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Chapter 5 Shoulder

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Chris Kinslow

on 21 January 2016

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Transcript of Chapter 5 Shoulder

Chapter 5 Shoulder
Clinical Management of the Musculoskeletal System I

Chapter 5 Shoulder
Overview:
Primary function of the shoulder complex is to position the hand in space, allowing interaction with the environment
Multiaxis, ball and socket synovial jt.
Three axis and three degrees of freedom
Resting position of GH jt is 55d of abduction and 30 degees of horizontal adduction.
Close pack position is full abduction and external rotation
Anatomy
Special Test
Overview:
Degree of mobility is contingent on:
A healthy articular surface
Intact muscle-tendon units
Supple capsuloligamentous restraints

Degree of stability is dependent on:
Intact capsuloligamentous structures
Proper function of the muscles
Integrity of the osseous articular structures
Rotator cuff controls osteokinematics and arthrokinematics of humeral head.
The RTC (along with the bicep tendon) does what to the humeral head during elevation of the arm?????
Anatomy:
Three bones:
Humerus
Clavicle
Scapula
Three joints:
Sternoclavicular (SC)
Acromioclavicular (AC)
Glenohumeral (GH)
Also consider:
Scalulothoracic “joint”
Suprahumeral space/
Subacromial space

Glenohumeral Joint:


True synovial-lined diarthrodial joint

Head of the humerus faces
Medially
Posteriorly
Superiorly
Glenohumeral Joint:
Glenoid fossa is made about 50% deeper by the labrum
Labrum attaches to the glenoid cavity, joint capsule and lateral portion of the biceps
Glenohumeral Joint:
At any point during elevation, only 25-30% of the humeral head is in contact with the glenoid

Most significantly reduced when the humerus is positioned in:
Adduction, flexion and IR
Abduction and elevation
Adducted at the side with downwardly rotated scapula


Glenohumeral Joint:
Dynamic mechanisms include
Muscles of the rotator cuff
Other force couples
Static stabilization comes from
Joint capsule
Joint cohesion
Ligamentous support
Glenohumeral Joint:
Scaption (or plane of the scapula)
Arm elevation with the arm held 30-45o anterior to the frontal plane

Sixteen muscles attach to the scapula
Six of these support and move the scapula
Ten of these are concerned with GH motion
Glenohumeral Joint
Capsule:
Laterally attaches to the neck of the humerus
Medially attaches to the periphery of the glenoid and its labrum
Inferiorly attaches to the inferior portion of the glenoid and is loose to allow gliding during elevation
Anteriorly is reinforced by the Z ligaments and the RC tendons
Glenohumeral Joint:
Ligaments
Superior GH ligament is under tension when the shoulder is in adduction. It holds up on the humeral head as we move the arm down.
Middle GH ligament is under tension when the shoulder is flexed and ER (limits External roation)
Primary restraint against anterior and posterior humeral head dislocation
Other Ligaments
Coracohumeral ligament
Coracoacromial ligament
Inferior GH ligament is under tension when the shoulder is ABD, extended and/or ER.
Most important of the GH ligament
! Has three parts... an anterior band, posterior band, and and axillary pouch between.
Glenohumeral Joint:
Coracoacromial Arch
Houses the Subacromial space and the following structures
Head of the humerus
Long head of the biceps tendon
Superior aspect of the joint capsule
Supraspinatus and upper margins of the subscapularis and infraspinatus
Subdeltoid bursa
Subacromial bursa
Inferior surface of the coracoacromial arch
Glenohumeral Joint:
Normal size is 10-11mm in height, 5 d of superior tilt to the joint.

