Shoulder exam studentsandresidents

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  • Gustavo.....great job on this lecture. I found your slides as I was putting together my own lecture on the same subject. I am borrowing several slides from your talk and will be sure to give you full credit!! Jenny Reed, MD
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  • <number>
    Evaluation of shoulder pain - Applied EvidenceJournal of Family Practice,  July, 2002  by J. Herbert Stevenson,  Thomas Trojian
  • <number>
    Evaluation of shoulder pain - Applied EvidenceJournal of Family Practice,  July, 2002  by J. Herbert Stevenson,  Thomas Trojian
  • <number>
    Evaluation of shoulder pain - Applied EvidenceJournal of Family Practice,  July, 2002  by J. Herbert Stevenson,  Thomas Trojian
  • <number>
    Evaluation of shoulder pain - Applied EvidenceJournal of Family Practice,  July, 2002  by J. Herbert Stevenson,  Thomas Trojian
  • Shoulder exam studentsandresidents

    1. 1. History & Physical Examination of the Shoulder Garry W. K. Ho, M.D. VCU / Fairfax Family Practice Sports Medicine Fellow January 2007
    2. 2. Objectives Review pertinent anatomy of the shoulder Review differential diagnosis of shoulder complaints Review clinical history and physical examination of the shoulder Review common shoulder injuries & characteristic physical exam findings
    3. 3. Brief Epidemiology Shoulder pain: a common complaint in primary care – 2nd only to knee pain for specialist referrals – Most common causes in adults (peak ages 40-60) Subacromial impingement syndrome Rotator cuff problems Athletic injuries – Shoulder: 8-13% of all athletic injuries
    4. 4. Anatomy 3 Bones – – – Humerus Scapula Clavicle 3 Joints – – – Glenohumeral Acromioclavicular Sternoclavicular 1 “Articulation” – Scapulothoracic
    5. 5. Anatomy Humerus – – – – Head * Greater tubercle* Lesser tubercle* Intertubercular (bicipital) groove – Deltoid tuberosity Scapula – Angles Superior Inferior Lateral (Head)
    6. 6. Anatomy Scapula – – – – – – Glenoid Acromion Coracoid Subscapular fossa Scapular spine Supraspinatus fossa – Infraspinatus fossa
    7. 7. Anatomy Glenohumeral joint – “Ball and socket” vs “Golf ball and tee” – Very mobile – Price: instability – 45% of all dislocations – Joint stability depends on multiple factors
    8. 8. Anatomy Glenohumeral joint – Passive stability Joint conformity Glenoid labrum (50%) Joint capsule Ligaments Bony restraints
    9. 9. Anatomy Muscles – – – – – – – – – Deltoid Trapezius * Rhomboids * Levator scapulae * Rotator cuff Teres major Biceps Pectoralis muscles * Serratus anterior * * Scapular stabilizers
    10. 10. Anatomy Rotator Cuff Muscles – S – Supraspinatus – I – Infraspinatus – t - Teres minor – S- Supscapularis
    11. 11. Anatomy Bursae – Subacromial (Subdeltoid) – Subscapular
    12. 12. Anatomy Neurologic – Nerve roots – Brachial plexus – Peripheral nerves
    13. 13. Anatomy Coordinated shoulder motion – Glenohumeral motion – Acromioclavicular motion – Sternoclavicular motion – Scapulothoracic motion Scapular-humeral rhythm
    14. 14. Differential Diagnosis Impingement syndrome – – – – Subacromial bursitis Rotator cuff tendinopathy Rotator cuff tear Biceps tendinopathy Adhesive capsulitis SC joint arthritis, sprain AC joint arthritis, sprain Glenohumeral joint OA Instablity – GH dislocation – GH subluxation – Labral tear (e.g. Bankart, SLAP, etc.) Clavicle fracture Proximal humerus fracture Scapular fracture Other arthritic disease – Rheumatoid, Gout, SLE – Septic, Lyme, etc. Avascular necrosis Neoplastic disease Thoracic outlet syndrome CRPS Myofascial pain Referred pain – – – – – Cervical radiculopathy Cardiac Aortic aneurysm Abdominal / Diaphragm Other GI
    15. 15. Clinical History Characterize pain Location of pain Night pain Weakness Deformity Instability Locking / Clicking / Clunking Sport / Occupation Previous treatments Alleviating / Exacerbating Acute vs. Chronic Traumatic vs. Overuse History of prior injury
    16. 16. Clinical History Mechanism of Injury
    17. 17. Physical Exam Observation – Undress waist → up Palpation Active & passive ROM Strength testing Special tests
    18. 18. Physical Exam – Observation / Inspection Front & Back Height of shoulder & scapulae Asymmetry Obvious deformity Ecchymosis Muscle atrophy – – – Supraspinatus Infraspinatus Deltoid
