• NEUROVASCULAR INJURIES AROUND THE SHOULDER JOINT

• NEUROVASCULAR ASSESSMENT
• NEURODYNAMIC ASSESSMENT
• TAKING HISTORY
• THE PHYSICAL EXAM
• SHOULDER INVESTIGATIONS
• SPECIAL TESTS
NEUROVASCULAR
INJURIES AROUND
THE SHOULDER
JOINT
Dr Riafat Mehmood
• Nerve injuries around the shoulder are common.
• They usually occur as a result of motor vehicle accidents, gunshot or
athletic injuries, or overuse and chronic repetitive stress often
observed in sports involving repetitive overhead or throwing
activities.
 Mechanisms Of Nerve Injury
• Direct pressure,
• repetitive microtrauma,
• compression- or stretch-induced ischemia.
• The severity and extent of compression is related to the degree of the
nerve injury.
• Distinct clinical syndromes involving the shoulder joint area can
develop after injuries to the axillary, musculocutaneous,
suprascapular, long thoracic, and spinal accessory nerves, as well as
the proximal brachial plexus trunks and the lower cervical nerve
roots.
Seddon's classification
Diagnosis
• Based upon physical examination and a knowledge of the relative
anatomy. Palpation, neurological testing and provocative
manoeuvres are mainstays of physical diagnosis.
• Diagnostic suspicion can be confirmed by electrophysiological testing,
including electromyography and nerve conduction studies.
In the shoulder
• injury is caused by a blow to the neck and results in trapezius paralysis
with sparing of the sternocleidomastoid muscle.

• Scapular winging results from paralysis of the serratus anterior because

of injury to?

• A lesion of the nerve may mimic a rotator cuff tear with pain a weakness
of the rotator cuff.

• nerve injury often follows anterior shoulder dislocation

NEUROVASCULAR
ASSESSMENT
PERFORM A
NEUROVASCULAR
ASSESSMENT
ASSESS THE 6 PS.

• They would typically ask the person to note the location and severity
of pain as well as whether it radiates, or spreads from the point of
injury.
• Paraesthesia can be assessed by applying light touch to the
extremities or pricking the area with the end of a pen cap.
• The clinician can grade pulses using a 0 to 3+ point scale with 0
signifying absent pulses and a 3+ indicating strong and bounding, or
forceful, pulses. If the pulse is very faint or difficult to find, a Doppler
scan, which utilizes sound waves to assess blood flow, can be used.
• Pallor can present differently in various skin tones but can be assessed
by comparing the color of the skin on both sides of the body and looking
for unusually pale or purplish discoloration of the skin.
• To assess temperature, the back of the clinician's hands should be
placed on the individual’s extremities, bilaterally.
• Lastly, the range of motion should be tested by asking the person to
perform certain movements with their arms and legs.
NEURODYNAMIC ASSESSMENT
• The main reason for using a ULTT is to check cervical radiculopathy.
• These tests are both diagnostic and therapeutic.
• Once the diagnosis of cervical radiculopathy is made the tests are
done to mobilise the entrapped nerve.
Method
• Each test is done on the normal/asymptomatic side first.
• Traditionally for the upper limb, the order of joint positioning is
shoulder followed by forearm, wrist, fingers, and lastly elbow.
• Each joint positioning component is added until the pain is provoked
or symptoms are reproduced. To further sensitive the upper limb
tests, side flexion of cervical spine can be added.
• If pain is provoked in the very initial position, then there is no need to
add further sensitisers.
Upper Limb Tension Test 1 (ULTT1, Median nerve bias)
• Shoulder girdle depression
• Shoulder abduction
• Shoulder external rotation
• Forearm Supination
• Wrist and Finger extension
• Elbow extension
• Cervical side flexion
Upper Limb Tension Test 2B (ULTT2B, Radial nerve bias)

• Shoulder girdle depression

• Elbow extension
• Medial rotation of the whole arm
• Wrist, finger and thumb flexion
Upper Limb Tension Test 3 (ULTT3, Ulnar nerve bias)

• Shoulder girdle depression

• Shoulder abduction
• Shoulder external rotation
• Wrist and Finger extension
• Elbow flexion
• Shoulder abduction
Musculocutaneous Nerve Tension Test (ULTT musculocutaneous)

