Shoulder examionation


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examination,impingement syndrome,rotator cuff injury,shoulder,shoulder instability
All about orthopaedic shoulder examination. comprehensive ppt with all tests arranged symptom wise

Shoulder examionation

  1. 1. DR. PRUTHVIRAJ NISTANEDeptt. Of Orthopaedics,Unit -2 Govt. Medical College and Rajindra Hospital, Patiala
  2. 2.  Pertinent anatomy Differential diagnosis Clinical history Physical examination Common shoulder injuries
  3. 3.  Shoulder pain: a common complaint o More common causes in adults o Peak ages 40-60 o Impingement syndrome o Rotator cuff problems o Frozen shoulder o 8-13% of all athletic injuries
  4. 4.  3 Bones  Humerus  Scapula  Clavicle 3 Joints  Glenohumeral  Acromioclavicular  Sternoclavicular 1 “Articulation”  Scapulothoracic
  5. 5.  Humerus  Head  Greater tubercle  Lesser tubercle  Intertubercular(bicipital) groove  Deltoid tuberosity
  6. 6.  Scapula  Angles  Superior  Inferior  Lateral  Glenoid  Acromion  Coracoid  Scapular spine  Subscapular fossa  Supraspinatus fossa  Infraspinatus fossa
  7. 7.  Glenohumeral joint  “Balland socket” vs “Golf ball and tee”  Verymobile at cost of stability  45% of all dislocations  Joint stability depends on multiple factors
  8. 8.  Glenohumeral joint  Passive stability  Joint conformity  Glenoid labrum (50%)  Joint capsule  Ligaments  Bony restraints
  9. 9.  Muscles Deltoid Trapezius * Rhomboids * Levator scapulae * Rotator cuff Teres major Biceps Pectoralis muscles * Serratus anterior *  * Scapular stabilizers
  10. 10.  Rotator Cuff Muscles S – Supraspinatus I – Infraspinatus t - Teres minor  S- Supscapularis
  11. 11.  Bursae  Subacromial (Subdeltoid)  Subscapular  Subcoracoid  Coracobrachial  Axillary recess
  12. 12.  Neurologic  Nerve roots  Brachial plexus  Peripheral nerves
  13. 13.  Coordinated shoulder motion  Glenohumeral motion  Acromioclavicular motion  Sternoclavicular motion  Scapulothoracic motion Scapular-humeral rhythm
  14. 14.  Impingement syndromes Other arthritic disease  Subacromial bursitis – Septic  Rotator cuff tendinopathy – Tubercular  Rotator cuff tear  Biceps tendinopathy – Rheumatoid, Gout, SLE Adhesive capsulitis – Septic, Lyme, etc. SC joint arthritis, sprain Avascular necrosis AC joint arthritis, sprain Neoplastic disease Glenohumeral joint OA Thoracic outlet syndrome Instablity  GH dislocation CRPS  GH subluxation Myofascial pain  Labral tear (e.g. Bankart, SLAP, Referred pain etc.) Clavicle fracture – Cervical radiculopathy Proximal humerus fracture – Cardiac Scapular fracture – Aortic aneurysm – Abdominal / Diaphragm
  15. 15. Diagnosis Primary Care Age %Subacromial Impingement 48-72 23-62SyndromeAdhesive Capsulitis 16-22 53Acute Bursitis 17 -Calcific Tendonitis 6 -Myofascial Pain Syndrome 5 -Glenohumeral Joint Arthrosis 2.5 64Thoracic Outlet Syndrome 2 -Biceps Tendonitis 0.8 -
  16. 16. History
  17. 17. oAge - 2nd & 3rd decades instability 4th & 5th decades impingement, frozen shoulder, inflammatory joint disease 6th decade onwards rotator cuff tears , degenerative joint diseaseoPainoWeaknessoDeformityoInstabilityoLocking / Clicking / ClunkingoSport / OccupationoPrevious treatmentsoAlleviating / ExacerbatingoAcute vs. ChronicoTraumatic vs. OveruseoHistory of prior injuryoMechanism of injury
