00:01
Osteopathic evaluation of
the shoulder joint.
00:04
What we're going
to do is
start with our mantra of
look, feel, move.
00:07
We want to take a look
at the shoulder
and see if there's any
gross asymmetries.
00:10
You want to check both sides
and compare sides,
compare shoulder heights,
look at the clavicles.
00:15
Does it
appear even?
Check for the position of
the humerus.
00:19
Does one side appear the
same as the other?
Usually, evaluation of
the shoulder,
you want to look
at the patients
as they're walking,
their gait,
how they’re carrying
themselves.
00:29
Are they protecting
the shoulder
or does one arm
does not swing
as much as the
other.
00:34
It'll give you
some clues
as to what might be going around
with the shoulder.
00:38
So we're going to palpate
and feel next.
00:40
I'm going to kind of look
at the clavicles,
palpate some
key landmarks,
and see if there's
tenderness present,
the sternoclavicular joint,
acromioclavicular joint,
posteriorly the
scapula,
the muscles around the
shoulder joint,
and just feel and see if there's
any sort of tenderness.
00:57
You have your
humerus here
and the greater and
lesser tubercles
where the long head of the
bicep also runs through.
01:03
Sometimes we might be able
to elicit tenderness
along the anterior portion
of the shoulder.
01:07
So palpating all your
landmarks
over the shoulder and the
muscles is important.
01:13
To perform range of motion
testing for the shoulder,
what we're going to do is to
perform gross motion testing,
and we could do
active or passive.
01:20
What we're going to do here
today is to do active.
01:23
Remember that the shoulder
moves on the glenoid.
01:26
So we want to stabilize
the scapula
as we're moving
the shoulders
to get the most accurate
degrees of motion.
01:32
We're going to first test in
the sagittal plane.
01:34
What we're going
to do is
we’re going to kind of support
the elbow here,
and I want you
to relax.
01:38
I'm going to slowly extend
the shoulder
which you note how far
it could come back.
01:43
Then we're going
to flex.
01:44
The shoulder should be
able to flex
up to 180
degrees.
01:47
To test motion testing in
the coronal plane,
we're going to abduct
the shoulder
all the way up and bring
it back down.
01:55
For adduction, because
the body
kind of gets in
the way,
we're going to bring the arm
up forward a little bit
so that we could adduct
the shoulder
and see how far
it could adduct.
02:05
Finally, we're going to motion test
in the coronal plane.
02:08
We just motion tested in
the coronal plane
and we're going to now test in
the transverse plane.
02:12
For the transverse
plane,
we're going to test internal
and external rotation.
02:16
For internal and external
rotation,
what we're going to do is
we’re going to bring,
with the shoulders
stabilized
and the elbow next to
the body here,
we're going to bring the hand
towards the body
for internal rotation, and away
for external rotation.
02:27
Another way to do this is to
bring the shoulder,
abduct it to 90 degrees,
this is zero,
and we're going to let the hand
fall forward
for internal rotation and come up
for external rotation.
02:39
It's important to stabilize the scapula
here and the elbow.
02:42
If you let the elbow move
too much,
you could falsely create
increased motion.
02:49
If we noted some sort of restriction
of motion in the shoulder,
then that could be a potential
somatic dysfunction.
02:56
We name somatic dysfunctions for
the restriction of motion,
and then we name it
for the freedom.
03:02
We're going to take
an example.
03:06
If we had decreased
shoulder flexion,
let's say we can only flex
up to 90 degrees,
that is a left shoulder
flexion restriction.
03:17
We name it for its
freedom
so this would be a left shoulder
extension dysfunction.
03:21
The range of motion testing
is important
because that helps you
to diagnose
any sort of motion
restriction,
and then we name the
somatic dysfunction
for the freedom
of motion.
03:31
There are a couple of
special tests
that we could perform
to help confirm
if a patient has a specific pathology
of the shoulder.
03:40
The first test that we're
going to look at,
the Apprehension test, is
a test that helps
to check for possible instability
of the left shoulder.
03:51
The shoulder tends to dislocate
anterior and inferior.
03:55
What we're going to do
with this test,
if a patient
comes in
with complaints of instability
of the shoulder,
that they feel like,
it feels like
it's going to come out
of the joint,
they have that shoulder pain
associated with it,
we're going to actually recreate
the possibility
of that joint dislocating
anterior and inferior.
04:13
I usually warn the
patient
that if I move the shoulder into
uncomfortable position
to let me know as soon
as possible.
04:19
You don't want to actually
cause and force
an anterior dislocation
of the shoulder.
04:24
But this test, the Apprehension
test,
is going to see if they’re
apprehensive
when that joint is at risk
for dislocation.
04:31
So to perform
this test,
we're going to bring
the arm up.
04:36
I'm going to hold on to the hand
and externally rotate.
04:40
So we have the shoulder
joint now
pretty much abducted
to 90 degrees,
externally rotated
fully.
