When assessing the shoulder joint which movements should the nurse Assess?
The prerequisite for any treatment in the shoulder region of a patient with pain is a precise and comprehensive picture of the signs and symptoms as they occur during the assessment and as they existed until then. Because of its many structures (most of which are in a small area), its many movements, and the many lesions that may occur either inside or outside the joints, the shoulder complex is difficult to assess. Having a systematic and structured approach to the shoulder history and examination ensures that key aspects of the condition are elicited and important conditions are not missed. Information gathered in this process can help guide decisions about the need for special tests or investigations and ongoing management. Show Note, the evaluation strategies based on clinical tests and diagnostic imaging has been challenged over time, with clinical tests appearing unable to clearly identify the structures that generated pain. The interpretation of diagnostic imaging is also still controversial. The range of motion (ROM) of the arm relative to the trunk does not just come from the glenohumeral joint. Movement also occurs in the acromioclavicular (a.c.) joint, sternoclavicular (s.c.) joint and the upper costosternal and costovertebral joints. Another prerequisite for normal movement is that the scapula should be able to move freely, relative from the dorsal thorax wall. The glenohumeral joint is a multiaxial, ball-and-socket, synovial joint with a relatively shallow socket: the cavitas glenoidalis. The joint depends primarily on the muscles and ligaments for its support, stability and integrity. The ring of firbocartilage labrum (glenoid labrum), surrounds and deepens the glenoid cavity of the scapula about 50%. Stability is mostly offered by the periarticular muscles, that originate from the scapula and insert on the caput humeri. This rotator cuff includes the m.supraspinatus, m. infraspinatus and m. subscapularis. The spina scapulae is a bony ridge on the dorsal side and is the insertion location of the m. trapezius and m. deltoideus. The spina scapulae broadens on the lateral side, shaping the acromion. The space between the acromion and humerus head is called the subacromial space. In this space you'll find the tendons of the rotators and the bursa subacromialis (= bursa subdeltoidea). The tuberculum minus and tuberculum majus are divided by the sulcus intertubercularis, where the tendon of the caput longum m. biceps brachii runs. This tendon continues into into the joint and has its insertion on the top ridge of the cavitas glenoidalis (labrum glenoidale). For a full overview of shoulder anatomy, please read this page on the shoulder. Anamnesis refers to the client's account of their past medical history. The anamnesis is a significant part of the assessment of patients with musculoskeletal dysfunction. Different anamnestic elements are collected including
These elements are all weighted and included in the clinical reasoning process to guide the subsequent physical examination
Questions to ask to determine possible pathologies[edit | edit source]
Asking about the mechanism of any specific injury is critical, particularly about three factors relating to the time of injury: anatomical site, limb position and subjective experiences. Take care to clarify the patient’s description of the anatomical site. A description of the arm position at the time of the injury is also valuable. For example, falling on an abducted and externally rotated arm increases the risk of shoulder dislocation or subluxation. Finally, exploring the subjective experiences of the patient at the time of injury can be useful. For example, a snapping or cracking sound may be related to a bone or ligament breaking; feeling something ‘pop out’ may suggest a joint dislocation or subluxation. This video gives a 15 minute great summary of the key important procedures. ] The cervical spine can refer pain to the shoulder/scapular region. It is imperative that the cervical spine be screened appropriately as it may be contributing to the patient’s clinical presentation. See Cervical Examination The key principle with this phase of the shoulder examination is symmetry. The shape, position and function of each shoulder should be relatively similar. Some differences can occur due to shoulder dominance; the dominant shoulder may sit lower and may appear somewhat larger due to larger muscle mass. Also look at position of scapula and or winging and any abnormal postures of swellings/injuries. Palpation of the shoulder region may provider the physical therapist with valuable information. The physical therapist should note the presence of swelling, texture, and temperature of the tissue. Additionally the physical therapist may observe asymmetry, sensation differences, and pain reproduction. Key palpable structures include:
A comprehensive neurological examination may be warranted in patients that present with a primary complaint of shoulder pain. The presence of neurological symptoms including numbness and tingling may warrant this examination.
Pathological Reflexes[edit | edit source]Deep Tendon Reflexes[edit | edit source]
The patient performs active movements in all functional planes for the shoulder. This includes flexion, extension, abduction, adduction and internal and external rotation. Estimate the range of movement or measure with a goniometer and compare the affected with the unaffected shoulder and with the normal expected range. Active Range of Motion (ROM)[edit | edit source]Active movements of the shoulder complex[15]Active movements of the shoulder complexROMElevation through abduction170°-180°Elevation through forward flexion160°-180°Elevation through the plane of the scapula170°-180°Lateral (external) rotation80°-90°Medial (internal) rotation60°-100°Extension50°-60°Adduction50°-75°Horizontal adduction/abduction (cross-flexion/ cross-extension)130°Circumduction200°Scapular protractionScapular retrationCombined movements (if necessary)Repetitive movements (if necessary)Sustained positions (if necessary)Dysfunction - affecting movements. Which movements are limited, as this can help isolate the problem. Consider the following if movements are limited by:
Passive ROM[edit | edit source]May include each of the motions stated in the active ROM section. The therapist may opt to include overpressure to further stress the joint. Muscle Length Assessment[edit | edit source]Assessment of the flexibility of certain muscles may be warranted in patients with shoulder pain. These muscles may include, but are not limited to:
Muscle Strength[edit | edit source]Resistive testing of the shoulder muscles typically includes the following motions:
Resistive testing of the scapular stabilisation muscles may include: Joint Mobility Assessment[edit | edit source]Assessment of the mobility of the joint may indicate hypomobility within the joint and/or reproduce symptoms.
Special Tests[edit | edit source]Several special tests exist for particular disorders of the shoulder. Below are links to the specific pages for each pathology that describe the special tests: Patients with shoulder pain should be questioned for the presence of red or yellow flags. A thorough medical history and possibly the use of a medical screening form is the initial step in the screening process. The chart below highlights some of the most common red flag conditions for patients with shoulder pain. Red flags are sign and symptoms alerting the physiotherapist on a possible presence of a non-musculoskeletal, life-threatening pathology, fracture, infection, tumor and inflammatory rheumatic conditions. Examples include:
To assess for yellow flags, if suspected these tools may be used;
Fractures may result from trauma such as falls onto an outstretched hand. These are known as FOOSH injuries. Commonly fractured within the shoulder region are:
Diagnostic Imaging Radiographs of the shoulder can be used to identify cysts, sclerosis, or acromial spurs, osteoarthritis of the acromioclavicular and glenohumeral joint, or calcific tendonitis. Common radiographic views may include (this may vary depending on medical provider): What would be the best approach for the nurse to use when performing a functional assessment on an older client?There are two approaches for performing a functional assessment, asking individuals about their abilities to perform the tasks (using self-reports) or actually observing their ability to perform the tasks.
Which angular motion involves moving the arm away from midline of the body?Abduction occurs when a bone moves away from the midline of the body. Examples of abduction include moving the arms or legs laterally to lift them straight out to the side. Adduction is the movement of a bone toward the midline of the body. Movement of the limbs inward after abduction is an example of adduction.
How would the nurse document normal muscle strength?A common method of evaluating muscle strength is the Medical Research Council Manual Muscle Testing Scale. This method involves testing key muscles from the upper and lower extremities against gravity and the examiner's resistance and grading the patient's strength on a 0 to 5 scale.
|