  18. 18. • ACJ pain - well localised• Cervical pain - Neck pain, pain over trapezius or medial border of scapula• Neurogenic Pain - Assoc pain in wrist or hand +/- parasthesiae• Subacromial and rotator cuff pathology - Poorly localised pain from deltoid region usually• Night pain - often rotator cuff disease, glenohumeral arthritis and frozen shoulder• Acute calcific tendonitis - Sudden onset excruciating pain is typical of reorptive phase of• Painful arc - Pain occurring in part of the range of shoulder abduction is termed
  19. 19.  Any history of trauma? Was shoulder dislocated? How many dislocations since then? Was dislocation spontaneous? If atraumatic dislocation is there history of joint laxity? Painless clicks in the shoulder are common and usually have no significance
  20. 20.  Following traumatic event - important to exclude brachial plexus injury May be due to pain (would examine with local anaesthetic joint examination in shoulder clinic)
  21. 21.  Restriction of both passive and active movements Usually associated with frozen shoulder, osteoarthritis, rheumatoid arthritis, chronic dislocation and cuff tear
  22. 22.  Undressupto waist  Compare both sides Inspection Palpation Measurements Active & passive ROM Strength testing Special tests Distal neuro-vascular status, Lymph nodes
  23. 23.  Front & Back Above Axilla Laterally Asymmetry Attitude Obvious deformity Swelling Skin condition Ecchymosis
  24. 24.  Height of shoulder & scapulae Muscle atrophy / contractures  Supraspinatus  Infraspinatus  Deltoid Contour of shoulder Neck Epicondyles
  25. 25.  At rest & with movement Bony structures Joints Axilla Soft tissues Codman’s methodo Swelling ,crepituso Irregularitiso Local temperatureo Local tendernesso Lymph nodes
  26. 26.  Surface Anatomy (Anterior)AC joint  Manubrium  Clavicle biceps  SC Joint  Acromion processSC joint  AC Joint  Deltoid  Coracoid process  Pectoralis major  Trapezius  Humeral head  Greater tubercle  Lesser tubercle  Biceps (long head)
  27. 27.  Surface Anatomy (Posterior)Supraspinatus  Scapular spine  Acromion process  Supraspinatus Infraspinatus  Infraspinatus Inferior angle of scapula  Deltoid  Trapezius  Latissumus dorsi  Scapula  Inferior angle  Medial border
  28. 28. 30° to coronal plane Forward flexion: (160 - 180°) Anterior deltoid, Pectoralis major, coracobrachialis Extension: (40 - 60°) Latissimus dorsi,teres major, posterior deltoid Adduction: (45 °) Pectoralis major, latissimus dorsi, teres major
  29. 29.  Abduction:(180°) glenohumeral rhythm (2: 1)  By fixing the scapula with thumb and finger try to quantify glenohumeral movement only middle deltoid, supraspinatus Internal rotation: (60 - 90 °) subscapularis, pectoralis major, latissimus dorsi, teres major; anterior deltoid External rotation: Apley Scratch Test (40-60 °) infraspinatus, teres minor; posterior deltoid Circumduction
  30. 30. Abduction•60°-120° painful – impingementsyndrome•Whole range painful – arthritis ofGH joint,acute tendinitis•>90° painful – AC joint arthritis•Upto 30° difficult – rotator cufftear•Restricted movements – Frozenshoulder, ankylosis
  31. 31. Abduction with Adduction withexternal rotation internal rotation Quick screening test
  32. 32.  scapular motion• Scapular dyskinesis (Scapulothoracic dysfuntion)  Compare scapular motion through ROM on both sides  Wall push-ups  Symmetrical  Smooth Winging Medial winging results from injury to long thoracic nerve, Lateral winging results from trapezius weakness( accessory spinal nerve ).
