Shoulder Joint Assessment PDF

SHOULDER JOINT ASSESSMENT JOINTS DEMOGRAPHIC DATA 1. Age Many problems of the shoulder are age-related: Rotator cuff degeneration: between 40 and 60 years of...

SHOULDER JOINT ASSESSMENT JOINTS DEMOGRAPHIC DATA 1. Age Many problems of the shoulder are age-related: Rotator cuff degeneration: between 40 and 60 years of age. Primary impingement (due to degeneration and weakness): older than 35 years. Calcium deposits: may occur between the ages of 20 and 40. Chondrosarcomas: may be seen in individuals older than 30 years of age. Frozen shoulder: between the ages of 45 and 60 years, if it results from causes other than trauma. 2. Occupation Secondary impingement (due to instability caused by weakness in the scapular or humeral control muscles): More common in late teens or 20s. Especially affects individuals involved in vigorous overhead activities, such as swimmers or pitchers in baseball. 3. Hand Dominance The dominant shoulder is often lower. The dominant shoulder usually shows greater muscularity but often less range of motion (ROM).  CHIEF COMPLAINT HISTORY Pain 1. PRESENT ILLNESS Restricted motion a. Anatomical site – e.g fall on or receive a Instability blow to the tip of the shoulder, or the land Feeling of weakness and heaviness in the limb on the elbow, driving the humerus up after activity: against the acromion may suggest ○ Limb tires easily? May indicate vascular acromioclavicular dislocation or involvement. subluxation Symptoms such as swelling or stiffness: b. Limb position – e.g FOOSH injury may ○ May extend all the way to the fingers, indicate a fracture or dislocation of the suggesting venous symptoms. shoulder c. Subjective experiences – snapping or EXAMPLE: cracking sound may be related to a bone or Thoracic outlet syndrome, in which pressure may be ligament breaking. Feeling something ‘pop applied to the vascular and/or neurological structures as out’ may suggest a joint dislocation or they enter the upper limb in three locations: at the subluxation. scalene triangle, at the costoclavicular space, and under the pectoralis minor and the coracoid process. 2. PAIN HISTORY a. Pain location (Where) b. Referred pain c. Pain duration (When) – e.g Frozen shoulder goes through 3 phases depending on how long the condition has persisted. d. Type of pain (What) e. Aggravating and relieving factors 3. PAST MEDICAL HISTORY a. Medical history b. Surgical history c. Personal d. Occupational  REFERRED PAIN PAIN LOCATION Acromioclavicular Joint Isolated symptoms directly over the joint. Pain was also reported in the ○ Anterolateral neck region ○ Along the upper trapezius muscle, with extension distally to the anterolateral Pain into the lateral aspect of the shoulder or deltoid. continuing into the elbow and distal upper extremity Subacromial Space ○ Rule out involvement of the cervical spine or elbow joints. Many visceral diseases are known to appear as unilateral shoulder pain. KEHR’S SIGN – History of abdominal trauma, abdominal rigidity, nausea and vomiting, and reflex pain which radiates to the left shoulder and approximately 1/3 of the arm. Associated with acute injury to the spleen. Lateral aspect of the deltoid. Pain over the lateral border of the acromion (AC joint remains pain free) Lack of posterior scapular and neck symptoms. C6 Radiculopathy Stiffness Pain pattern is similar to the one for If stiffness occurs according to the capsular acromioclavicular joint. pattern, then it is most likely a frozen shoulder. Except for the presence of posterior neck pain If stiffness occurs outside of the capsular and exacerbation of the pain with movements pattern, then it may suggest muscle tightness. of the cervical spine in cases of C6 Radiculopathy. NOTE: Indications of muscle spasm, deformity, bruising, wasting, paresthesia, or numbness can C7 Nerve Root Compression help the examiner determine the acuteness of Affects the pectoral region, the medial axilla, the condition and, potentially, the structures the region of the scapula, and the triceps, as injured. well as the dorsal aspect of the forearm and Note what the patient is unable to do elbow and middle finger. functionally. Tenderness is often most noted over the Difficulty in talking/swallowing, hoarseness vertebral border of the scapula opposite could indicate an injury to the sternoclavicular vertebral segments T3 and T4. joint (if there is swelling) or a posterior dislocation of the joint because