Pocket Guide to Msukculoskeletal Assessment by RICHARD f. BAXlfR

AXTER



POCKET GUIDE TO MUSCULOSKELETAL ASSESSMENTJ RICHARD f. BAXlfR, MPl .::; Chief of Physical Therapy Munson Army Health Center Fort Leavenworth, Kansas W.B. SAUNDERS COMPANY A Division of Harcourt Brace & Company Philadelphia London Toronto Montreal Sydney Tokyo



CONTENTS Chapter 1 •••••••••• ••••••••••••••••••••• 0 •••• ••• Introduction Chapter 2 Cervical Spine .............................. ........ 7 Chapter 3 Shoulder ............................................. 19 Chapter 4 41 Elbow Chapter 5 55 Wrist and Hand Chapter 6 69 Thoracic Spine Chapter 7 Lumbar Spine. . . . .. . . . ... . . . . .. .. . . . . . . . . . . . . . . . . . 77 Chapter 8 93 Hip..... Chap,ter 9 107 Knee Chapter 10 . 123 Foot and Ankle Chapter 11 . 137 Respiratory Evaluation Chapter 12 141 Inpatient Physical Therapy Cardiac Evaluation Chapter 13 145 Lower Extremity Amputee Evaluation Chapter 14 149 Neurologic Evaluation ix

x------------------- Chapter 15 151 Inpatient Orthopedic Evaluation Appendix A 160 Dermatomes Appendix B . . ..... . . . . ..... . . . . .. . . . . . . . ..... 161 Sclerotomes Appendix C 162 Auscultation Appendix 0 163 Normal Range of Motion Appendix E 161 Ligament Laxity Grading Scale Appendix F 168 Capsular Pattern and Closed Pack Positions for Selected Joints Appendix G 169 Radiology Appendix H 111 Physical Agent and Modalities Appendix I 180 Types of Traction Appendix J 183 Normal Values for Commonly Encountered Laboratory Results Appendix K 185 Abbreviations and Definitions Index 189

D 1 INTRODUCTION KISS: \"Keep It Super Simple.\" KISS oz is the essence of this quick refer- ence guide to neuromusculoskeletal I- evaluations and treatment options U for some common conditions en- countered in the clinic. This is nei- oo~ ther a comprehensive text nor an at- tempt to capture all aspects of a: physical therapy and reduce them to fit a pocket handbook. This guide is meant to provide only a I- framework for a thorough neuromusculoskeletal eval- Z uation and treatment. I hope you will use this guide, as I do, to keep patient examinations organized, effi- ... cient, and thorough. When examining a patient, you may find it helpful to open the guide to the body re- gion in question and lay the book on the nearest available flat surface. Located at the beginning of each section is S/Pt Hx for subjective/patient history/profile and 0 for objective, which are portions of the SOAGP note for- mat. The A (assessment), G (goals), and P (plan) are left up to you, the evaluator, but the treatment op- tions portion of each section is meant to assist in these areas. While examining a patient, you may find it necessary to glance at the outline to maintain an efficient, organized thought flow. If the correct proce- dure for performing a special test slips your mind dur- ing the examination, turn to the material after the out- line to refresh your memory. Although there are many more special tests and modifications of the tests I have included, this handbook provides a basic group of commonly used special tests; you should feel free to write in other tests that you use in your practice.

2---------------- The treatment options are, in fact, options; they of- fer only a starting point. There are many more treat- ment regimens, protocols, and techniques than could be presented in this text. In some cases, I included tools for diagnosis or treatment that may be beyond the scope of practice for the providers using this text. For example, physical therapists within my scope of practice are credentialed to order radio- graphs, although this is outside the scope of practice for many, as may be the case for treatment options that include the prescription of NSAIDs. In some in- stances, I have included options that only a physician or surgeon may consider, such as injection or sur- gery. These ideas about the continuum of care may ... be helpful in patient education or useful as a re- minder of the various options available to the patient who is referred for further intervention. Z Basic outlines for respiratory, cardiac, amputee, ----i ::0 neurologic, and acute inpatient evaluations are given o o c to help in acute care settings. To save space, many n standard terms are abbreviated throughout the book. ----i o These are explained in Appendix K. Z My sincere hope is that this guide is a useful tool for you in the clinic and that it motivates you to con- tinued study, learning, and growth. Many physical therapy and physician assistant students, as well as practicing physical therapists and physician assis- tants, have found it to be helpful, and I believe you will too! Subjective Examination Although not exhaustive, the following is the framework for the subjective examination used in the evaluation outlines throughout the text. Only those items that are most pertinent to each region have been included in an abbreviated format in the specific body region subjective examination outlines.

______________ 3 • Age oz • Sex • Chief complaint ui= • Onset of Sx (insidious, from trauma or overuse) :oo::J • Body chart (body diagram with location of Sx, depth/quality/type of pain, whether pain is con- cc: stant/intermittent, interaction between pain sites, presence of paresthesia) f- Z • Duration of Sx (if insidious) ... • MOl (if due to trauma) • Nature of pain (constant/intermittent, deep/super- ficial, boring/sharp/stabbing/hot!ache, AM/PM differ- ence in the Sx, sclerotomal or dermatomal pattern) (see Appendices A and B) • AGG (positions or activities, how long it takes to aggravate Sx and how long to recover) • Easing factors (what relieves Sx) • Radiographs/CT scans/MRI/lab results • Meds • Occupation/recreation/hobbies • Diet/tobacco/alcohol • Exercise • PMH x (e.g., H/O cancer, cardiovascular disease, HTN, adult/child illnesses) • PSH x • Family history • Review of systems and SO I General health/last physical examination I Unexplained weight loss I Night pain I Bilateral extremity numbness/tingling I Systems* *Region-specific questions are located in applicable evaluation outlines.

