In the name of GOD

1. In the name of GOD Sheikhlotfolah mosque Isfahan

2. Shoulder &Upper arm Physical Examination BabakVahdatpour MD Assistant professor Department of Physical Medicine & Rehab. Isfahan University of Medical Sciences

8. DDx. of Shoulder Pain or reduced R.O.M • Rotator Cuff Dis. • Adhesive Capsulitis • Calcific Tendonitis • Dynamic Functional Instability • A.C Degenerative Joint Dis. • Glenohumeral Degenerative Joint Dis. • Arthropathy(crystalline & Rheumatoid) • Cervical Radiculopathy • Tumors(shoulder girdle & lung apex)

9. Physical Examination • inspection • palpation • range of motion • strength • provocative shoulder test • neck & elbow

10. Inspection • both shoulders exposed • inspection of both shoulders • swelling • asymmetry • muscle atrophy • scars • ecchymosis • venous distension

11. Inspection • squaring of the shoulder→ anterior dislocation Swollen subacromial bursa in R.A Rupture of the left pectoralis major tendon.

12. Inspection Fractured left clavicle. Swollen sternoclavicular joint due to a fracture of the medial end of the left clavicle

13. scapular "winging"→ shoulder instability serratus anterior dysfunction trapezius dysfunction • Rupture of the long head of the biceps tendon (arrow).

14. Inspection • atrophy of the supraspinatus or infraspinatus→ rotator cuff tear suprascapular nerve entrapment neuropathy

15. Palpation • tenderness • deformity

16. 1.subacromial space → rotator cuff tendinitis impingement syndrome calcific tendinitis rotator cuff tear2.bicipital groove → bicipital tendinitis bicipital tendon subluxation, tear 3.acromioclavicular joint 4.anterior glenohumeral joint → glenohumoral arthritis osteonecrosis glenoid labrum tear adhesive capsulitis 5.sternoclavicular joint

17. 6.posterior edge of acromion → rotator cuff tendinitis calcific tendinitis rotator cuff tear 7.suprascapular notch → suprascapular nerve entrapment 8.Quadrilateral space → axillary nerve entrapment

19. Range of Motion testing • compared with the unaffected side • active & passive: loss of active motion alone → weakness of muscle than joint ds: LOM with both active & passive Ex → arthropathies adhesive capsulitis

20. Range of Motion testing • Flextion & Extension • Abduction & Adduction (scapulohumeral rhythm) • Internal rotation & External rotation • Scapular Retraction & Protraction

22. Apley scratch test

24. Painful arc of abduction. Passive shoulder abduction

25. Shrugging of the scapula to increase abduction (right shoulder)

27. Measurement of rotation in 90° abduction. A, Neutral position. B, External rotation. C, Internal rotation.

29. Muscle testing • Scapular stabilizers • Rotator cuff • Humeral Adductor/Internal Rotators • Humeral Abductors • Elbow Flexors & Extensors

30. Scapular stabilizers • Serratus ant. • Rhomboids • Trapezius

31. Evaluating the Rotator cuff • supraspinatusinfraspinatusteres minorsubscapularis • pain • weakness

32. Supraspinatus • "empty can" test (Jobe test) FIGURE 3. Supraspinatus examination ("empty can" test). The patient attempts to elevate the arms against resistance while the elbows are extended, the arms are abducted and the thumbs are pointing downward.

33. Infraspinatus and Teres minor FIGURE 4. Infraspinatus/teres minor examination. The patient attempts to externally rotate the arms against resistance while the arms are at the sides and the elbows are flexed to 90 degrees

34. Subscapularis & other int. rotators

35. Humeral Adductor/Internal Rotators • Pecturalis Major • Latissimus Dorsi

36. Humeral Abductors • Deltoid • Supraspinatous

38. Elbow Flexors & Extensors • Biceps • Brachialis • Brachioradialis • Triceps

39. Provocative test

40. Neer'stest(sign) • subacromialimpingement • impingement test: injection FIGURE 5. Neer's test for impingement of the rotator cuff tendons under the coracoacromial arch. The arm is fully pronated and placed in forced flexion.

41. Hawkin's test • subacromialimpingement • rotator cufftendonitis FIGURE 6. Hawkins' test for subacromial impingement or rotator cuff tendonitis. The arm is forward elevated to 90 degrees, then forcibly internally rotated.

42. Drop-arm test • rotator cuff tear • supraspinatus dysfunction

43. O`Brien test A.C joint or labrum injury

44. Cross-chest test • acromioclavicularjoint dysfunction FIGURE 7. Cross-arm test for acromioclavicular joint disorder. The patient elevates the affected arm to 90 degrees, then actively adducts it.

45. Ant. Apprehension • ant. instability FIGURE 8. Apprehension test for anterior instability. The patient's arm is abducted to 90 degrees while the examiner externally rotates the arm and applies anterior pressure to the humerus.

46. Relocation & Release test

47. Jerk test & post. Apprehension test • Post. instability

48. Sulcus sign • inferior glenohumeralinstability FIGURE 10. Sulcus test for glenohumeral instability. Downward traction is applied to the humerus, and the examiner watches for a depression lateral or inferior to the acromion.

49. Speed's maneuver • proximal tendon of the long head of the biceps

50. Yergason test • biceps tendon FIGURE 9. Yergason test for biceps tendon instability or tendonitis. The patient's elbow is flexed to 90 degrees, and the examiner resists the patient's active attempts to supinate the arm and flex the elbow.