Evaluating the Shoulder & Upper Arm Richard Frazee, MS, LAT,

Evaluating the Shoulder & Upper Arm Richard Frazee, MS, LAT, ATC Program Director The University of West Florida Athletic Training

Thank you SEATA students Dr. R.T. Floyd & MRs. Karen Lew Fierman UWF students https://www.youtube.com/ watch?v pMHZh5XlOVA The University of West Florida Athletic Training Program

Purpose: 1. Review the Evaluation Process 2. Discuss Scapular Dyskinesia 3. Conduct Shoulder Lab The University of West Florida Athletic Training Program

The Shoulder Complex The University of West Florida Athletic Training Program

Review of the Evaluation Process All you need to know is: History Observation Palpation Special tests Range of motion testing-movement patterns Manual muscle testing Specific functional/agility tests The University of West Florida Athletic Training Program

135 Special Tests of the shoulder!! The University of West Florida Athletic Training Program

Evaluating the shoulder complex Complex? Intimidating? Where do I begin? The University of West Florida Athletic Training Program

Evaluation Process History Observation Palpation Special tests Range of motion testing-movement patterns Manual muscle testing Specific functional/agility tests The University of West Florida Athletic Training Program

Evaluation Process HOPS Protocol Consistent sequential method Thorough and reproducible From the HOP, what do we learn? History, MOI, LOP S – Special Tests- For what? The University of West Florida Athletic Training Program

HOPS Protocol History-A great deal is learned from listening to the patient Importance of ROM The University of West Florida Athletic Training Program

Review of the Evaluation Process Shoulder evaluations can be lumped into four main categories: 1. Bone/Joint Integrity 2. Stability 3. Muscular concerns 4. Other Soft Tissue Stuff The University of West Florida Athletic Training Program

Evaluation Process To be proficient, you must know: Functional Anatomy Joint Mobility Musculature Joint Stability Bony congruence Ligamentous structure Musculature The University of West Florida Athletic Training Program

Review of the Evaluation Process From the information gathered from HOP, you can determine which “Special Tests” will be appropriate. History Detailed Specific Pertinent The University of West Florida Athletic Training Program

Observation ROM/ movement patterns Symmetry Deformities Carrying angle Sensations The University of West Florida Athletic Training Program

Sensations and Possible Causes Clicking labral tears, subluxations/dislocations Snapping - biceps tendon subluxation, bursal thickening under acromion Grating - calcium in joint, bursal or synovial thickening, osteoarthritic changes Tearing - rotator cuff strain The University of West Florida Athletic Training Program

Sensations and Possible Causes Locking or catching - labral tear, loose body Numbness - nerve root impingement, cervical rib entrapment, thoracic outlet problem, brachial plexus or cutaneous nerve Tingling - neural or circulatory problem, thoracic outlet affecting subclavian artery The University of West Florida Athletic Training Program

Sensations and Possible Causes Warmth - active inflammation or infection, red hot burning due to acute calcific tendinitis Shoulder “Going out” - subluxing G-H The University of West Florida Athletic Training Program

Palpations Areas of point tenderness Deformities Crepitus Signs of inflammation Heat, redness, swelling, What else? The University of West Florida Athletic Training Program

Special Tests ROM Muscular strength Joint stability Impingement conditions The University of West Florida Athletic Training Program

Special Tests- Instability CC? MOI? Glenohumoral? Acromioclavicular? Why so many Tests? Over 130 different SPs for shoulder evaluations Instability may only be reproducible in one specific position The University of West Florida Athletic Training Program

StatisticsBriefly!! “Statistics are like bikinisthey reveal a lot- but they can also hide the really important things”- author unknown. Sensitivity- how good is the test if the problem is there Specificity- how good is it if the problem is not there The University of West Florida Athletic Training Program

Dr. Richard Sellers Dr. Steve Jordan 2 impingement 3 Rotator Cuff tests 4 Labral tests 2 biceps test 2 instability tests 2 AC joint tests Others as needed- based on HOP The University of West Florida Athletic Training Program Sitting -Inspection , palpation, ROM 1. Neer’s 2.Hawkins 3.O’Brien’s 4.Adduction 5.Bear Hug 6.Speed’s 7.Jobe- Empty Can-scaption-supraspinatus 8.Deltoid 9.Dynamic Labral Shear 10. Biceps Load II- Type II SLAP 11. ER Strength Test 12. Belly Press-Pos wrist flexion Supine 13. Apprehension 14. Relocation 15. GIRD ALWAYS IN THE SAME ORDER

It’s not just the shoulder! A thorough evaluation of the scapula and Scapulo-Thoracic (ST) rhythm must be included. ST motions, and muscles responsible: The University of West Florida Athletic Training Program

The University of West Florida Athletic Training Program

The University of West Florida Athletic Training Program

Clinical Examination of Shoulder Injuries Palpation of the posterior shoulder 1. Spine of the scapula Superior angle 2. Inferior angle 3. Infraspinatus 4. Teres minor 5. Supraspinatus 6. Teres major 7. Rhomboid major 8. Rhomboid minor 9. Levator scapulae 10. Trapezius 11. Latissimus dorsi 12. Posterior deltoid 13. Triceps brachii The University of West Florida Athletic Training Program

Part 2 Scapular Dyskinesia Defined as: Visible alterations in scapular position and motion patterns. believed to occur as a result of changes in activation of the scapular stabilizing muscles; damage to the long thoracic, dorsal scapular, or spinal accessory nerves The University of West Florida Athletic Training Program