Muscle imbalances or capsular contractures can cause an increase in superior translation of the humeral head, narrowing the subacromial space
In overhead athletes what part of the capsule is stretched that leads to glenohumeral laxity?
Cyriax capsular pattern of the shoulder is what?
Glenohumeral Joint:
Neurology
Anterior shoulder joint – axillary, subscapular and lateral pectoral
Posterior shoulder joint – suprascapular nerve, small branches of the axillary nerve
Others – long thoracic nerve, musculocutaneous nerve, and spinal accessory nerve


Glenohumeral Joint:
Vascularization
Shoulder complex is primarily the axillary artery
GH joint is from the anterior and posterior circumflex humeral and suprascapular and circumflex scapular vessels
Biceps brachii is from the brachial artery
Rotator cuff is from the thoracoacromial, Suprahumeral and subscapular arteries



Acromioclavicular Joint
Anteromedial border of the acromion faces anteriorly, medially and superiorly
The AC joint serves as the main articulation that suspends the UE from the trunk
Coracoclavicular ligament is the primary support for the AC joint It has two parts...
Conoid and trapezoid ligaments
provide mainly vertical stability, with control of superior and anterior translation as well as anterior axial rotation


If a patient seperates their shoulder to the point we see a step deformity what ligaments do we know are torn?
Acromioclavicular Joint:
Capsular pattern
Pain at the extremes of ROM, esp. horizontal adduction and full elevation
Close packed position
90 degrees of abduction
Open packed position
Arm by the side
Sternoclavicular Joint:
Joint components
Medial end of the clavicle
Clavicular notch on the manubrium
Cartilage of the first rib, which forms the floor of the joint
Capsular pattern
Pain at the extremes of ROM, esp. full arm elevation and horizontal adduction
Close packed position
Maximum arm elevation and protraction
Open packed position
Arm at the side
Sternoclavicular Joint:
If held vertically, the proximal end of the clavicle is convex (manubrium is concave)
If held A/P, the proximal end of the clavicle is concave (manubrium is convex)
A thick meniscus is the key to the curvature
A/P and Sup/Inf translation allow for 3 DOF:
Protraction/retraction
Elevation/depression
Upward/downward

Scapulothoracic Joint:


An integral part of the shoulder complex, but not a true “joint”
Available motion consists of approx.:
60 degrees of upward rotation of the scapula
40-60 degrees of IR/ER
30-40 degrees of anterior and posterior tipping of the scapula

Scapulothoracic Joint:


Capsular pattern: none
Close packed position: none
Open packed position:
30-45 degrees of IR, slight upward rotation and approx. 5-20 degrees of anterior tipping relative to the thorax


\Muscles of the Shoulder Complex:
Scapular Pivoters
Trapezius
Serratus Anterior (SA)
Levator Scapulae (LS)
Rhomboid Major
Rhomboid Minor
For the traps to perform its actions, the cervical spine must first be stabilized by the anterior neck flexors to prevent simultaneous occipital extension


Muscles of the Shoulder Complex:


Latissimus Dorsi:
Functions as an extensor, adductor, and IR of the shoulder
Assists in scapular depression, retraction and downward rotation

Teres Major complements the actions of LD



Muscles of the Shoulder Complex:


Pectoralis Major performs:
IR
Horizontal ADD
Flexion
ABD (humerus 90+ deg ABD)
ADD (humerus below 90 deg ABD)

PMi draws the scapula inferior and medial towards the thorax
Muscles of the Shoulder Complex:
Humeral Positioners
Deltoid

Deltoid fibers function to position the humerus in space


Shoulder Protectors
Rotator Cuff (4)
Long Head of the Biceps Brachii (LHB)
RC (4) actively moves the humerus and fine-tunes the humeral head position in the glenoid
Other functions
Assist in the rotation of the shoulder and arm
Reinforce the GH capsule
Control much of the active arthrokinematics of the GH joint


Muscles of the Shoulder Complex:
Long Head of Biceps Brachii is a forearm supinator and secondary elbow flexor
Other functions
Humeral head depressor
Anterior stabilizer
Posterior stabilizer
Limiter of ER
Lifter of the glenoid labrum
Humeral head compressor of the shoulder
Role in decelerating a rapidly moving arm during OH activities
Scapulohumeral Rhythm:
Shoulder abduction up to 90 degrees = 2 to 1 ratio
60 degrees of GH abduction
30 degrees of ST upward rotation

