BLUE SKY SCHOOL OF PROFESSIONAL MASSAGE AND THERAPEUTIC BODYWORK Musculoskeletal Anatomy & Kinesiology SHOULDER ASSESSMENT

Transcription

1 BLUE SKY SCHOOL OF PROFESSIONAL MASSAGE AND THERAPEUTIC BODYWORK Musculoskeletal Anatomy & Kinesiology SHOULDER ASSESSMENT MSAK201-II Session 7 LEARNING OBJECTIVES: By the end of this session, the student will be expected to: 1. Apply all review material from MSAK 101 and Identify the bony landmarks and muscles around the shoulder girdle and shoulder. 3. Measure and identify normal and abnormal shoulder range of motion. 4. Perform tests to identify normal and abnormal strength and length of the muscles of the shoulder girdle and shoulder. 5. Demonstrate Shoulder Orthopedic Exams and discuss their implications. 6. Critically assess the spine of a client in preparation for soft tissue treatment. 7. Document assessment findings in SOAP format. Equipment: 1. Goniometer 2. Marking pencil 3. Tape measure Procedures: 1. While your client is in a standing position, find and mark the following structures: Scapula: Sternum: Medial and lateral borders Manubrium Inferior and superior angle Body Spine of the scapula Xyphoid process Root of spine of scapula Humerus Acromion process Head Coracoid process Greater Tubercle Clavicle Lesser Tubercle Anterior surface Bicipital groove Sternal (medial) end Biceps brachii tendon Acromion (lateral) end Olecranon process Styloid process of ulna 1

2 2. With your client in a standing position, observe the posture of the shoulder, humerus, and scapula from the posterior and lateral views. 3. Review origin, insertions, and actions of shoulder muscles. Identify the muscles on client: Pectoralis minor Levator scapulae Rhomboids Trapezius Upper Middle Lower Latissimus Dorsi Serratus anterior Coracobrachialis Biceps Triceps Pectoralis major Latissimus dorsi Teres major Rotator cuff: Supraspinatus Infraspinatus Teres minor Subscapularis Deltoids 4. Measure the range of motion of the shoulder complex by using a goniometer. a. Abduction 2 to 1 Rule: For every 2 degrees of glenohumeral movement, the scapula moves 1 degree. 180 degrees of abduction consists of 120 GH motion and 60 degrees of ST motion. The scapula with the glenoid as its contact point forms the platform for the humeral head articulation and motion. A stable platform is essential for normal shoulder biomechanics and is crucial for high demand activities like overhead work. 2

3 5. Test for external and internal rotation of shoulder muscles (Apley s Scratch Test): a. Purpose: To assess length of shoulder rotators. b. Test: Client is seated and is instructed to place the one hand behind the head and touch the opposite superior angle of scapula. The client is then instructed to place their other hand behind their back and attempt to touch the opposite inferior angle of the scapula. Therapist observes client movement posteriorly. c. Result: 1) If the client is able to perform this maneuver bilaterally, the shoulder rotators are of normal length. 2) If shoulder girdle depresses and the scapula wings out, client is compensating for limited shoulder joint medial rotation by substituting shoulder girdle movement. 3) Exacerbation of client s pain indicates tendonitis of one of the tendons of the rotator cuff. 6. Test for adductor muscle length (Adductor Length Test): a. Purpose: To evaluate length of adductor group in shoulder. b. Test: Supine client with knees bent to 90 degrees, feet flat on the table, and low back flattened. Client fully flexes both arms over their head and attempts to rest them on the table. Therapist observes degree of movement bilaterally. c. Result: 1) If the client is able to perform this maneuver bilaterally with the arms rested on the table, then the shoulder adductors are of normal length. 2) If the shoulder joint cannot be completely flexed with the back is held flat, the presence of shortness in the shoulder adductors is present. 7. Perform shoulder muscle strength testing: a. Flexion 1) Examiner immobilizes the client s scapula on the side being tested. This is achieved by grasping and holding the lower border with one hand. The client flexes the arm anteriorly to 90 degrees while the forearm is pronated and elbow slightly flexed. The examiner s free hand provides resistance just above the elbow. b. Extension - 1) Examiner fixes the scapula as described for testing flexion. The client extends the arm posteriorly through the range of motion. The examiner s other hand, which is placed just above the elbow, provides resistance. 3