SICK Scapula Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, dysKinesia of scapular movement The University of West Florida Athletic Training Program

SICK Scapula The University of West Florida Athletic Training Program

Philip McClure, PhD, PT, , et al, developed a clinical method for identifying scapular dyskinesia. Table 1. Scapular Dyskinesia Test: Operational Definitions and Rating Scale Operational Definitions Normal scapulohumeral rhythm: The scapula is stable with minimal motion during the Initial 30 to 60 of humerothoracic elevation, then smoothly and continuously rotates upward during elevation and smoothly and continuously rotates downward during humeral lowering. No evidence of winging is present. The University of West Florida Athletic Training Program

Scapular dyskinesia: Either or both of the following motion abnormalities may be present. Dysrhythmia: The scapula demonstrates premature or excessive elevation or protraction, non-smooth or stuttering motion during arm elevation or lowering, or rapid downward rotation during arm lowering. Winging: The medial border and/or inferior angle of the scapula are posteriorly displaced away from the posterior thorax. The University of West Florida Athletic Training Program

Kibler et al'- reported the reliability of a visually based classification system for scapular dysfunction that defined 3 different types of motion abnormalities: Type 1 inferior angle prominence, Type II medial border prominence. Type III excessive superior border elevation. The University of West Florida Athletic Training Program

Scapular Dyskinesia Type I The University of West Florida Athletic Training Program

Scapular Type II The University of West Florida Athletic Training Program

Type I –Inferior Angle prominence The University of West Florida Athletic Training Program

Type I –Inferior Angle prominence The University of West Florida Athletic Training Program

Type I –Inferior Angle prominence The University of West Florida Athletic Training Program

Type II -Medial Border prominence The University of West Florida Athletic Training Program

Scapulo-humeral rhythm The Rotator Cuff The four rotator cuff muscles, the supraspinatus, infraspinatus, subscapularis, and teres minor are responsible for the important movement and function of the shoulder. The University of West Florida Athletic Training Program

“The function of the rotator cuff is to position the head of the humerus so that the glenoid fossa provides the optimal biomechanical platform for humeral motion regardless of the position of the hand in space.” Dr. Frank Jobe The initial action of the supraspinatus is to depress, compress, and stabilize the head of the humerus into the glenoid fossa. The University of West Florida Athletic Training Program

Importance of understanding the function of the muscles that act on the scapula Strength balance between large scapular muscles and small rotator cuff muscles The University of West Florida Athletic Training Program

Kent Morgan, MS, CSCS Understanding how the body moves and understanding how joints work together and effect what other joints do is very important. constant postural changes perform a movement repetitively, predictable muscle imbalances that would need to be addressed. The University of West Florida Athletic Training Program

Part 3 LAB Time Can you name/recognize the following conditions? The University of West Florida Athletic Training Program

# 1 The University of West Florida Athletic Training Program

#2 Palpation site for what? The University of West Florida Athletic Training Program

#3. X-ray indicates : The University of West Florida Athletic Training Program

# 4. All three pics reveal a . The University of West Florida Athletic Training Program

What Happened!!? # 5. The University of West Florida Athletic Training Program # 6. s # 7.

#8 The diagram labeled C represents a: A. Grade 2 sternoclavicular separation B. Grade 2 acromioclavicular separation C. Grade 3 sternoclavicular separation D. Grade 3 acromioclavicular separation C

9. Label each of the boxes with the correct term: A B A B C D E C DD E

Answers 1. 2. 3. 4. 5. 6. 7. 8. 9. Myositis Ossificans/Blocker’s Exostosis Biceps Brachii Epiphyseal fx. Of humerus Pectoralis rupture Biceps brachii rupture from origin Biceps brachii rupture from insertion Fx clavicle D. A-AC, B- Supraspinatus, C-clavicle, D-Anterior Labrum, Elong head of biceps The University of West Florida Athletic Training Program

GET A PARTNER!! Share your techniques https:// www.youtube.com/watch?v RC05vP-fLkE The University of West Florida Athletic Training Program https://

Anterior Instability Perform, compare and discuss: Load & Shift (Anterior/Posterior Translation) Test vs. Apprehension (Crank) Test Any other two tests The University of West Florida Athletic Training Program

Glenoid Labrum Glenoid Labrum Clunk Test vs. O’Brien Sign test The University of West Florida Athletic Training Program

Tests for Scapular Stability Winging Scapula Test vs. Lateral Scapula Slide Test The University of West Florida Athletic Training Program

Tests for Thoracic Outlet Syndrome Roos Test (EAST) vs. Wright Test or Maneuver vs. Costoclavicular Syndrome (Military Brace) Test The University of West Florida Athletic Training Program

Differential Diagnosis Differentiate between: Anterior Impingement and AC sprain SupraspinatusTendinitis and Subacromial Bursitis Glenoid Labrum tear and Inflamed rotator cuff Glenohumeral dislocation and Clavicular fracture The University of West Florida Athletic Training Program

In Conclusion Thorough Evaluation Accurately depicting source of the problem Specific strength/rehabilitations exercise Total arthrokinematic picture. https://www.youtube.com/watch? v 5IpYOF4Hi6Q The University of West Florida Athletic Training Program

Thank You! The University of West Florida Athletic Training Program