The test result is positive when scapular retraction decreases the pain or impingement associated with the Jobe relocation test. The Rotator Cuff 2. It originates from the anterior portion of the scapula (subscapularis fossa) and inserts onto the lesser tuberosity of the humerus. The shoulder is then internally rotated and angled forward 30 degrees: the thumb should be pointing toward the floor. The examiner stabilizes the scapula and elevates the arm. [] First, the shoulder is carefully inspected visually, followed by palpation and range-of-motion assessment. No independent studies have validated this test or examined its clinical utility. Naredo and coworkers reported a test described by Patte in 1995 for assessing tears of the infraspinatus and teres minor (see Fig. The rhomboids include the major and minor divisions and are innervated by the dorsal scapular nerve (C5). 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. When indicated, the axilla should be evaluated for masses, lymph nodes, and palpation of the muscles. The teres minor originates from the superior lateral portion of the scapula and inserts onto the inferior aspect of the greater tuberosity. Passive motion testing can then be performed to isolate motions for accurate evaluation. There has been no independent verification of this study, and its clinical usefulness has not been adequately studied. Conclusion Clinical examination of shoulder should be guided according to patients age, chief complains and professional activities. A good history and full clinical examination, together with a detailed knowledge of the anatomy, suffices to solve the majority of the shoulder problems. Pain should radiate into the deltoid region. Then, we can carry on some specialized tests that will help us uncover any lesions of the muscular or ligamentous structures of the joint. Internal rotation of the shoulder can be performed by asking the patient to place the arms up the back with the thumbs up ( Fig. Remember, if you have forgotten something important, you can go back and complete this. The shoulder joint is the most mobile joint in the body. It also allows the arm to move in a circular motion and to … Methods: Thirty one consecutive patients with a first flare of shoulder pain were … The, The Ludington test was designed to compare the biceps muscle shape side to side. Look for lateral symmetry, swelling, position of scapula and signs of muscle wasting. The rotator cuff muscles (supraspinatus, infraspinatus, subscapularis, and teres minor) are the inner layer; these muscles serve first to provide compressive force of the humeral head into the glenoid and secondly to provide rotation of the arm. This method of measurement can be reproducible for one individual, but the relationship of the thumb tip to various vertebral levels has not been shown to be accurate or reproducible. 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 to compare the strength of lateral rotation. (Reproduced with permission from Hawkins RJ, Bokor DJ: Clinical evaluation of shoulder problems. The infraspinatus is best assessed by testing external rotation with the arms at the side. Shoulder Exam; Hand Exam; Elbow Exam; Hip Exam; Lower Back Exam; Detailed examination of the joints is usually not included in the routine medical examination. The same protocol is done for the third position. The long head of the biceps is anterior, between the lesser and greater humeral tuberosities, and is difficult to palpate because of the large deltoid muscle. 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. Basics of shoulder anatomy and function The upper limb. Elements of the shoulder exam. 4.24 ): [Have] the patient flex his shoulder [elevate it anteriorly] against resistance while the elbow is extended and the forearm supinated. Introduce yourself to the patient including your name and role. The first position of the test is with the arm relaxed at the side. By externally rotating the arm and flexing and extending the elbow, the examiner may be able to feel the tendon moving in the anterior shoulder. 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. 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. 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. The examiner then asks the patient to try to keep the hand on the shoulder while the examiner attempts to pull it off the opposite shoulder. 