4---------------- Skin Musculoskeletal Endocrine Pulmonary Cardiovascular Lymphatic Gastrointestinal Neurologic Urinary/reproductive t Patient's goals Objective Examination Although not exhaustive, the following is the frame- work for the objective examination used in the evalu- ation outlines throughout the text. Only those posi- tions and items that are most pertinent to each region have been included in an abbreviated format in each region-specific evaluation outline. Z -l o::0 Position Sequence o c I. Standing n -l II. Sitting o Z III. Supine IV Sidelying V Prone Items to Assess in Each Position as Applicable I. R/O other pathology by \"clearing\" joint above and below or other areas that refer similar Sx* II Observation A. Gait (e.g., cadence, stride length, weight bearing, antalgic, base of support, sequence) *For the musculoskeletal screening examination of adjacent joints, apply only the most sensitive tests for the most com- mon musculoskeletal abnormalities. Check AROM, PROM, GMMT. The purpose is to assist in detecting all areas of involvement or additional findings that may alter the diagno- sis.

_____________ 5 B. Posture oz C. Abnormalities, deformities, muscular ui= atrophy D. Function oo=:l III. AROM (see Appendix OJ IV GMMT or myotomal screen a: V Special tests (per specific region) VI. Sensation (e.g., light touch, vibration, hot/cold, f- sharp/dull, two-point discrimination) Z VII. Palpation (e.g., defects, pain, spasm, edema/ effusion, tissue density) ... VIII. Joint play (per Magee' and Maitland2) References 1. Magee DJ: Orthopedic Physical Assessment, 3rd ed. Philadelphia, WB Saunders, 1997 2. Maitland GD: Peripheral Manipulation, 3rd ed. Boston, Butterworth-Heinemann, 1991.



7 CfRVICAl SPINf \\ Subjective Examination t Pt Hx (region specific): nature of w pain (dermatomal or sclerotomal)? Z (see Appendices A and B) CL t Does coughing, sneezing, strain- VJ ing, or anything that increases intradiscal and in- trathecal pressure aggravate the Sx? u«-I t SQ: bilateral UE numbness and tingling, recent on- > set of headache, dizziness/visual disturbance/nau- sea, difficulty swallowing 0w: t Type of work and posture/positions assumed at U work, sleeping positions, type and number of pil- lows used N t Trauma? If so, was there loss of consciousness? t Review of systems (endocrine, neurologic, cardio- vascular, pulmonary, gastrointestinal)

8------------- Objective Examination I. Standing A. Observation 1. Posture: structure and alignment in three planes II. Sitting A. R/O shoulder or thoracic spine pathology B. Observation 1. Posture (C5 or C6 radiculitis/radiculopathy tends to feel better with the arm resting overhead; C7 radiculitis/radiculopathy tends to feel better with the arm cradled against the abdomen) a. Forward head n b. Rounded shoulders m c. Protracted scapulae and other signs :::0; n C. AROM (note quality, rhythm, pain, assessed rl> by estimation, inclinometer, or other (f) methods; apply overpressure, if necessary, to --0 Z these motions) m 1. Cervical flex 2. Cervical ext 3. Cervical sidebending 4. Cervical rot 5. Combined motions (e.g., chin tuck, sidebending with rot) D. Myotomal screen and GMMT 1. Neck flex (C1-C2) 2. Shoulder elevation/shrug (C3-C4) 3. Shoulder abd (C5) 4. Elbow flex/wrist ext (C6) 5. Elbow ext/wrist flex (C7) 6. Thumb IP joint ext/finger flex (C8) 7. Finger add (T1) E. MSRs

---------------9 1. Biceps (C5) w 2. Brachioradialis (C6) 3. Triceps (C7) Z F. Pathologic reflexes: Hoffmann's sign CL G. Special tests (as applicable) 1. Foraminal encroachment: compression (f) ---.J (Spurling's) test, distraction test 2. Thoracic outlet syndrome: Adson's u<r: maneuver, costoclavicular syndrome test, :a>: hyperabduction test, Halstead's maneuver, Allen's test w 3. VA test u H. Sensation: dermatomes (see Appendix A) III. Supine N A. Special tests: upper limb tension testing B. Joint play: lat and anterior glides, cervical distraction IV. Prone A. Palpation: bony landmarks and soft tissue B. Joint play 1. PACVP 2. PAUVP 3. Transverse pressure 4. Lat glides

o • SPECIAL TESTS FOR THE CERVICAL SPINE Test Detects Compression (Spurling'sl test' Foraminal encroachment Distraction test' Foraminal encroachment Ouadrant position' Foraminal encroachment Vertebral artery test/neck ext-rot test' VA compression or occlusion Test 1 Test 2 Rules out inner ear as cause of dizziness Upper limb tension test (brachial plexus Dural/meningeal irritation or nerve root tension testl' (median nerve biasl impingement (similar to SLR test in LEI ..........

Test Procedure Positive Sign Pt sitting and laterally flexes cervical Pt experiences radicular pain that spine to one side. Examiner presses radiates into arm toward which head/ straight down on PI's head. This cervical spine is flexed procedure is repeated on opposite side. Pain in neck and into UE is relieved or PI sitting. Examiner places one hand decreased when cervical spine is under PI's chin and other hand around distracted occiput. Examiner slowly lifts PI's head. Pain radiates into arm toward which PI sitting. PI performs combined ext, lat head/cervical spine is extended, laterally flex, and rot. This reduces size of flexed, and rotated intervertebral foramen. Reproduction of PI's Sx Have PI keep eyes open to observe nystagmus if it occurs (indicative of VA compression, causing lack of blood supply to brain stem and cerebelluml Pt sitting and places cervical spine in Rapid eye movements, pupils dilate, combined ext and rot such that PI is dizziness, syncope, Iightheadedness looking back over shoulder. Pt must keep Controversy exists in medical community eyes open. This is performed to each concerning this test. Some suggest that side for 20 sec. it possesses low sensitivity' Apply at your own risk, and use caution with this PI standing. Examiner stabilizes PI's test. Examiner should first have Pt head by holding PI's head with hands. perform cervical rot to see if this PI then rotates trunk and holds produces Sx of VA insufficiency before maximum rot for 20 sec to each side. proceeding to described test position. PI supine. Examiner takes PI's UE into Same as for test 1 glenohumeral abd (110 deg approxl, If Sx were not induced, cause of forearm supination, wrist and finger ext, dizziness was most likely not an inner shoulder ER 190 deg approxl. elbow ext ear problem and neck lat flex away from testing side. Radicular pain/paresthesia into tested UE TCI/lII/I/lI'd

