2022 Shoulder Complex Kinesiology

Slide 55

Labral Tear

O’Brien Test

• Position patient’s shoulder in 90 deg
flexion, elbow extended, and 15 degrees
adducted (medial to sagittal plane).

• Point thumb down. Examiner stands
behind patient and applies downward
force.

• Repeat with arm supinated (thumb up).

• If pain is elicited in first maneuver only, Sensitivity: 0.47 | Specificity: 0.55
then suggests labral tear (if pain “inside”
shoulder) or AC joint abnormality (if https://youtu.be/qkDvVBi0gg8
pain “on top” of shoulder).

3 min video

“The patient sits with the test shoulder in 90 degrees of forward flexion, 40
degrees of horizontal adduction, and maximal internal rotation.

• The examiner stands with one hand grasping the subject’s wrist.
• The patient horizontally adducts and flexes the test shoulder against

the examiner’s manual resistance.
• The test is then repeated with the subject’s arm in an externally

rotated position.
• Pain or popping in the internally rotated position (but not in the

externally rotated position) is a positive test.”

Slide 56

Biceps Muscle

Yergason Test Sensitivity: 0.74 | Specificity: 0.58

• Position patient’s https://youtu.be/_Cjahul5yuI
elbow at 90 degrees
with the thumb up.
Have the patient
supinate and flex elbow
against examiner’s
resistance (holding at
wrist)

2 min video

“This test is used to check the ability of the transverse humeral ligament to
hold the biceps tendon in the bicipital groove.”

“Patient sits while examiner stands in front.
• The patient’s elbow is flexed to 90 degrees and the forearm is in a
pronated position while maintaining the upper arm at the side.
• Patient is instructed to supinate arm while examiner concurrently
resists forearm supination at the wrist.
• Localized pain at the bicipital groove indicates a positive test.”

Slide 57

Biceps Muscle

Sensitivity: 0.90 | Specificity: 0.14 Speed’s Test

https://youtu.be/gbG_O9Gv8aQ • Place the patient's arm in
shoulder flexion, external
rotation, full elbow extension,
and forearm supination;

• manual resistance is then
applied by the examiner in a
downward direction.

• The test is considered to be
positive if pain in the bicipital
tendon or bicipital groove is
reproduced.

3 min video

This test looks for biceps muscle or tendon pathology

“The patient’s arm is forward flexed to 90 degrees and then the patient is
asked to resist an eccentric movement into extension, first with the arm
supinated, then pronated.

• A positive test elicits increased tenderness in the bicipital groove,
especially with the arm supinated.”

Slide 58

Inferior Glenohumeral Capsule Laxity

Sulcus Sign Sensitivity: 0.47 | Specificity: 0.55
• Patient sitting or standing;

shoulder in neutral position,
elbow flexed at 90o; muscles
relaxed.
• Downward traction applied
at elbow.
• Positive if dimpling of skin
below acromion or widening
of subacromial space on
palpation of >2cm.

https://youtu.be/vV7u2JtdYWI

2 min video

Test for the presence of shoulder instability.

Because the head of the humerus is less stable within the glenoid
fossa, patients with an MDI frequently subluxate or dislocate.

The inferior portion of the glenohumeral capsule is often most lax,
and as a result the head of the humerus can easily shift inferiorly.

By applying a distal pull on the humerus, a glenohumeral joint that
displays capsular, muscular, or ligamentous laxity will translate
inferiorly greater than an asymptomatic joint.

This excessive gapping between the acromion and humeral head is
considered a positive sulcus sign.

Slide 59

The DASH

The Disabilities of the Arm, Shoulder and Hand

The DASH questionnaire is a
30-item questionnaire that
looks at the ability of a
patient to perform certain
upper extremity activities.

Slide 60

The DASH

The Disabilities of the Arm, Shoulder and Hand

The DASH questionnaire is a self-
report questionnaire that patients
can rate difficulty with daily life
activities on a 5-point Likert scale
• Reliability: ICC=0.96
• Validity: r>.70

Slide 61

Shoulder Intervention

Common treatment methods Commonly used outcome measures

• neuromuscular electrical stimulation • PAIN: visual analogue scales (VAS)
(NMES) perhaps Transcutaneous • UE MOTOR FUNCTION: Fugl-Meyer
Electrical Nerve Stimulation (TENS)
Assessment (FMA)
• heat and stretching • FUNCTIONAL STATUS: Functional
• taping
• slings/orthoses Independence Measure (FIM)
• ROM: goniometers to measure both

active and passive range of motion
• SUBLUXATION: x-rays to measure

degrees of subluxation
• SPASTICITY: the Modified Ashworth

scale (MAS)

Slide 62

Wow, I feel so smart with all
of this information. What
can I do with it? What is the
functional importance of the

shoulder?