04:48
My hand is going to be
on the humerus
and I’m going to be applying an
anterior inferior force
to see if the patient is
apprehensive
with me moving the shoulder
in this position.
04:58
If the patient shows any sort
of apprehension to it,
meaning that they don't
want me to do it,
they may cry out, they may
complain of pain,
that would be a
positive test.
05:07
A negative test would be if
I do this position
and they are able to
tolerate the position.
05:15
If patients come in and
they complain
about shoulder
pain
and it's associated with some
decrease in motion,
or there’s shooting
pain
and it’s shooting
down the arm,
there are different tests that
we could perform
to try to discern
the issue.
05:30
So one of the tests that
we could do
to perform a test
to rule out
any sort of rotator
cuff issue
especially the supraspinatus
is the drop arm test.
05:42
What the drop arm
test is doing,
it is testing the integrity of the
supraspinatus muscle
because the supraspinatus
muscle,
remember, it does abduction
of the shoulder.
05:52
What we want to do is to
have the patient
bring their arms up
over the head
and touch the back of their
hands together.
05:59
What they're going to do is
to slowly bring it
back down to the sides
of their body.
06:02
If they're able to do
this smoothly,
that means that the
supraspinatus is intact.
06:07
If they were bringing
it down,
and all of a sudden the
arm drops
because they're unable
to hold
the weight of their
arm up,
that means that there
might be
compromise of the supraspinatus
tendon.
06:16
We begin to think that
there might be
a possible rotator
cuff tear
and needing further
evaluation from there.
06:24
The empty can test
is a test that helps
to test for any sort
of rotator cuff tear.
06:28
Remember, the rotator
cuff
including the
supraspinatus
is the most commonly
irritated muscle
that could potentially
be torn.
06:36
So what we want to do
is to check
for the integrity of
the person
able to abduct their arm
against resistance.
06:42
So I'm going to start by internally
rotating the hand
on both sides and have the patient
hold up their arms
pretty much at 90 degrees
on both sides.
06:51
In this position, you're going
to test now
by gently tapping on
their shoulder
to see if they could resist
that force
and keep their
arms up.
07:00
If I tap and they're able
to resist,
that is a negative
test.
07:04
However, if I tap and
the effect is
this side kind of
just drops,
then that is a
positive test
because they're not
able to hold
their arm up against
the resistance
and there might
be a tear
of one of the rotator
cuff muscles.
07:16
Sometimes patients
may come in
complaining of
shoulder pain
especially with certain
motions and movements.
07:21
Remember that in the
suprahumeral space,
you have a lot of
important structures.
07:26
Some tendons run
through there.
07:28
There's some
tissue there.
07:29
That space is dependent
on the scapula
moving when you
move your humerus.
07:34
So certain motions can
impinge or compress
on the tissue in
that area
and cause pain throughout
the shoulder.
07:41
Flexion, abduction, and
internal rotation
tend to narrow that space in
that suprahumeral space.
07:48
So what we do with
the Neer’s test
is a test for impingement
syndrome.
07:53
We're going to add the
two motions
to try to narrow down that
suprahumeral space.
07:58
We're going to start with
internal rotation,
and then I'm going to passively
bring the arm
up to 180
degrees.
08:05
A patient that has pain
in the area
or is unable to fully
reach that range
is going to
complain of pain.
08:13
That's going to be
a positive test.
08:15
A negative test is
to be pain-free
as I do the
motion fully.
08:21
We have the
Hawkins' test.
08:23
What the Hawkins'
test does is
it also will compress the
suprahumeral space
with particular
motions.
08:31
So the Hawkins' test will
start with flexion.
08:35
Holding and supporting
the elbow,
I'm going to add internal
rotation to the shoulder.
08:40
That will compress the
suprahumeral space.
08:43
If you have pain
with that motion,
that would be
a positive test.
08:48
A negative test would be
lack of pain
and being able to fully perform
the motions there.
08:56
If a patient complains of shooting
pain down the arm,
it could potentially
be from
compression of the
brachial plexus.
09:03
Thoracic outlet syndrome
is compression
of the brachial plexus in three
possible areas.
09:09
What we're doing with
the Adson’s test
is to try to recreate
that compression.
09:15
Remember, the brachial plexus
is a nerve bundle
that runs also with the
blood vessels.
09:20
It's a neurovascular bundle
that runs
from the neck all the way
down to the hand.
09:26
So what we're monitoring here
is whether or not
the blood vessels are
compressed
with certain motions
of the neck.
09:34
The Adson’s test, I'm going to
feel for pulse.
09:37
I'm on the radial side here
by the thumb.
09:40
Once I assess
that pulse,
I'm going to slowly bring
the arm up
to 90 degrees
of abduction,
and then I'm going to
ask the patient
to slowly bring their
head
side bending
towards me,
and then also rotating
their head
a little and adding
extension.
09:57
This motion
will compress
the thoracic
outlet region.
10:01
If I feel a loss
of pulse,
that would be a
positive test
for thoracic outlet
syndrome.