.... N • SPECIAL TESTS FOR THE CERVICAL SPINE Continued Test Detects Upper limb tension test (brachial plexus Dural/meningeal irritation or nerve root tension testl' (Radial nerve biasl impingement (similar to SLR test in LEI Upper limb tension test (brachial plexus Dural/meningeal irritation or nerve root tension test)' (ulnar nerve bias) impingement (similar to SLR test in LEI Hoffmann's sign' (pathologic reflex for Corticospinal tract lesion of spinal cord UE similar to Babinski sign for LEI Thoracic outlet syndrome See Shoulder Special Tests and Thoracic Outlet Syndrome Tests table in Chapter 3 Special Condition Hx/Symptoms Acute cervical radiculitis or CS-C6 and C6-<::7 nerve roots radiculopathy (may be caused by disc commonly involved bulge/HNP or narrowing of Radicular Sx in UE with distal intervertebral foramenl paresthesia Usually distal Sx worse than proximal w

Test Procedure Positive Sign Pt supine. Examiner depresses PI's Radicular pain/paresthesia into tested shoulder, extends elbow, flexes PI's UE thumb into palm, pronates forearm, and ulnarly deviates wrist. Radicular pain/paresthesia into tested UE Pt supine. Examiner depresses PI's shoulder, pronates forearm, extends Induced flex of thumb and other fingers wrist. flexes elbow, and abducts arm. Examiner grasps and stabilizes PI's hand and \"flicks\" distal phalanx of middle finger in direction of ext (causing a quick stretch of finger flexors) Signs/Objective Findings Treatment Options If in lower cervical spine, Pt feels better Acute: relative rest, ice/heat. may with arm held close to abdomen. If in consider cervical collar for 2-3 days for upper cervical spine, Pt feels better with Pt comfort (but not more than a few forearm resting overhead. days). sustained cervical traction, Pt education (neck carel Objective neurologic signs with radiculopathy (decreased MSRs, UE Goal is to centralize Sx muscle weaknessl Check neurologic system each visit Advise Pt that Sx may not improve for 7-10 days Address posture Subacute: Begin AROM in a painfree range Chronic: AROM, cervical isometrics Refer Pt to orthopedic surgeon or neurosurgeon for progressive neurologic deficit Ccmti\"'H'd ..

• TREATMENT OPTIONS FOR THE CERVICAL SPINE Continued Special Condition Hx/Symptoms Cervical spondylosis (ODD) C5-C6 and C6-C7 most commonly Cervical DJO (involves facet jointsl involved Nerve root/spinal cord pressure common from foraminal encroachment and spinal stenosis, resulting in radicular Sx Upper cervical Gradual onset Forward head posture Crepitus Muscle strain or contusion Muscle pain/soreness Hx of trauma/overuse Acute torticollis (\"wry neck\"l Hx of unexpected movement or pro- From acute facet locking longed prone lying with head rotated to one side Sharp pain that is unilateral and well localized

Signs/Objective Findings Treatment Options AM stiffness that is eased with AROM exercises several times per day movement but worsens later in day with Cervical isometrics (painfree) continued activity Cervical traction (intermittent) Moist heat Radiograph may confirm and show Pt education (neck carel/self-treatment decreased disc space and osteophytes/ spurring AROM exercises several times per day Cervical isometrics (painfreel Pain and stiffness with rest that Cervical traction (intermittentl improves with movement Moist heat AROM rot and lat ftex most limited Pt education (neck carel/self-treatment Palpable thickening of facet joint Soft tissue mobilization margins Radiograph may confirm Tender soh tissue with palpation First, ensure PI is stable/no Fx ARDM limited by pain Acute: Relative rest, ice for first 48-72 hours, moist heat with interferential Protective deformity of lat flex and rot electrical stimulation or ultrasound with away from pain electrical stimulation after initial 72 Muscle guarding hours, add ARDM to tolerance Neurologic system: normal Subacute/chronic' ARDM, SCM and up- per trapezius stretching, shoulder rolls, cervical isometrics (painfreel. postural education Acute: supine lying to unload facet, ice, gentle manual distraction in line with de- formity Gentle PROM away from painful side Cervical collar for 2-3 days to unload facets Subacute/chronic: muscle energy tech- niques to regain ARDM, progress to cer- vical isometrics Continu\"d ...

