> [!key points] Major considerations > - [[Shoulder dislocation]] > - **adhesive capuslitis** (frozen shoulder) -- elderly diabetic injury 3 months ago > - worse at night or lying flat > - decrease ROM > - diabetes, smoking, HLD, protease inhibitors. > - F > M > - most sensitive sign: *loss of passive external rotation* -- place hand on top of shoulder to immobilise scapula for test > - tx: steroids (oral or intra-articular), NSAIDs, physio when in "thawing" stage > - supraspinatus tendonitis > - NSAIDs for tendonitis > - sometimes 1.25mg/h GTN patch over subacromial space for non-calcific tendonitis > - biceps tendon rupture or supraspinatus rupture > - subacromial bursitis > - similar pain and management as for tendonitis ## Intro - wash hands, intro, consent ## position/exposure - comfortable position for pt -- often standing ## General inspection - age, gender, body habitus +/- dysmorphic features, deformity, general position, posture, assistance devices - ADL -- can they undress themselves? - Look for posture, deformity - spasm, swelling (joint effusion), skin changes, scars/wasting (esp deltoid) - bony landmarks for swelling, tenderness, or deformity - sternoclavicular joint - clavicle - acromioclavicular joint - coracoid and acromion processes - borders of scapula - muscles -- deltoid, biceps, triceps - move -- assess symmetry, quality of movement - active and passive - grade restrictions in movement - function eg brushing hair or hanging washing | movement | degrees | structure involved | | --------------------- | ------- | ------------------------------------------------------------------------------- | | flexion | 180 | - upper fibres of pec major<br>- anterior fibres deltoid | | extension | 45 | - latissimus dorsi<br>- posterior fibres of deltoid | | abduction | 120 | - 180 deg if scapula rotates<br>- deltoid<br>- supraspinatus | | adduction | | - teres major<br>- latissimus dorsi<br>- mec major | | internal <br>rotation | | - pec major<br>- subscapularis<br>- teres major<br>- anterior fibres of deltoid | | external<br>rotation | 80 - 90 | - infraspinatus<br>- teres minor<br>- posteriod deltoid | ## Special tests **Biceps tendon tests** - *Speed's Test* - flex the shoulder against resistance applied over the distal humerus while maintaining the elbow in extension and the forearm in supination. tenderness in the bicipital groove indicates biceps tendonitis - *Yergason's test* -- elbow flexed, forearm pronated. a positive test is pain at the bicipital groove **Hawkins-Kennedy test (subacromial impingement)** - flex the patient's elbow and shoulder to 90 deg. The examiner supports the elbow with one hand and uses the other to internally rotate the shoulder. the test is positive if pain is reproduced **Empty-can test (supraspinatus tear/rotator cuff test)** - abduct arm to 90 deg in neutral position and test abduction strength. then internally-rotate the arm and position the arm in 30 deg of horizontal flexion from the coronal plane and test again **Apprehension test (for anterior stability)** - if sitting or standing, the examiner applies an anterior force to the head of the humerus to produce anterior movement of the humeral head. ensure you watch the patient for signs of distress **winged scapula (paralysis of the serratus anterior muscle, innervated by long thoracic nerve)** - pushup against the wall