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Shoulder Pain and the Shoulder Exam. CHA Ambulatory Didactics Kate Lupton, MD. Shoulder Overview. Very complex structure with tremendous ROM 4 joints – sternoclavicular , acromioclavicular , glenohumeral , scapulothoracic

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shoulder pain and the shoulder exam

Shoulder Pain and the Shoulder Exam

CHA Ambulatory Didactics

Kate Lupton, MD

shoulder overview
Shoulder Overview
  • Very complex structure with tremendous ROM
  • 4 joints – sternoclavicular, acromioclavicular, glenohumeral, scapulothoracic
  • Glenohumeral – ball and socket joint (golf ball on a tee), glenoid only covers 25% of humeral head
shoulder activity rom
Shoulder Activity/ROM
  • Static glenohumeral stability – joint surfaces, capsule and labrum
  • Dynamic stability – RC & scapular rotators (trapezius, serratus anterior, rhomboids, levator scapulae)
  • Rotator cuff – depress humeral head against glenoid
  • Internal rotation - Subscapularis
  • External rotation - Infraspinatus, teres minor
  • Abduction - supraspinatous
  • Scapular stability – trapezius, serratus anterior, rhomboids
  • Upward scapular rotation – trapezius & serratus anterior
  • Scapular retraction – trapezius & rhomboids
history
History
  • Background – Handedness, occupation, recreational activities
  • CC: Pain vs instability vs decreased movement
  • Characterize CC: “loose” arm, “dead” arm
  • Injury? -> Mechanism
  • Associated Sx – neurovascular, stiffness, crepitus
  • Function – putting on jacket, overhead activities, sleeping
principles of the msk exam
Principles of the MSK Exam
  • Good exposure (clothing removed, in gown)
  • LOOK
  • FEEL
  • MOVE
  • SPECIAL TESTS
slide8
Look
  • SEADS – swelling, erythema, atrophy, deformity, scars
  • Dominant shoulder usually slightly lower than non-dominant side
  • Head forward posture, shoulders rolled forward, scapula protracted
  • Squaring of shoulder – r/o dislocation
  • SC joints, clavicle deformity - ?fracture
  • AC joints – step deformity - ?separation
  • Atrophy – trapezius, infraspinatus, teres minor
slide9
Feel
  • Palpate joints – SC joint, along clavicle, AC joint, coracoid process, along scapula
  • Palpate muscles and tendons – trapezius, posterior shoulder, biceps tendon, supraspinatus insertion
  • Feel for crepitus while rotating the arm
move active range of motion
Move – Active Range of Motion

Flexion/Extension

  • Trace arc while reaching forward with elbow straight
  • Normal flexion to 160°-180°, extension to -60°

Abduction/Adduction

  • Trace arc reaching to side with straight arm
  • Normal range is 0°-180°
move active range of motion1
Move – Active Range of Motion

Abduction & internal rotation

  • Should be able to reach to ~C-7 level (prominent bump on C-spine)

Adduction & external rotation

  • Should be able to reach lower border of scapula (~T7 level)
move passive rom
Move – Passive ROM
  • If pain or limitation w/ active ROM, assess with passive ROM testing
  • Grasp humerus, move through flexion/extension, abduction, adduction
  • Feel for crepitus with hand on shoulder
  • Note movements that precipitate pain – pain/limitation on active but not passive ROM suggests muscle/tendon problem
  • Note limitations in movement – where in arc does it occur? Due to pain or weakness? Symmetric or asymmetric?
slide13
Move
  • Painful arc on abduction? Glenohumeral joint from 60-120°, AC joint 170-180°
  • Watch scapular motion – look for asymmetry, jerky motion
  • Wall push-up for scapular winging
rotator cuff anatomy and function
Rotator Cuff Anatomy and Function
  • 4 Major Muscles
  • Depress humeral head, keep it in contact with glenoid throughout wide ROM
  • Supraspinatus – abducts shoulder (to ~80°)
  • Infraspinatus – external rotation
  • Teres minor – external rotation
  • Subscapularis – internal rotation
special tests supraspinatus
Special Tests - Supraspinatus

