Shoulder

Subjective:
Questions:

Injury mechanism?, gradual or acute onset?

Location, deep/superficial, with or without mvt, click or clunks (=pain?)?
Activities such as: hand on back (putting shirt in pants, money in back pocket), Hand on head
(washing hair, eating), putting on seatbelt, throwing, hanging up washing...
Differential Diagnosis: Tx, Cx

Observation:
Make sure you know the physiological mvt (Scapulohumeral Rhythm)- this varies slightly depending on
literature:
Abd:
0-20deg:
80-140deg:
Above 140deg:

mostly GHJ, small amount of scapula rot, elevation of SCJ, Scapula:

Humerus=1:7
increased lat rotation of scapula, Scapula:Humerus= 1:2, Clavicle :post rotation
less GHJ mvt, more scapula rot

Motor control:
0-60deg:
60-120deg:
Above 120deg:

Utrap, Serratus ant (Stabilisers: MTRap, Ltrap)

Deltoid, RC (till approx 90deg), serratus ant (Stabilisers: Mtrap, Rhomb)
LTrap, Serratus , RC to stabilise (Stabilisers: Mtrap, Rhomb)

UTRap primarily helps for Elevation and Rotation of Clavicula. Should be able to perform 20-30deg
(otherwise suspect fatigue of Utrap).

Postural ananlysis
Musble bulk
Step deformity
Shoulder levels
Scapular position

Standing or sitting

Functional test: perform movement of pain: try to correct position of Humeralhead (caudal or posterior),
Scapula (tilt, rotation, mvt) - Improvement, worse or no change?
AROM
Flexion
Abduction
Adduction
Internal Rotation
External rotation
Hand above head
Hand behind back

Standing or sitting- Overpressures (VAS before and after)

Watch for scapular control

Clear other joints

Above and below and thoracic
Strength
Resisted Flexion, extension, abduction, adduction, internal and external rotation
Roshni Naran & Andrea Noebauer

Special Tests
Diagnosis/Complaints Tests to perform to confirm
Instability (Rotator Cuff)
Clicks, clunks,
overhead activities,

Sulcus sign
(capsule)

A lot of test possible:

Try to differentiate bw
structural (labral tear,
weak capsule) and
functional (RC, ms
coordination-force
couples) Instability

Possible
Treatment
Dynamic
strengthening, Ms
strengthening (RC),
Scapula
stabilisation

Retraining:
Dynamic
Relocation
(see Mark Jones
DRST)

Anterior drawer
(capsule) slow slow quick quick quick

Relocation/ Apprehension test

(capsule)
Apprehension test is without the AP compressionRelocation should reduce symptoms

Roshni Naran & Andrea Noebauer

RC tests-empty can (SupraS)

Reversed empty can/ Full can test (InfraS)

LH Biceps
Resistance into Shoulder and Elbow Flexion (from
neutral),
also move from Extension into Flexion

Teres minor (ER)

Bear hug(Subscapularis)
Roshni Naran & Andrea Noebauer

Or if restricted mobility test this way:

O Brien (Slap lesion, ACJ, LH Biceps)

The patient is instructed to flex their arm to 90 with the

elbow fully extended and then adduct the arm 1015medial to sagittal plane. The arm is then maximally
internally rotated and the patient resists the examiner's
downward force. The procedure is repeated in
supination. The O'Brien Test is designed to maximally
load and compress the ACJ and superior labrum.
Positive sign: Pain elicited by the first manoeuvre is
reduced or eliminated by second
Roshni Naran & Andrea Noebauer

Dynamic Rotation Stability test (different ranges)

Movement test and compare to physiological mvt

Neer
Impingement:
Pain with overhead
activities, painful arc....

Stretching post
capsule in SL, A/P
Caudal glide
treatment

Hawkins

Impingement due to
Rotator Cuff
insufficiency?

Treat RC
accordingly
(strengthening)
A/P

Roshni Naran & Andrea Noebauer

Caudal glide

Impingement vs
Instability
SLAP lesion
ACJ (Tossy I-III)
Biceps tendinopathy

Compress or distract subacromial/coracoidal space

See above

See Instability

See Instability

Biceps test, RC Tests, Impingement?

RC strain/tear

See Instability
Degenerative or acute?

Dislocations

Can result in Instability

(Relocation/apprehension test)
Injury mechanism athlete?

Treat the cause of

tendinopathy
Restore
physiological mvt
what possible, is
there impingement
or instability? Treat
the cause
See instability
(surgery:)
Initially passive
movement for 3-4
weeks till 90degr +
avoid ER, from
week 4 active
assistant + active
above 90deg) but
see surgeons
protocol
Maintain: elbow,
wrist, finger, Cx
activities
Distractions/
Manual treatment
Ms strengthening if
impingement due to
ms weakness
Manual
techniques+Mobility
exc + Ms
strengthening

Clinic
X-Ray, MRI
Acute dislocations without surgery:guideline
Intensive isometric exc to strengthen IR
After 3 weeks active ER
Abd + ER avoid for 6 weeks

Bursitis

Pain with no mvt?

Due to impingement?

OA(Humerus,
ACJ/SCJ)

Adhesive Capsultis
(Frozen shoulder)
Restriction in all
directions?night pain,
gradual onset, age
Roshni Naran & Andrea Noebauer

PT?
Self limiting after
approx one year

group (40-60yo)
Fractures

Clinic
X-ray

Elbow:
Subjective:
Questions:
Roshni Naran & Andrea Noebauer

Sling up to 6
weeks,
depending on
fracture, location
and patient age,
also if surgery or
conservative
medical treatment
Maintain: elbow,
wrist, finger, Cx
activities

Injury mechanism?, gradual or acute onset?

Location, deep/superficial, with or without mvt, click or clunks (=pain?)?
Activities such as: throwing, eating, writing
Differential Diagnosis: Shoulder, Cx,
Diagnosis/Complaints
Instability:
Click or clunks, throwing
or weightbearing activity
problems

Lateral
epicondylitis(Tennis
elbow)
Pain with grip or holding
objects, radiating down
in forearm,
Often throwing sports

Tests to perform to confirm

Varus/Valgus Test

Lateral pivot shift apprehension

test
Posterolateral rotatary drawer test
Palpation ms origin
ECRB (to base of third Metacarp)lift middle finger into ext and give
resistance

Grip strength
Pain with Ext+pron+Rad deviation

Mills test: Resisted wrist extension

Roshni Naran & Andrea Noebauer

Possible Treatment

Lateral glide, TP on ms
bulcs, C5-6, taping
Rest
Ice
Deep friction
Ultrasound
Advice and Education
Brace
Stretching to Wrist ext
Strengthening

Medial epicondylitis
(Golfer elbow)
Fracture

dislocation

Radial nerve testing

Pain on resisted wrist flexion and
forearm pronation = reversed Mills
test
Clinic
X-Ray

Clinic
X-Ray

Roshni Naran & Andrea Noebauer

Manual treatment-depending
on mvt restrictions,
Muscle training if wasting or
weakness
Keep wrist and shoulder
mobile whilst in cast