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17 References w Z 1. Magee DJ: Orthopedic Physical Assessment, 3rd ed. Philadelphia, WB Saunders, 1997. 0.... Ul 2. Bland JH: Disorders of the Cervical Spine: Diagnosis and Medical Management, 2nd ed. Philadelphia, WB Saunders, 1994. «-l 3. Maitland GD: Vertebral Manipulation, 4th ed. Boston, U Butterworths, 1973. :a>: 4. Cote P, Kreitz BG, Cassidy JD, Thiel H: The validity of the extension-rotation test as a clinical screening procedure before w neck manipulation: A secondary analysis. J Manipulative Physiol U Ther 19:159-164,1996. N 5. Butler DS: The upper limb tension test revisited. In Grant R (ed): Physical Therapy of the Cervical and Thoracic Spine, 2nd ed. New York, Churchill Livingstone, 1994. 6. Kandell ER, Schwartz JH, Jessell TM (eds): Principles of Neural Science, 3rd ed. New York, Elsevier Science Publishing, 1991 . Bihliography Hertling D, Kessler RM: Management of Common Musculoskeletal Disorders: Physical Therapy PrinCiples and Methods, 2nd ed. Philadelphia, JB Lippincott, 1990. Highland TR, Dreisinger TE, Vie LL, et al: Changes in isometric strength and range of motion of the isolated cervical spine after eight weeks of clinical rehabilitation. Spine 17(Supplement 6)S77-S82, 1992. Jones H, Jones M, Maitland GD: Examination and treatment by passive movement. In Grant R (ed): Physical Therapy of the Cervical and Thoracic Spine, 2nd ed. New York, Churchill Livingstone, 1994. Kisner C, Colby LA: Therapeutic Exercise: Foundations and Techniques, 2nd ed. Philadelphia, FA Davis, 1990. Magarey ME: Examination of the cervical and thoracic spine. In Grant R (ed): Physical Therapy of the Cervical and Thoracic Spine, 2nd ed. New York, Churchill Livingstone, 1994. Saunders HD, Saunders R: Evaluation, Treatment and Prevention of Musculoskeletal Disorders: Spine, 3rd ed, vol 1. Chaska, Minnesota, Educational Opportunities, 1993.

1 S • • •

1 1 - - - - - -19 SHOUlDfR Subjective Examination • Pt Hx (region specific): which is the dominant UE, radicular Sx (der- • matomal or sclerotomal)? (see Ap- pendices A and B) • Functional limitations a: w •SQ, if applicable: night pain, bilateral UE numb- o ness/tingling, unexplained weight loss) .....J • Review of systems (cardiovascular, pulmonary, gas- trointestinal) o:::J I (/)

20 - - - - - - - - - - - - - - Objective Examination I. Standing A. Observation 1. Posture 2. Abnormalities, deformities, atrophy B. AROM (note quality, scapulohumeral rhythm, pain, and common substitutions) 1. Shoulder flex (165-180 deg) 2. Shoulder ext (50-60 deg) 3. Shoulder abd (170-180 deg) 4. Shoulder horizontal abd and add C. PROM if lacking AROM in any motions D. Special tests (as applicable) 1. Impingement: impingement relief test (f) II. Sitting I o A. R/O cervical pathology (see Special Tests for C ro the Cervical Spine in Chapter 2) m :JJ B. Observation 1. Posture 2. Abnormalities, deformities, atrophy C. AROM may also be assessed in sitting D. PROM if lacking AROM in any motions E. GMMT and myotomal screen 1. Shoulder elevation/shrug (C3-C4) 2. Shoulder abd (C5) 3. Shoulder flex (C5-C7) 4. Shoulder ext 5. Elbow flex/wrist ext (C6) 6. Elbow ext/wrist flex (C7) 7. Thumb IP joint ext/finger flex (C8) 8. Finger add (T1) F. MSRs, if applicable 1. Biceps (C5-C6) 2. Brachioradialis (C5-C6)

--------------21 3. Triceps (C7) a: G. Special tests (as applicable) ow 1. Instability: anterior/posterior apprehension tests, relocation test. sulcus sign -l 2. Biceps tendinitis/tendon instability: o::> Yergason's, Speed's, Ludington's, and THL tests I 3. Impingement: painful arc test, Hawkin's (f) impingernent test, impingement relief test, Neer's impingement test 4. Rotator cuff tear: drop-arm test, supraspinatus test (empty can test) 5. Thoracic outlet syndrome: Adson's maneuver, costoclavicular syndrome test. or Halstead's maneuver; hyperabduction syndrome test H. Sensation: LT and 2-point discrimination I. Palpation 1. Tendons of the rotator cuff 2. Bicipital groove/biceps tendon 3. Bony landmarks III. Supine A. Special tests (as applicable) 1. Impingement: impingement relief test (may be performed standing or supine) 2. Joint play a. AP glide b. Long-axis distraction c. AP motions of the clavicle at the AC and SC joints IV. Prone A. AROM 1. Shoulder IR (70-80 deg) 2. Shoulder ER (80-90 deg) B. GMMT 1. Shoulder IR 2. Shoulder ER

• SPECIAL TESTS FOR THE SHOULDER Test Test Detects m 191 lei T Impingement of long head of biceps PI sitti Neer's impingement test' 2 tendon and/or supraspinatus tendon elevate forcing Hawkin's impingement test' Impingement of inflamed supraspinatus acrom tendon Pt sitti Painful arc' test Pathology of subacromial origin (e.g., flexes impingement, rotator cuff tendinitisl elbow rotates tendon Pt sitt neutra Impingement relief test' Helps confirm Ox of impingement Pt sta 3-5 of on give pain. applie glide arc. P subje Test N W

Procedure Positive Sign ing or standing. PI's arm is passively Reproduction of PI's Sx ted through forward flex by examiner, g greater tubercle of humerus against Reproduction of PI's Sx mion. Reproduction of Sx in a 60-120 deg arc. ting or standing. Examiner forward Pain stops or is dramatically reduced when PI's arm to 90 deg, and flexes PI's humeral head glides inferiorly. \"No pain --> pain --> no pain\" w to 90 deg, then passively internally es shoulder, forcing supraspinatus n against coracoacromial ligament. ting or standing. Pt abducts arm in al position (no IR or ERI tanding, performs active flex and abd Outcomes and their interpretations are as times while examiner records location follows: nset of painful arc range. Pt asked to a subjective indication of amount of Complete relief of pain: indicates that . Test is then repeated while examiner humeral head is capable of moving under ies a gentle inferior or posteroinferior subacromial arch without impinging. This e just before onset of recorded painful indicates contractile tissue as primary cause PI is then asked again to give a and recommend a Rx regimen aimed at ective indication of amount of pain. training contractile tissue to balance force couple and scapulohumeral rhythm le.g., may be modified to a supine position strengthening, proprioception, scapular stabilizationl. Partial relief of pain at same point in range of motion: suggests that, in addition to contractile tissue weakness, noncontractile tissue is involved. Joint mobilization in addition to strengthening and re-education should be part of Rx regimen. No relief or reduction of pain: indicates inability of humeral head to depress because of noncontractile tissue tightness. As part of treatment program, perform joint mobilization to restore accessory motions to achieve inferior and posteroinferior glide of humeral head. Inability to reduce pain by stretching and joint mobilization may indicate pathology other than impingement as source of pain. Conti/wct! ...