    19. 19. Palpation At rest & with movement Bony structures Joints Soft tissues
    20. 20. Palpation Surface Anatomy (Anterior) AC joint biceps SC joint – – – – – – – – – Clavicle SC Joint Acromion process AC Joint Deltoid Coracoid process Pectoralis major Trapezius Biceps (long head)
    21. 21. Palpation Surface Anatomy (Posterior) Supraspinatus Infraspinatus Inferior angle of scapula – – – – – – – – Scapular spine Acromion process Supraspinatus Infraspinatus Deltoid Trapezius Latissumus dorsi Scapula Inferior angle Medial border
    22. 22. Range of Motion Forward flexion: 160 - 180° Extension: 40 - 60° Abduction: 180◦ Adduction: 45 ° Internal rotation: 60 - 90 ° External rotation: 80 - 90 ° Apley Scratch Test
    23. 23. Range of Motion Scapular dyskinesis (Scapulothoracic dysfuntion) – Compare scapular motion through ROM on both sides – Wall push-ups – – – Symmetrical Smooth No or minimal winging
    24. 24. Strength Testing Test & compare both sides Be specific to muscle or muscle group Grade strength on 0 → 5 scale – 0: no contraction – 1: muscle flicker; no movement – 2: motion, but not against gravity – 3: motion against gravity, but not resistance – 4: motion against resistance – 5: normal strength
    25. 25. Strength Testing External rotation – Tests RTC muscles that ER the shoulder Infraspinatus Teres minor – Arms at the sides – Elbows flexed to 90 degrees – Externally rotates arms against resistance
    26. 26. Strength Testing Internal rotation – Tests RTC muscle that IR the shoulder Subscapularis – Arms at the sides – Elbows flexed to 90 degrees – Internally rotates arms against resistance – Subscapularis Lift-Off Test – Other techniques
    27. 27. Strength Testing Supraspinatus – “Empty can" test – Jobe’s Test – Tests Supraspinatus – Attempt to isolate from deltoid – – – – – Positioned sitting Arms straight out Elbows locked straight Thumbs down Arm at 30 degrees (in scapular plane) – Attempts to elevate arms against resistance
    28. 28. Special Provocative Tests Impingement Signs Drop-Arm Test Speed’s Test Yergason Test Cross-Arm Adduction Sulcus Sign Apprehension test Relocation test O’Brien’s Test Crank test
    29. 29. Subacromial Impingement Syndrome Impingement of: – Subacromial bursa – Rotator cuff muscles and tendons – Biceps tendon Between – – – – – Acromion Coracoacromial ligament AC joint Coracoid process Humeral head Rotator cuff tendonosis
    30. 30. Impingement Signs Neer’s Sign – Arm fully pronated and placed in forced flexion – Trying to impinge subacromial structures with humeral head – Pain is positive test
    31. 31. Impingement Signs Hawkin’s Sign – Arm is forward elevated to 90 degrees, then forcibly internally rotated – Trying to impinge subacromial structures with humeral head – Pain is positive test
    32. 32. Rotator Cuff Tear Partial thickness tear Full (Complete) thickness tear May be due to: – – – – Impingement Degeneration Overuse Trauma Partial tears – Conservative Complete tears – Surgery
    33. 33. Rotator Cuff Tear: Drop-Arm Test Abducted arm slowly lowered – May be able to lower arm slowly to 90° (deltoid function) – Arm will then drop to side if rotator cuff tear Positive test – patient unable to lower arm further with control – If able to hold at 90º, pressure on wrist will cause arm to fall
    34. 34. Biceps Tendonosis Injury to long head of biceps tendon Typically an overuse injury – Repetitive (overhead) lifting – Impingement
    35. 35. Biceps Tendonosis: Speed’s Test Forward flex shoulder to about 90° Abduct shoulder to about 10° Arm in full supination Apply downward force to distal arm Pain is positive test Weakness without pain: muscle weakness or rupture
    36. 36. Biceps Tendonosis: Yergason’s Test Elbow flexed to 90° Start in pronated position Active supination & flexion against resistance Palpate biceps tendon Pain or painful pop is positive test – Tendonosis – Subluxation
    37. 37. AC Separation AC Sprain / Separation – Typically due to fall onto tip of shoulder (acromion) – Arm tucked into side – Treatment depends on type
    38. 38. AC Arthritis / DJD
    39. 39. AC Joint: Cross-Arm Adduction Test Arm flexed to 90° Arm adducted to > 45° Hyperadduct shoulder (down on elbow) Positive test is pain in AC joint Watch out for falsepositives – Where is the pain?