• Shoulder girdle depression

• Elbow extension
• Shoulder extension
• Ulnar deviation of the wrist with thumb flexion
• Either medial or lateral rotation of the arm could further sensitize this
nerve
• https://youtu.be/g3DSgCOXpWc
• https://youtu.be/x3ivtuDwCDI
• https://youtu.be/wKnpaf7OI7s
• https://youtu.be/iEfZ5GjqylY
TAKING HISTORY
• acromioclavicular joint pain and bicipital pain are well localized,
the pain of most other shoulder pathologies is more diffuse.
• The onset of shoulder pain
• acute (e.g. a dislocation, subluxation, or rotator cuff tear),
• insidious (e.g. rotator cufftendinopathy).
• Night pain is very common in rotator cuff dysfunction and adhesive
capsulitis.
• Sensory symptoms such as numbness or pins and needles should be
noted, as should any episodes of "dead arm" (in a baseball pitcher
this suggests labral injury).
• Assess upper limb strength. He or she may report catching and
locking, or inability to develop normal speed in the action
THE PHYSICAL EXAM
• 1) Type: esthesia (hyper-, hypo-,), mobility (hyper- or hypo-), thermal sensation, coloration,
crepitis, and strength (fatigue and/or weakness); this in turn should be evaluated as to
whether the symptoms are constant or variable.
• 2) Severity: percentage of initial (if sudden onset) and percentage of maximal possible pain
that could be tolerated.
• 3) Irritability (response to the following): activity (walking and specific use of the affected
extremity), inactivity (standing, ipsilateral side lying, and gravity eliminated positioning),
treatment modalities (heat, cold, compression, elevation, massage, traction, splinting or sling,
and medication), circadian behavior, and any other additional means of increasing or
decreasing the symptoms.
 A COMPLETE EXAMINATION INVOLVES:
1. Observation 3. Passive movements
(a) from the front (a) to (e) as for active movements (above)
(b) from behind.
4. Resisted movements
2. Active movements external rotation
(a) arm elevation-watch scapular subscapularis lift-off test-Gerber's test
motion and position deltoid
(b) external rotation with elbows at supraspinatus
side Uppercut
(c) external rotation at 90° of 5. Palpation
abduction (a) acromioclavicular joint
(d) internal rotation (b) rotator cuff tendon
(c) bicipital groove
(e) horizontal flexion
Observation
• Inspection –
from the front and back!
• Asymmetry
• Bony deformity or abnormal
contour
• Muscle atrophy or bulge
• Scapular winging
• Posture
Range of Motion

• Active
• Passive
• Apley’s “scratch” test
• Scapular movement
• Strength Testing/Resisted Movements
Observation from behind. Look for
wasting or asymmetry of shoulder
height, scapular position, and muscle
bulk
Active movements-elevation. Watch for
prominence of the medial scapular
border. This indicates Joss of scapular
control, which is called "scapular
dyskinesis"
Palpation

• AC, SC, and GH joints

• Biceps tendon
• Coracoid process
• Acromion
• Scapula
• Musculature
SHOULDER
INVESTIGATIONS
• X-ray Plain
• Routine views (AP with internal and external rotation, and axillary lateral)
• AP view is useful for assessing joint space narrowing (i.e. arthritis).
• In cases of Tauma, an adequate axillary view may not be possible and it is
mandatory to obtain a true lateral film to exclude dislocation.
• The conditions that can be identified on plain films are:
• calcific tendinopathy glenohumeral
• joint arthritis
• impingement (sclerosis of anterior and/or lateral acromion, sclerosis of
greater tuberosity)
• proximal humeral head migration (severe rotator cuff dysfunction)
• fractures.
• Typical shoulder X-ray views include:
• Antero-posterior (AP) view
• Lateral/scapula Y view (named due to the “Y” shape of the scapula
in this view)
• An axial view can also be used as an alternative to the scapula Y
view if the patient is unable to tolerate the positioning required to
obtain this view.
fracture
Ultrasound
• Evaluate rotator cuff and adjacent
muscles, bursa, long head of biceps,
fluid collections
• Diagnose tendinopathy, tears, bursal
thickening, impingement
• However, not great at quantifying
large tears
• Less expensive, non-invasive
• Static and dynamic evaluation
MRI
• Multiplanar, non-invasive
• Can better characterize large RC tears, can diagnose occult
fractures, morei nformation on ligaments and nerves
• More expensive, static
• Do not need immediately if full ROM and only complains of pain
and weakness
• Add arthrogram (contrast) for labral pathology
• Degenerative joint disorders like arthritis
• Shoulder impingement, or pressure on tendons or nerves in the shoulder
• Rotator cuff injury
• Torn ligaments
• Sports injuries
• Repetitive strain that causes injury and pain
• Bone infections
• Shoulder pain that doesn’t get better with treatment
• Trouble moving your shoulder
• Shoulder healing after surgery
• Tumors
SPECIAL TESTS
Rotator Cuff
• “Drop-arm”
• “Empty can,” lift-off,
and resistance testing

Impingement
• Neer’s
• Hawkins/Kennedy
Biceps
• Speed’s
• Yergason’s

AC Joint
• Cross-arm/scarf test
Shoulder Instability
• Sulcus sign
• Apprehension,
relocation,release

Load and shift

• Labrum
• O’Brien’s
• Crank test
• SLAP prehension
• 1. Lie prone on a table with your arm over the edge
and with your shoulder flexed 90 degrees, elbow
extended, and a weight in your hand Lift the weight
away from the table in a sideward motion.

• a. What is the shoulder joint motion?

• b. What type of contraction (isometric, concentric,
• eccentric) is occurring?
• c. What muscles are prime movers in this shoulder joint
motion?
• 2. Stand with your arm adducted at the side of your body, elbow
flexed to 90 degrees, and hold a loop of elastic tubing whose
other end is anchored in front of you at the same level as your
hand. In a sawing motion (back and forth motion like you are
sawing wood), pull back on the tubing.

• a. What is the shoulder joint motion?

• b. What type of contraction (isometric, concentric,eccentric) is occurring?
• c. What muscles are prime movers in this shoulder joint motion?
• The ability of this gymnast to perform
this iron cross maneuver may be limited
by the strength of which group of
shoulder joint muscles?