Physical Therapy: Shoulder Joint Assessment

Sternoclavicular Joint

• The sternoclavicular joint is the only skeletal articulation between the upper extremity and the axial skeleton.
• It is a synovial stellar joint, with articular surfaces that lack congruity.
• The joint has a disc that completely separates the joint and attaches to the cartilage of the 1st rib and the capsule.
• The capsule is very lax, allowing for mobility, and ligaments are strong, providing stability.

Clavicle

• The clavicle is shaped like an italic 'f' and acts as a strut to the upper extremity, resisting compressive forces.
• The medial portion of the clavicle moves the least, while the main function of the clavicle is stability.

Scapula

• The scapula is a thin, flat triangular shape that provides a concave surface, allowing it to glide easily over the convex thorax and ribs.
• The scapula's functions include:
  • Increasing the positions available for the hand in space by varying the original position of the proximal humerus.
  • Providing stability for the upper extremity during functional activities of the hand.

Scapular Articulations

• There are four joints that make up the scapular articulations: sternoclavicular, acromioclavicular, scapulothoracic, and glenohumeral.
• All of these joints work together to provide simultaneous mobility and stability.

Acromioclavicular Joint

• The acromioclavicular joint is a synovial gliding joint with a lax capsule and strong ligamentous support.
• The joint allows the scapula to glide and the clavicle to rotate.
• The joint moves in a way that allows for 35 degrees of elevation and 45-50 degrees of rotation during full overhead elevation.

Scapulohumeral Rhythm

• The scapulohumeral rhythm is a concept that describes the coordinated movement of the scapula and humerus during arm elevation.
• The rhythm is essential for maintaining the orientation of the glenoid fossa with the humeral head to prevent impingement and shear forces.
• The scapula and humerus move in a 2:1 ratio, with the scapula contributing to about 60 degrees of elevation and the humerus contributing to about 120 degrees of elevation.

Rotator Cuff

• The rotator cuff is a group of muscles that surround the glenohumeral joint and provide dynamic stability.
• The muscles of the rotator cuff include the supraspinatus, infraspinatus, teres minor, and subscapularis.
• The rotator cuff works together to generate a force couple that depresses the humeral head and maintains the humeral head in the glenoid fossa.

Instability

• Instability can be classified into two categories: TUBS (Traumatic, Unilateral, Bankart, Surgery) and AMBRI (Atraumatic, Multidirectional, Bilateral, Rehabilitation, Inferior Capsular Shift).
• The direction of instability can be anterior, posterior, inferior, or multidirectional.
• The Bankart lesion is a common pathology associated with instability, where the periosteum and capsule of the IGHL/anterior labrum complex detach from the scapular neck and adhere to the overlying subscapularis tendon.

Labral Lesions

• Labral lesions are tears or detachments of the glenoid labrum, which can be classified into four types: Type 1 (degenerative/shredded), Type 2 (superior separation), Type 3 (bucket handle tear), and Type 4 (complete separation of the labrum and biceps tendon).
• The MOI of labral lesions is often related to throwing or falling, and the prevalence of labral lesions increases with age.

RTC Pathology

• Rotator cuff pathology is a common occurrence, especially in older adults.
• The pathology can be classified into three stages: tendinitis, partial tears, and full-thickness tears.
• The natural degenerative tendon change as we age, leading to an increased risk of rotator cuff tears.

Adhesive Capsulitis

• Adhesive capsulitis, also known as frozen shoulder, is a condition characterized by spontaneous onset of pain and gradual loss of active and passive shoulder motion.
• The pathology involves irritation of the GH synovium, chronic capsular inflammation, and capsular fibrosis and perivascular infiltration of adhesions into the lax folds of the anterior and inferior capsule.
• The treatment for adhesive capsulitis is often difficult and may involve a combination of physical therapy, steroid injections, and surgery.

GH Osteoarthritis

• GH osteoarthritis is a condition characterized by the loss of joint space, osteophytes, subchondral sclerosis, and subchondral cysts.
• The severity of GH osteoarthritis can be classified using the Kellgren-Lawrence scale or the Weinstein scale.
• The treatment for GH osteoarthritis often involves a combination of physical therapy, pain management, and surgery.### Shldr Pain Decision
• Tissue irritability guides intensity of physical stress
• Impairment type-irritability level also guides intensity of intervention tactics

Imaging Limitations

• MRI findings were most equally frequent on uninvolved side in pts with unilateral shoulder pain
• MRI can accurately identify tissue pathology, but cannot discriminate whether the pathoanatomy is associated with specific clinical presentation or complaint

Shldr Pain Mapping

• Pain on palpation is sensitive but not very specific
• Injection of hypertonic saline into healthy AC joint and SA space

Patient History and Diagnostic Studies

• Subjective hx: past med hx, systems review, previous related injuries, fam hx
• Diagnostic studies: radiographs, arthrography, MRI/CT scan, EMG/NCV
• Pain above clavicular level indicates ACJ involvement or cervicothoracic contribution to problem

Shldr Specific Red Flags

• Severe and/or persistent pain unrelieved by rest or aggravated by exam, activity, or exertion
• Soft tissue mass on palpation
• Absence of sleep disturbance
• Systemic illness/constitutional sx's
• Pleuritic sx's

Differential Dx

• Unlikely causes to rule out: spleen, heart, gallbladder, or lung involvement
• Kehr's sign: referred pain to L shoulder following blunt trauma to spleen
• Myocardial or pericardial disease: heart attack often causes L shoulder pain
• Gallstones: pain referred to R scapula
• Neoplasms: lung cancer

Risk Factors

• Pts with low HDL, high cholesterol, high triglycerides, overweight, pre or diabetic, and HTN are at high risk for shldr pain

Yellow Flags

• Slower prog/return: previous shldr hx, disproportionate illness behavior, adverse sociolegal status, long-term absence from work or sport, expectation of passive tx, mood, fear behavior, and coping skill

Factors to Baseline Monitor

• Pain level
• Self-report fxnal and psychosocial status
• Pt satisfaction (monitor only)

Outcome Measurement Tool

• Patient's rating of their overall condition since the previous evaluation
• Single assessment numerical evaluation: how would you rate your shoulder today as a percentage of normal?

Rotational Normals

• Total arc: whats normal? (activity specific, age, sex specific)
• Adaptations: osseous, humeral retroversion, glenoid retroversion, capsular, muscular

End Feels

• Firm capsular or muscular tension for rotations, flexion, extension, add, and horizontal add
• Soft tissue approximation for horizontal add
• Firm capsular/hard bony end feel for abduction

Pain Resistance Sequence

• Sequence of pain on the motion barrier
• P1 before R1: acute
• P1 before R1-2: subacute
• P1 at R-2: chronic

Symptomatic Arc

• Includes pain, clicking, grating, crepitation
• 70-120: chronic subdeltoid bursitis, supraspinatus tendinitis, or upper fiber subscap tendinitis

Functional Reach Tests

• Fxnal Reach Test / Apley Scratch Test
• Behind Back Reach: normal = T5-6
• Cross Body Reach: normal = 15-20cm
• Behind Neck Reach: normal = T1-2

Manual Muscle Testing (MMT)

• Important to know reliability, construct validity, and relevance of each