Shoulder joint

Clinical assessment of scapula

Upper limb is designed in such a way that there is ample amount of mobility which is required for manipulative activities that are a part of daily functional activities. In recent days there is increased interest on the role of scapula, its related pathologies and how entire upper extremity function is dependent on the controlled movement of scapula.

For a full, efficient as well as atleast functional range of motion of entire upper limb, scapula plays many roles in facilitating optimal shoulder function by glenohumeral integration, motion on thoracic wall and as a part of scapula-humeral rhythm. With good proximal control there is good distal mobility. Any alterations in the activity of scapula hamper the control over all upper limb activities leading to pain, impingement and other clinical syndromes which gradually causes disability.

 

Observable alterations in the position of the scapula & the pattern of scapular motion in relation to thoracic cage are called scapular dyskinesis. It causes many clinical dysfunction of the shoulder leading to disabilities.

 

Causes of Scapular Dyskinesia:

 

  1. Bony injuries or abnormalities- Types of acromion process or postural alteration 
  2. .Alteration of muscle function- upper cross syndrome, inhibited muscle- serratus anterior, lower fibres of trapezius, rhomboids, deep neck flexors, force couples.

 

  1. Contracture & other flexibility problems- pectoralis minor & major, joint capsule, upper fibres of trapezius, levator scapula

 

  1. Nerve injury/ proprioceptive dysfunction- long thoracic nerve, spinal accessory nerve

 

 

Classification of Scapular Dyskinesia:

 

               (Slideshare.net)

  • Type I – Abnormal rotation around transverse axis: commonly found secondary after rotator cuff dysfunction- inferior angle becomes prominent
  • Type II – Abnormal rotation around vertical axis: commonly seen in patients with glenohumeral joint instability- medial border becomes prominent
  • Type III – Abnormal superior translation of entire scapula: commonly seen in rotator cuff dysfunction and deltoid-rotator cuff force imbalances- superior border becomes prominent
  • Type IV- both scapula are symmetrical at rest & during motion; they rotate symmetrically upward with inferior angles rotating laterally away from midline. This indicates scapular control muscles are not stabilizing the scapula.

 

 

Types of Winging:

  1. Static winging- winging happens at rest, usually caused by structural deformity of scapula, ribs, clavicle or spine.
  2. Dynamic winging- winging happens with shoulder motion. It can be cause of trapezius weakness or serratus anterior weakness. In case of trapezius weakness, scapula depresses and moves move laterally with inferior angle rotated laterally. In case of serratus anterior weakness, scapula elevates amd move medially with inferior angle rotated medially.

 

One more clinical syndrome exists which is coined as S.I.C.K scapula

S- Scapular mal-position

I- Inferior angle prominent

C- Coracoid pain

K- Dyskinesia

 

Clinical assessment of scapula includes evaluating posture, motion, muscular activation and control and corrective maneuvers. Steps for assessment

  1. History taking
  2. Thoracic and cervical posture – trigger points and flexibility
  3. Check for the shoulder posture- trigger points and flexibility
  4. Shoulder strength – especially supraspinatus, infraspinatus, and subscapularis, Serratus anterior, lower trapezius
  5. Shoulder ROM @ 0 and 90 degrees – GIRD
  6. Scapula position @ rest
  7. Scapula position during active abduction and flexion – especially watch descending phase
  8. Scapulothoracic bursitis

 

 

Few important tests include Lennie test, Lateral scapular slide test, Scapular assistance test, scapular isometric pinch test, wall push test, Labral tests, impingement tests, tendinitis tests, etc.

 

References

  • Kibler B, McMullen J. “Scapular dyskinesis and its relation to shoulder pain”. J Am Acad Orthop Surg. 2003;11:142-151.
  • Magee DJ. “Shoulder. Orthopaedic Physical Assessment.” 5th Philadelphia: WB Saunders. 2012; 231-360.

 

What is Resisted isometric movements?