    40. 40. Shoulder Instability Failure to keep humeral head centered in glenoid Dislocation – Complete disruption of joint congruity or alignment Subluxation – Partial or incomplete dislocation Laxity – Slackness or looseness in joint – May be normal or abnormal
    41. 41. Instability: Sulcus Sign Inferior instability Arm relaxed in neutral position Arm pulled downward at wrist Positive test is a visible sulcus at infra-acromial area – Compare to contralateral side
    42. 42. Instability: Apprehension Test Anterior instability Shoulder abducted to 90° Slight stress to humeral head directed in anterior direction While externally rotating shoulder Positive test is apprehension due to feeling of instability or impending dislocation – Beware if false positives
    43. 43. Instability: Relocation Test Anterior instability After a positive apprehension Apply posteriorly directed force over externally rotated humeral head Positive test is relief of apprehension Anterior release test
    44. 44. Glenoid Labral Tear Tear in glenoid labrum Usually due to instability SLAP Tear (Superior Labrum Anterior to Posterior) – Superior labral tear – Fall on outstretched hand or shoulder – Rotator cuff tendonosis or tears Bankart Lesion – Anterior-inferior labral tear – Anterior shoulder dislocation / subluxation
    45. 45. O’Brien’s Active Compression Test Labral, AC, or biceps pathology Arm flexed to 90° Arm cross-arm adducted 10-15° Elbow extended Max pronation Resist downward force Positive test if painful Beware location of pain – AC – Biceps – Internal +/- click
    46. 46. O’Brien’s Active Compression Test For labral pathology – Repeat testing with – Max supination – Should be pain free
    47. 47. Labral Tear: Crank Test Abduct arm to 90120° Stabilize shoulder Elbow secured with one hand Axially load with ER / IR at shoulder Positive test: audible or painful click / catch / grind
    48. 48. Diagnostic Injection AC joint Subacromial space Glenohumeral joint Biceps tendon (long head)
    49. 49. Thanks! Questions?
    50. 50. Rotator Cuff Tear History / Maneuver Study Qual Sens (%) Spec (%) LR+ LR- PV+ (%) PV(%) History of trauma 2b 36 73 1.3 0.88 72 37 Night pain 2b 88 20 1.1 0.6 70 43 Painful arc 2b 33 81 1.7 0.83 81 33 Empty can test 1b 84 89 50 58 1.7 2 0.22 0.28 36 98 22 93 Drop arm 1b 21 100 >25 0.79 100 32
    51. 51. Impingement / Instability Test Study Qual Sens (%) Spec (%) LR+ LR- PV+ (%) PV(%) 1b 87 89 60 2.2 0.18 71 83 Relocation 2b 57 100 >25 0.43 100 73 Apprehension 2b 68 100 >25 0.32 100 78 Impingement Hawkin’s Instability
    52. 52. AC Joint / SLAP Tear History / Maneuver Study Qual Sens (%) Spec (%) LR+ LR- PV+ (%) PV(%) 1b 100 97 >25 0.01 89 100 Crank 2b 91 93 13 0.10 94 90 Active compression 1b 100 99 >25 0.01 95 100 AC Joint Active compression SLAP Tear
    53. 53. Differential Diagnosis Diagnosis Subacromial Impingement Syndrome Adhesive Capsulitis Acute Bursitis Calcific Tendonitis Myofascial Pain Syndrome Glenohumeral Joint Arthrosis Thoracic Outlet Syndrome Biceps Tendonitis Primary Care Age % 48-72 23-62 16-22 17 53 - 6 5 - 2.5 2 64 - 0.8 -

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