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PS SESSION : EXAMINATION OF SHOULDER
This document provides an overview of performing an exam of the shoulder. It reviews relevant anatomy including bones, joints, ligaments, muscles of the rotator cuff. It describes taking a history including questions about chief complaints, pain characteristics, instability, neurological symptoms, loss of function. The physical exam section reviews inspecting for deformities, palpating various structures, evaluating range of motion including forward flexion, abduction, and rotational movements. Special tests like the painful arc maneuver are also outlined. Differential diagnoses for common shoulder conditions are listed.
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PS SESSION : EXAMINATION OF SHOULDER
- 1. History & Physical Examof the Shoulder DR UTKARSH SHAHI ASSISTANT PROFESSOR DEPARTMENT OF ORTHOPEDICS
- 2. REVIEW OF SHOULDERANATOMY
- 3. REVIEW OF SHOULDERANATOMY Bones Scapula Clavicle Humeral head Posterior rib cage Joints Sternoclavicular Acromioclavicular Glenohumeral Scapulothoracic
- 4. GLENOHUMERAL JOINT 25%humeral head surface in contact with glenoid Joint space thinning seen with OA
- 5. GLENOHUMERAL JOINT Humeralhead coverage increased to 75% with glenoid labrum
- 6. MORE SHOULDER ANATOMY Ligaments Coracoclavicular Acromioclavicular Glenohumeral Superior GH Middle GH Inferior GH Coracohumeral Subacromial bursa Subdeltoid bursa
- 7. ROTATOR CUFF Supraspinatus,infraspinatus, teres minor, subscapularis Form cuff around humeral head Keep humeral head within joint (counter act deltoid) Abduction, external rotation, internal rotation
- 8. MUSCLES OF THEROTATOR CUFF The four major muscles of the rotator cuff rotate the humerus and properly orient the humoral head in the glenoid fossa (socket). The tendons of these four muscles merge, forming a cuff around the glenohumeral joint. Supraspinatus: abducts the humeral head and acts as a humeral head depressor Infraspinatus: externally rotates and horizontally extends the humerus Teres minor: externally rotates and extends the humerus Subscapularis: internally rotates the humerus
- 9. SHOULDER CONDITIONS Injury andmechanical derangement. Congenital and developmental abnormalities. Infection and inflammation. Arthritis and rheumatic disorders. Metabolic and endocrine disorders. Tumours and lesions that mimic them. Neurological disorders and muscle weakness.
- 10. HISTORY TAKING PATIENT DETAILSCHIEF COMPLAINTS HISTORY OF PRESENT ILLNESS PAST HISTORY FAMILY HISTORY PERSONAL HISTORY TREATMENT HISTORY NEGATIVE HISTORY
- 11. COMPLAINTS PAIN STIFFNESS SWELLING DEFORMITY WEAKNESSINSTABILITY PARASTHESIA LOSS OF FUNCTION
- 12. PAIN Site Time andmode of onset Severity or Intensity Character or Nature Progression Referred pain Aggravating factors Relieving factors Any diurnal variation Any seasonal variation
- 13. SHOULDER PAIN KEYPOINTS Shoulder pain is a common complaint in primary care 2nd only to knee pain for referral to Ortho or primary care sports medicine Most common causes in adults (peak ages 40-60) Subacromial impingement syndrome Rotator cuff problems Athletic injuries Shoulder accounts for 8-13% of athletic injuries History and examination are keys to diagnosis
- 14. PAIN The extentof reference is governed by a number of factors. The depth of the structure beneath the skin. The position of the structure within the dermatome. The severity of the lesion
- 15. PAINFUL ARC Thisis not a diagnosis but a localising sign. There are 4 common causes of a painful arc at the shoulder joint. All involve soft tissues being pinched between the humerus and the underside of the acromion. These are: Supraspinatus (pain on resisted abduction) Infraspinatus (pain on resisted lateral rotation). Subscapularis (pain on resisted medial rotation). Subacromial bursa (pain at extremes of all passive ranges
- 16. PAINFUL ARC Thepatient’s arm is passively and actively abducted from the rest position alongside the trunk. Pain in the acromioclavicular joint occurs between 140°and 180° of abduction. Increasing abduction leads to increasing compression and contortion in the joint. (In an impingement syndrome or a rotator cuff tear, by comparison, pain symptoms will occur between 70° and 120°.
- 17. PAINFUL ARC Inthe evaluation of the active and passive ranges of motion, the patient can often avoid the painful arc by externally rotating the arm while abducting it. This increases the clearance between the acromion and the diseased tendinous portion of the rotator cuff, avoiding impingement in the range between 70° and 120°.
