Physiotherapy Shoulder Ax

This page includes: Subjective Ax, objective Ax, Passive ROM, Active ROM, Strength Tests, Rotator cuff tests, Special tests, Differential Diagnosis.

The Shoulder Assessment  is vital in the diagnosis of shoulder pain. It should include a full subjective and objective examination with use of special tests to aid differential diagnosis. The best way to learn good assessment skills is through hands on practice and watching experts. Try to spend a day with a consultant or extended scope practitioner to see how they perform an assessment. Visit the student room to  find preparation notes for work experience days.

Useful tip  “One way to get better at assessing is by practicing. Organizing small groups and role playing the clinical environment is useful so that someone can observe and give you constructive criticism. You will feel more confident with your questions, handling techniques and tests if you have practiced them on a friend five times before.”

Areas to focus on:

  • Communication
  • Question asking
  • Hand holds
  • Professionalism

Subjective Ax

The subjective examination aims to gain valuable information on how the symptoms have come about and what is causing them.

  • Dominant hand
  • Functional limitations
  • Does the pain presentation lie within a dermatomal region?
  • Mechanism of injury –This gives you clues as to which structures may have been stressed.

 

RED FLAGS –

These are the special questions which may indicate that something more sinister may be going on. Patients should be referred immediately back to the GP with your concerns noted. Ask a seniors advice on the severity of these symptoms and whether and A and E referral is more appropriate. Mechanism of Injury is important here, if they fell from a height, lost conciousness or have neck pain this may indicate a cervical fracture.

  • Bilateral pins and needles/numbness, unexplained weight loss.
  • Pathology from cardiovascular, pulmonary or gastrointestinal systems can refer to shoulder.

Assessment video

Objective Ax

 The objective examination gives you quantifiable measures to rule out what structures are involved and to reassess after treatment to determine improvement/deterioration. For example a gentleman with a frozen shoulder (Adhesive capsuitis) may have 100 degrees shoulder flexion however post treatment may have 120 degrees. Continually re-assessing will enable you to see whether treatments have been effective.

  • Check ROM of the neck
  • Observation – Posture, Muscle bulk,
  • AROM – Flexion (1650-1800), Extension(500-600), Abduction(1700-1800)External Rotation (800-900), Internal Rotation(700-800),
  • PROM
  • Strength
  • Myotomes
  • Reflexes – Biceps(C5), Triceps(C7), Brachioradalis (C6) Hoffmanns Sign.
  • Sensation
  • Palpation

What does this tell you?

“As a student I wanted everything to fit into a box, unfortunately it doesn’t. Take an anatomy book, pick a joint and list the structures that may be affected if it were to have a force through it in any direction. As you learn your anatomy you will discover the list becomes longer and longer. As a physiotherapist anatomy is your bread and butter which enables so you to rule out  structure that may be causing the issue. It is rare that only one structure is affected with no damage to surrounding structures so bear this in mind. The following is aimed as a rough guide to give you some ideas however is by no means an exhaustive list.”

  • Poor Quality of movement –Is there an imbalance in the stabilizing muscles of the shoulder?
  • Unable to perform movement – Is this due to pain or weakness? Pain may suggests a partial muscle tear, joint dysfunction or soft tissue compression.
  • If there is no pain but the patient is unable to lift their arm is this because of a complete rupture of the muscle or perhaps its innervation (nerve supply) is incomplete?
  • Pins and needles of paraesthesia (numbness) in the arm or hand? This normally suggests a neural element which maybe coming from the neck or compression of the nerve somewhere along its course.
  • If you press on a structure and this reproduces the patients symptoms this may suggest referred pain is occuring (ie C5 unilateral AP/PA the patient may feel symptoms in the C5 dermatomal region).

 

Useful Tip: Not everything is black and white. Symptoms may be caused by combination of problems, which can include more than one structure. Use the tests aid differential diagnosis.

 

Active movements

(This tells you whether there is weakness or pain on active movements which may indicate that a muscle could be the source of the problem)

Active movements are assessed first. The patient is asked to elevate the shoulder to demonstrate any limitation of movement or painful arc.  If movement is limited then an examining hand placed on the scapula during active elevation will show whether the limitation is glenohumeral or scapulothoracic, or both. A painful arc may be more marked with elevation in abduction rather than flexion. With the elbow locked into the side active external rotation is compared with the unaffected arm, and finally active internal rotation is assessed by comparing how far up the spine the thumb of the affected arm will go compared to the normal side. For this latter test, elbow function must be equal on both sides.

Neck ROM should always be checked to rule out referred pain.
             

Passive movements

(If the movement is painful with active movement but not on passive this may indicate the muscle is the source of the problem. If the pain is elicited on AROM and PROM this suggests that the structures on stress(ie tight) are causing the pain or perhaps tissues are being compressed?)

Passive movements are those performed by the physiotherapist or surgeon. They allow structures to be tested without patient effort so help to identify the structure involved. Elevation, external rotation and internal rotation are again measured with the surgeon holding the distal humerus in one hand and the inferior angle of the scapula under the palm of the other hand. The range, pattern of movement, end point, excess over active movement and degree of pain are all noted.

