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HOWTRAININGMATERIAL2010/11 SESSION1

THESHOULDER
History
Painfromshoulderoritssurroundingtendonsisfeltanterolaterally&attheinsertionof
deltoids;sometimesitradiatesdownthearm.Painontopofshouldersuggests
acromioclaviculardysfunctionoracervicalspinedisorder.Theentireshoulderisacommon
siteofreferredpainfromcervicalspine,heart,mediastinum&diaphragm
Stiffnessmaybeprogressive&severe:somuchsoastomeritthetermfrozenshoulder
Deformitymayconsistsofprominenceofacromioclavicularjtorwingingofscapula
Lossoffunctionisexpressedasinabilitytoreachbehindtheback&difficultywithcombinghair
ordressing
Thepainfulshoulder
a) Referredpain
1 Cervicalspondylosis
2 Mediastinalpathology
3 Cardiacischaemia
b) Jointdisorders
1 Glenohumeralarthritis
2 Acromioclaviculararthritis
c) Rotatorcuffdisorders
1 Tendinitis
2 Rupture
3 Frozenshoulder
Examination
Theptshouldalwaysbeexaminedfrominfront&frombehind.Bothupperlimbs,neck&chest
mustbevisible.Becauseshoulder&necksymptomsareoftenfeltinsameareas,examination
ofshouldermustincludeafullexaminationofneck&viceversa
Look
a) Skin
Scarsorsinusesarenoted;dontforgettheaxilla!
b) Shape
Asymmetryofshoulders,wingingofscapula,wastingofdeltoidorshortrotators&
acromioclaviculardislocationarebestseenfrombehind;jtswellingorwastingof
pectoralmusclesismoreobviousfrominfront.Ajteffusionmaypointinaxilla
c) Position
Ifthearmisheldinternallyrotated,thinkofposteriordislocationofshoulder
Feel
Becausethejtiswellcovered,inflammationrarelyinfluencesskinT.thesofttissues&bony
pointsarecarefullypalpated,followingamentalpictureofanatomy.Startwith
sternoclavicularjt,thenfollowclaviclelaterallytoacromioclavicularjt,ontoanterioredgeof
acromion&aroundacromiotobackofjt.Thesupraspinatustendonliesjustbelowanterior
edgeofacromion.Tenderness&crepituscanoftenbeaccuratelylocalizedtoaparticular
structure

HOWTRAININGMATERIAL2010/11 SESSION1
Move
a) Activemovements
Theptisaskedtoraisebotharmssidewaysuntilfingerspointtoceiling.Abductionmay
be
1 Difficulttoinitiate
2 Diminishedinrange
3 Alteredinrhythm,thescapulamovingtooearly&creatingashruggingeffect
Ifmovementispainful,thearcofpainmustbenoted;paininmidrangeofabduction
suggestsarotatorcufftearorsupraspinatustendinitis;painattheendofabductionis
oftend/tacromioclaviculararthritis
Ptisthenaskedtoperformotheractivemovements;flexion&extensionbyraisingthe
armsforwards&thenbackwardsasfaraspossible;adductionbymovingeacharm
acrossthefrontofbody;androtationbyholdingthearmsclosetobody,flexingelbows
to90&1stseparatinghandsaswidelyaspossible(externalrotation)&thenfoldingthe
forearmsacrossfrontofbody(internalrotation)
3compositemovementsareessentialfornormalfunction
1 Claspingthehandsbehindnecks
2 Reachinghighuponback
3 Performingacircularpotstirringmovementwitheacharminturn
b) Passivemovements
Thesecanbedeceptivebecauseevenwithastiffshoulderthearmcanraisedto90by
scapulothoracicmovement
Totestglenohumeralabduction,scapulamust1stbeanchored;thisisdonebypressing
firmlydownontopofshoulderwith1handwhiletheotherhandmovesptsarm
c) Power
Deltoidisexaminedwhileptabductsagainstresistance
Totestserratusanterior(longthoracicnerve),askpttopushforcefullyagainstawall
withbothhands;ifthemuscleisweak,scapulaisnotstabilizedonthorax&standout
prominently(wingedscapula)
Pectoralismajoristestedbyptthrustingbothhandsfirmlyintowaist.Anydifferencein
musclebulkbetween2sidesisnotedatthesametime
Imaging
Atleast2xrayviewsshouldbeobtained:anAPviewinplaneofglenoid&anaxillary
projectionwitharminabductiontoshowrelationshipofhumeralheadtoglenoid.Lookfor
evidenceofsubluxation,ordislocation,jtspacenarrowing,boneerosion&calcificationinsoft
tissues
Doublecontrastarthrography,US,CTandMRIareusefulmethodsfordiagnosingrotatorcuff
tearsoratypicalformsofshoulderinstability
Arthroscopy
Isusefulfordiagnosingintraarticularlesions,detachmentofglenoidlabrum&rotatorcuff
tears.Insomecasesthedisordercanbedealtwithsurgicallyatthesametime

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