N Test ~ • SPECIAL TESTS FOR THE SHOULDER Continued PI si Test Detects place deg/9 Stability Tests Anterior instability rot fo Anterior apprehension test' PI su Relocation test' Anterior instability test. appre Sulcus sign' Inferior instability and Posterior drawer sign' Posterior instability the P Pt st with grasp dista PI su forea deg. in 80 With scap flexe head load-shift test' Anterior, posterior, or multidirectional Pt sittin instability over P Then, Miscellaneous Tests AC joint pathology head, Cross-arm adduction test' AC joint lesion/DJD that it fossa. AC joint shear test' posteri and en Yergason's test\" Unstable biceps tendon due to THl tear Speed's test' Could also detect biceps tenosynovitis Pt sittin (passiv Bicipital tendinitis PI sittin hand o clavicle force a Pt sitti deg, w resists supina Pt sitti with fo comple biceps arm do

t Procedure Positive Sign itting, standing, or supine. Examiner Pt has look of alarm or apprehension and es PI's shoulder in abd and ext rot (90 resists further motion. PI may also have pain 90 deg). Then examiner applies an ext with this movement. orce. PI's alarm or apprehension disappears, pain upine. Same procedure as apprehension may be relieved, and further ext rot is Upon finding a positive anterior allowed rehension test, maintain that position Sulcus (gapl appears at glenohumeral joint apply a posterior force with one hand to Must compare with uninvolved shoulder PI's arm. Posterior displacement can be felt as thumb tanding or sitting with arm by side and slides along lat aspect of coracoid process h shoulder muscles relaxed. Examiner PI may also have apprehension ps PI's forearm below elbow and pulls ally/inferiorly. upine. Examiner grasps PI's proximal arm with one hand and flexes elbow 120 Then examiner positions PI's shoulder 0-120 deg abd and 20-30 deg flex. h other hand, examiner stabilizes PI's pula. As PI's arm is internally rotated and ed, examiner attempts to sublux humeral d with thumb. ing. First, examiner places one hand Excessive displacement anteriorly, PI's clavicle and scapula for stability. posteriorly, or both compared with grasping proximal arm near humeral uninvolved shoulder examiner \"loads\" humeral head such Reproduction of PI's Sx at AC joint is in a neutral position in glenoid Reproduction of Pt's Sx at or excessive Examiner then applies an anterior or motion in AC joint rior force, noting amount of translation nd-feel. localized reproduction of PI's Sx in bicipital groove ing. Examiner horizontally adducts ve) PI's arm across chest wall. Reproduction of PI's Sx localized to bicipital groove ing. Examiner cups hands, with one on PI's scapula and other hand over COllt;lIIU'd ~ e and then squeezes, causing a shear at AC joint. ing or standing. PI's elbow flexed 90 with arm at side of body. Examiner s at wrist while PI attempts to ate a pronated forearm. ing or standing. PI's shoulder is flexed orearm supinated, and elbow is etely extended. Examiner palpates s tendon in bicipital groove and forces own in ext as PI resists.

1 SPECIAL TESTS FOR THE SHOULDER Continued Test ITest Detects Pt sit on to Ludington's test\" I Rupture of long head of biceps tendon then bicep I Functional method of assessing shoulder bicep in IR and ER Apley's scratch test' Pt pe attem Drop-arm test' Rotator cuff tear (specifically, scapu supraspinatus tendon) ER w behin Supraspinatus test (empty Torn supraspinatus muscle or tendon shoul can testI' Supraspinatus tendinitis Neuropathy of suprascapular nerve Pt sit abdu instru Exam Pt sit posit horiz resis Test* Detects Te Adson's maneuver\" Entrapment in scalene triangle Pt Costoclavicular syndrome test\" Entrapment between 1st rib and clavicle Pt and Hyperabduction syndrome Entrapment between coracoid process ext test 14 and pectoralis minor as Halstead's maneuver' Entrapment in scalene triangle Pt and L bac Pt and is o hol Pt the and ext app dee 'These tests detect subclavian artery and brachial plexus entrapment.

t Procedure Positive Sign tting or standing. Pt clasps both hands Examiner feels tendon on uninvolved side op of head and interlocks fingers. Pt but not on involved side during contraction of biceps muscle simultaneously contracts and relaxes ps muscles while examiner palpates Gives examiner an idea of functional ps tendon proximally at bicipital groove. capacity/AROM of Pt's shoulders This is recorded by the anatomic landmark erforms combined IR with add in that Pt is able to reach and touch (e.g., to mpt to touch or \"scratch\" opposite inferior angle of scapula1 ula. Second motion involves combined with abd in attempt to place hand Arm drops suddenly to side because of nd head and touch top of opposite weakness and/or pain ulder. Reproduction of PI's Sx or weakness tting or standing. Examiner passively Compare with uninvolved side ucts PI's shoulder to 90 deg. Pt is then ucted to maintain arm in that position. miner then presses inferiorly on PI's arm. tting or standing. Pt in \"empty can . tion 90-deg shoulder abd, 30-deg zontal abd, and maximum IR. Examiner sts PI's attempt to abduct. est Procedure Positive Sign sitting. Examiner locates Pt's radial pulse. Reproduction of pain and paresthesia in then rotates head toward test shoulder tested UE with diminished or absent pulse d extends head/neck. Examiner then ternally rotates and extends Pt's shoulder Pt takes a deep breath and holds it. sitting. Examiner palpates radial pulse Reproduction of pain and paresthesia in d then draws PI's shoulder down and tested UE with diminished or absent pulse ck (depression and retractionI. sitting. Examiner palpates radial pulse Reproduction of pain and paresthesia in tested UE with diminished or absent pulse d hyperabducts Pt's arm so that PI's arm overhead. Pt takes a deep breath and lds it. sitting. Examiner palpates radial pulse. Pt Reproduction of pain and paresthesia in en rotates head away from test shoulder tested UE with diminished or absent pulse d extends head/neck. Examiner then ternally rotates and extends PI's shoulder, plying downward traction as Pt takes a ep breath and holds it. ----~