10:07
You can bring your
head back.
10:08
If we perform that
motion
and I still feel
the pulse,
then that's a
negative test.
10:16
If the patient has pain shooting
down the arm,
that could be
potentially from
a nerve root
compression.
10:22
A cervical disc could
protrude posteriorly
and compress on those
cervical roots.
10:28
The Spurling's test
will test for
any sort of cervical
root compression.
10:34
What we're doing with the
Spurling's test
is we're narrowing
the foramina
where the nerves
exit
and recreating any sort of
compression there
and seeing if that
causes pain
shooting down
the arm.
10:47
For the Spurling's
test,
what we're going to
do is first,
we're going to position
the patient
into a little
extension,
side bending
towards
and rotating towards
the affected side.
10:56
If the patient has pain then,
you want to stop.
10:58
That's a positive
test.
11:00
If they don't
have pain,
what you’re going
to do is
you’re going to add an
axial compression
to further narrow
the foramina
to see if it recreates
symptoms.
11:07
So I'm going to gently
put my hands
on top of the head and slowly
push down
providing axial
compression
and seeing if that
recreates the pain.
11:16
If the pain, if any pain,
is reproduced
radiating down
the arm,
that is a positive
Spurling's test
which indicates that
there might be
some sort of nerve
root disorder
and compression in the
cervical spine.
11:31
Patients with anterior
shoulder pain,
we may suspect some sort of
bicipital tendon issue.
11:37
So if we suspect bicipital tendon
inflammation or pain
or instability, we could perform
a Yergason’s test.
11:44
Yergason’s test is
a test where
we're going to be activating
the biceps muscle.
11:50
Remember, the biceps muscle
is a strong
elbow flexor and also a
strong supinator.
11:58
So we're going to activate
supination here
to test the biceps
muscle.
12:03
First, we're going
to find
the bicipital groove
by finding
the greater and lesser tubercles
of the humerus,
and then here is the
tendon itself.
12:11
Remember, the tendon is held in
by a thin ligament.
12:14
Sometimes that ligament
could be disrupted.
12:17
We want to see if
that ligament
is also intact with
this test.
12:21
So my thumb is
going to cover
that region of
the groove.
12:25
My other hand is going to
support the forearm.
12:28
I'm going to keep the elbow
close to the body.
12:31
I'm going to take
the forearm
and I'm going to ask the
patient to try
to supinate or turn
their palm up
against my
resistance.
12:40
I'm going to hold it a little
bit in pronation.
12:42
Go ahead and
try to turn
your palm up for me
and relax, good.
12:46
So when the patient supinates
against my resistance,
I'm assessing whether
or not I feel
any sort of click in the
bicipital groove.
12:55
If the tendon is
unstable,
it may come out of
that groove.
12:59
If pain is recreated, then that
would be a positive
Yergason’s test for bicipital
tendonitis or instability.
13:07
Apley’s scratch test is a
range of motion test
that we could try
to screen
for any sort of range
of motion restriction.
13:14
This is an active test.
I'm going to ask
the patient to do three
different things
trying to use their hand to reach
the opposite scapula.
13:22
First, I'm going to
ask the patient
to take
their hand
and try to reach behind
their back
and try to touch their
opposite scapula.
13:30
You can relax
your arm.
13:31
You, as a physician, you're
going to note
how far they could
reach.
13:35
Go ahead and reach with
your opposite arm.
13:37
Very good. Relax
your arm.
13:39
So here, we note that there
is a clear asymmetry
with how far the patient
could reach.
13:46
The second motion is to
have the patient
reach across
their neck
to touch their opposite
scapula. Good.
13:52
Now, the other side.
Good.
13:55
You can relax
your arms.
13:56
So here, it appears a little
bit more symmetric.
14:00
Then the third motion is
to have them
take their hands and
slowly bring it
behind their head
to touch
the opposite scapula.
Good.
14:10
The other side.
Good. Relax.
14:13
So here also, fairly
symmetric.
14:16
What we noted
was that
there was a lot
of decreased
range of motion in the
right shoulder
in the ability to touch the
opposite scapula.
14:25
So when you note
an asymmetry,
that is a positive Apley’s
scratch test.
14:29
When you have a
positive test,
that indicates that
you have to
further test the
affected shoulder.
14:34
What does each
motion
that the patient goes
through
with their hand
mean?
So if a patient cannot reach
behind their back
to touch the opposite
scapula,
your main motions
are extension
and also internal rotation
to come and try
to touch the opposite
scapula.
14:55
If a patient cannot reach
across their neck
to touch the opposite
scapula,
it's going to be a combination
of abduction,
flexion, and adduction
to touch
the opposite
scapula.
15:08
If they can't reach behind
their head
to touch the opposite
scapula,
it's going to be a combination
of flexion,
and then external
rotation,
and then touching the
scapula there.
15:19
So when you have an
asymmetric finding,
then you need to further motion
test the shoulder
to narrow down which motion
is restricted.