Working with the patients in the clinic and assessing their structural affection has always been a mind scratching job. Multiple tests are performed but there remains a doubt that which structure/ tissue is involved – contractile or non- contractile/ inert tissue. Contractile tissue refers to Muscle, Tendon, Musculo – Tendinous junction, Teno – Periosteal junction, Nerves, etc.  

Contractile tissue assessment involves voluntary contraction of muscles. These contractions include strong isometric contraction, multiple angle isometrics or concentric/ eccentric contraction. During this testing, it is checked if there is any pain or not and if it is then what is the intensity and quality of pain. Along with the pain it is also assessed what is the strength of contraction and which type of contraction is painful as well as weak.

For solving the above queries, the testing is done by Resisted Isometric Movements. However these movements are always tested last in the examination of the joints. This type of movement consists of a strong, isometric voluntary contraction of muscles and primarily detects muscles as well as nerves supplying the tested muscles.

  • If the muscle, its tendon or the bone into which they insert is at fault, pain & weakness result; the severity of pain and weakness helps to judge the degree of injury and patient’s pain threshold.

Some of the important points to be taken care of while assessing:

  1. There should not be any movement while performing the test because if movement occurs then inert tissue will also move and it will be difficult to find out which is the offending structure- contractile or inert.
  2. The test joint should be put in neutral or resting position in order to minimize tension on inert tissue.
  3. The movements should be done in resting position of the joint as in this position muscle is in its optimal length so that maximum force can be elicited.
  4. Moreover this position can be modified if required when assessing for tight or lengthened structures as well performing multiple angle isometric testing.
  5. This test involves isometric hold so it is essential to have the muscle strength of grade 3 to 5 on the muscle test grading scale.
  6. If there is difficulty in differentiating between grades 4 and 5, eccentric break test can be used. The test starts as an isometric contraction, but then assessor applies sufficient force to cause eccentric contraction or break in the isometric contraction.
  7. Post testing isometrics, other types of contraction can also be checked for according to patient’s complain.

Steps to perform Resisted Isometric Movements:

  1. The joint is placed in neutral or resting position. Every joint has a specific resting position.
  2. The patient is asked to perform strong isometric contraction, not to move the part and the assessor will resist with almost equal amount of force to prevent any movement from occurring and also to ensure that patient exerts maximum effort.
  3. However movement cannot be completely eliminated, but this will minimize it.

After these movements are performed, the assessor determines the contractile tissue affected by judging the degree of pain & strength of contraction. Along with these movements, functional testing, myotomes assessment, manual muscle testing, palpation and special tests are also equally important.

Active movements as well as passive movements can also be performed. And it has been observed that if contractile tissue is injured, active movement is painful in one direction (contraction) and passive movement is painful in opposite direction (stretch). Resisted isometric movement is painful in the direction of active movement.

There are 4 classic Patterns of contractile tissue lesions, according to pain & strength. They are as follows:

  • Strong & Pain free: – There is no lesion of the contractile tissue (muscles as well as nerves supplying) which is being tested regardless of being tender on touch.

 

  • Strong & Painful – In this there is local lesion of muscle or tendon. 1st or 2nd degree muscle strain. 2nd degree strain produces more muscle weakness and pain than 1st degree strain.

There can be tendinitis, tendinosis, paratenonitis or paratenonitis with tendinosis or partial avulsion fracture, but in this contraction will be strong (not as good side) and painful, pain will be around the tendon and not the muscle.

 

  • Weak & Painful: – This is seen in cases of severe lesion around of joint such as fracture. Weakness is usually caused by reflex inhibition of muscles around the joint secondary to pain.

 

  • Weak & Pain free: – This indicates complete rupture of muscle or tendon (3rd degree) or involvement of peripheral nerve or nerve root supplying that muscle. With neurological involvement, assessor must differentiate between affection of (a) peripheral nerve by checking muscles & (b) nerve root by checking myotomes and dermatomes. Differentiate between UMN & LMN lesions.

3rd degree strains usually are painless, but many a times along with this there is 1st or 2nd degree strain of surrounding muscles resulting into pain. To find out 3rd degree strain, one must check for presence of hole or gap in muscle by palpation or check the muscle bulk when contraction is attempted and how it gives appearance of obvious deformity.