30 degrees of Scapular Thoracic upward rotation =
20-25 deg of clavicular elevation
5-10 deg of upward rotation of the AC joint
After the first 90d its it a 1-1 ration of scapular to GH movement
Scapulohumeral Rhythm
Shoulder abduction of 90-180 degrees =
60 deg of GH abduction
30 deg of ST upward rotation

During this late phase
Clavicle elevates 5 deg at the SC joint
Scapula upwardly rotates 20-25 deg at the AC joint


Scapulohumeral Rhythm


During first 30 degrees – the traps and SA are considered the prime upward rotators of the scapula

Prime muscles that abduct the GH joint are the middle deltoid and supraspinatus muscles

Prime muscles that elevate the GH joint are the anterior deltoid, coracobrachialis and LHB brachii


Figure 16-14 The scapulohumeral rhythm


Scapulohumeral Rhythm



Patient History:


Patient’s age
Protection of the limb
Mechanism of injury
Movements that cause pain
Extent and behavior of the pain
Activities that increase pain
Positions that alleviate pain
Functional difficulties
Indication of nerve injury
Dominant hand


Rehab Ideas
ROM
Flexibility
Scapular Retraining
Strengthening
Integration
Evaluation

Patient History:


Patient’s age
Protection of the limb
Mechanism of injury
Movements that cause pain
Extent and behavior of the pain
Activities that increase pain
Positions that alleviate pain
Functional difficulties
Indication of nerve injury
Dominant hand



Tests and Measures:


Observation
Step deformity
Sulcus sign
Dominant side lower than non-dominant
Winging
Scapular tilt
Scapular position and movement
Muscle symmetry
Medial scapular spine should be equal with T3 SP
Inferior angle should be even with T7 SP
Medial border extends from T2 to T7 SPs



Tests and Measures:


AROM
Pain during 70-110 deg of abduction is deemed a “painful arc”
May indicate RC impingement/tearing or subacromial bursitis
Pain during 120-180 may indicate involvement of the AC joint



Tests and Measures:


AROM
Imbalances between the deltoid and RC are common
When the deltoid is dominant, the humeral head glides superiorly during elevation
Downward pull of the RC muscles is insufficient to counterbalance the upward pull of the deltoid
Called “Humeral Superior Glide Syndrome”
Humeral Anterior Glide Syndrome consists of anterior glide of the humeral head during elevation
Suggests that posterior deltoid has become the dominant ER



Tests and Measures:


AROM
Quick IR test – Apley’s Scratch Test
Hand positioned behind back with thumb extended
Thumb tip should reach the T5-T10 level

During elevation, the scapula should stop its rotation when the arm has been elevated to approximately 140 degrees
Upon completion, the inferior angle of the scapula should be in close proximity to the midline of the thorax



Tests and Measures:


AROM
ROM with unilateral elevation should be greater than bilateral elevation

Joints of the CT junction have to be permitted to rotate toward the elevating arm


Tests and Measures:

Resistive Tests
Perform MMTs
Pain with isometric muscle testing is generally considered a sign of 1st or 2nd degree M/T lesion
Pain that occurs during a muscle contraction is more likely to indicate a lesion within a muscle belly
Pain that occurs on release of the contraction is more likely to indicate a lesion within the tendon
Test inert tissues for involvement before coming to the conclusion that only the M/T structure is at fault



Functional Testing



Functional Testing


Shoulder Outcome Scales
UCLA Shoulder Rating Scale (Table 16-19)
Simple Shoulder Test (Table 16-20)
Shoulder Pain and Disability Index
Disabilities of the Arm, Shoulder and Hand (DASH) (Table 16-21)
Penn Shoulder Score (Table 16-22 & 16-23)