Slide 63

Functional Assessment

• Shoulder

• Integral role in ADL (open and
close kinematic chain)

• Placing hand behind the head
(e.g., combing hair) requires
full external rotation

• Placing hand in small of the
back (e.g., to undo a bra)
requires full internal rotation.

The Kinetic Chain is a way of describing human movement and it can
either be an open kinetic chain or a closed kinetic chain (CKC).

• In an open kinetic chain, the segment furthest away from the body(
e.g., hand/wrist) is free and not fixed to an object.

• In a closed kinetic chain, the segment furthest away from the body
is fixed.

Both types of kinetic chain exercises have their advantages.

The biggest advantage of an open kinetic chain (OKC) exercise is that it
can isolate a muscle.

Slide 64

ROM Necessary for Certain ADLs

• Eating

• 70-100o horizontal ADD
45-60o ABD

• Combing Hair

• 30-70o horizontal ADD
105-120o ABD
90o lateral rotation

Slide 65

ROM Necessary for Certain ADLs

• Reach Perineum

• 75-90o horizontal ABD
30-45o ABD
90o+ internal rotation

• Hand Behind Head

• 10-15o horizontal ADD
110-125o forward flexion
90o lateral rotation

Slide 66

ROM Necessary for Certain ADLs

• Putting Something on a Shelf

• 70-80o horizontal ADD
70-80o forward flexion
45o external rotation

Slide 67

Occupational Therapy Interventions

• Activities of Daily Living • Environmental Adaptation • Pre-Prosthetic and
• Adaptive Equipment • Ergonomics
• AROM AAROM PROM • Exercise Prosthetic Training
• Assistive Technology • Functional Training • Prevention
• Biofeedback • Health Promotion • Problem Solving
• Body Awareness • Home Modification • Rehabilitation
• Body Mechanics • Job Modification • Relaxation Techniques
• Cogn Behavior Therapy • Job Retraining • Splint
• Compensation • Joint Protection • Stretching
• Driving Adaptations • Orthotics • Work Hardening
• Durable Medical • Caregiver/Family Education • Work Reconditioning/
• Physical Agent Modalities
Equipment • Postural Training Conditioning
• Edema Control • Many, many other
• Energy Conservation
activities and occupations

to choose from.

Slide 68

Do you have
any W’s??

Slide 69

Identifying Shoulder Muscles

• A useful teaching aid for placing
these electrodes accurately-
they should fit beneath a
relaxed hand placed over the
shoulder with your middle
finger over supraspinatus, your
thumb over the posterior
deltoid electrode, palm over
middle deltoid and 5th finger
over anterior deltoid.

Slide 70

Recommendations for Use of NMES in Hemiplegic Shoulder Subluxation

Indication Patient Position Electrode Placement Parameter Recommendations

Prevention or treatment Patient sitting with One channel over muscle belly of NMES WAVEFORM: symmetric or asymmetric
of shoulder arm supported supraspinatus and posterior biphasic PC
subluxation resulting deltoid.
from UE flaccidity FREQUENCY: 30–35 Hz
Avoid upper trapezius fibers and
poststroke excessive shoulder shrug. PULSE DURATION: 250–300 msec

Applying a second channel to CURRENT AMPLITUDE: sufficient to produce a smooth,
stimulate the long head of sustained muscle contraction and reduction of shoulder
biceps can be beneficial in subluxation. (tetanic contraction)
correcting humeral head
alignment. ON:OFF CYCLE: 10–15 s ON time with progressively
shorter rest time (30 s ON time, 2 s OFF time).

RAMP-UP TIME (1-4 sec) is set to ensure patient comfort;
a longer ramp-down time may be required to prevent
pain or tissue stretching when the arm sags due to
gravity.

TREATMENT SCHEDULE: progress to 2–4 h/d on the
basis of muscle fatigue

Session Frequency: 7 d/wk for 4–6 wk or until voluntary
control has been restored

Glenohumeral subluxation

Glenohumeral subluxation (GHS) is a frequent complication in patients
with post-stroke hemiplegia,

It is a factor associated with shoulder pain development and with arm
motor recovery and should be treated in the acute stage of hemiplegia.

Slide 71

Now you are • Remember that OT is 25% difficult, hard to
set to practice understand (let alone explain) material and
based on 75% cheerleading!
where you can
demonstrate • Always keep an anatomy/kinesiology text
there is a close by.
need.
• Helpful to refresh memories sometimes
• Useful when explaining your evaluation findings

• Peer collaboration is always present in some
form or another. If you need additional help,
seek out a mentor.

• Remember, though, if you have successfully had
a mentor in the past, you should consider
returning the favor and mentoring someone
with less clinical reasoning experience than you.