Empty/Full Can Test

  • Hold arms at 1:00 and 11:00, abducted 30 °
  • Internally rotate so thumbs point down (“empty can”), pt lifts up against resistance. Repeat with thumbs pointed up
  • Note pain (tendinopathy, partial tear), weakness (tear)
  • Deltoid is responsible for abduction beyond 70-80 °
special tests infraspinatus
Special Tests – Infraspinatus

External Rotation

  • Fully adduct arm, flex elbow to 90 °, medially rotate humerus 45 ° (hand at 12:00)
  • Have pt try to externally rotate while you resist against their forearms
special tests subscapularis
Special Tests - Subscapularis

Posterior (Gerber’s)Lift Off

  • Pt places hand behind back, palm facing out
  • Pt lifts hand away from the back
  • Note pain, weakness

Belly Press

  • Place hands on abdomen, elbows out
  • Press in on abdomen or keep elbows out while posteriorly directed force is applied to elbows
  • Positive test if unable to keep elbows out
shoulder impingement bursitis
Shoulder Impingement/Bursitis
  • 4 tendons of the RC pass under the acromion and coracoacromial ligament and insert in the humeral head
  • Space between arcromion, coracoacromial ligament and tendons can narrow, causing impingement of tendons (espsupraspinatus)
  • Resulting friction inflames tendons and subacromial bursa
  • Causes shoulder pain, esp with reaching overhead
special tests impingement
Special Tests - Impingement

Neer’s Test

  • Place hand on pt’s scapula, other on forearm
  • Pt fully internally rotates (thumb pointed down)
  • Passively forward flex arm through full range of motion
  • Pain = impingement
special tests impingement1
Special Tests - Impingement

Hawkins-Kennedy Test

  • Flex arm to 90°
  • Stabilize shoulder with one hand
  • Forcibly internally rotate shoulder, thumb pointed down
  • Pain = impingement
special tests bursitis
Special Tests - Bursitis

Subacromial Palpation

  • Identify acromion by following scapular spine to distal end
  • Palpate in subacromial space
  • Pain = inflamed bursa and/or tendons
biceps tendon
Biceps Tendon
  • Long head of biceps tendon runs in the bicipital groove of humerus, inserts at superior glenoid
  • Biceps flexes and supinates forearm
  • Subject to similar stresses as RC tendons
  • Inflammation causes pain in top and anterior shoulder, especially with flexion/supination
special tests biceps tendon
Special Tests – Biceps Tendon

Palpation

  • Palpate along biceps tendon/bicipital groove
  • Confirm location by having pt supinate while palpating

Yergason’s Test

  • Flex elbow to 90°with arm adducted (elbow against side)
  • Grasp pt’s hand, resist while they supinate
  • Pain = tendinopathy
special tests ac joint
Special Tests – AC Joint

Palpation

  • Palpate point at which distal clavicle articulates with acromion

O’Brien

  • Flex shoulder to 90° while internally rotated (thumb down)
  • Adduct arm 10-15° from 12:00
  • Apply downward force to arm while pt resists
  • Repeat with thumb pointed up
  • If there is pain with first maneuver and not second, indicates labral or AC joint pathology

Cross Arm /Forced Flexion

  • Flex shoulder to 90°, flex elbow, then actively adduct
special tests shoulder instability
Special Tests – Shoulder Instability

Apprehension/Relocation

  • With patient supine, abduct shoulder 90°, flex elbow 90°
  • Externally rotate shoulder by moving forearm from perpendicular to parallel with body
  • Pain or sense of instability with further external rotation is a positive test, indicating anterior shoulder instability
  • If sx are relieved with posterior force applied to proximal humerus, that is a positive relocation test and further supports dx

Sulcus Sign

  • Arm hangs relaxed at the side
  • Pull arm straight down, look for step-off under lateral acromion
  • Indicates inferior instability
many thanks
Many Thanks
  • Anthony Luke, MD – UCSF
  • Charlie Goldberg, MD - UCSD