Passive Accessory Motion Tests

Assess in resting position as much as possible
Feel for any restrictions (close eyes)
Compare both sides
Same positions used for intervention with the following guidelines:
Grades I and II oscillations are used for pain, and graded depending the stage of healing
Grade III-V techniques are used to increased ROM


Passive Accessory Motion Tests

Distraction of the GH joint
Distraction force is perpendicular to the plane of the glenoid fossa
Lateral, anterior and inferior direction
Inferior Glide of the GH joint
Cup the head of the humerus with the hand
Bring patient to as close to 90o abduction as tolerated
Glide humeral head inferiorly



Passive Accessory Motion Tests

Posterior Glide of the GH joint
Position patient between 45-90o abduction, as tolerated
Posteriorly glide humeral head with thenar eminence positioned on the anterior aspect of the humeral head
Anterior Glide of the GH joint
Supine –
Clinician palpates posterior aspect of humeral head
Glides the humeral head anteriorly at the GH joint, parallel to the AP plane of the glenoid fossa
Prone –
Clinician palpates posterior aspect of the humeral head with one hand
Glides the humeral head anteriorly at the GH joint, parallel to the AP plane of the glenoid fossa
Passive Accessory Motion Tests

Scapulothoracic ‘Joint’
Distraction
Position patient in sidelying with upper extremity resting at side
Clinician loops distal arm through and grasps the distal end of the medial border
Clinician places the proximal hand on the proximal surface of the medial border
Clinician moves the scapula medially and inferiorly and then lifts the scapula away from the ribs


Passive Accessory Motion Tests

Scapulothoracic ‘Joint’
Position patient as in ST distraction, then perform:
Superior Glide
Inferior Glide
Medial Glide
Lateral Glide


Passive Accessory Motion Tests

AC Joint
During GH ABD, or shoulder elevation:
Lateral end of the clavicle moves superiorly
Medial end slides and rolls inferiorly
Clavicle rotates anteriorly
During GH ADD, or shoulder depression:
Lateral end of the clavicle moves inferiorly
Medial end rolls and slides superiorly
Clavicle rotates posteriorly


Passive Accessory Motion Tests

AC Joint
To assess mobility, the patient lies supine
Clinician stabilizes the humerus with one hand
Grasps the anterior and posterior aspects of the lateral clavicle with the other hand using the thumb, index and middle fingers
Clinician passively pulls the clavicle into the limit of anterior rotation and assesses the end feel
Then passively pushes the clavicle into the limit of posterior rotation and assesses the end feel


Passive Accessory Motion Tests

SC Joint
To assess inferior glide, the patient lies supine
Clinician palpates the superior aspect of the medial end of the clavicle and the SC joint
Applies inferior glide to the SC joint
Quality and quantity of motion is assessed
To assess superior glide, the patient lies supine
Clinician palpates the inferior aspect of the medial end of the clavicle and the SC joint
Applies a posterosuperior glide to the SC joint
Quality and quantity of motion is assessed


Special Tests:

Special tests for the shoulder are divided into diagnostic categories
Selection for their use is:
at the discretion of the clinician
based on a complete patient history and findings from the physical examination
Rarely is a diagnostic test sensitive and specific enough to be used as the sole determinant
Multiple tests may provide more diagnostic confidence
Tests for Impingement
Neer Impingement Test
Patient’s arm forcefully elevated through forward flexion
Causes a “jamming’ of the greater tuberosity against the anteroinferior border of the acromion
Positive test is pain
Indicative of an overuse of the supraspinatus muscle and sometimes the biceps tendon
Tests for Impingement
Hawkins-Kennedy Impingement Test
Examiner flexes the patient’s arm to 90o (elbow at 90o) then forcefully internal rotate the shoulder
This movement pushes the supraspinatus muscle and tendon against the anterior surface of the coracoacromial ligament and the coracoid process
Positive test is pain
Tests for Impingement

