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Examination of the shoulder
The work or the late Dr James Cyriax was based on 3 principles.
While today we recognise that not all pain is of organic origin, the majority of patients seen in general practice and in hospital Physiotherapy departments will have an organic root to their symptoms.
Pain originating in the soft tissues may appear at some distance from the source. The lack of objective findings through radiology or laboratory investigation adds to the problem of localising a lesion.
Cyriax spent his life pursuing the origin of soft tissue pain and dysfunction, ultimately devising a system of examination for the moving structures, based upon their function rather than palpation.
Pain is a noxious sensory experience dependent upon many factors. It is localised in the sensory cortex and qualified in the thalamus. Pain is appreciated segmentally and thus localisation of pain from a deep structure is dependent upon its embryological derivation.
The shoulder is derived from the fifth cervical segment and therefore refers pain into the C5 dermatome. The acromio-clavicular joint is a C4 structure and refers pain into the C4 dermatome.
The extent of reference is governed by a number of factors.
The shoulder is deep and proximal in the C5 dermatome, hence it can potentially refer pain a great distance. Conversely the acromio-clavicular joint is a superficial structure at the distal end of the dermatome causing it to give rise to accurate, local pain
Typically pain of gleno-humeral origin is felt in the upper arm, often at the insertion of the deltoid. Severe shoulder problems can cause pain to radiate as far as the radial side of the wrist.
Other potential sources of pain at the shoulder need to be eliminated (angina, pleuritic pain or neck pain.)
Pain behaves in a predictable manner. There are several 'rules of referral'
The exception to the rules of referred pain is the dura mater which will give rise to extrasegmental referred pain.
Cyriax categorised the moving structures into:
Inert structures are tested by placing them under maximum possible stretch i.e. passive movement.
Contractile structures are tested by Static resisted Contraction. This places the contractile mechanism under stress with the joint in Mid Position to avoid stretching the inert structures.
End feel is the type of resistance to further joint movement at its limit of range, as felt by an examiner. The end feel is characteristic for each normal joint and pathological change will tend to alter the end feel.
eg. Flexion at the elbow is limited by the soft tissue apposition of forearm & biceps, extension is limited by a hard bony block and forearm pronation/supination is limited by a leathery ligamentous feel. Osteoarthrosis will change the soft end feel of flexion to an atypical hard end feel. Other abnormal end feels exist such as 'Spasm, springy, empty etc.' each of which has a particular significance at a given joint.
This section concerns the gleno-humeral joint alone, hence the movements at the scapulo-thoracic junction are not addressed.
Cyriax noticed that a joint will tend to adopt a particular proportion of limited movement when affected by inflammation of whatever cause. The degree varies according to the severity of the condition, but the proportion remains constant for any given joint. All shoulders are alike and all hips are alike, but a shoulder will be different from a hip.
The Capsular pattern at the shoulder is lateral rotation most limited: gleno—humeral abduction next most limited: medial rotation least limited.
Movement may still be restricted, but in a non-capsular pattern. This means that something other than the joint is affected, eg. Chronic sub-deltoid Bursitis, which will restrict all movements by about 10°.
This is not a diagnosis but a localising sign. There are 4 common causes of a painful arc at the shoulder joint. All involve soft tissues being pinched between the humerus and the underside of the acromion.
The shoulder is a complex of joints Involving the scapulo-thoracic joint, the acromio & sterno-clavicular joints and the gleno-humeral joint itself.
The gleno-humeral joint itself is a cup & saucer joint, which relies upon the muscles of the rotator cuff for its stability.
Elevation of the arm is a combination of 90° gleno-humeral abduction, 60° scapulo-thoracic rotation and 30° of gleno-humeral adduction. Thus even in the totally ankylosed shoulder, there should be 60° apparent abduction.
The main muscles acting upon the shoulder are:
|infraspinatus||(primary lateral rotator)|
|teres minor||(secondary lateral rotator)|
|subscapularis||(primary medial rotator)|
|pectoralis major||(primary adductor, secondary medial rotator)|
|latissimus dorsi||(primary adductor, secondary medial rotator)|
|teres major||(primary adductor, secondary medial rotator)|
|biceps brachii||(elbow flexor & supinator)|
The sub-acromial bursa lies deep to the acromion and allows free gliding of the structures attached to the head of the humerus under the bony arch.
The last 3 questions determine the irritability of the joint.
Preliminary examination of the forequarter
As pain could be referred from the neck, it is important to eliminate a cervical origin for the symptoms.
All Six movements should be full & painfree if the neck is normal.
The shoulder joint - findings on examination