cNo • TREATMENT OPTIONS FOR THE SHOULDER Special Condition Hx/Symptoms S Impingement syndrome Pain with overhead motion or when P hand is placed behind back P Pain may refer down lat arm or anterior humerus P M C im C ca P fa Supraspinatus tendinitis Pain with overhead motion or when hand is placed behind back Pain may refer down lat arm or anterior humerus N to

Signs/Objective Findings Treatment Options Positive painful arc Acute: relative rest, ice, NSAIDs Positive Hawkin's impingement test Gentle ROM ICodman's/pendulum, wand Positive Neefs impingement test exercisesI Must R/O cervical pathology Subacute/chronic: isometric shoulder flex! exVIR/ER exercises progressing to isotonic Check for instability that may be allowing (tubing or free weights) as Sx improve mpingement May consider ultrasound to aid in healing/ Check for tight posterior and/or inferior improve blood flow apsule or muscle imbalance Shoulder proprioception exercises PI may have poor posture as a causative actor Closed chain shoulder stabilization leg., quadruped position and examiner applies perturbation to Pt) Work on neuromuscular control of rotator cuff/shoulder girdle musculature Scapular stabilization exercises le.g., push- up with a plus, seated press-upsI Posterior/inferior capsule stretch if indicated Avoid overhead activities/work that aggravates Sx Key finding is exquisite pain with resisted Acute: relative rest. ice, NSAIDs movement involving supraspinatus muscle Gentle ROM iCodman's, wand exercises) ipositive supraspinatus/empty can test) Subacute/chronic: isometric shoulder flex/ R/O cervical pathology ext/IR/ER exercises progressing to isotonic (tubing or free weightsl as Sx improve Will also have positive impingement tests Supraspinatus-specific exercises May consider ultrasound to aid in healing/ improve blood flow Closed chain shoulder stabilization le.g., quadruped position and examiner applies perturbation to Pt) Work on neuromuscular control of rotator cuff/shoulder girdle musculature Scapular stabilization exercises le.g., push- up with a plus, seated press-upsI Posterior/inferior capsule stretching if indicated Avoid overhead activities/work that aggravates Sx COli till\"I'd ...

~ TREATMENT OPTIONS FOR THE SHOULDER Continued Special Condition Hx/Symptoms Bicipital tendinitis Pain over anterior shoulder Does Pt perform repetitive curls/elbow flex against high resistance at work or recreation/weight lifting? Pt may report \"snapping\" in region of bicipital groove Subacromial/subdeltoid bursitis Pain at superior portion of M glenohumeral joint a Pain at night with difficulty sleeping T Paln may radiate down arm a D m R w....

Signs/Objective Findings Treatment Options Exquisite tenderness to palpation over Acute: Relative rest, ice, NSAIDs bicipital groove Gentle ROM ICodman's, wand exercisesI Mayor may not have positive Vergason's Avoid AGG and initiate Pt education or Speed's tests May have exquisite pain with resisted Subacute/chronic: isometric shoulder flex/ horizontal add of shoulder that is in 90 ext/IR/ER exercises progressing to isotonic deg ER Itubing or free weightsl as Sx improve Check for posterior capsule tightness (avoid strenuous resistance in early R/O cervical pathology phasesl IR stretch (towel/door stretch) May consider ultrasound to aid in healing/ improve blood flow or phonophoresis/ iontophoresis for pain relief and to decrease inflammation Shoulder proprioception exercises Closed chain shoulder stabilization le.g\" quadruped position and examiner applies perturbation to Pt) Work on neuromuscular control of rotator cuff/shoulder girdle musculature Scapular stabilization exercises (e.g., push- up with a plus, seated press-ups) Marked restriction of shoulder flex and Acute: relative rest. ice, NSAIDs, abd phonophoresis or iontophoresis Tenderness to palpation over deltoid Subacutelchronic: gentle prom (Codman's) around acromion progressing to AAROM (wand, pulleyl Distraction of glenohumeral joint inferiorly Isometric shoulder flex/ext/IR/ER exercises may relieve Sx progressing to isotonic (tubing or free weightsl as Sx improve R/O cervical pathology Joint mobilization May consider ultrasound Closed chain shoulder stabilization (e.g., quadruped position and examiner applies perturbation to Pt) Work on neuromuscular control of rotator cuff/shoulder girdle musculature Scapular stabilization exercises (e.g., push- up with a plus. seated press-upsI Pt education to avoid overhead activities/ work Avoid overhead work/activities that aggravate Sx

W N • TREATMENT OPTIONS FOR THE SHOULDER Continued Special Condition Hx/Symptoms S Anterior shoulder instability (after Hx of acute traumatic abd-ER injury P subluxation or dislocation) Ifall on outstretched arm or grasp of t arm during throwing motion! P t Posterior instability (after Hx of trauma subluxation or dislocation) ww