  33. 33.  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
  34. 34.  Apparent lengths – from seventh cervical spine to tip of radial styloid True length – angle of acromion – tip of lateral epicondyle - tip of radial styloid Wasting Anterior and posterior axillary folds – Bryants sigh Girth of axilla - Callaways test
  35. 35.  Hamilton ruler test Duga’s test
  36. 36. Intrinsic– Subacromial bursa– Rotator cuff muscles and tendons tears– Biceps tendon– Rotator cuff tendonosis– Cuff thickening/bursitis– Calcific tendinitis– fracturesExtrinsic– Instability / # – young– Subacromial spurs – old
  37. 37. Between – Acromion – AC joint – Coracoacromial ligament – Coracoid process – Humeral head Pain with activity above shoulder height At night Painful arc of abduction – 60-120 degrees Positive impingement signs
  38. 38. Neer’s Impingement Sign– Arm fully pronated and placed in forced flexion– Trying to impinge subacromial structures with humeral head– Pain is positive test Neer’s Impingement test
  39. 39. Hawkin’s Sign– Arm is forward flexed to 90 degrees, then forcibly internally rotated– Trying to impinge subacromial structures with humeral head– Pain is positive test
  40. 40.  Jobes Empty can / full can test test:• arm abducted to 90, in the plane of the scapula, 30° flexion and full internal rotation (empty can) or 45°external rotation (full can), elbow extended• Patient resists downward pressure exerted by examiner at patients elbow or wrist.• Muscle testing against resistance• Weakness or insufficiency of supraspinatus• Tear / impingement
  41. 41.  Internal Rotation Resistance Stress Test  to differentiate between internal and classic impingement  Shoulder in 90 degrees of abduction and 80 degrees of external rotation.  A manual isometric muscle test is performed for external rotation and compared with one for internal rotation in the same position.More weakness in internal rotation - internal impingementmore weakness in external rotation - classic outlet impingemen
  42. 42.  Gerber Subcoracoid Impingement Test impingement between the rotator cuff and the coracoid process Shoulder flexed 90 degrees and adducted 10 to 20 degrees across the body to bring the lesser tuberosity into contact with the coracoid. Pain indicates coracoid impingement
  43. 43.  Partial thickness tear Full (Complete) thickness tear Supraspinatus > Infraspinatus > subscapularis Reduced function and night pain Painful arc, gap may be felt May be due to:  Impingement  Degeneration  Overuse  Trauma Partial tears  Conservative Complete tears  Surgery
  44. 44. Rent Sign/Test Tests for a torn rotator cuff or rotator cuff impingement Patient seated,palpate anterior to the anterior edge of the acromion with one hand while holding the patient’s flexed elbow with the other The examiner passively extends the shoulder while slowly rotating the shoulder into external and internal rotation. The greater tuberosity will be prominent and a depression of about 1 finger width will be felt if a rotator cuff tear is present.
  45. 45. Rent Sign/Test
  46. 46.  Resisted abduction with arms by side Jobes Empty can / full can test test: arm abducted to 90°, 30° flexion, in the plane of the scapula and full internal rotation (empty can) or 45°external rotation (full can), elbow extended Patient resists downward pressure exerted by examiner at patients elbow or wrist.
