OMT Shoulder

The OMT Shoulder section provides High Yield Information needed for COMLEX Level 1, 2, 2PE, 3, Medical School, Residency, and as a practicing Physician.

Osteopathic Structural Exam (OSE) 1-5

• 1. observation
  
• 2. static structural exam
  
• 3. ROM
  
• 4. Layer-layer palpation
  
• 5. intersegmental motion

Bones of the shoulder girdle

• clavicle
• scapula
• humerus

Shoulder Joints

• Acromioclavicular joint
  • the irregular joint between the acromion process of the scapula and the distal clavicle
    
  • -fibrous
    
  • -most susceptible to superior trauma
• Glenohumeral joint
  • The synovial ball-and-socket joint of the shoulder
  • on 25% of humeral head makes contact with glenoid fossa
    
  • makes very susceptible to injury
• Scapulothoracic joint
  • -gives the additional 60 degrees in abduction
  • -a common area of shoulder dislocation
• Sternoclavicular joint
  • Articulation between the clavicle and the sternum- most trauma when push or pull

Motor Strength

Shoulder Dysfunction

Adhesive Capsulitis (Frozen Shoulder)

• Presentation:
  • Decreased passive and active range of motion in all planes
    
  • More stiffness than pain
• Causes:
  • Prior trauma
    
  • DM
    
  • CVA
    
  • Hypothyroidism
    
  • Female
• Treatment:
  • Spencer Technique

Glenohumeral Dislocation

• has a 90% chance of damage to axillary nerve

Referred shoulder pain

• cholecystitis
  
• myocardial infarction
  
• intrathoracic tumors

Rotator cuff tear

• Most commonly torn:
  • supraspinatus
• Causes:
  • -Trauma
    
  • -Chronic impingement syndrome

Sternoclavicular joint damage somatic

• clavicle anterior and superior to sternum
  
• resists posterior and inferior glide

Subacromial Impingement

• Tests:
  • 1. Positive Hawkins-Kennedy Test
    
  • 2. Painful Arc Sign
    
  • 3. Infraspinatus Manual Muscle Test
    
• often from the upper cross
• Causes:
  • Swimming throwing
    
  • abduction, internal rotation, overhead activities

Physical Tests

Apley’s Scratch Test

• – Used to evaluate ROM in the shoulder
• – Test abduction/external rotation ask patient to reach behind the head and touch the opposite shoulder
• – To evaluate internal rotation and adduction, ask pt to reach in front of the head and touch opposite should
• – To evaluate further internal rotation and adduction, instruct the patient to reach behind the back and touch the inferior angle of the opposite scapula

Cross Arm Adduction Test

• Forward elevation to 90 degrees
  
• active adduction
  
• -positive for AC separation

Drop Arm Test

• identifies tear and/or full rupture of rotator cuff
  
• -drop arm in last 15 degrees

Empty Can Test

• Flex arm to 90
• Abduct to 45
• internally rotate to thumb down
• resist flexion
• great for rotator cuff tear

Hawkins test

• -Pain indicates rotator cuff tear or impingement. Flex elbow to 90 degrees and abduct the arm to ninety and internally rotate humerus.
  
• -subacromial impingement syndrome

Jobe’s test

• empty beer can test
  
• weakness/tear of supraspinatus muscle
  
• patient internally rotates with thumb pointing to floor. arm is then abducted to 90 degrees. resistance applied downwards.

Neer’s impingement sign

• Arm pronated, scapula stabilized, forced flexion.
• Pain = positive rotator cuff tear.

Neer’s Test Positive Test

• Pain when internal rotate arm and force flex arm towards the ear.
  
