Speaker key
KL Keith Littlebury
KL My name is Keith Littlebury; I’m an extended scope physiotherapist for
Connect Physical Health. Today I’m going to demonstrate a shoulder assessment.
This assessment is done with the patient in standing; first of all we do observation of the shoulder. Now things I’m looking for in this shoulder joint are general posture, any muscle wasting, any obvious deformities, any swelling or any discolouration.
Then the first active test we do is an active abduction test, this is probably the most useful test because it can pick up a lot of different pathologies. First of all I’m going to ask Nicola to do full active abduction with the palm facing downwards.
So in normal active abduction there is no pain, no trick movements and full range of movement to the vertical position. Several things could show up on this test, for example a painful arc. This is where the patient develops pain in the range of approximately 90 degrees which then disappears at full abduction and is again painful on the way down. This is very indicative of subacromial impingement. A second thing that can be picked up on this test is if the patient has trouble raising the arm fully and has to use assistance with the other hand.
Patients will often demonstrate this because they’ve got used to reaching up for a cupboard and using the other arm to help; this is indicative of a possible complete rupture of one of the rotator cuff muscles. The last possible outcome of this test is the trick movement. So here the patient demonstrates a trick movement because she lacks the full range of movement at the glenohumeral joint and uses additional techniques to get the arm above 90 degrees which involves shoulder hitching and sideways leaning.
This is indicative of glenohumeral pathology, possible frozen shoulder.
Next we go onto passive movements. This is to demonstrate and to look for the
Capsular Pattern. The Capsular Pattern is restriction of external rotation more than abduction, which is restricted more than medial rotation. So passive lateral rotation would be painful and restricted; this would be more than passive abduction which may also be restricted, and this would be more than medial rotation which would also be restricted. If the passive movements do not fit into this pattern then it’s not a
Capsular pattern.
So if passive lateral rotation is more restricted than passive abduction, this indicates glenohumeral pathology. If passive abduction is more restricted than lateral rotation, this would indicate possible impingement.
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I’m now going to go onto some special tests – if you can just turn and face me. First is the Hawkins-Kennedy Impingement test. The idea of this test is to compress the subacromial structures to reproduce the impingement. The left hand here is just fixing the scapula; the right hand is controlling the arm. And I’m going to take the patient’s shoulder into horizontal flexion and gradually increase the compression there, looking for a patient’s pain. If this is painful, it is a positive impingement sign. If you find the painful spot and then add internal rotation and the pain gets worse, it’s a more positive impingement sign.
Next we’re going to do resisted rotator cuff tests, and if you can just turn and face the front again. We place ourself in an advantageous position, so you don’t have to use all your strength; in this position I’m going to ask Nicola to push her arm outwards into abduction and resist that movement. This is testing the supraspinatus muscle; a positive test would be if it was painful, indicating the supraspinatus tendon is at fault, as no other joint is moving. It may also be weak, indicating a possible tear.
Next I’m going to fix the elbow in and ask Nicola to push laterally – this is testing lateral rotation, the infraspinatus muscle. Next I’m going to get her to pull inwards, testing medial rotation, subscapularis muscle. Next is a stability test, this also doubles as a labral test, left hand again fixing the scapula, my right hand is grasping the head of humerus - it’s a load and shift test because I compress the joint and shift it backwards and forwards testing for any stability. If there is a positive clunk on this test, it could be indicative of labral tear.
Specific labrum test is the grind test, this is compression through the length of the humerus, trying to compress the head of the humerus against the labrum and a rotational grind; positive test is clunking or pain, this can be done in various different angles to test different parts of the labrum. This is testing the superior labrum; this is testing inferior labrum.
And finally just palpation test, if you can turn that way. Starting at the back of the acromion, I’m palpating the posterior angle of the acromion and the lateral border of the acromion, looking for pain which would indicate possible bursitis or impingement pain. As we come round to the front, you find the V-notch of the AC joint and this can test the acromioclavicular joint for pain.
And that concludes my examination.
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