Shoulder Special Tests

Shoulder Tests helps identify the structure causing the pain. They vary in sensitivity  and specificity with many stressing more than one structure therefore you will need to perform a variety and rule out possible conditions.

 

  • Anterior Apprehension test – Physio puts patients shoulder in 90 degrees abduction and 90 degrees external rotation. Then physio applies external rotation. Positive sign: Unwillingness to allow motion to occur ie resists further motion. Pain.
  • Relocation test : (position as per apprehension test) Apply a posterior force to the humeral head. Positive Sign: Patient’s apprehension is reduced. Pain may be reduced. Further ER can sometimes be achieved.
  • Sulcus Sign  patient sitting with arm relaxed. Physio holds patients forearm (beneath elbow and applies an inferior force.)
  • Hawkins and Kennedy impingement – Physio flexes arm to 900, elbow flexed to 900, physio passively internally rotates shoulder.  Positive sign: Reproduces symptoms.
  • Painful Arc – Patient abducts arm. Reproduction of symptoms between 600-1200. Symtoms reduced above and below this.
  • Ludingtons Test – Patient places hands on top of head with linked fingers. Contracts and relaxes bicep muscle while physio palpates biceps tendon.
  • Apleys scratch test – patient internal rotates and adducts shoulder to place hand behind back and attempt to touch the opposing scapula. Positive Sign: Reproduces symptoms or reduced ROM
  • Empty Can Patient abducts shoulder 90, internally rotates shoulder and brings arm out horizontally 30. Patient asks patient to maintain movement and applies vertical force to distal limbs. Positive Sign: Reproduces Symptoms.

Rotator cuff strength

The glenohumeral joint is poorly designed for structural stability and relies on four muscles to dictate its position and movement. The clinical test of rotator cuff function is an integral part of every examination of the shoulder.

The Supraspinatus test 

This test is carried out with the patient standing. With the elbow straight, the arm is placed in 20 degrees of abduction and flexion, and the patient is told to hold it there. The examiner assesses the strength of abduc­tion, and the patient reports the amount of pain produced by this manoeuvre. The examiner then tests the opposite normal shoulder for comparison. Weakness on testing denotes a rotator cuff tear. Unfortunately, if there is a lot of pain, then weakness will be apparent due to pain inhibition, and the test will have to be performed after an impingement injection test.

The Impingement injection test

This test allows the surgeon to establish whether subacromial impingement is causing the painful arc. For the test, 5 ml 1 per cent lignocaine (US: lidocaine) is injected under the anterior edge of the acromion. After 10 minutes the patient is re-examined, and if the painful arc is improved or abolished, then the site of pain has been established.

The Infraspinatus test

This test is very similar to the supraspinatus test, and is a test of resisted active external rotation of the shoulder. The infraspina­tus is the only efficient external rotator of the glenohumeral joint. Pain and weakness are sought, weakness denoting a rotator cuff tear.

The Subscapularis test

This test is similar, but opposite, to the infraspinatus test. With the elbow locked against the patient’s side active resisted inter­nal rotation of the glenohumeral joint is tested. Unfortunately this movement is produced by pectoralis major and latissimus dorsi, as well as subscapularis, and therefore is not such a sensitive test.

Useful reference: Intrarater reliability of assessing strength of the shoulder and scapular muscles.(2012) Celik D, Dirican A, Baltaci G. J Sport Rehabil. 3:1-5.

 

Differential Diagnosis

Possible conditions include:

  • Rotator Cuff Tear/Repair
  • Slap lesion
  • Disclocation/ Post Stabilisation
  • Sub-acromial Impingement
  • Arthritis
  • Poor scapulohumeral rhythm
  • Postural shoulder pain

 

Click here for a full list of shoulder conditions.

Click here to The Shoulder Symptom Modification Procedure (SSMP) (An objective shoulder Ax).

Click here for an exempler objective assessment sheet.
Click here to view exempler Shoulder notes

 

 Check your anatomy and improve skills by reading X-Rays and completing a self directed image interpretation course, brought to you by Heidi Nunn DCR (D) Pgcert.

Reading:

Things seniors wished they’d known as a student:

  1. Be careful with sensitive questions ie ask – “Have you ever received radiotherapy or chemotherapy? ” rather than “Have you had cancer?”
  2. If you are unsure of someones age it may be better to ask “Are you working?” rather than “Are you retired?” to avoid offending anyone. If they are retired you could ask “How do your fill you days?” Many will volunteer in charity shops, attend coffee mornings or garden which may give you clues to the cause of symptoms.
  3. Do not assume that because someone cannot lift their arm that it is due to muscle weakness. Neuropraxia, pain due to soft tissues and muscle rupture could also present in a similar manner.


 

Other things that might interest you …

Student room

Interview questions

Assessments

Anatomy 

Dissections

 

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