Yocum Test
Patient seated and rests hand on opposite shoulder
Elbow is lifted to shoulder height
Positive test is pain
Indicative of a subacromial impingement

Tests for Impingement

Painful Arc Test
Patient in standing and asked to actively abduct the involved shoulder
Positive test is painful report with shoulder in the 60-120o range
Indicative of subacromial impingement
Pain at end range may indicate AC pathology


Tests for Rotator Cuff Integrity
Drop Arm Test
Clinician passively abducts the patient’s shoulder to 90o
Clinician asks the patient to take the weight of the arm and slowly lower the arm to the side
Positive test is indicated by inability to slowly lower the arm or severe pain when attempting to do so
Positive test indicates a tear of the RC complex

Clicks, pops (instability), and clunks (movement, more significant) are also indicators of weakness or end stage OA.
Tests for Rotator Cuff Integrity
Empty Can Test/Full Can Test
Patient’s shoulder is abducted to 90o in the scapular plane and placed in full IR (pts thumb should be pointing to the ground)
Resistance to abduction is given while the clinician looks for weakness or pain
Positive test is pain, more weakness in empty can vs full can.
Positive test can indicate a supraspinatus tear or neuropathy of the supraspinatus nerve. Impingement patients will have some pain but minimal weakness.
Tests for Rotator Cuff Integrity
External Rotation Lag Sign
Patient is seated, elbow is passively flexed to 90o and shoulder is held at 20o elevation in the scapular plane near maximal ER
Patient is then asked to actively hold that position of ER as the therapist releases the wrist (maintain support at elbow)
Positive test is when a lag or angular drop occurs
Clinician then asks the patient to actively hold the elbow
The lag or angular drop is assessed
Indicative of a tear of the supraspinatus and/or infraspinatus


Tests for Rotator Cuff Integrity

Lift Off Test
Patient stands and places the dorsum of the hand over the small of the back
Clinician gives mild resistance with finger to the patient’s palm and asks the patient to lift hand away from the back
Positive test is pain or inability to perform test
Indicative of a subscapularis lesion


Tests for Rotator Cuff Integrity

Internal Rotation Lag Sign
Patient stands and places the dorsum of the hand over the small of the back
Clinician lifts the patient’s arm off the back and asks the patient to maintain that position
Positive test is pain and/or inability to maintain pre-placed position
Positive test indicated a subscapularis tear


Tests for Rotator Cuff Integrity

Posterior Impingement Sign
Patient lies supine with shoulder placed at 90-110o of abduction and full ER
Positive test is pain in the deep posterior shoulder
Indicative of RC tear and/or posterior labral tear


Tests for Rotator Cuff Integrity

Hornblower’s Sign
Patient is seated or standing
Arm is supported at 90o abduction in the scapular plane with elbow flexed to 90o
Patient is asked to ER against resistance
Positive test is the patient’s inability to ER against resistance and/or pain
Hornblower’s sign is present if the patient cannot ER in stated position
Indicative of Teres Minor pathology
Tests for Biceps Tears

Speed’s Test
Patient standing with shoulder flexed to 80-90o, full ER and full elbow extension
Clinician resists forward shoulder flexion
Positive test is pain in the bicepital groove
Indicative of biceps tendonitis
May produce pain if a SLAP lesion is present
In a severe 2nd or 3rd degree strain, profound weakness may be present
More effective than Yergason’s Test because the bone moves over the tendon during Speed’s test
Tests for Biceps Tears

Yergason’s Test
With patient’s elbow flexed to 90o, stabilized against the thorax and forearm pronated, the examiner resists supination while the patient also laterally rotates the arm against resistance
Positive test is pain or tenderness in the bicepital groove
Indicative of biceps tendonitis


