Advance Orthopedic Assessment

Ming Dong Li, Ph.D., L.Ac.

 Rotator Cuff Pain
• Rotator cuff pain is most commonly caused by
an inflamed tendon (tendinitis) or torn
tendon.
 Anatomy
The rotator cuff consists of four muscles:
Supraspinatus,
Infraspinatus,
Teres minor,
Subscapularis
• Four muscles surround the shoulder blade and attach to the humerus
vs tendons come together to form the cuff that covers the anterior,
superior, and posterior aspects of the humeral head, allowing you to
lift and rotate your arm. Issues with any one of these can cause
rotator cuff pain.
• As there muscles assist in elevation of the
arm, the rotator cuff, primarily the
superapinatus tendon , is pulled repetitively
under the coracoacromial arch. The
acromioclavicular joint capsule.
 1.1 Rotator cuff tendinitis

• Rotator cuff tendinitis pathology presents a

continuum from edema and hemorrhage to
chronic inflammation and fibrosis to
microscopic tendon fiber failure progressing to
full-thickness rotator cuff tear. The etiology is
likely a combination of factors, including loss
of microvascular blood supply to the tendon
and repeated mechanical insult as the tendon
passes under the corcoaromial arch.
 Clinical Manifestations
• Gradual onset of anterior and lateral shoulder
pain exacerbated by overhead activity is
characteristic. Night pain and difficulty
sleeping on the affected side are also
common. Atrophy of the muscles about the
top and back of the shoulder may be apparent
if the patient has had symptoms for several
months.
 1.2 Rotator Cuff Tear

• The rotator cuff is composed of four muscles:

the supraspinatus, the infraspinatus, the
subscapularis, and the teres minor. There
muscles from a cover around the head of the
humerus and function to rotate the arm and
stabilize the humeral head against the glenoid.
 Pathology
• While rotator cuff tear can occur with acute
injury, most are the result of age-related
degeneration, chronic mechanical impingement,
and altered blood supple to the tendons. Tears
generally originate in the supraspinatus tendon
and can progress posterior and anterior. Full-
thickness tear are uncommon in individuals
younger than age 40 years, but are present in
25% of individuals over age 60 years. Most older
people with rotator cuff tears are asymptomatic
or have only mild, nondisable symptoms.
 Clinical Symptoms
• Patients often report recurrent shoulder pain
for several months and a specific injury that
triggered the onset of the pain. Night pain and
difficulty sleeping on the side are the
characteristic. Weakness, catching, and grating
are common symptoms, especially when lifing
the arm overhead.
 2. Frozen Shoulder
( Adhesive capsulitis, Fifty shoulder)

• Frozen shoulder, as know as adhesive

capsulitis , is defined as an idiopathic loss of
both active and passive motion. It is
considered distinct from age-related
degeneration or posttraumatic shoulder
injuries. Frozen shoulder most commonly
affects patients between ages 50 to 70 years,
women are more commonly than men, 20%
diabetes get frozen shoulder compared to 5%
of the rest population.
ROM of Shoulder and Wrist
 Examination
• The glenohumeral joint is the most mobile joint in
the body, but the large multi-directional range of
motion is a trade-off for joint stability. The lack of
stability makes the shoulder more susceptible to
a large spectrum of injuries, especially with
overhead activities involved in sports such as
baseball, volleyball, swimming and weight lifting.
The shoulder girdle is important because is serves
as the connecting joint between the arm and the
axial skeleton. It serves as the base of support for
movements occurring at the elbow, wrist and
hand.
• During an examination, taking a thorough history
is as important as the physical exam itself. The
clinician should inquire about the patients hand
dominance, as well as their occupation and
recreational activities. It is also important to
establish their chief complaint, which may include
pain, instability, weakness, or loss of range of
motion. Complaints of numbness and tingling
may be associated with neurovascular disorders,
and stiffness may suggest adhesive capsulitis
and/or arthritis.
• Furthermore, any crepitus may indicate bursa,
osteoarthritis or rotator cuff pathology. It is also
important to have patients try and establish an
approximate timeline for when the injury
occurred and what event or mechanism, if any,
lead to the injury or onset of symptoms. For
patients who report a dislocation, it should be
asked what position the arm was in at the time of
the dislocation, and what the frequency of
dislocations or subluxations were.
• Finally it is important to establish what type of
activities of daily living the patient can and
cannot perform. Such activities include simple
everyday tasks like getting dressed, lifting an
object overhead, sleeping on the shoulder,
brushing your teeth, combing your hair,
putting on shoes, and carrying or lifting
objects like groceries.
 Palpation
• There are several important bony and soft tissue
structures that need to be palpated during the
shoulder physical exam. Bony structures should
include: the sternoclavicular joint, the clavicle,
the acromioclaviular joint, the coracoid process,
the borders of the scapula, and the greater and
lesser tuberosities of the humerus. Soft tissue
landmarks should include: the subacromial
bursae, the supraclavicular fossa, the long head
of the biceps tendon, the trapezius, and other
associated muscles and tendons.
 ROM of the Shoulder Complex
• Abduction 170- 180 degree
• Flexion 160 – 180 degree
• Elevation through the plane to the scapula
170 – 180 degree
• Lateral rotation 80 – 90 degree
• Medial rotation 60 – 100 degree
• Adduction 50 – 75 degree
• Horizontal adduction 130 degree
• Circum-duction 200 degree
Apley’s Scratch Test
 Codman’s Pendulum
• Have the patient standing in a relaxed
position, and tell them to swing their weak
arm in a circular motion while keeping their
shoulder nice and relaxed. Be sure they swing
their arm in both the clockwise and
counterclockwise directions.
 Frozen Shoulder: External Rotation
• To improve range of motion, special exercises
such as Codman’s Pendulum can be
performed to help relax the muscles around
the shoulder, reduce pain, and increase
motion.
Empty Can Test (Supraspinatus Test) & Drop-Arm Test
Speed’s Test (Biceps or Straigh –Arm Test), Yergason’s
Test, Ludington’s Test