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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

Shoulder Problem Evaluation

MS3 Family Medicine


Shoulder problem evaluation


Objectives
Objectives

  • Review pertinent anatomy

  • Discuss common pathology

  • Discuss historical clues to diagnosis

  • Select cases

  • Physical exam in small group discussions


Bony anatomy anterior
Bony AnatomyAnterior


Bony anatomy anterior and posterior
Bony AnatomyAnterior and Posterior




Where do things go wrong dislocations and separations
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 separations1
Where do things go wrong??Dislocations and Separations

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


Glenohumeral joint
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
Bony Anatomy“Static Stabilizers”


What goes wrong besides separations and dislocations
What goes wrong…Besides separations and dislocations??

Instability!!!



What goes wrong tears and tendonopathies
What goes wrong?Tears and tendonopathies


The rotator cuff muscles dynamic stabilizers
The Rotator Cuff Muscles“dynamic stabilizers”


The rotator cuff muscles sits

SupraspinatusABD

InfraspinatusER

Teres minor ER

Supscapularis IR

The Rotator Cuff Muscles: SITS

Depress humeral head against glenoid to allow full abduction



What can go wrong
What can go wrong???

Impingement!!!!!!!



Other anatomy

Deltoid

Rotator cuff

Teres major

Latissimus dorsi

Biceps

Pectoralis muscles

Other Anatomy



Shoulder problem evaluation

Don’t forget the

scapular stabilizer muscles


So what causes shoulder pain
So…what causes shoulder pain?

  • Impingement

  • Labrum and biceps pathology

  • A-C joint pathology

  • Rotator Cuff Injury

  • Instability

    Among other things…


Clinical exam history
Clinical ExamHistory

  • Pain

  • Acute

  • Chronic

  • Weakness

  • Deformity


Clinical exam history1
Clinical ExamHistory

  • Single event

  • Repetitive overload

  • Instability

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

  • Catching/Locking


Clinical exam history2
Clinical ExamHistory

  • Sport / Occupation

  • Previous injury

  • Previous treatment

  • Other joints involved

  • Disability


Physical exam big 6
Physical Exam: Big 6

  • Inspection

  • Palpation

  • Range of Motion

  • Strength

  • Neurovascular

  • Special Tests


Special tests
Special Tests

Impingement

Rotator Cuff Integrity

Labrum and Biceps

AC (SC) Joints

Instability


Physical exam
Physical Exam

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


Which rotator cuff muscle s are responsible for external rotation

0

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

  • Supraspinatus

  • Infraspinatus

  • Subscapularis

  • Teres Minor

  • Both 2 and 4


The apex bottom of the scapula is at what level of the spine

:00

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

  • C7

  • T3

  • T7

  • T12

  • L4


Case 1
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 11
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
Acromioclavicular (A-C) Sprain

  • Special Tests

    • Shear Test

    • Cross Arm Test

    • A-C Palpation

    • Resisted Extension

    • Active compression test


Acromioclavicular a c sprain1
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
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
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
X RAYS

DIAGNOSIS???


Shoulder dislocation anterior instability
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 instability1
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 tests glenoid labrum and instability
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


Which of the following structures can be impinged

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
Case #3

  • 35-year-old male tennis player

  • Shoulder pain exacerbated by practicing serves

  • Develops dull, aching pain in right shoulder


Shoulder pain physical exam
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 pain physical exam1
Shoulder PainPhysical Exam

Hawkin’s positive

Neer’s positive

IMPINGEMENT???


Impingement as a clinical sign
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
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
Case #4 Impingement:

  • 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 41
Case #4 Impingement:

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
Rotator Cuff Tear Impingement:

  • 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
Case #5 Impingement:

  • 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 exam1
Physical Exam Impingement:

  • 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
Shoulder pain isn’t always the shoulder!! Impingement: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
In the human body, which is the most incredible joint? Impingement:

  • PIP

  • Knee

  • Ankle

  • Shoulder

  • None of the above


Case 6
Case #6 Impingement:

  • 40-year-old male

  • Recently shoveled 16” of snow

  • Can hardly lift left arm due to pain

  • Special Tests? Diagnosis?


Biceps tendonopathy
Biceps Tendonopathy Impingement:

  • Speed Test

  • Yergason Test

  • Direct palpation


Biceps tendonopathies
Biceps Tendonopathies Impingement:

  • Repetitive overhead activity

  • Repetitive forearm flexion/supination

  • Difficult to discern from rotator cuff tendinopathy or impingement


Conclusion
Conclusion Impingement:

  • 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
QUESTIONS? Impingement:


Physical exam inspection
Physical Exam Impingement:Inspection

Front & back

Height of shoulder and scapulae

Muscle atrophy, asymmetry


Physical exam range of motion
Physical Exam Impingement:Range of Motion

Abduction 0-180o


Physical exam range of motion1
Physical Exam Impingement:Range of Motion

Forward flexion:

0o – 180o


Physical exam range of motion2
Physical Exam Impingement:Range of Motion

  • Extension

    • 0o – 40 to 60o


Physical exam range of motion3
Physical Exam Impingement:Range of Motion

  • Internal rotation

    • T5 segment

  • External rotation

    • 80-90o


Physical exam strength
Physical Exam Impingement:Strength

Empty can test

30o angle

Steady downward pressure

Tests supraspinatus strength and pain


Physical exam strength1
Physical Exam Impingement:Strength

Resisted external rotation

Tests infraspinatus, teres minor strength


Physical exam strength of subscapularis
Physical Exam Impingement:Strength of Subscapularis

Liftoff test Belly press test


Cross arm adduction test
Cross-Arm Adduction Test Impingement:

AC joint pathology

Arm flexed to 90°

Hyperadduct arm across body as far as possible

Pain in AC = (+) test


A c shear test
A-C Shear Test Impingement:

Interlock fingers with hand on distal clavicle and spine of scapula

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


Sulcus sign
Sulcus Sign Impingement:

Inferior instability

Arm relaxed in neutral position, pull downward at elbow

(+) test = sulcus at infra-acromial area

compare to unaffected side


Apprehension test
Apprehension Test Impingement:

Anterior instability

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

(+) test = dislocation apprehension

some false (+)


Relocation test
Relocation Test Impingement:

Perform after positive apprehension test

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

(+) test = increased ER tolerance


Load shift test
Load & Shift Test Impingement:

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
Impingement Signs Impingement:

Hawkins

Neer


Drop arm test suggestive of rotator cuff tear
Drop Arm Test Impingement:Suggestive 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 test biceps tendinopathy
Speed’s Test Impingement:Biceps 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 compression slap lesion superior labrum antero posterior
O’Brien’s Active Compression Impingement:SLAP 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 compression slap lesion
O’Brien’s Active Compression Impingement:SLAP lesion

Supination should be pain free (decreased pain)


Crank test labral injury
Crank Test Impingement:Labral 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