Shoulder MSK Evaluations

The shoulder complex, known as the most mobile joint in the human body, exhibits its mobility primarily due to the osseous and dynamic stability it possesses. Functioning as a tri-axial joint, it is classified as a ball and socket joint, albeit with an intriguing characteristic: the "socket" portion is significantly smaller, around 3-4 times, than the "ball". Visualize the shoulder as a ball placed on a tee, which grants it exceptional mobility but also renders it heavily reliant on dynamic and passive stabilization components.

The shoulder complex, known as the most mobile joint in the human body, exhibits its mobility primarily due to the osseous and dynamic stability it possesses. Functioning as a tri-axial joint, it is classified as a ball and socket joint, albeit with an intriguing characteristic: the "socket" portion is significantly smaller, around 3-4 times, than the "ball". Visualize the shoulder as a ball placed on a tee, which grants it exceptional mobility but also renders it heavily reliant on dynamic and passive stabilization components.

I want to emphasize the importance of evaluating the thorax and breathing, as they play a crucial role in overall health. However, I'd like to keep the main focus on exploring the intricacies of the shoulder from a local perspective, while also including some global components. I don't want to get too caught up in the complexities that might overwhelm readers, but instead, I aim to provide a more accessible and concise understanding of shoulder-related issues. By taking this approach, I hope to offer valuable insights and practical information that will be beneficial for both practitioners and individuals seeking to improve their shoulder health and function.

Passive Components of the Shoulder:

• Glenoid Labrum: A fibrocartilaginous ring that deepens the socket and provides stability to the joint.

• Ligaments: Several ligaments, including the coracohumeral ligament, superior glenohumeral ligament, middle glenohumeral ligament, and inferior glenohumeral ligament, provide passive stability to the shoulder joint.

• Joint Capsule: A fibrous envelope that surrounds the joint, providing stability and containing synovial fluid for lubrication.

• Bursae: Fluid-filled sacs located in areas of high friction to reduce friction between structures.

Dynamic Components of the Shoulder:

• Rotator Cuff Muscles: Comprised of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles, the rotator cuff muscles provide dynamic stability and control movement of the humeral head within the socket.

• Deltoid Muscle: The deltoid muscle is responsible for shoulder abduction and provides additional stability to the joint.

• Scapular Stabilizers: Muscles such as the trapezius, serratus anterior, and rhomboids play a crucial role in stabilizing the scapula, allowing proper shoulder movement and stability.

It is the interaction and coordination between these passive and dynamic components that enable the shoulder to achieve its remarkable mobility while maintaining stability. However, problems can arise when there is an imbalance or dysfunction in these components, leading to shoulder pain, instability, and reduced function.

Evaluating the Shoulder

A subjective history is likely the most important aspect of a comprehensive shoulder evaluation. The patient history will often guide the clinician on how to streamline the evaluation process and utilize the appropriate clinical test to rule in or rule out a potential diagnosis and determine the appropriate prognosis. In addition to this a comprehensive subjective history will shed light on potential patho-mechanical mechanisms and develop comprehensive rehabilitation programs that match the patient history. Example, a traumatic dislocation of the shoulder on a joy-jitsu athlete could potentially result in a different type of labral tear versus a peal back mechanism type injury. Rehabilitation for each of these injuries will differ as well in my opinion. As one will have a heavier focus on OKC stability and motor control versus the Jiu-Jitsu athlete may require a lot more CKC. Both athletes will receive either variation but emphasis will differ from each phase of rehabilitation.

Following a comprehensive subjective history and systems review, clinicians should emphasize specific aspects of the subjective history that can either confirm or exclude a diagnosis. While this is essential, the order in which the MSK examination is conducted holds significant importance. Personally, I prefer not to provoke patients with aggressive testing at the beginning of the evaluation, as it can lead to a higher number of false positive findings throughout the rest of the examination. Therefore, I propose the following sequence for evaluating the shoulder:

1. Subjective History

2. Systems Review

3. Structural Inspection

4. Neurovascular Screen

5. AROM

6. PROM

7. Sum-Maximal Isometric Assessment

8. Dynamometry Strength Testing

9. Special Testing

10. Palpation

Starting with Why…

The order of examination, as listed, follows a logical sequence that allows for a comprehensive assessment of the individual. Let's break down the reasons for this order:

1. Subjective History: Starting with the subjective history allows the clinician to gather important information about the patient's symptoms, medical history, and any relevant factors that may impact the examination. This information guides the subsequent examination process.

2. Systems Review: Helps identify any systemic issues or non-musculoskeletal factors that may contribute to the patient's condition. This step ensures a thorough evaluation and helps identify potential red flags or areas that may require further investigation.

