Download Shoulder Problem Evaluation MS3 Family Medicine

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 Anatomy
Anterior
Bony Anatomy
Anterior 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”
The Rotator Cuff Muscles: SITS

Supraspinatus ABD


Infraspinatus ER

Teres minor ER
Supscapularis IR
Depress humeral head against glenoid to allow full abduction
Finally…the subacromial space
What can go wrong???
Impingement!!!!!!!
Impingement
Other Anatomy



Deltoid
Rotator cuff
Teres major



Latissimus dorsi
Biceps
Pectoralis muscles
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 Exam
History
Pain
Acute
Chronic
Weakness
Deformity
Clinical Exam
History
Single event
Repetitive overload
Instability

Does it feel like it’s
going to come out?
Catching/Locking
Clinical Exam
History
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…
Which rotator cuff muscle(s) are
responsible for external rotation
1. Supraspinatus
2. Infraspinatus
3. Subscapularis
4. Teres Minor
5. Both 2 and 4
The apex (bottom) of the scapula is
at what level of the spine?
1.
2.
3.
4.
5.
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 nonoperatively
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 capsulelabrum 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 Tests
Glenoid 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”?
1. Biceps tendon
2. Subacromial
Bursa
3. Rotator Cuff
Tendons
4. All of the above
25%
25%
25%
25%
30
10
0
0
1
2
3
4
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
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 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 nonoperative 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?
1.
2.
3.
4.
5.
PIP
Knee
Ankle
Shoulder
None of the above
20%
1
20%
2
20%
20%
3
4
20%
5
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 Exam
Inspection
Front & back
Height of shoulder
and scapulae
Muscle atrophy,
asymmetry
Physical Exam
Range of Motion
Abduction 0-180o
Physical Exam
Range of Motion
Forward flexion:

0o – 180o
Physical Exam
Range of Motion
Extension

0o – 40 to 60o
Physical Exam
Range of Motion
Internal rotation

T5 segment
External rotation

80-90o
Physical Exam
Strength
Empty can test



30o angle
Steady downward pressure
Tests supraspinatus strength and pain
Physical Exam
Strength
Resisted external
rotation

Tests infraspinatus,
teres minor strength
Physical Exam
Strength of Subscapularis
Liftoff test
Belly 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 Test
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
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)
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
Supination should be
pain free (decreased
pain)
Crank Test
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