Shoulder problem evaluation
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Shoulder Problem Evaluation. MS3 Family Medicine. Second most common musculoskeletal complaint Difficult joint to examine Multidirectional range of motion- UNIQUE! Shoulder injury can affect nearly every sport and many daily activities. Objectives. Review pertinent anatomy

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Shoulder Problem Evaluation

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Shoulder Problem Evaluation

MS3 Family Medicine


  • Second most common musculoskeletal complaint

  • Difficult joint to examine

  • Multidirectional range of motion- UNIQUE!

  • Shoulder injury can affect nearly every sport and many daily activities


Objectives

  • Review pertinent anatomy

  • Discuss common pathology

  • Discuss historical clues to diagnosis

  • Select cases

  • Physical exam in small group discussions


Bony AnatomyAnterior


Bony AnatomyAnterior and Posterior


Radiographic Anatomy


Where do things go wrong??Fractures


Where do things go wrong??Dislocations and Separations

Dislocations and separations are protected by both “static” and “dynamic” stabilizers…


Where do things go wrong??Dislocations and Separations

Oh, yeah…Arthritis can happen at these joints, too…


Glenohumeral Joint

  • Shallow (“golf ball sitting on a tee”)

    • Inherently unstable (maximizes ROM)

  • Static stabilizers

    • glenohumeral ligaments, glenoid labrum and capsule

  • Dynamic stabilizers

    • Predominantly rotator cuff muscles

    • Also scapular stabilizers

      • Trapezius, leavator scapulae, serratus anterior, rhomboids


Bony Anatomy“Static Stabilizers”


What goes wrong…Besides separations and dislocations??

Instability!!!


LABRUM


What goes wrong?Tears and tendonopathies


The Rotator Cuff Muscles“dynamic stabilizers”


SupraspinatusABD

InfraspinatusER

Teres minor ER

Supscapularis IR

The Rotator Cuff Muscles: SITS

Depress humeral head against glenoid to allow full abduction


Finally…the subacromial space


What can go wrong???

Impingement!!!!!!!


Impingement


Deltoid

Rotator cuff

Teres major

Latissimus dorsi

Biceps

Pectoralis muscles

Other Anatomy


Shoulder Anatomy


Don’t forget the

scapular stabilizer muscles


So…what causes shoulder pain?

  • Impingement

  • Labrum and biceps pathology

  • A-C joint pathology

  • Rotator Cuff Injury

  • Instability

    Among other things…


Clinical ExamHistory

  • Pain

  • Acute

  • Chronic

  • Weakness

  • Deformity


Clinical ExamHistory

  • Single event

  • Repetitive overload

  • Instability

    • Does it feel like it’s going to come out?

  • Catching/Locking


Clinical ExamHistory

  • Sport / Occupation

  • Previous injury

  • Previous treatment

  • Other joints involved

  • Disability


Physical Exam: Big 6

  • Inspection

  • Palpation

  • Range of Motion

  • Strength

  • Neurovascular

  • Special Tests


Special Tests

Impingement

Rotator Cuff Integrity

Labrum and Biceps

AC (SC) Joints

Instability


Physical Exam

  • The physical exam will be demonstrated during small group discussions…


0

Which rotator cuff muscle(s) are responsible for external rotation

  • Supraspinatus

  • Infraspinatus

  • Subscapularis

  • Teres Minor

  • Both 2 and 4


:00

The apex (bottom) of the scapula is at what level of the spine?

  • C7

  • T3

  • T7

  • T12

  • L4


Case #1

  • 22-year-old male rugby player falls onto his right shoulder while being tackled

  • Severe pain on top of his right shoulder


Case #1

  • Notable deformity over superior shoulder

  • Painful range of motion

    • Unable to lift right arm above waist

  • Special Tests??

  • Diagnosis???


Acromioclavicular (A-C) Sprain

  • Special Tests

    • Shear Test

    • Cross Arm Test

    • A-C Palpation

    • Resisted Extension

    • Active compression test


Acromioclavicular (A-C) Sprain

  • Damage to A-C joint ligaments

  • Pain and/or deformity over A-C joint

  • Graded I-VI

    • I-III usually treated non-operatively

    • IV-VI referred to orthopedic surgery


AC Joint Sprain Treatment

  • Analgesics, ice prn

  • Sling for as long as needed

  • Physical Therapy

    • ROM restoration

    • Gradual strength exercise

    • Return to sport activity as tolerated


Case #2

  • 24-year-old male handball player

  • Fell onto his shoulder after being pushed

  • Intense pain

  • Hand is tingling and arm feels like it’s hanging

  • X-rays


X RAYS

DIAGNOSIS???


Shoulder Dislocation/Anterior Instability

  • Humeral head dislocates from glenoid fossa

  • Almost always anterior (95%)

  • Usually traumatic with injury to capsule-labrum complex


Shoulder Dislocation/Anterior Instability

  • Treatment

    • Reduction of dislocation

    • Protection & rehab, rehab, rehab

    • Most will have future dislocations and/or instability

      • At least 70%!!! (young)

    • May require surgical tightening/repair of the capsule/labrum complex


Special TestsGlenoid Labrum and Instability

  • Biceps Load I and II

  • Kim Test

  • Jerk Test

  • Active-Compression Test (O’Brien)

  • Crank Test

  • Apprehension Test

  • Relocation Test

  • Load and Shift

  • Sulcas Sign


30

10

0

0

Which of the following structures can be “impinged”?