• Neer to ear

Popeye Sign

• biceps tendon rupture

Spurling’s maneuver

• Spurling’s maneuver is a provocative test used to assess for cervical radiculopathy.
  side bend, extend and compress to the side of pain

Yergason’s Test

• Assess the stability of biceps tendon in the bicipital groove
  
• – pt flexes elbow to 90 while physician grasps elbow w/ one hand and wrist other pull and physician resists supination of forearm + external rotation of the shoulder
  
• (+) Test = pain as biceps tendon pops out of the bicipital groove

Physical Tests assess

• Speed test and Yergason Test assess:
  • Bicipital Tenosynovitis or tendonitis (Aggravated by resisted supination of the forearm)

Shoulder Techniques

Spencer technique

• Adhesive capsulitis
• Articulatory technique
• Model: Biomechanical, Respiratory‐Circulatory, Neurological, Metabolic‐Energy, Behavioral

1. shoulder extension w/ elbow flexion
2. shoulder flexion w/ elbow extension
3. circumduction w/ compression
4. circumduction w/ traction
5. abduction w/ shoulder flexion
6. adduction and external rotation w/ elbow flexion
7. internal rotation w/ arm abducted
8. distraction (scooping motion)

Muscles treated in Spencers technique

Spencer Technique Steps

• MNEMONIC:
  • Step 1 “Shake hands with the patient,”
  • Step 2 “Let’s go for a walk,”
  • Step 3 “Would you like an ice cream cone?”
  • Step 4 “How about a tall ice cream cone?”
  • Step 5 “Do you like pistachio?” (Make the letter “P”)
  • Step 6 “Don’t make me twist your arm,”
  • Step 7 “Let’s be friends.” 

Step 1 Extension (“Shake hands with the patient,”)

Step 2 Flexion (“Let’s go for a walk,”)

Step 3 ABduction, circumduction + compression (“Would you like an ice cream cone?”)

• stabilize the clavicle and scapula. 
• Flex the patient’s elbow and ABduct humerus to 90°. 
• Apply a mild, gentle compression into the GH joint. Hold compression and circumduct the humerus in a clockwise direction (start with small circles, progress to bigger circles in a cone-shaped manner to increase ROM). 
• Reverse directions.
• Modify elbow pressure and direction so forces are directed at the area of restriction.
• No ME

Step 4 ABduction, circumduction and distraction (“How about a tall ice cream cone?”)

• stabilize the clavicle and scapula. 
• ABduct the humerus to 90°, grasp the distal humerus and apply traction. OR extend elbow, grasp the wrist and apply traction. 
• Hold traction and circumduct humerus clockwise (start with small circles, progress to larger circles to increase ROM). 
• Reverse directions.
• Modify arm traction and/or change circle circumference so forces are directed at the area of restriction.
• No muscle energy variant

Step 5 Abduction (“Do you like pistachio?” (Make the letter “P”))

• stabilize the clavicle and scapula. 
• Flex and hold the elbow. 
• ABduct the humerus to the restrictive barrier. 
• Apply gentle springing force toward the restriction in abduction to improve ROM.

Muscle energy technique variation: at the barrier, have the patient apply a force to ADDuction while you maintain counterforce in ABduction.

Step 6 ADDuction and ER (“Don’t make me twist your arm,”)

• stabilize clavicle and scapula.
• Place the patient’s hand on your stabilizing arm. 
• Apply a gentle springing force toward the restriction in flexion, ADDuction, and external rotation to improve ROM.

Muscle energy variation: at the barrier, have the patient apply a force into internal rotation (“push your elbow out towards my hand”) while you are holding the ADDucted and externally rotated counterforce.

Step 7 IR and ADDuction

• stabilize clavicle and scapula.
• Bring the GH joint into internal rotation by flexing elbow and bringing hand posterior to the lower back.
• Put elbow anteriorly to internally rotate the humerus gently into the restrictive barrier. 
• Apply gentle springing force toward the restriction in ABduction to improve ROM. 

Muscle energy technique variation: at the barrier, have the patient apply a force into external rotation (“push your elbow back toward my hand”) while holding counterforce in internal rotation.

Step 8 GH joint gapping (“Let’s be friends.”)

• extend elbow, abduct humerus, and place the patient’s hand on your shoulder.
• Place both of your hands on the humerus with fingers spread over the humeral head and intermittently apply a caudal force to scoop the humeral head from the glenoid fossa, creating a general pumping motion of the joint.
• Aim the pumping motion in multiple directions and repeat until better motion is achieved.
• No muscle energy variant