  47. 47. Drop-Arm TestAbducted arm slowlylowered – May be able to lower arm slowly to 90° (deltoid function) – Arm will then drop to side if rotator cuff tearPositive test – patient unable to lower arm further with control
  48. 48.  Strength Testing  Tests Supraspinatus  Attempt to isolate from deltoid  Sitting  Arms straight out  Elbows locked straight  Thumbs down  Arm at 30 degrees (in scapular plane)  Attempts to elevate arms against resistance
  49. 49.  Resisted ER with the arms by side Drop test: Shoulder in 90 degrees of abduction and at almost full external rotation with the elbow flexed at 90 degrees. The patient is asked to maintain this position The sign is positive if a lag or “drop” occurs
  50. 50.  External Rotation Stress Test / swing door test patients arms by his or her side in neutral flexion and abduction, the shoulders are externally rotated 45 to 60 degrees. The examiner applies force against the dorsum of the hands, attempting to rotate the shoulders internally back to neutral while the patient is asked to resist. Pain and weakness
  51. 51.  External Rotation Lag Sign The patient is asked to maintain the position of maximal external rotation actively as the examiner maintaining support of the arm at the elbow. The sign is positive when a lag or angular drop
  52. 52. Hornblower’s Sign (Patte Test) strength of the teres minor Abduct the patient’s arm to 90 degrees in the scapular plane. Flexe the elbow to 90 degrees, and the patient is asked to laterally rotate the shoulder. A positive test occurs with weakness and/or pain
  53. 53. Hornblower’s Sign (Patte Test)
  54. 54.  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
  55. 55.  Gerbers lift off test: dorsum of the hand is placed against the lower back. If the patient is unable to lift the dorsum of the hand off the back and push examiners hand away from hand behind back position the test is positive
  56. 56.  Internal rotation lag sign: inability to hold hand away from the lumbar region in maximal internal rotation
  57. 57.  Belly Press Test (Napolean sigh)• patient presses the abdomen with the flat of the hand and attempts to keep the arm in maximal internal rotation• If the strength of the subscapularis is impaired, maximal internal rotation cannot be maintained, the patient feels weakness, and the elbow drops back or can only exercise abdominal pressure by a retropulsion of the arm and by bending the wrist
  58. 58.  Modified Belly Press Test (Quantitative)
  59. 59.  Internal rotation  TestsRTC muscle that IR the shoulder  Subscapularis  Arms at the sides  Elbows flexed to 90 degrees  Internally rotates arms against resistance
  60. 60.  Injury to long head of biceps tendon Typically an overuse injury  Repetitive (overhead) lifting  Impingement
  61. 61.  AERS test: (Abduction External Rotation Supination test). Pt feels pain on resisted supination in this position. Tenderness over antero-superior deltoid bulge on shoulder rotations
  62. 62.  Forward flex shoulder to about 90° Abduct shoulder to about 10° Elbow - extended Arm in full supination Apply downward force to distal arm Pain is positive test Bicepital tendinitis, SLAP Weakness without pain: muscle weakness or rupture
  63. 63.  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
  64. 64.  Deltoid: resisted abduction over 30º Serratus anterior: "Winging" test
  65. 65. Failure to keep humeralhead centered in glenoidDislocation – Complete disruption of joint congruity or alignmentSubluxation – Partial or incomplete dislocationLaxity – Slackness or looseness in joint – May be normal or abnormal
  66. 66.  Sulcus Sign Arm relaxed in neutral position Arm pulled downward at wrist Positive test is a visible sulcus at infra- acromial area  Compare to contralateral side
  67. 67.  Feagin maneuver -
  68. 68.  Apprehension Test 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  Augmentation test – apply anteriorly directed force by extending shoulder
  69. 69.  Relocation Test After a positive apprehension Apply posteriorly directed force over externally rotated humeral head Positive test is relief of apprehension Anterior release test
  70. 70. subluxation tests: (Load and Shift Test) Anterior subluxation test: abduction and external rotation "apprehension test" with thumb posteriorly and fingers anteriorly over humeral head Shoulder Latchman Posterior subluxation test: internal rotation, adduction, flexion and push posteriorly
  71. 71.  Apprehension TestFlex and internally rotate the shoulder Circumduction TestCircumduction in abduction