pressure is being applied to the trachea. TYPE OF PAIN ASSOCIATED WITH CONDITIONS Thoracic Outlet Syndrome / Acute AGGRAVATING AND RELIEVING FACTORS Brachial Plexus Neuropathy Movements or positions that cause the patient pain or Deep, boring, toothache-like pain in the neck, symptoms. shoulder region, or both. SAMPLE CASE: Cervical spine movements causing pain in the shoulder Rotator Cuff Strain Usually causes dull, toothache-like pain that is Recurrent dislocations/instability of the shoulder – may find that any movement worse at night. involving lateral rotation bothers them Acute Calcific Tendinitis Long head of biceps pathology – pain that moves medially and laterally with medial and Usually causes a hot, burning type of pain. lateral rotation of the shoulder Rotator Cuff Tears Nerve root pain – may find that elevating the arm overhead relieves symptoms. Night pain and resting pain are often related to rotator cuff tears and, on occasion, to tumors. Instability or inflammatory conditions - lifting DIURNAL VARIATION – fluctuations that occur the arm over the head usually exacerbates during the daytime in a specific phenomenon or shoulder problems. measurement.  PAST MEDICAL HISTORY ASSESSMENT PAST MEDICAL HISTORY or PRE-EXISTING CONDITIONS OCULAR INSPECTION Diabetes mellitus Rheumatoid arthritis Posture (sitting and standing) Pelvic position SURGICAL HISTORY Spinal alignment Rotator cuff repair Shoulder alignment Total shoulder arthroplasty Protective guarding Open or closed reduction after fracture PERSONAL HISTORY STANDING POSTURE Sleeping position - the subacromial space is ANTERIOR VIEW narrower during scapular protraction as compared with scapular retraction Dominant side is slightly lower Tennis shoulder – dominant side droops with OCCUPATIONAL HISTORY apparent scoliosis. Determining whether the shoulder has been ○ Scapula is in PDD – protracted, overstressed or overused is important. For depression, downward rotation example, in swimmers and baseball pitchers. LATERAL VIEW Forward head posture – associated with rounded shoulders POSTERIOR VIEW Scapula lower than normal – sup. medial border may “washboard” (kiskis) over the ribs causing snapping or clunking sound when abducting or adducting the shoulder Hand-on-hip position – assess scapula symmetry ‘ GAIT Posture during walking Limb movement and its symmetry Note any external devices TROPICAL CHANGES (color, texture, scar, bruises) PECTORALIS MAJOR RUPTURE Ecchymosis and swelling Massive swelling and bruising Loss of axillary fold PALPATION LATERAL COMPARTMENT ANTERIOR POSTERIOR Supraspinatus tendinitis Clavicle Spine of scapula Subacromial/subdeltoid SC joint Spinous process of bursitis AC joint lower cervical and Sulcus sign indicating a Coracoid process thoracic spine multidirectional Sternum instability Ribs and Costal cartilage Humerus Rotator cuff muscles Axilla POSTERIOR COMPARTMENT ANTERIOR COMPARTMENT Infraspinatus Bicipital tendinitis tendonitis/strain Subscapularis tendinitis Teres minor Coracoacromial tendonitis/strain ligament pain Posterior capsule pain secondary to rotator secondary to chronic cuff impingement subluxation Anterior capsule pain Posterior impingement secondary to chronic Thinker’s position subluxations, status post macrotraumatic dislocation Sternoclavicular joint sprain Clavicular fracture SUPERIOR COMPARTMENT Acromioclavicular joint sprain Supraspinatus tendinitis Subacromial/subdeltoid bursitis Upper trapezius strain Levator scapula strain/spasm  DEFORMITIES SCAPULA STATIC WINGING Winging occurring at rest Caused by a structural deformity of the scapula, clavicle, spine, or ribs. SPRENGEL’S DEFORMITY Developmental condition High or undescended scapula – smaller than normal and medially rotated. SHOULDER STEP DEFORMITY Visible separation/depression between acromion and clavicle seen at rest due to dislocation. Indicates an acromioclavicular and coracoclavicular ligament tear. Accentuated by asking the patient to horizontally adduct the arm or medially rotate shoulder and bring it posteriorly and superiorly. SULCUS SIGN Sulcus/groove below the acromion. Note that this is LATERAL TO THE ACROMION MUSCLE WASTING Wasting of the deltoids – paralysis or ant. dislocation of shoulder joint Upper trapezius – CN11 nerve palsy, can also lead to winging Supraspinatus/Infraspinatus – supraspinous nerve palsy Serratus anterior – long thoracic nerve palsy Congenital absence of sternal head of pectoralis major