Objective Assessment of the Shoulder

Introduction

At the end of our questioning from our subjective examination, we ought to be able to have a rough top three sort of injuries or locations that we think the patient's problem is coming from. And then we can narrow that down with our objective examination.

Objective Assessment

Exclude Cx spine

Spurling's test

Arm squeeze test

STAR Assessment

Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder)

For the rehabilitation classification, 3 levels of irritability are proposed and defined, with corresponding strategies guiding intensity of treatment based on the physical stress theory.(McClure PW, Michener LA. Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder). Phys Ther. 2015 May;95(5):791-800. doi: 10.2522/ptj.20140156. Epub 2014 Dec 11. PMID: 25504491.)

SIN

Petersen EJ, Thurmond SM, Jensen GM. Severity, Irritability, Nature, Stage, and Stability (SINSS): A clinical perspective. Journal of Manual & Manipulative Therapy. 2021 May 15:1-3.

Severity, irritability, and the nature of the problem. And the

Severity

• use a VAS scale, a visual analogue score, which is useful to classify that. So the

Irritability

Irritability is assessed by judging

1. The vigor of activity required to provoke a patient's symptoms
2. The severity of those symptoms
3. The time it takes for the symptoms to subside once aggravated (i.e., pain persistence)

"WHAT activity, after HOW LONG, brings on HOW MUCH pain ? And HOW LONG does is take to subside?"

Nature is to whether their condition is sort of

• Inflammatory
• Traumatic
• Degenerative
• Mechanical

And they sort of give us these little classifications to think about there. So high VAS greater than seven, that sort of tends to disturb the sleep, moderate is four to six out of 10 may be intermittent pain at night and then a low, okay, no pain at rest. So again, this slightly gives us a bit of information. As I said previously, that i

It is very important to take these into consideration because if we don't understand what the SIN is, then we may set off into our objective examination and flare them up very early on in our examination, which then means we have to stop our examination and will not have much idea of what's going on.

Special tests

Crank Test

Hawkins-Kennedy Test

Posterior Instability

Anterior Instability

Posterior Impingement

Shoulder Symptom Modification Procedure

Described by Jeremy Lewis in 2009 the Shoulder Symptom Modification Procedure(SSMP) is a reliable approach to the assessment of individuals with rotator cuff and subacromial pathology. SSMP is a set of four mechanical techniques used in a sequence while the patient performs a movement that reproduces their symptoms. The aim is to identify one or more methods that reduce their symptoms and/or increasing movement and function. This tool offers a method to objectively assess the shoulder with the focus being to identify movements and techniques that might be contributing factors to the symptomatic movement and not to label the pathology or exact cause of pain and then utilise these movements and techniques as a means to guide treatment.

The SSMP techniques involve:

1. Alterations to thoracic kyphosis - The first procedures of the SSMP aim to determine the influence of increasing and decreasing the thoracic kyphosis on the presenting symptoms.  If the thoracic manoeuvre reduces the symptoms by 100%, then the assessment is complete and treatment is initiated with a combination of postural awareness, exercise (including motor control during the provocative activity), and manual therapy (to ensure adequate joint and soft tissue compliance). In this scenario, the aim of treatment is to improve thoracic extension, especially during the identified provocative activity or activities
2. Scapular positioning techniques - If the thoracic procedures do not or only partially alleviate symptoms, then symptom changes secondary to scapular procedures are assessed.
3. Humeral head positioning procedures - If the scapular procedures do not fully alleviate symptoms, the clinician progresses to assess the effects of the humeral head procedures. The purpose of the procedures is to positively influence the patient’s symptoms by applying techniques that aim to depress, elevate, or anteriorly or posteriorly glide the humeral head.
4. Pain and symptom neuromodulation procedure - If the first 3 stages of the SSMP do not completely alleviate or reduce symptoms, then the final stage of the SSMP (neuromodulation) involves assessing the influence of manual procedures, such as pressure-based procedures (aimed at the soft tissues and joints), that may modulate shoulder symptoms and are routinely performed throughout the cervical, thoracic, and shoulder regions.

• Rotator Cuff Tendinopathy: Navigating the Diagnosis Management Conundrum
• SSMP Tool
• SSMP summary by Eleanor Richardson & Jeremy Lewis