Tests for Posterior/Inferior Labral Tears
Tests for Superior Labral Tears

O’Brien’s Test (aka Active Compression Test)
Patient stands with involved shoulder at 90o flexion, 10o of horizontal adduction and maximum IR (elbow extended)
In this position, the patient resists a downward force by the clinician
Patient is asked to report any pain as either “on top of the shoulder” (AC joint) or “inside the shoulder” (SLAP lesion)
The test is repeated except with the arm in maximum ER
Positive test for glenoid labral tear if the patient reports painful clicking or pain ‘inside the shoulder’ with IR, that is relieved by ER of the shoulder


Tests for Superior Labral Tears

Anterior Slide Test
Patient sitting with arm to side
Clinician stabilizes the scapula and clavicle with one hand
Clinician then applies an anteriosuperior force at the elbow
Positive test can be popping, snapping and/or pain
Indicative of labral tear

Tests for AC Joint Pathology
O’Brien’s Test
Patient stands with involved shoulder at 90o flexion, 10o of horizontal adduction and maximum IR (elbow extended)
In this position, the patient resists a downward force by the clinician
Patient is asked to report any pain as either “on top of the shoulder” (AC joint) or “inside the shoulder” (SLAP lesion)
The test is repeated except with the arm in maximum ER
Positive test for AC joint pathology if the patient reports pain ‘on top of the shoulder’


Tests for AC Joint Pathology


Crossover Impingement/Horizontal Adduction Test
Patient sitting with arm at 90o of flexion
Clinician passively moves the patient’s arm into horizontal adduction and applies overpressure
Positive test if pain is reported in the AC joint

Tests for AC Joint Pathology


Acromioclavicular Resisted Extension Test
Patient sitting with shoulder at 90o of elevation combined with IR and 90o of elbow flexion
Patient is asked to horizontally abduct the arm against resistance
Positive test if pain is reported in the AC joint



Tests for Anterior Instability
Load and Shift
Patient seated, arm at side
Gently load GH joint - anterior and posterior
25% anterior translation normal
Grade I – up to 50% of humeral head translation with head riding up onto glenoid rim and spontaneous reduction
Grade II – greater than 50% of humeral head translation with head riding over glenoid rim and spontaneous reduction
Grade III – humeral head rides over glenoid rim and does not reduce spontaneously
Posterior 50% of translation is normal thus one would expect greater laxity posterior than anterior in normal individual
Tests for Anterior Instability
Apprehension Test/Fulcrum Test
Patient supine with arm at 90o abduction and ER
Clinician applies overpressure into ER
Perform test slowly so you don’t dislocate the shoulder
Watch patient’s face for apprehension signs
Positive test is apprehension, not pain
If painful anteriorly, this may be positive for anterior microsubluxation
If painful posteriorly, this may be positive for internal impingement.
Fulcrum test i
nvolves placing the hand on posterior shoulder and adding additional P-A overpressure to increase the anterior stretss on the shoulder.

Tests for Anterior Instability
Jobe Subluxation/Relocation Test
Clinician places patient in position as described in the Apprehension test and stabilizes test position via grasping the patient’s elbow
Clinician applies an anterior pull on the humerus
Pain and apprehension from the patient indicate a positive test for labral tear or anterior instability (subluxation)
Clinician then applies posterior force to shoulder through the humeral head (relocation)
Test is positive if apprehension and/or pain are decreased

Tests for Anterior Instability


Rockwood Test
Clinician behind seated patient
ER the shoulder with arm abducted passively to 45o, 90o, and 120o
Positive test is indicated when apprehension I noted
Different positions are utilized because the stabilizers of the shoulder vary at differing angles of abduction and ER
Tests for Inferior and Multidirectional Instability

Sulcus Sign
Patient sits with arm at side
Clinician grasps forearm below elbow and pulls arm distally
The presence of sulcus sign demonstrates inferior instability

Tests for Inferior and Multidirectional Instability

Sulcus Sign
Graded by measuring the inferior margin or acromion to the humeral head
+1 sulcus implies distance of less than 1cm
+2 sulcus implies distance of 1-2cm
+3 sulcus implies distance of more than 2cm

