Shoulder joint difference clinical assessment view in critical condition
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Excellent — I now have comprehensive information from both textbooks and authoritative physiotherapy sources. Here is the full physiotherapy clinical assessment of the shoulder joint:
Shoulder Joint — Physiotherapy Clinical Assessment
A physiotherapy assessment follows a structured framework, especially critical in acute/compromised patients who cannot fully cooperate with active testing.
1. SUBJECTIVE ASSESSMENT (History)
| Component | Key Questions |
|---|---|
| Chief complaint | Pain, weakness, instability, stiffness, clicking |
| Onset & mechanism | Traumatic (fall on outstretched hand, direct blow) vs. insidious |
| Location & radiation | Anterior (biceps, AC joint), lateral (subacromial), posterior (RC, labrum) |
| Aggravating/easing factors | Overhead activity, lying on shoulder, rest pain (night pain = RC tear) |
| Functional limitation | Ability to dress, lift, reach behind back |
| Red flags | Neurovascular compromise, bilateral symptoms, constitutional symptoms |
In a critical condition (ICU/post-surgical/stroke), history is obtained from notes/carers; primary concern is positioning, subluxation prevention, and passive ROM maintenance.
2. OBSERVATION & POSTURE
- Static posture: Forward head, protracted scapula, rounded shoulders → subacromial impingement risk
- Muscle wasting: Supraspinatus/infraspinatus fossa atrophy → rotator cuff pathology; deltoid wasting → axillary nerve injury
- Asymmetry: Deformity (step deformity = AC joint dislocation; squared-off = anterior dislocation)
- Scapular dyskinesia: Winging (serratus anterior weakness) or altered scapulohumeral rhythm during elevation
- Swelling/bruising: Effusion, ecchymosis
3. PALPATION
| Structure | Clinical Significance |
|---|---|
| Supraspinatus tendon (anterior to acromion, arm in extension/IR — Codman's position) | Tenderness = rotator cuff pathology |
| Bicipital groove / biceps tendon | Tenderness = biceps tendinopathy |
| AC joint | Step deformity, tenderness = AC joint injury |
| SC joint | Displacement, crepitus |
| Coracoid process | Tenderness = subcoracoid impingement |
| Greater tuberosity | Fracture tenderness |
| Sulcus sign (palpation below acromion with inferior traction) | Depression/gap ≥1 cm = inferior GH instability / subluxation |
Critical care note: In hemiplegic/stroke patients, palpate for the sulcus gap (finger-breadth method) to detect GH subluxation — the most common shoulder complication in this population.
4. RANGE OF MOTION (ROM) ASSESSMENT
Normal Values:
| Movement | Normal ROM |
|---|---|
| Flexion | 0–180° |
| Extension | 0–60° |
| Abduction | 0–180° |
| Adduction | 0–50° |
| Internal Rotation | 0–70° (hand behind back to T10 level) |
| External Rotation | 0–90° |
| Horizontal Adduction (cross-body) | 0–130° |
Active ROM (AROM):
Tests muscle strength + joint mobility combined. Note painful arc (60–120° abduction = subacromial impingement).
Passive ROM (PROM):
Clinician moves the limb. If PROM > AROM → muscular weakness or neuromuscular inhibition. If PROM is globally limited in a capsular pattern (ER > ABD > IR) → frozen shoulder / adhesive capsulitis.
Critical care: In unconscious or hemiplegic patients, only PROM is assessed. Avoid forced ROM — risk of subluxation, heterotopic ossification.
5. MUSCLE STRENGTH TESTING (MMT / Oxford Scale)
| Muscle / Test | Technique | Significance |
|---|---|---|
| Supraspinatus — Jobe/Empty Can Test | Arm at 90° abduction, 30° forward in scapular plane, thumb down; resist downward force | Pain/weakness = supraspinatus tear or impingement |
| Infraspinatus / Teres Minor — ER Lag Sign | Elbow at 90°, resist external rotation | Weakness/lag = infraspinatus tear |
| Subscapularis — Lift-Off Test (Gerber) | Hand behind back; patient lifts hand off back | Inability = subscapularis lesion |
| Subscapularis — Belly-Press Test | Patient presses hand into abdomen | Elbow drops back = subscapularis tear |
| Subscapularis — Bear-Hug Test | Hand on opposite shoulder; resist lift-off | Weakness = subscapularis lesion |
| Deltoid | Resist abduction at 90° | Weakness = axillary nerve injury |
| Serratus Anterior | Wall push-up; observe scapular winging | Winging = long thoracic nerve palsy |
| Drop-Arm Test | Examiner places arm at 90° abduction, releases | Cannot sustain = massive supraspinatus tear |
6. SPECIAL TESTS — BY PATHOLOGY CATEGORY
(From Miller's Review of Orthopaedics & Rockwood and Green's, 10th ed.)
