexed to 90° Hyperadduct arm across body as far as possible Pain in AC = (+) test
Slide 106-

A-C Shear Test Interlock fingers with hand on distal clavicle and spine of scapula Pain in A-C joint when hands squeezed together = (+) test
Slide 107-

Sulcus Sign Inferior instability Arm relaxed in neutral position, pull downward at elbow (+) test = sulcus at infra-acromial area compare to unaffected side
Slide 108-

Apprehension Test Anterior instability Shoulder at 90° abducted, slight anterior pressure & External rotation (+) test = dislocation apprehension some false (+)
Slide 109-

Relocation Test Perform after positive apprehension test Apply post force over humeral head during external rotation (ER) (+) test = increased ER tolerance
Slide 110-

Load & Shift Test Test for multidirectional instability Grasp humeral head, slide anteriorly and posteriorly while securing rest of shoulder (+) if greater than 50% displacement (graded 1-3)
Slide 111-

Impingement Signs Hawkins Neer
Slide 112-

Drop Arm TestSuggestive of Rotator Cuff Tear Passive abduction to 90° Instruct patient to slowly lower arm At 90° abducted arm will suddenly drop, may need to add slight pressure (+) drop = (+) test
Slide 113-

Speed’s TestBiceps Tendinopathy Long head of biceps tendonitis Fwd flex to 90°, abd 10°, full supination Apply downward force to distal arm Pain = (+) test weakness w/o pain = muscle weakness or rupture
Slide 114-

O’Brien’s Active CompressionSLAP lesion (Superior Labrum Antero-Posterior) Labral/AC pathology Arm flexed to 90°, elbow extended, adduct 10-15°, resist downward force + if AC pain or internal pain/click
Slide 115-

O’Brien’s Active CompressionSLAP lesion Supination should be pain free (decreased pain)
Slide 116-

Crank TestLabral injury Glenoid labrum tear Abduct arm to 160°, pt is supine or upright, elbow secured with one hand axial load at shoulder with other (+) if audible/painful catch/grind is noted