Tests for Inferior and Multidirectional Instability

Feagin Test
Modification of the Sulcus Sign
Patient’s arm abducted to 90o with elbow extended and resting on clinician’s shoulder
Clinician’s hands clasped over the patient’s humerus, between the upper and middle thirds
Clinician pushes humerus down and forward
Positive test is apprehension
This testing position puts more stress on the inferior GH ligament


Tests for Posterior Instability
Posterior Apprehension or Stress Test
Patient supine
Clinician flexes arm to 90o
Clinician applies posteriorly directed force on patient’s elbow
While applying axial load, the clinician horizontally adducts and IR the patient’s arm
Positive test is apprehension or alarm on the patient’s face
Can also be performed at 90o shoulder abduction
Should be no greater than 50% of humeral head’s diameter of posterior translation
Sternoclavicular Joint
Bony Joints, Capsule, and Ligaments
Interventions
Muscles and Movement
Tom Meyers
Functional Anatomy Chain/Trains
Glenoid fossa faces
Laterally
Superiorly
Anteriorly
Test for Labral Tears
Causes of Scapular Dyskinesia
Bony: Thoracic kyphosis, Clavical facture non or malunion
Joint: AC joint instability, AC arthrosis, GH Internal derrangement
Neuro: Cervical radiculopathy, Long thoracic nerve palsy, Spinal assessory nerve palsy
Soft tissue: Hypo mobility of pec minor,
altered muscular activation or force couple actions (most common)
Blocked patient won't like this
basically its just joint mobilization evalution looking for instability
Jerk Test
Patient sitting with the arm at 90o of abduction and IR.
Clinician standing to the side and slightly behind the patient
Clinician grasps the patient’s elbow with one hand and the scapula with the other and axially loads the humerus in a proximal direction.
Axial loading compression is maintained while the patient’s arm is moved into horizontal adduction
A positive test for recurrent posterior instability is the production of a sudden "jerk" or clunk as the humeral head slides off (subluxes) the back of the glenoid (Figure 5-72). Sharp shoulder pain with or without a clunk or click is also a positive test. When the arm is returned to the original 90° abduction position, a second jerk may be felt as the head reduces. Kim, et al.208 reported that the positive signs also indicate a positive test for a posteroinferior labral tear.
1 The patient assumes either a sitting or supine position. The examiner typically stands at the side of the involved extremity.
2 The examiner places the patient’s shoulder in 160 degrees of abduction and elbow in 90 degrees of flexion. Other text state Compression Rotation Test can be done at a variety of positions of abduction (20d)
3 The examiner first applies a compression force to the humerus and then rotates the humerus repeatedly into
internal rotation and external rotation in an attempt to pinch the torn labrum.
4 A positive test is indicated by the production of pain either with or without a click in the shoulder or by reproduction of the patient’s concordant complaint (usually pain or catching).
Crank Test
Compresion Rotation test
or
***Realize that if you are initially suspecting capsular instability with your patient and you perform this test and they have no apprehension but you feel a clunk, click, or shift then this test just became a labral test (Clunk Test). Don't confuse clunk with crank because in this case you did not apply axial loading.
Apprehension/Fulcrum/Relocation combination
External Rotation Resistance Test (Infraspinatus pathology and all Stages of Subacromial Impingement)
Tests for Rotator Cuff Integrity
1 The patient is standing with elbow in 90 degrees flexion, neutral forearm rotation, and elbow adducted against the body.
2 The examiner stands to the side of the patient and provides an internal rotation force while the patient resists.
3 A positive test is indicated by patient giving way due to
either pain or weakness.
Lateral Jobe test:
1 The patient is standing with arms abducted to 90 degrees.
2 The patient internally rotates to end-range humeral motion.
3 The examiner applies an inferior force to the patient’s elbows as the patient resists.
4 A positive test is indicated by pain reproduction or weakness or inability to perform the test.
Scapular mobility
Scapula stabilization
NOT A GREAT EXERCISE!
WHY?
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