The most common presenting symptom is pain.The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed.
Pain: The shoulder joint is supplied by C4 and C5 nerve root. The pain in the shoulder region therefore may be referred to the neck, down the arm or pain from the above dermatomes may be referred to the shoulder. The exact site of pain and association with movements of shoulder, e.g. painful arc will help in the diagnosis.
Limitations of Movements: All shoulder pathologies will lead the some restrictions of movement with or without pain. Restriction of internal rotation will be the first sign in the case of frozen shoulder. This limitation of movement is due to adhesions in the rotator cuff and the synovial lining of shoulder joint. The rotator cuff is a musculotendinous unit comprising subscapularies, supraspinatus, infraspinatus and teres minor fused to the capsule of the glenohumeral joint.
Examination
Inspection
With the patient stripped upto the waist, the joint should be inspected from the front, side behind and above for:
1. Contour of Shoulder - flat (deltoid, wasting, dislocations), prominent (subdeltoid bursitis or effusion).
2. Position - in shoulder pathologies, the arm is usually supported by the other hand and medially rotated and slightly flexed.
3. Deformity in bony arc - it may be seen in sternoclavicular joint subluxation, acromiocavicular (AC) joint subluxation or dislocation, old fractures of clavicle.
4. Position of scapula - small, high or winged. Winging of scapula means the vertebral border stands prominently away from the back of chest indicative of serratus anterior paralysis.
5. Scars, sinuses or swelling.
Palpation
With the arm by the side of the chest, the shoulder joint is palpated for:
1. Warmth - infection or calcifying tendinitis will give a warm shoulder.
2. Tenderness - Along anterosupenrior slope of shoulder - bicipital tendinitis
Below acromion - Supraspinatus tendinitis
Just below coracoid - Glenohumeral joint tenderness
In painful arc syndrome, the tender spot will disappear on hyperabduction as the inflamed tissue goes deep under the acromion process. Diffuse tenderness usually indicates infection or calcifying supraspinatus tendinitis.
In AC joint - acromioclavicular joint arthritis or subluxations
In Coracoid process - coracoid impingement.
3. Crepitus- crepitus on various movements may indicate glenohumeral arthritis, acomioclavicular joint arthritis, and coracoid impingement or scapular exostosis.
4. Bony arch - it is formed by spine of scapula, acromion and clavicle. The medial surface of humerus is palpated up into the axifla for swelling or irregularity.
5. Effusion in shoulder joint is usually seen in the axilla as the capsule is redundant inferiorly. The deltoid muscle laterally will mask the swelling; hence it is difficult to find it laterally.
Codman’s method: Here the patient is in sitting position with the examiner standing behind. The clinician uses his left hand to palpate the right shoulder and vice versa. The thumb is placed along the depression below the spine of scapula to palpate the posterior aspect of glenohumeral joint. The tip of index finger is placed anterior to acrornion to feel the superior aspect of the joint. Middle finger lies in the acromioclavicular joint and the rest of the fingers support the clavicle. The examiner's other hand holds the fixed elbow and the joint is examined in varying positions.
Movements
The shoulder movements occur at 300 to the coronal plane of the body (i.e.) in abduction, the arm goes forwards and outwards and in adduction backwards and inwards. The flexion and extension occurs 90 degree to this plane. Hence in flexion, the arm goes forward and medially and in extension, backwards and laterally. Both active and passive range of motion should be measured. The appearance and disappearance of pain in varying movements should be noted.
In painful arc syndrome, pain is felt at 60 degree- 120degree of abduction, the rest being painless. In AC joint arthritis, sharp pain is felt when the arm is raised above shoulder. In acute supraspinatus tendinitis and glenohumeral arthritis, pain will be present throughout the range of motion. Even in alkalosis of glenohumeral joint, there will be some movement at shoulder due the scapulothoracic articulation. Except for the initial 25-
30 degree of abduction, the shoulder joint moves in conjunction with the scapulothoracic joint. For every 150 movement, the glenohumeral joint contributes 100 and scapulothoracic joint 5 degree.
As a screening test for rotational movements in shoulder, the patient is asked to lift his both arms above and place both hands behind his head. This tests external rotation. The patient is asked to place the hand behind the opposite shoulder blade to test internal rotation.
Instability tests
Apprehension test: On attempted abduction and external rotation, the patient will have a fear of an attack of dislocation of shoulder and resists further movements. In chronic recurrent dislocation of shoulder, the joint may be lax and may translate anteriorly or posteriorly. Movements of cervical spine should be tested to rule out cervical pathology.
Measurements
Axillary fold circumference is increased in anterior dislocation of shoulder known as Callaway's test-longitudinal measurement of upper limb is done from angle of acromion to lateral epicondyle of humerus and radial styloid.
Neurological Examination
Axillary nerve, suprascapuarnerve and long thoracic nerves should be tested by testing deltoid, supraspinatus and serratus anterior muscles respectively.
Lymphatic System: Axillary nodes and supraclavicular nodes should be looked for.
Doctor's Choice Physical Therapy department treats patients suffering from a Shoulder Injury. Relieve the pain, strengthen the shoulder and restore motion with shoulder physical therapy.
Through Physical Therapy, shoulder strength and mobility may be restored. Whether you've just had surgery or suffered an injury to your shoulder, Physical Therapy will give you the exercises, stretches and mobility techniques necessary to address your specific problem.Physical Therapy can restore shoulder strength and mobility. The Shoulder is the most flexible joint in the human body. What allows the shoulder to have the freedom to move in almost any direction is the range of motion. It’s very important for the shoulder joint to have complete functionality, especially in sporting events. The Goal of Physical Therapy is to improve the function of the muscles that surround the shoulder. Most people only strengthen a few of the large muscles around the shoulder. Physical therapy targets the smaller, but more important muscles around the shoulder that are commonly neglected. By strengthening these muscles, therapy can help compensate for damaged tendons and improve the mechanics of the shoulder joint.
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