4 c. External Rotation 1) Assess with the client s arm abducted to 90 degrees, with the elbow flexed to 30 degrees, and with the hand and fingers pointing forward. The examiner supports the client s elbow by holding it with one hand while the client rotates the arm upward against resistance that is applied by the examiner s other hand, which is placed on the client s forearm proximal to the wrist. d. External Rotation 1) Test with the arm abducted to 90 degrees, eth elbow flexed to 90 degrees, and the hand pointed forward. The examiner supports the client s elbow with one hand while the client rotates the arm downward against graded resistance that is applied by the examiners other hand, which is placed on the client s forearm proximal to the wrist. e. Abduction 1) Client s arm is at their side, while the forearm is between pronation and supination, and while the elbow is flexed a few degrees. The examiner stabilizes the scapula as described for flexion. The client abducts the arm to 90 degrees. This abduction occurs against resistance applied by the examiner s other hand, which is placed proximal to the client s elbow. f. Adduction 1) Client adducts the arm anteriorly through the horizontal plane and against graded resistance. NERVE COMPRESSION AND OTHER PATHOLOGY 1. Thoracic Outlet Syndrome (TOS) a. Pathology: TOS is an entrapment of the brachial plexus. Three types of TOS exist. All have similar symptoms with differing pathology. Entrapment occurs between Anterior and Middle Scalene, under Pectoralis Minor, or due to anomalous cervical ribs. b. Symptoms: Tingling, pain or numbness and/or motor symptoms like weakness or partial paralysis in the upper extremity. c. Treatment: Assess cervical and shoulder ROM, evaluate muscle length of scalenes and pec minor. Utilize Reverse Bakody s and Costoclavicular. Palpate and treat as indicated. Reassess. 2. 4

5 Reverse Bakody s Maneuver Assessment for TOS The seated client flexes their head, places the palm of the affected extremity on the top of the head, and raises the elbow to a height approximately level with the head. This action causes the interscalene compression increases. The sign is present when radiating pain appears or is worsened with the maneuver. 3. Costoclavicular Maneuver Assessment for TOS The client is seated with the arms at their sides. The examiner bilaterally palpates the radial pulse. The examiner extends the client s shoulders as the client flexes the cervical spine. The test is positive if the radial pulse of the affected arm disappears. A positive test indicates thoracic outlet syndrome due to compression by Pectoralis Minor. 4. Suprascapular Nerve Entrapment a. Pathology: The Suprascapular arises from the trunk formed by the union of the fifth and sixth cervical nerves. It runs lateralward beneath the Trapezius and the Omohyoid; it then passes beneath the Supraspinatus, and curves around the lateral border of the spine of the scapula to the infraspinatous fossa. b. Symptoms: The main symptom is deep and diffuse pain poorly localized in the posterior and lateral aspects of the shoulder. Pain may be referred to the neck, into the arm, or generally to the upper anterior chest, but localized to the acromioclavicular joint. Scapular motion aggravates the pain. Often, the client says that shoulder motion causes the pain, but it is scapular motion and not actually glenohumeral motion that does so. c. Treatment: Observe scapular motion for symmetrical movement. Test shoulder lateral rotation and abduction for weakness but no pain. Passive shoulder horizontal adduction which may stretch the nerve may be painful. Increased pain can usually be elicited applying digital pressure to the supraspinatus muscle. In chronic conditions there may be atrophy of the supra- and/or infraspinatus muscles. Palpate and treat supraspinatus and related shoulder girdle stabilizers with the goal of restoring flexibility. Reassess. 5. Rotator Cuff Injuries a. Pathology: Rotator cuff tendonitis occurs when one or more of the rotator cuff is inflamed or irritated. Supraspinatus is most commonly irritated by undersurface of the acromion. b. Symptoms: Pain in anterosuperior shoulder that worsens with overhead activity. Mild popping or crackling sensation in shoulder. Weakness in abduction or flexion activities and stiffness. Clients often complain of difficulty sleeping on the affected shoulder at night. c. Treatment: RICE in acute stages. Referral may be necessary. 5

6 6. Codman s Sign (AKA Drop Arm Test) Assessment for Tear in the Rotator Cuff Client s arm is passively abducted to 90 degrees. The client tries to lower the arm slowly to their side in a smooth arc of movement. If the client is unable to return the arm to the side slowly or has severe pain, the test is positive. A positive test suggests a tear in the rotator cuff complex and a referral may be necessary. 7. Bicipital Tendonitis a. Pathology: Inflammation of biceps tendon due to repetitive overhead activity. b. Symptoms: Pain when arm is overhead or bent. Discomfort is localized over bicipital groove in the anterior proximal humerus. Weakness in flexion can be noted as well as snapping of the tendon over the greater and lesser tubercles with rotation. Clients often complain of difficulty sleeping on the affected shoulder at night. c. Treatment: RICE in acute stages. Referral may be necessary. 8. Speed s Test Assessment for Bicipital Tendonitis While seated, the client flexes the affected shoulder. The examiner then provides resistance. While flexing the shoulder, the client supinates the forearm and completely extends the elbow. A positive test elicits increased tenderness or snapping in the bicipital groove and indicates bicipital tendonitis. References: Hoppenfeld, S Physical Examination of The Spine and Extremities. Appleton-Century- Crofts, East Norwalk. Kendall, F. P. and W. A. Romani, 5th Ed Muscles, Testing and Function With Posture and Pain. Williams & Wilkins, Baltimore. Norkin, C. C., and D. J. White Measurement of Joint Motion: A Guide to Goniometry. F.A. Davis Company, Philadelphia. Sahrmann, S. A Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, Inc., St. Louis. Sobush DB: The Lennie test for measuring scapular position in healthy young adult females: a reliability and validity study, JOSPT 23:39,