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Skin
Scars
Symmetry
Swelling
Atrophy
Hypertrophy
Scapular winging
Palpation
Compare active and passive motion, both sides, with the patient in seated
or standing position
Six planes of motion should be examined and documented
forward elevation (150-180° considered normal)
active
external rotation at 90 degrees abduction
active
external rotation at side
active
abduction
active
internal rotation to vertebral height (T4-T8 considered normal)
active
internal rotation at 90 degrees abduction
Neurovascular Exam
Sensation
check dermatomes of following nerves
axillary
musculocutaneous
medial Brachial/Antebrachial Cutaneous
median
radial
ulnar
Motor
Deltoid, Biceps, Triceps, Extensor Pollicis Longus, Flexor Digitorum
Profundus, Dorsal Interossei
Vascular
brachial, radial, ulnar artery pulses
Differential
cervical radiculopathy
suprascapular neuropathy
brachial neuritits
Impingement
t Sign
indicative of impingement of rotator cuff tendon/bursa against the
coracoacromial arch
other abnormalities can produce a positive test including
stiffness
OA
instability
bone lesions
technique
use one hand to prevent motion of the scapula
raise the arm of the patient with the other hand in forced elevation
(somewhere between flexion and abduction)
pain is elicited (positive test) as the greater tuberosity impinges against
the acromion (between 70-110°)
note you must have full range of motion for "positive" finding.
Neer Impingement Test
positive when there is a marked reduction in pain from
above impingement maneuver following subacromial lidocaine injection
technique
usually a combination of
4cc 1% Lidocaine
4cc 0.50% Bupivicaine (Marcaine)
2cc corticosteroid)
Hawkins Test
positive with impingement
technique
performed by flexing shoulder to 90°, flex elbow to 90°, and forcibly
internally rotate driving the greater tuberosity farther under the CA
ligament.
Jobe’s Test
positive with supraspinatus weakness and or impingement
technique
abduct arm to 90°, angle forward 30° (bringing it into the scapular plane),
and internally rotate (thumb pointing to floor).
then press down on arm while patient attempts to maintain position
testing for weakness or pain.
Internal Impingement
patient supine or seated
abduct affected side to 90° and maximally externally rotate (throwing
position-late cocking phase) with extension
if this maneuver reproduces pain experienced during throwing (posteriorly
located) considered it is considered positive.
further confirmed with relief upon performing relocation test
re-perform test in abduction/max
ER with elbow in front of plane of body and pain disappears.
Subscapularis Strength
do not test with isolated IR strength with the arm at the side due to
contribution of pectoralis major and latissimus dorsi
Internal Rotation Lag Sign
this tests is the most sensitive and specific test for subscapularis
pathology.
technique
stand behind patient, flex elbow to 90°, hold shoulder at 20° elevation
and 20° extension. Internally rotate shoulder to near maximum holding
the wrist by passively lifting the dorsum of the hand away from the
lumbar spine – then supporting the elbow, tell patient to maintain position
and release the wrist while looking for a lag.
Increased Passive ER
a person with a subscapularis tear may have increased Passive ER
rotation when compared to contralateral side
Lift Off Test
more accurate for inferior portion of subscapularis.
technique
hand brought around back to region of lumbar spine, palm facing
outward; Test patient’s ability to lift hand away from back (internal
rotation). Inability to do this indicates subscapularis pathology. Is
confounded by other muscles. More accurate if the tested hand can
reach the contralateral scapula.
Belly Press
test positive with subscapularis pathology
more accurate for superior portion of subscapularis
technique
patient presses abdomen with palm of hand, maintaining shoulder in
internal rotation. If elbow drops back (does not remain in front of trunk)
Supraspinatus Tests
Supraspinatus Strength
strength is assessed using Jobe’s Test (see below) – pain with this test is
indicative of a subacromial bursitis/irritation – not necessarily a supra tear.
Only considered positive for tear with a true drop arm. i.e. arm is brought
to 90° and literally falls down.
Jobe’s Test
tests for supraspinatus weakness and/or impingement
technique
abduct arm to 90°, angle forward 30° (bringing it into the scapular plane),
and internally rotate (thumb pointing to floor). Then press down on arm
while patient attempts to maintain position testing for weakness or pain.
Drop Sign
tests for function/integrity of supraspinatus
technique
passively elevate arm in scapular plan to 90°. Then ask the patient to
slowly lower the arm. The test is positive when weakness or pain causes
them to drop the arm to their side.
Infraspinatus
Infraspinatus Strength
external rotation strength tested while the arm is in neutral
abduction/adduction
External Rotation Lag Sign
positive when the arm starts to drift into internal rotation
technique
passively flex the elbow to 90 degrees, holding wrist to rotate the
shoulder to maximal external rotation. Tell the patient to hold the arm
in that externally rotated position. If the arm starts to drift into internal
rotation, it is positive.
Teres Minor
Pectoralis
Axillary Webbing
look for a defect in the normal axillary fold. A deformity may be indicative
of an pectoralis major muscle rupture
Biceps Injuries
AC Joint
Instability
Anterior Instability
Sulcus Sign
have the patient stand relaxed with their arms at their side. Grab their
affected arm and pull it inferiorly. If there is a sulcus that forms at the
superior aspect of the humeral head, the test is positive. Sulcus is
considered positive if it stays increased (2+ or 3+) with ER at side
(pathologic rotator interval).
Sulcus grading
1+ acromiohumeral interval < 1cm
2+ acromiohumeral interval 1-2 cm
3+ acromiohumeral interval > 2cm
Other
Wright's Test
test for thoracic outlet syndrome.
positive if the patient losses their radial pulse
technique
passively externally rotate and abduct the patient's arm while having the
patient turn their neck away from the tested extremity.
Medial Scapular Winging
test for serratus anterior weakness or long thoracic nerve dysfunction.
positive if the inferior border of the scapula migrates medially
technique
while standing, have the patient forward flex their arm to 90 degrees and
push against a wall (or other stationary object).
Lateral Scapular Winging
test for trapezius weakness or spinal accessory nerve (CNXI) dysfunction
positive if the inferior boarder of the scapula migrates laterally
technique
while standing, have the patient forward flex to 90 degrees and push
against a wall (or other stationary object).