A. Impingement / Rotator Cuff
| Test | Technique | Positive Finding |
|---|---|---|
| Neer's Impingement Sign | Passive forward flexion >90° (scapula stabilised) | Pain = subacromial impingement |
| Neer's Impingement Test | Pain relief after subacromial lidocaine injection | Confirms impingement syndrome |
| Hawkins-Kennedy Test | Arm at 90° forward flexion, passively internally rotated | Pain = subacromial impingement |
| Painful Arc | Active abduction 60°–120° | Pain in arc = subacromial impingement |
B. Instability / Capsular
| Test | Technique | Positive Finding |
|---|---|---|
| Apprehension Test | Supine; shoulder at 90° abduction + ER | Apprehension (not just pain) = anterior GH instability |
| Jobe's Relocation Test | Posterior force on humeral head during apprehension test | Relief of apprehension = confirms anterior instability (PPV 96%) |
| Sulcus Sign | Inferior traction with arm at side | ≥1–2 cm depression below acromion = inferior laxity/instability |
| Load & Shift Test | Anterior/posterior force on humeral head | Degree of translation grades laxity |
| Gagey Test | Hyperabduction >105° with scapula stabilised | >15° asymmetry = IGHLC incompetency |
| Jerk Test | Posterior force + adduction in 90° FF | Clunk = posterior subluxation |
C. Labrum / Biceps / SLAP
| Test | Technique | Positive Finding |
|---|---|---|
| O'Brien's (Active Compression) Test | 90° FF, 10° adduction, full pronation → resist; repeat in supination | Pain in pronation relieved in supination = SLAP lesion / AC joint pathology |
| Speed's Test | Elbow extended, forearm supinated; resist active shoulder flexion | Pain at bicipital groove = biceps tendinopathy / SLAP |
| Crank Test | Full abduction + axial load + rotation | Pain/click = SLAP lesion |
| Yergason Test | Resisted supination + ER with elbow at 90° | Pain at bicipital groove = biceps tendinopathy |
D. AC Joint
| Test | Technique | Positive Finding |
|---|---|---|
| Cross-body Adduction Test | Passive horizontal adduction across chest | Pain at AC joint |
| Paxino's Test | Posterior-superior pressure on AC joint with inferior pressure on distal clavicle | Pain = AC joint pathology |
7. NEUROLOGICAL ASSESSMENT
- Dermatomes: C4 (shoulder cap), C5 (lateral arm), C6 (lateral forearm/thumb)
- Myotomes: C5 = shoulder abduction/ER; C6 = elbow flexion/wrist extension
- Reflexes: Biceps (C5/C6), brachioradialis (C6)
- Axillary nerve: Test deltoid sensation (regimental badge area); loss = anterior dislocation complication
- Brachial plexus tension test: Upper limb neurodynamic test (ULNT) for cervical/neural involvement
8. FUNCTIONAL & OUTCOME MEASURES
| Tool | Use |
|---|---|
| DASH (Disabilities of Arm, Shoulder, Hand) | Upper limb functional disability |
| ASES (American Shoulder & Elbow Surgeons Score) | Shoulder-specific outcome |
| Constant-Murley Score | Pain, ADLs, ROM, strength |
| WOSI (Western Ontario Shoulder Instability Index) | Instability-specific outcomes |
| VAS / NPRS | Pain severity |
9. ASSESSMENT IN CRITICAL CONDITION — Special Physiotherapy Considerations
| Concern | Assessment/Management |
|---|---|
| Hemiplegic shoulder subluxation (stroke) | Palpate sulcus gap (finger-breadth method); radiographic confirmation if needed; check positioning in bed/chair |
| ICU / unconscious patient | Passive ROM only; check for contracture, dependent oedema, pressure injury over acromion |
| Post-surgical / immobilised | Assess swelling, neurovascular status (radial pulse, capillary refill, grip), wound integrity |
| Pain-limited assessment | Prioritise PROM, palpation, neurological screen; defer provocative instability tests |
| Positioning | Arm supported in slight abduction with pillow/sling to prevent inferior subluxation from gravity |
Risk factors for shoulder subluxation in critical patients: severe motor loss, improper positioning, pulling on the hemiplegic arm during transfers, prolonged gravitational load without muscle counterforce. — Physiopedia: Hemiplegic Shoulder Subluxation
Summary: Clinical Assessment Framework
Subjective History
↓
Observation & Posture
↓
Palpation (bony/soft tissue + sulcus sign)
↓
ROM (AROM → PROM → accessory motion)
↓
Muscle Strength Testing (MMT + specific lag signs)
↓
Special Tests (cluster by suspected pathology)
↓
Neurological Screen
↓
Functional Outcome Measures
Sources: Miller's Review of Orthopaedics 9th Ed. (Table 4.7); Rockwood and Green's Fractures in Adults 10th Ed.; Physiopedia — Shoulder Special Tests & Hemiplegic Shoulder Subluxation; Alberta Health Services MSK Shoulder Assessment Clinical Pathway.
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