  • Biceps tendon

  • Subacromial Bursa

  • Rotator Cuff Tendons

  • All of the above


Case #3

  • 35-year-old male tennis player

  • Shoulder pain exacerbated by practicing serves

  • Develops dull, aching pain in right shoulder


SHOULDER PAINPhysical Exam

  • Tenderness to palpation anterior shoulder

  • Pain with abduction starting around 90 degrees

  • Unable to lift arm past 120 degrees

  • Pain with forward flexion at 90-120 degrees

  • Special Tests??? Diagnosis???


Shoulder PainPhysical Exam

Hawkin’s positive

Neer’s positive

IMPINGEMENT???


Impingement as a Clinical Sign

  • Repetitive overhead activities

  • Subacromial bursa and/or rotator cuff impinged between acromion & humerus

  • Physical therapy, activity modification +/- medications


Diagnoses associated with clinical sign of Rotator Cuff Impingement:

  • Subacromial bone spurs and / or bursal hypertrophy

  • AC joint arthrosis and /or bone spurs

  • Rotator cuff disease

  • Superior labral injury

  • Glenohumeral instability

  • Scapular dyskinesis

  • Biceps tendinopathy

    A diagnostic injection sometimes helps to clarify the diagnosis


Case #4

  • 45-year-old weight lifter

  • Caught bar as it was falling off his shoulder

  • Sudden pain

  • Severe weakness left shoulder

  • Worse with overhead activities; while sleeping at night

  • Pain in anterior lateral shoulder

  • Special tests?


Case #4

Drop Arm Test Positive

External Rotation Lag Sign positive

Weakness with Empty Can Sign

Normal bear hug and belly press tests…

Diagnosis?????


Rotator Cuff Tear

  • Supraspinatus tendon most common

  • Acute trauma or chronic tendinopathy

  • Treatment dependent upon age/activity

    • Young, active usually require operative treatment

    • Older, low-activity usually respond to non-operative treatment


Case #5

  • 42-year-old female with dull pain right shoulder

  • Pain is diffuse in nature

  • Sometimes spreads to between shoulder blades

  • Seems worse at night


Physical Exam

  • Obese, pleasant female

  • Diffuse pain

  • Normal shoulder exam

  • Not able to reproduce pain during exam

  • What else do you want to do???


Shoulder pain isn’t always the shoulder!!Get more history…

  • Gall bladder disease

  • Peptic Ulcer Disease

  • Cervical radiculopathy

  • Cardiac ischemia

  • Pulmonary conditions

    • ie Pancoast’s tumor, Pneumonia


In the human body, which is the most incredible joint?

  • PIP

  • Knee

  • Ankle

  • Shoulder

  • None of the above


Case #6

  • 40-year-old male

  • Recently shoveled 16” of snow

  • Can hardly lift left arm due to pain

  • Special Tests? Diagnosis?


Biceps Tendonopathy

  • Speed Test

  • Yergason Test

  • Direct palpation


Biceps Tendonopathies

  • Repetitive overhead activity

  • Repetitive forearm flexion/supination

  • Difficult to discern from rotator cuff tendinopathy or impingement


Conclusion

  • Shoulder injuries are common.

  • Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis.

  • Impingement is a clinical sign, not a diagnosis.

  • Don’t forget about medical causes.


QUESTIONS?


Physical ExamInspection

Front & back

Height of shoulder and scapulae

Muscle atrophy, asymmetry


Physical ExamRange of Motion

Abduction 0-180o


Physical ExamRange of Motion

Forward flexion:

0o – 180o


Physical ExamRange of Motion

  • Extension

    • 0o – 40 to 60o


Physical ExamRange of Motion

  • Internal rotation

    • T5 segment

  • External rotation

    • 80-90o


Physical ExamStrength

Empty can test

30o angle

Steady downward pressure

Tests supraspinatus strength and pain


Physical ExamStrength

Resisted external rotation

Tests infraspinatus, teres minor strength


Physical ExamStrength of Subscapularis

Liftoff testBelly press test


Cross-Arm Adduction Test

AC joint pathology

Arm flexed to 90°

Hyperadduct arm across body as far as possible

Pain in AC = (+) test


A-C Shear Test

Interlock fingers with hand on distal clavicle and spine of scapula

Pain in A-C joint when hands squeezed together = (+) test


Sulcus Sign

Inferior instability

Arm relaxed in neutral position, pull downward at elbow

(+) test = sulcus at infra-acromial area

compare to unaffected side


Apprehension Test

Anterior instability

Shoulder at 90° abducted, slight anterior pressure & External rotation

(+) test = dislocation apprehension

some false (+)


Relocation Test

Perform after positive apprehension test

Apply post force over humeral head during external rotation (ER)

(+) test = increased ER tolerance


Load & Shift Test

Test for multidirectional instability

Grasp humeral head, slide anteriorly and posteriorly while securing rest of shoulder

(+) if greater than 50% displacement (graded 1-3)


Impingement Signs

Hawkins

Neer


Drop Arm TestSuggestive of Rotator Cuff Tear

Passive abduction to 90°

Instruct patient to slowly lower arm

At 90° abducted arm will suddenly drop, may need to add slight pressure

(+) drop = (+) test


Speed’s TestBiceps Tendinopathy

Long head of biceps tendonitis

Fwd flex to 90°, abd 10°, full supination

Apply downward force to distal arm

Pain = (+) test

weakness w/o pain = muscle weakness or rupture


O’Brien’s Active CompressionSLAP lesion (Superior Labrum Antero-Posterior)

Labral/AC pathology

Arm flexed to 90°, elbow extended, adduct 10-15°, resist downward force

+ if AC pain or internal pain/click


O’Brien’s Active CompressionSLAP lesion

Supination should be pain free (decreased pain)


Crank TestLabral injury

Glenoid labrum tear

Abduct arm to 160°, pt is supine or upright, elbow secured with one hand axial load at shoulder with other

(+) if audible/painful catch/grind is noted


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