Signs/Objective Findings Treatment Options Positive apprehension and/or relocation Acute: radiographs to R/O Hill-Sach's or test Bankhart lesion (if Pt being seen for the Positive load-shift test (with anterior first time! translation! Protection (immobilization and PI education to avoid shoulder ER with abdl. ice, NSAIOs Gentle ROM (Codman's, wand exercisesi in painfree and apprehension-free range Subacute/chronic: isometric shoulder ftex/ ext/IR/ER exercises progressing to isotonic (tubing or free weightsI as Sx improve Shoulder proprioception exercises Closed chain shoulder stabilization le.g., quadruped position and examiner applies perturbation to Ptl Work on neuromuscular control of rotator cuff/shoulder girdle musculature Scapular stabilization exercises le.g., push- up with a plus, seated press-ups! Pylometrics progressing to least stable osition Positive posterior drawer sign Refer PI to orthopedic surgeon if stability not improving Positive load-shift test (with posterior Acute: radiographs lif PI being seen for translation) first timel Protection (immobilization and Pt education), ice, NSAIDs Gentle ROM (Codman's, wand exercises) in painfree and apprehension-free range Subacute/chronic: isometric shoulder flex/ ext/IR/ER exercises progressing to isotonic (tubing or free weightsl as Sx improve Shoulder proprioception exercises Closed chain shoulder stabilization (e.g., quadruped position and examiner applies perturbation to Pt! Work on neuromuscular control of rotator cuff/shoulder girdle musculature Scapular stabilization exercises (e.g., push- up with a plus, seated press-upsI Pt education to avoid overhead activities/ work that aggravates Sx Refer Pt to orthopedic surgeon if stability not improving TCOlltllllU'd

TREATMENT OPTIONS FOR THE SHOULDER Continued Special Condition Hx/Symptoms S Multidirectional instability Pt C/O instability and may be able to P demonstrate P Pt may have pain or impingement type a Sx due to excessive movement/laxity of glenohumeral joint Rotator cuff tear May have Hx of FOOSH, throwing, or P lifting injury P P May be seen in older individuals as a W result of degeneration of rotator cuff w (Jl

Signs/Objective Findings Treatment Options ~ Positive sulcus sign Acute relative rest. Ice, NSAIOs Positive load-shift test (with both anterior and posterior translation! Gentle ROM ICodman's, wand exercises) Subacute/chronic: isometric shoulder flex/ ext/IR/ER exercises progressing to isotonic (tubing or free weights! as Sx improve Shoulder proprioception exercises Closed chain shoulder stabilization le.g., quadruped position and examiner applies perturbation to Pt! Work on neuromuscular control of rotator cuff/shoulder girdle musculature Scapular stabilization exercises le.g., push- up with a plus, seated press-upsl Pt education to avoid activities/work that aggravates Sx or places PI in an unstable position If stability does not improve over several months of aggressive rehabilitation, refer Pt to orthopedic surgeon Positive drop-arm test Acute: relative rest, ice, NSAIDs Positive impingement signs Gentle ROM ICodman's exercisesI Positive painful arc test Weakness of specific rotator cuff muscles Subacute/chronic: isometric rotator cuff May observe abnormal scapulohumeral strengthening progressing to isotonic motion li.e.. scapular hiking before upward Itubing or free weights) as Sx improve rotl Shoulder proprioception exercises Closed chain shoulder stabilization le.g., quadruped position and examiner applies perturbation to Pt! Work on neuromuscular control of rotator cuff/shoulder girdle musculature Scapular stabilization exercises le.g., push- up with a plus, seated press-ups) If severity of tear warrants, surgical intervention/repair may be necessary C lit III ...

w Ol • TREATMENT OPTIONS FOR THE SHOULDER Continued Special Condition Hx/Symptoms AC joint separation Hx of fall onto shoulder Adhesive capsulitis Common for ages 40-60 yr R p Several weeks' Hx of shoulder pain and restriction Pt may not be able to pull wallet from back pocket or fasten clothes that fasten in back Thoracic outlet syndrome Sx include pain and paresthesia and P possibly muscle weakness in shoulder, M arm, and/or hand Very similar to cervical radiculitis/ radiculopathy

Signs/Objective Findings Treatment Options Depending on severity of injury, Pt mayor Immobilization in Kenny-Howard/AC joint may not have a noticeable \"step-off\" from sling (type I. 1 wk; type II, 2 wks; type III, clavicle to acromion IV, or V. until Sx subsidel Positive AC joint shear test Ice Positive cross-arm adduction test Early ROM within limits of pain Tenderness to palpation over involved AC Progress to general rotator cuff and joint shoulder strengthening as Sx subside Rx of type III still controversial; some recommend surgical Rx, and others have obtained good results with nonoperative Rx. However, acute Rx of type III should be the same as for a type II injury. See the Cook, Dias, and Mulier entries in the Bibliography for treatment options. For type IV and V injuries, surgery is more of a consideration. See the Cook and Dias entries in the Bibliography for treatment options. Restricted ARDM in a clear capsular Acute: ice, NSAIDs, pain-relieving modalities in initial stages pattern IER > abd > IRI Codman's exercises for 2-3 min every 1-2 hr Positive thoracic outlet syndrome tests Must differentiate from cervical pathology Subacute/chronic: after pain subsides somewhat. begin stretching to increase ER, abd, and IR through wand exercises and joint mobilization Ultrasound to axilla to heat joint capsule before joint mobilization and AAROM/ stretches (remember to address glenohumeral, scapulothoracic, and AC joints) NSAIOs Avoid AGG Stretch appropriate structures causing Sx Neural stretch (scalenes, levator scapulae, pectoralis minorl Strengthen scapular stabilizers