 

Reference

  • Magee DJ. “Orthopaedic Physical Assessment.” 5th Philadelphia: WB Saunders. 2012.
  • Image : http://www.ptonthenet.com

 

Soft endfeel

How to check End feel during examination?

Soft endfeel

It has always been a query regarding the end feel for a particular joint and its movement. In order to solve this query here is a bit of overview on it. Hope it clarifies the doubts and solves the issue with better ease for judging the particular type of end feel.

Defining the End Feel in easier terms is the feel that is perceived by the assessor at the end of any movement. The movement that the patient performs actively is repeated passively and when the end of the available range is reached over pressure is applied to get a feel of resistance of tissue. This feel of barrier at the end of a passive range of motion is called end feel.

Steps to be noted while assessing End Feel

  1. Movement & end pressure should be done slowly and carefully
  2. Detect the end of available range of motion
  3. Distinguish between normal & abnormal end feel
  4. Caution to be taken not to be too forceful and injure the tissue
  5. Always compare it with the contra lateral side

Significance of taking End feel

  • It helps the assessor to differentiate between limiting structures
  • It guides in measuring range of motion and compare with the contra lateral side and thereby detect the pathology
  • It determines if the limitation is due to articular or peri-articular problem
  • Proper evaluations of end feel help determine a prognosis for the condition & learn severity or stage of problem.
  • The quality of resistance at end range
  • Each joint has a normal end feel at a normal point in Range of Motion (ROM)
  • Incorrect end feel, or correct end feel at incorrect ROM indicate pathology

 

 

 

 

 

NORMAL OR PHYSIOLOGICAL END FEEL

1. Soft tissue approximation Subcutaneous tissues (muscle bulk, fat) are pushing against each other

e.g.- Knee Flexion, Elbow Flexion

2. Tissue stretch (Muscle stretch) Passive elastic stretch (Tension)

Feels like stretching a bicycle tire inner tube

e.g.- Hip Flexion with Knee Extension

 

3. Tissue stretch (Capsular stretch) Tension in joint capsule

Feels like stretching a leather belt; more resistance than ligament

e.g.- Extension of MCP Joint of Fingers

4. Tissue stretch (Ligamentous stretch) Tension in ligaments surrounding the joint

Feels like stretching a leather belt

e.g.- Forearm Supination

5. Hard (Bony) Bone contacting bone (painless)

Feels like pushing 2 wooden surfaces together

e.g.- Elbow Extension

 

 

ABNORMAL OR PATHOLOGICAL END FEEL

1. Soft Capsular Related to compressing & stretching of soft tissues

Similar to Normal but with restricted ROM. Is often found in acute conditions with stiffness occurring early in range & increases until end of range

Soft boggy end feel

e.g.- Synovitis, Soft Tissue Oedema

2. Hard Capsular Similar limitation comes abruptly after smooth, friction free movement

e.g.- Frozen Shoulder, Chronic Conditions

3. Early Muscle Spasm Invoked with movement, with a sudden arrest of movement often accompanied by pain

End feel is sudden

e.g.– Acute protective spasm associated with Inflammation

4. Late Muscle Spasm Restriction occurs at or near end of ROM

Caused by instability & the resulting irritability caused by movement

e.g.- Chronic condition, spasm caused by instability

5. Springy When passive movement performed rebound phenomenon occurs

e.g.- Meniscal Tear or spasm

6. Empty Sensation is painful at certain limit.

Range is not restricted but patient is not willing to allow motion to end of range because of anticipated pain and so assessor did not reach end feel

Feels like the joint has more range available, but patient is purposefully preventing movement through full ROM.

e.g.- Acute Joint Inflammation, Bursitis, Abscess, Fractures, Psychogenic disorders

7. Bone to Bone Similar to normal end feel but range is not complete

e.g.- Osteophyte formation, Myositis Ossificans

 

 

References

  • Magee DJ. “Orthopaedic Physical Assessment.” 5th Philadelphia: WB Saunders. 2012.
  • Image courtsey : bostonbodyworker.com