  72. 72. Tear in glenoid labrumUsually due to instabilitySLAP Tear (Superior LabrumAnterior to Posterior)– Superior labral tear– Fall on outstretched hand or shoulder– Rotator cuff tendonosis or tearsBankart Lesion– Anterior-inferior labral tear– Anterior shoulder dislocation / subluxation
  73. 73.  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
  74. 74.  For labral pathology  Repeat testing with  Max supination  Should be pain free
  75. 75.  Labral Tear: Crank Test  Abduct arm to 90-120°  Stabilize shoulder  Elbow secured with one hand  Axially load with ER / IR at Shoulder shoulder .Apley’s  Positive test: audible or painful click / catch / grind
  76. 76.  Jobe Apprehension-Relocation Test to distinguish between primary impingement and secondary impingement due to anterior instability patient supine, the arm is abducted 90 degrees and externally rotated, which produces pain Posteriorly directed force to the humeral head, relocating it in the glenoid, does not change the pain in patients with primary impingement, but relieves the pain in patients with instability (subluxation) and secondary impingement
  77. 77. Jerk Test Tests for posterior instability/ torn posterior or posteroinferior labrum.(reverse Bankarts)  The examiner grasps the elbow with one hand and the scapular with the other and elevates the patient’s arm to 90° of abduction and internal rotation An axial compression load to the humerus through the elbow maintaining the horizontal position. The compression force is maintained as the examiner moves the arm into horizontal adduction.  A positive test is indicated by sharp pain in the shoulder with or without a clicking sound
  78. 78. Jerk Test
  79. 79. Biceps Load Test Integrity of the superior labrum. supine with shoulder abducted to 90 degrees and externally rotated, and forearm is supinated. externally rotates the shoulder until the patient becomes apprehensive. Rotation is stopped and resisted elbow flexion while in this position. Pt worsens and apprehension remains, the test is considered positive. If apprehension decreases or the patient feels more comfortable, the test is negative for a SLAP lesion.  Biceps Load Test 2: shoulder abducted to 120 *
  80. 80. Biceps Load Test
  81. 81.  Capsule sticks to humeral head IR  Flexion  ER GLOBAL RESTRICTION ROM NIGHT PAIN Cause often unknown – but beware diabetes Self limiting condition (6mth-2yrs). Painful Restrictive Resolution
  82. 82. – Typically due to fall onto tip of shoulder (acromion) – Arm tucked into side• Pain with activity (esp overhead, or weight training)• AC Jt tender• Crepitus/clicking• Deformity – Treatment depends on type
  83. 83.  Arm flexed to 90° Arm adducted to > 45° Hyperadduct shoulder (down on elbow) Positive test is pain in AC joint Watch out for false- positives  Where is the pain?
  84. 84. AC Shear Test To test for acromioclavicular pathology The patient is in sitting position while the examiner cups his or her hands over the deltoid muscle with one hand on the clavicle and the other on the spine of the scapula. The examiner then squeezes the heels of the hand together. Abnormal movement is a positive test.
  85. 85. AC Shear Test
  86. 86.  Where is the pain?  Neurology  over deltoid – think  C5 deltoid (S, M), shoulder biceps (R)  over traps – think  C6 thumb (S), biceps neck (M), BrRad (R)  Radicular pain –  C7 digit 3(S), triceps think neck (M, R)  C8 digit 5(S), FDP/S (M) Examine  T1 medial elbow (S),  Cervical spine ROM finger abduction (M)  Radial nerve  Ulnar nerve  Median nerve
  87. 87.  Assess cervical spine to see if neck movements recreate shoulder symptoms In full extension of C spine nose parallels the floor and in full flexion chin should rest on chest Lateral rotation approx 80o Lateral flexion 40o
  88. 88.  Sensation dermatomes C4 toT2 Power around elbow, wrist and hand Shoulder power tested separately Test peripheral nerves, esp. Axillary nerve Biceps and triceps reflexes Tests for thoracix inlet syndrome Radial / Ulnar pulses
  89. 89.  AC joint Subacromial space Glenohumeral joint Biceps tendon (long head)
  90. 90.  Plain XR  AP (IR and ER)  Axillary lateral view  Supraspinatus outlet view  AC joint
  91. 91.  U/S scan  Cuff tears, tendinopathy, bursitis  Undercalls cuff pathology  Can inject at the same time
  92. 92.  Bone scan  MRI  Esp if referring for  Cuff tears ACJ surgery  MRA CT arthrogram  Labral pathology and  Particularly useful instability for recurrent instability  Arthrogram  Arthroscopy  Joint aspiration
  93. 93.  THANK YOU !!!!