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Adam Meakins Shoulder Exam

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Adam Meakins Shoulder Exam

  1. 1. Examining the Shoulder Adam Meakins Clinical Lead Physiotherapist
  2. 2. Shoulder Pain Is common… • 3rd most common MSK complaint • Prevalence rates between 6-30% • ‘Impingement’ most common Luime JJ (2004) Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. ;33(2):73-81
  3. 3. “The shoulder complex often renders the clinician with frustrating uncertainty” Jørgen Jevne http://blogs.bmj.com/bjsm/2015/01/06/the-sexy-scalpel-unnecessary-shoulder-surgery-on-the-rise/
  4. 4. Why…? Shoulders can be complicated • Many pathologies cause shoulder pain • Many clinical tests are not specific or sensitive • Pain is a complex phenomenon Dean BJ (2013). Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain. Br J Sports Med. Nov;47(17):1095-104. Hegedus EJ (2012). Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. Nov;46(14):964-78. Melzack R, and Katz J (2013). Pain. Cognitive Science. Vol 4, Issue 1, 1–15, DOI: 10.1002/wcs.1201
  5. 5. But shoulders don’t have to be complicated
  6. 6. Painful Shoulders Are either… 1. Stiff and painful 2. Weak and painful 3. Unstable and painful
  7. 7. Three criteria… Can help plan best Mx… 1. Hx of trauma 2. Age 3. Shoulder External Rotation Test
  8. 8. But First… Is it even the shoulder…? • RED FLAGS • Pain on neck movement • Pain below the elbow • Neural symptoms • +ve Spurling Test
  9. 9. The Stiff and Painful Shoulder
  10. 10. Stiff and painful…? 1. Trauma = No 2. Age = >50 3. Ext Rot = Reduced both ACTIVE and PASSIVE Dx = OA or Frozen Shoulder Mx = X-ray (not US) / Physio
  11. 11. Stiff and painful…? 1. Trauma = Yes 2. Age = Any 3. Ext Rot = Reduced both ACTIVE and PASSIVE Dx = Missed Frac / Disloc Mx = X-ray (not US) / Ortho
  12. 12. The Weak and Painful Shoulder
  13. 13. Weak and painful…? 1. Trauma = No 2. Age = 30+ 3. Ext Rot = Weak/painful on RESISTED testing Dx = Rotator Cuff Tendinopathy Mx = Refer to Physio
  14. 14. Rotator Cuff Tendinopathy: Other Signs • +ve Painful arc sign • +ve Hawkins Kennedy test • +ve Neers test • Pain/Weak full/empty can • Pain/Weak resisted ER >3 +ve tests = +LR2.93 (95% CI 1.6-5.3) Michener LA (2009) Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Arch Phys Med Rehabil. Nov;90(11):1898-903. Weak and painful…?
  15. 15. Weak and painful…? 1. Trauma = Yes 2. Age = <50 3. Ext Rot = Weak/painful on RESISTED testing Dx = Rotator cuff tear Mx = Refer to Ortho
  16. 16. Weak and painful…? Rotator Cuff Tears: Other Signs SP 77% +ve test can NOT rule in a tear SN 73% -ve test FAIR to rule out a tear SP 94% +ve test CAN rule in a tear SN 46% -ve test can NOT rule out a tear SP 84% +ve test FAIR to rule in a tear SN 100% -ve test CAN rule out a tear • Drop Arm Test • ER Lag Test • IR Lag Test Miller CA (2008) The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation. Arch Phys Med Rehabil. Jun;89(6):1162-8.
  17. 17. The Unstable and Painful Shoulder
  18. 18. Unstable and Painful…? 1. Trauma = No 2. Age = 20+ 3. Ext Rot in Abd = Painful and/or APPREHENSIVE Dx = Congenital Instability Mx = Refer to Physio
  19. 19. Unstable and Painful…? 1. Trauma = Yes (>6/52+) 2. Age = Any 3. Ext Rot in Abd = Painful and/or APPREHENSIVE Dx = Structural defect Mx = Refer to Ortho if had physio
  20. 20. Unstable and Painful…? Posterior Apprehension Test • Rare < 10% • Usually fits/electrocution • Can be traumatic
  21. 21. Unstable and Painful…? Inferior Hyperabduction Test • Even rarer < 5% • Usually hypermobile
  22. 22. Summary Is the painful shoulder… – Stiff think OA / Frozen / missed dislocation – Weak think Rotator Cuff Tendinopathy / Tear – Unstable think congenital / structural defect Use three simple criteria to decide Mx… – Trauma – Age – Shoulder External Rotation
  23. 23. Thank You Questions

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