38 - - - - - - - - - - - - - References 1. Neer CS, Welsh RP: The shoulder in sports. Orthop Clin North Am 8583-591,1977. 2. Neer CS: Impingement lesions Clin Orthop 173:70-77, 1983. 3. Hawkins RJ, Bokor DJ: Clinical evaluation of shoulder problems. In Rockwood CA, Matsen FA (eds): The Shoulder. Philadelphia, WB Saunders, 1990. 4. Kessell L, Watson M The painful arc syndrome J Bone Joint Surg Br 59:166-172,1977. 5. Corso G: Impingement relief test: An adjunctive procedure to traditional assessment of shoulder impingement syndrome. J Orthop Sports Phys Ther 22: 183-192, 1995. 6. Magee DJ: Orthopedic Physical Assessment, 3rd ed. Philadelphia, WB Saunders, 1997. 7. Gerber C. Ganz R: Clinical assessment of instability of the shoulder. J Bone Joint Surg Br 66:551-556, 1984. 8. Silliman JF, Hawkins RJ: Clinical examination of the shoulder complex. In Andrews JR, Wilk KE (eds) The Athlete's (f) Shoulder New York, Churchill Livingstone, 1994. I o 9 Davies GJ, Gould JA, Larson RL Functional examination C r of the shoulder girdle. Phys Sports Med 9:82-104, 1981 o 10. Yergason RM: Supination sign. J Bone Joint Surg Am m :JJ 13160,1931. 11. Ludington NA: Rupture of the long head of the biceps flexor cubiti muscle. Ann Surg 77:358-363, 1923. 12. Adson AW, Coffey JR Cervical rib: A method of anterior approach for relief of symptoms by division of the scalenus anticus. Ann Surg 85:839-857, 1927. 13 Falconer MA, Weddell G: Costoclavicular compression of the subclavian artery and vein. Lancet 2539-544, 1943 14. Wright IS: The neurovascular syndrome produced by hyperabduction of the arms Am Heart J 29: 1-19, 1945. Bibliography Boissonnault WG, Janos SC Dysfunction, evaluation, and treatment of the shoulder. In Donatelli R, Wooden MJ (eds): Orthopaedic Physical Therapy. New York, Churchill Livingstone, 1989. Cook DA, Heiner JP: Acromioclavicular joint injuries: A review paper. Orthop Rev 19510-516,1990. Dias JJ, Gregg PJ: Acromioclavicular joint injuries in sport: Recommendations for treatment: Sports Med 11: 125-132, 1991.

- - - - - - - - - - - - - - 39 Ellman H: Diagnosis and treatment of rotator cuff tears. Clin 0: Orthop 25464-74, 1990. oW Hawkins RJ, Abrams JS: Impingement syndrome in the absence of rotator cuff tear (stages 1 and 21. Orthop Clin North Am --.J 18373-382, 1987. ::J Hertling D, Kessler RM: Management of Common Musculoskeletal Disorders. Physical Therapy Principles and o Methods, 2nd ed. Philadelphia, JB Lippincott, 1990. I Itoi E, Tabata S: Conservative treatment of rotator cuff tears. Clin Orthop 275:165-173,1992. (f) Karas SE: Thoracic outlet syndrome. Clin Sports Med 9:297-310, 1990. Kisner C, Colby LA: Therapeutic Exercise. Foundations and Techniques, 2nd ed. Philadelphia, FA Davis, 1990. Mulier 1. Stuyck J, Fabry G: Conservative treatment of acromioclavicular dislocation: Evaluation of functional and radiological results after six years' follow-up. Acta Orthop Belg 59255-262, 1993. Neviaser RJ, Neviaser TJ: The frozen shoulder Diagnosis and management: Clin Orthop 223:59-63, 1987. Pink M, Jobe FW: Shoulder injuries in athletes. Orthopedics 1139-47, 1991.



nr-------------41 ill HBOW Subjective Examination • Pt Hx (region specific): dominant hand, radicular Sx (dermatomal or sclerotomal) 7 (see Appendices A and B) • SO (if applicable) s o co .-J W

42 - - - - - - - - - - - - - - - Objective Examination I. Standing A. Observation 1. Posture a. Carrying angle for males (normal 5-10 deg valgus) b. Carrying angle for females (normal 15 deg valgus) II. Sitting A. R/O cervical or shoulder pathology B. Observation 1. Posture 2. Atrophy or deformities 3. Edema C. AROM m 1. Elbow flex (140-150 deg) ero- 2. Elbow ext (0 deg) o 3. Elbow pronation (70-80 deg) :2 4. Elbow supination (80-90 deg) D. GMMT and myotomal screen 1. Shoulder elevation/shrug (C3-C4) 2. Shoulder abd (C5) 3. Shoulder flex (C5-C7) 4. Elbow flex/wrist ext (C6) 5. Elbow ext/wrist flex (0) 6. Forearm pronation/supination 7. Thumb IP joint ext/finger flex (C8) 8. Finger add (T1) E. MSRs, if applicable 1. Biceps (C5) 2. Brachioradialis (C6) 3. Triceps (0) F. Special tests (as applicable) 1. Instability: varus/valgus stress test

43 2. Epicondylitis: tests for lateral and medial so epicondylitis a:l 3. Nerve impingement/entrapment tests: -l Tinel's sign at the elbow, Wartenberg's sign, elbow flex test, test for pronator teres W syndrome G. Sensation: LT and 2-point discrimination H. Palpation 1. Soft tissue 2. Bony landmarks I. Joint play 1. Radial and ulnar deviation (similar to valgus/ varus testing) 2. Ulnar distraction with the elbow in 90 deg flex 3. AP glide of radius

... ... SPECIAL TESTS FOR THE ELBOW Test Detects Varus stress test for elbow' Rupture of RCL Varus instability also associated with anterior radial head dislocation and annular ligament disruption Valgus stress test for elbow' Rupture of UCL Tests for lat epicondylitis' Lat epicondylitis Method 1 Lat epicondylitis Method 2 r Med epicondylitis E s Tests for med epicondylitis' , e d linel's sign (at elbow)' Regeneration rate of sensory fibers of ulnar nerve E g Wartenberg's sign' Ulnar neuritis (entrapment may be at P Elbow flex test' elbowl E Test for pronator teres syndrome' a Cubital tunnel syndrome P Impingement of median nerve by fo pronator teres muscle P E e