3. Structural Inspection: Visual observation of the patient's posture, alignment, and any visible abnormalities provides an initial assessment of the musculoskeletal system. It helps identify any obvious structural issues or asymmetries that may require further examination.

4. Neurovascular Screen: Assessing neurological and vascular function ensures that there are no significant impairments or abnormalities that need immediate attention. It helps rule out any underlying neurological or vascular conditions that may affect the examination findings.

5. Gross Motor Screen: Evaluating the patient's gross motor patterns provides information about their ability to move a joint or body part without assistance. This assessment helps identify any limitations or pain during voluntary movement.

6. PROM (Passive Range of Motion): Passive range of motion assessment involves moving the patient's joint or body part through its full range of motion while the patient remains relaxed. This allows the clinician to assess joint mobility and identify any restrictions or limitations.

7. Sum-Maximal Isometric Assessment: This step involves assessing the patient's ability to generate a sub-maximal voluntary contraction of specific muscles or muscle groups without joint movement. Motions of the shoulder should be specific to the actions of the muscles in order to determine if the patient’s pain are coming from contractile elements or not. Negative sub-maximal isometric testing may indicate that the patient may be experiencing neurological pain, referred pain or pain due to passive constraints of the shoulder.

8. Dynamometry Strength Testing: Dynamometry strength testing measures the force produced by the patient during specific muscle actions, providing valuable objective data on muscle strength. This assessment helps identify any deficits or areas that may require targeted intervention. However, it is important to consider the patient's pain levels during the evaluation. Personally, I refrain from performing a maximal isometric contraction with a dynamometer if the patient is experiencing pain rated above 2/10 on the Numeric Pain Scale (NPS). This is because pain can lead to muscle inhibition and a decrease in neuromuscular performance. Additionally, obtaining a strength number at this stage is unlikely to alter the initial plan of care significantly. In my view, it is more beneficial for clinicians to conduct objective measures when the patient is asymptomatic. Often, I witness clinicians obtaining objective measures on the first day, which can be challenging due to pain and weakness experienced by the patient. This approach may not provide meaningful information and could be perceived as a waste of time and discomfort for the patient. Instead, I encourage clinicians to use their clinical judgment to determine when to omit such testing. For instance, it would be inappropriate to test someone who reports a pain level of 7/10 and is unable to lift their arm overhead. By exercising discretion and considering the patient's pain levels, we can ensure a more appropriate and patient-centered approach to strength testing, optimizing the assessment process and avoiding unnecessary discomfort.

9. Special Testing: Special tests play a crucial role in assessing specific structures or functions. These tests are designed to target areas of concern or suspected diagnoses, assisting in the diagnosis or confirmation of certain conditions. At this point of the examination, it is important to select the appropriate special tests that align with your current hypothesis. By this stage, you should have gained insights into whether the issue involves contractile or non-contractile tissues through the subjective history, systems review, and neurovascular screen. These components contribute to forming a comprehensive evaluation. Therefore, the purpose of special tests is to support and reinforce your initial hypothesis, while also ruling out other potential injuries or conditions within your differential diagnosis. When selecting special tests, it is essential to use them strategically to confirm your initial hypothesis and exclude other possible factors. This approach ensures a more focused and targeted evaluation, enhancing the diagnostic accuracy and efficiency of your assessment. Performing tests that do not align with the initial hypothesis would not be efficient or yield meaningful results. Personally, I will perform special tests outside of my differential diagnosis if all tests are negative.

10. Palpation: Palpation plays a vital role in the examination process as it involves using touch and pressure to assess various body tissues, including muscles, tendons, ligaments, and bones. Through palpation, the clinician can identify areas of tenderness, swelling, or abnormalities that may require further investigation. Palpation serves as an essential component in the overall evaluation, providing valuable insights into the condition of the patient's tissues. By carefully examining and assessing these structures through touch, clinicians can gain a better understanding of the patient's physical presentation and tailor their treatment approach accordingly. It adds an important layer of information to the examination process, enhancing its overall effectiveness and facilitating optimal patient care.

By following this systematic order of examination, the clinician can gather relevant information and systematically evaluate the patient's musculoskeletal system. This step-by-step approach ensures a thorough assessment, allowing for the identification of potential issues and aiding in the formulation of an accurate diagnosis and appropriate treatment plan.

Final Thoughts…

Shoulders need to be both mobile and stable to function optimally. Passive range of motion exercises without accurate assessment can lead to over prescribing mobility interventions and inadvertent instability. Understanding the comprehensive anatomy and biomechanics of the shoulder is crucial for effective diagnosis and treatment. Tailored treatment approaches focusing on local strength, mobility, and stability/endurance are essential. Additionally, considering the influence of the thorax and pelvis on shoulder range of motion adds further complexity to the evaluation process. By addressing these factors, we can enhance shoulder function and prevent primary and secondary shoulder-complex injuries.