4.9 ), trapezius, serratus anterior, rhomboids, and the prime movers (pectoralis major/minor, latissimus dorsi, teres major, triceps, biceps, and deltoid; Fig. A positive test is indicated if the patient is unable to return the arm to the side slowly or has severe pain when attempting to do so ( Video 4-2 ). The cervical spine and trapezius should be palpated if the patient has neck pain. The neutral position is with the arm and forearm in the horizontal plane ( Fig. Instability The common disorders arise from diseases of the following structures: 1. The test is performed by having the patient pinch the scapulas together posteriorly in retraction. The infraspinatus is best tested with the arms at the side ( Fig. The patient was asked to lift the hand off the buttocks, and if this was not possible, then a subscapularis tendon tear was considered present. The tradeoff for this freedom of motion is a relative lack of stability, which makes the shoulder girdle susceptible to an array of injuries. They noted the supraspinatus was sufficiently activated in both positions ( Figs. Scars, atrophy, swelling, ecchymosis, erythema, rashes, deformities, shoulder heights, and scapular positioning should be evaluated. In 1934, in his classic book The Shoulder, Codman1 was the first to specifically address conditions that affect the shoulder joint. The supraspinatus could not be effectively isolated from the deltoid muscle when resisting abduction of the arm, but it is typically tested with the arm elevated 90 degrees with the thumb in internal, neutral, or external rotation. 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. A positive scapular retraction test indicates trapezius and rhomboid weakness. Always start with inspection and proceed as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by the examiner. It originates on the dorsal surface of the inferior angle of the scapula and inserts onto the medial lip of the intertubercular groove. Normal values of active range of motion for the shoulder joint are shown in Table 4.1 . Scapular winging may be seen and can be accentuated by muscle activation ( Fig. The AC joint is examined using the ‘cross body’ or ‘scarf’ test. Passive elevation of the arm in flexion with the arm in internal rotation while stabilizing the scapula from the back should result in pain into the deltoid region. Neer sign pain may be temporarily stopped by instilling 1% lidocaine into the bursa. Odom and coworkers concluded that âthe LSST should not be used to identify people with [or] without shoulder dysfunction.â. The pectoralis major lies anterior and covers the pectoralis minor, which is difficult to palpate. Acromioclavicular Joint Examination. *As the shoulder is a deep structure, both skin changes from erythema and joint swelling from effusions are not always apparent. 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. Shoulder examination comprises of examining the shoulder girdle as a whole which consists of 1. Shoulder pain, injuries, and stiffness are the third most common muscle and joint issue that bring people to the doctor. They originate from the ligamentum nuchae and spinous processes from C7 to T5 and insert onto the medial border of the scapula from the scapular spine to the inferior angle. Next, external rotation with the arm at the side should be compared with that of the opposite extremity. (See also Evaluation of the Patient With Joint Symptoms.) This procedure simulates the force-couple activity of the serratus anterior and lower trapezius muscles. 4.15 ). 4.16 ). The shoulder is a complex joint, with a wide range of motion and functional demands. The shoulder is then internally rotated and angled forward 30 degrees: the thumb should be pointing toward the floor. 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 […] The patient is asked to put hands on the head with palms down and to contract the biceps muscle. Internal rotation cannot be accurately measured with the arm at the side in this position because the trunk impedes the motion. The patient is asked to place the hand on his or her other shoulder and to raise the elbow without elevating the shoulder. The final position presents a challenge to the muscles in the position of most common function at 90 degrees of shoulder elevation …. SHOULDER EXAMINATION Introduction Shoulder disorders are can be broadly classified into the following types: 1. They cite a personal communication with Speed in 1952 and describe the test as follows ( Fig. The trapezius, rhomboids, and serratus anterior provide stabilizing forces because the scapula lacks rigid, bony fixation. The patient should be examined from the front and the back, where elements such as muscle bulk and scapular positioning can be easily observed. ), When examining the shoulders for rotation, the starting position is shown (. Gill and coworkers found that Speed’s test had a sensitivity of 50%, specificity of 67%, PPV of 8%, NPV of 96%, and likelihood ratio of 1.51 for detecting partial tears of the biceps tendon. The pain is typically into the deltoid area and sometimes worsens when bringing the arm down from an elevated position. Besides basic anatomy and function of the shoulder, this article discusses the most important clinical examinations and tests of the shoulder, the shoulder girdle joints, muscles, and capsuloligamentous complex. View from the rear, with the patient standing straight. Similarly, it was originally suggested that dyskinesia patterns could be associated with specific disease states. Several studies have shown that Speed’s test does not actually help the clinician in making the diagnosis of biceps tendon disorders. It originates from the lateral portions of the first eight ribs and inserts onto the anterior surface of the medial border of the scapula. 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