Clinical Decision

Making In Evaluation
of Shoulder
Dysfunction

ZOYA KHATOON
MUSCULOSKELETAL SCIENCES
 Objective:

AT THE END OF THE SEMINAR YOU SHOULD ABLE TO

1. DEFINE CLINICAL DECISION MAKING
2. EVALUATION OF SHOULDER DYSFUNCTION BASED ON
1. History
2. Observation
3. Examination
4. Special test
 CLINICAL DECISION MAKING

Clinical reasoning is a multidimensional process that involves a wide range of

cognitive skills physical therapists use to process information, reach decisions, and
determine actions.

Clinical decisions are the outcomes of the clinical reasoning process and form the
basis of patient/client management.
 Patient History
Age:
Many problems of the shoulder can be age-related.
For example,
rotator cuff degeneration usually occurs in patients who are between 40 and
60 years of age.
external rotation weakness, night pain, and age over 65 are indicative of
rotator cuff tears.
 Primary impingement: Weakness & degeneration older than 35 yrs
• Does the patient support the upper limb in a protected position or hesitate to move it?

In some cases, patients with lax shoulders ask, “What happens when I do this?”
 • If there was an injury, what exactly was the mechanism of injury?

Fall on outstretched hand: fracture or dislocation

of the glenohumeral joint

Did the patient fall on or receive a blow to the tip

of the shoulder: indicate acromioclavicular
dislocation or subluxation, Clavicle fracture
 Are there any movements or positions that cause the patient pain or symptoms?
keep in mind that cervical spine

Are there any activities that cause or increase the pain?

Do any positions relieve the pain?:

Patients with nerve root pain may find that elevating the arm over the head
relieves symptoms.
 Observation
Anterior View Posterior View

• A forward head posture is often • Scapular Positioning

associated with rounded shoulders,
• Lennie test
• Medially rotated humerus and a
protracted scapula resulting in the • Scapular winging
humeral head translating anteriorly,
• Scapular Dyskinesis
• Tight posterior capsule, tightness of
the pectoral, upper trapezius, and
levator scapulae muscles,
• Weakness of the lower scapular
stabilizers and deep neck flexors.

1. Sulcus Deformity
 Examination:
Active Movement:
Active movements (AROM) are “actively” performed by the patient’s voluntary
muscles
physiological movements.
Observe Trick movements.
Painful arc: caused by subacromial bursitis, calcium deposits, a peritenonitis or
tendinosis of the rotator cuff muscles

Scapulohumeral rhythm:
Confirmed by lateral scapular slide test
  Passive Movement:
Primarily performed to determine the available anatomical ROM and end feel.

The PROM may be within normal limits, hypermobile or hypomobile.

The end feel of capsular tightness is different from the tissue stretch end feel of muscle tightness.

If the problem is capsular, capsular tightness should be measured.

For example, a tight posterior capsule can cause

 increased scapular protraction and depression leading to ante-tilting and insufficient scapular
elevation, which in turn can lead to impingement.
 Resisted Isometric Movements:
Aim: to determine whether the contractile tissue is the tissue at fault, although the
nerve supplying the muscle is also tested.

If the muscle, its tendon, or the bone into which they insert is at fault, pain and
weakness result.
the amount of pain and weakness is related to the degree of injury and the patient’s
pain threshold.
By carefully noting which movements cause pain on isometric testing, the examiner
should be able to determine which muscle or muscles are at fault.

For example, if the patient experiences pain primarily on medial rotation but also on
abduction and adduction, the examiner would suspect a problem in the
subscapularis muscle
 Special Test:
Special tests are often used in shoulder examinations to
confirm findings or a tentative diagnosis.
For anterior shoulder (glenohumeral) instability:
Anterior/apprehension release (“surprise”) test
Anterior drawer test
For inferior and multidirectional shoulder (glenohumeral)
instability:
Sulcus sign
 For anterior impingement:
Hawkins-Kennedy test
Neer test
For scapular dyskinesia:
Lateral scapular slide test
 For muscle pathology:

Biceps

Speed’s test
Supraspinatus
Drop arm test
Empty can test
Subscapularis
Lift-off sign (Gerber’s test)
 Clinical evaluation of nonarthritic shoulder pain: diagnosis and treatment

Review: the physician and sports medicine journal 2015

Robert E. Holmes et al
 Common nonarthritic shoulder conditions presenting to
primary care physicians

1. Rotator cuff pathology and impingement syndrome

2. The painful, stiff shoulder: adhesive capsulitis
 Rotator cuff pathology and impingement syndrome:

History:
1. pain as a dull, aching sensation on the anterior and lateral aspects of the shoulder.

2. Night pain

3. Pain associated with compression from sleeping on the affected side are common
complaints.

4. Repetitive motion & Overhead activity.

 Examination:
Scapulothoracic dysfunction is an important contributor to shoulder pain as well and
must be assessed clinically

Strength:
1. Shoulder abduction motion is not a reliable predictor of rotator cuff pathology

2. Some patients with full-thickness tears can demonstrate high levels of abduction
strength.
 Test:
1. Neer test
2. Hawkins Kennedy tests
Increase the pain, particularly when there is associated impingement.
 Summary:

Introduction to clinical decision making

Evaluation of shoulder dysfunction based on:
1. History
2. Observation
3. Examination
4. Special test
 References

1. David J.Magee; Orthopedic physical assessment; 6th edition

2. Susan O Sullivan; Physical Rehabilitation; 6th edition.
3. Holmes RE, Barfield WR, Woolf SK. Clinical evaluation of nonarthritic shoulder
pain: Diagnosis and treatment. The Physician and sportsmedicine. 2015 Jul
3;43(3):262-8.