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- 20. FOCUSED HISTORY QUESTIONS Mechanism of Injury Helps predict injured structure Example: Fall directly onto anterior/superior shoulder AC joint injury (shoulder separation) Example: Arm forcefully abducted and externally rotated subluxation or anterior dislocation Example: If chronic pain, note activity that triggers pain, such as the cocking phase of throwing or the pull-through phase of swimming
- 21. Characteristics of pain FOCUSEDHISTORY QUESTIONS Night pain when lying on affected side, muscle atrophy Rotator cuff tear < 30 yo Biomechanical, inflammatory > 45 yo, Hx of trauma Rotator cuff tear - 35% of pts Painful arc (60-120°abduction) Subacromial impingement Pain > 120° abduction Acromioclavicular joint Catching, popping, clicking GH or AC joint arthritis, labral tear
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- 23. REFERRED PAIN Theshoulder is derived from the fifth cervical segment and therefore refers pain into the C5 dermatome. The acromioclavicular joint is a C4 structure and refers pain into the C4 dermatome. The shoulder is deep and proximal in the C5 dermatome, hence it can potentially refer pain a great distance. Conversely the acromio-clavicular joint is a superficial structure at the distal end of the dermatome causing it to give rise to accurate, local pain
- 24. REFERRED PAIN Typicallypain of glenohumeral origin is felt in the upper arm, often at the insertion of the deltoid. Severe shoulder problems can cause pain to radiate as far as the radial side of the wrist. Rotator cuff problems often include pain radiating to upper arm If pain starts in neck and radiates to shoulder, consider cervical spine disease
- 25. 25 Consider OTHERsources of referred pain Cervical spine – spondylolysis, arthritis, disc disease Cardiac - myocardial ischemia Diaphragmatic irritation Thoracic outlet syndrome Gallbladder disease Complex regional pain syndrome (a.k.a, reflex sympathetic dystrophy) REFERRED PAIN
- 26. INSTABILITY Time of Onset •Congenital •Developmental •Acquired Frequency •Singleepisode •Recurrent Aggravating factors Associated symptoms •Pain •Disability •Neurovascular Reducibility •Reducible •Irreducible Associated Illness
- 27. INSTABILITY History ofinstability Glenohumeral subluxation or dislocation Aggravating factors Overhead work, repetitive movements, sports Relieving factors/treatments tried Rest, immobility, medications, other treatments History of Prior Shoulder Problems or Surgeries
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- 29. LOSS OF FUNCTION Modeof onset • Sudden • Gradual Duration • Congenital • Chronic • Acute Involved region and function(s) Progression Associated features
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- 31. SWELLING Site Shape Size Firstnotice Associated Symptoms •Pain •Pressure •Neurological •Vascular •Articular Progression Any other swelling Reducibility Any discharge •If present •Duration •Regular or intermittent •Character of discharge
- 32. DEFORMITY Site Associated Symptoms • Neurological •Vascular • Articular Amount of disability Time of Onset • Congenital • Developmental • Acquired Correctability • Completely correctable • Partially correctable • Incorrectable
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- 34. DIFFERENTIAL DIAGNOSIS 1. __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
- 35. DIFFERENTIALS IN SHOULDER Trauma Impingement & Rotator Cuff Subcoracoid Impingement Outlet (subacromial) Impingement Calcific Tendonitis Rotator Cuff Tears Rotator Cuff Arthropathy Proximal Biceps Tendonitis Biceps Subluxation AC Pathology Acromio-Clavicular Injuries (AC Separation) Distal Clavicle Osteolysis AC Arthritis Instability Traumatic Anterior Shoulder Instability (TUBS) Posterior Instability & Posterior Dislocation Multidirectional Shoulder Instability (MDI) Luxatio Erecta
- 36. DIFFERENTIALS IN SHOULDER Injuries in throwing athlete SLAP lesion Internal Impingement Glenohumeral Internal Rotation Deficit (GIRD) Little Leaguer's Shoulder Posterior Labral Tear Degenerative Conditions Glenohumeral Arthritis Adhesive Capsulitis (Frozen Shoulder) Avascular Necrosis of the Shoulder Scapulothoracic Crepitus Neurovascular Disorders Scapular Winging Suprascapular Neuropathy Thoracic Outlet Syndrome Brachial Neuritis (Parsonage-Turner Syndrome) Quadrilateral Space Syndrome Scapulothoracic Dyskinesis Muscle Ruptures Pectoralis Major Rupture Deltoid Rupture Triceps Rupture Latissimus Dorsi Rupture
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- 38. GENERAL EXAMINATION Vitals •Pulse •Blood Pressure •RespiratoryRate •Temperature Consciousness Orientation Comfort level Position of Patient Height and Weight General Appearance Pallor Icterus Clubbing Cyanosis Pupillary Reaction Lymphadenopathy Dexterity Anything specific
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- 40. REGIONAL EXAMINATION • InspectionLOOK •PalpationFEEL • Strength TestingMOVE • Shortening or Lengthening • Range of Motion • Regional measurements MEASURE • Depends upon specific region in considerationSPECIAL TESTS
- 41. PHYSICAL EXAM -GENERAL Develop a standard routine Alleviate the patient's fears Adequate exposure - bilateral Males – shirtless Females – tank top or sports bra Compare shoulders
- 42. EXAMINATION OF THESHOULDER 1. Observe the patient, front and back. 2. Observe the shoulder. 3. Observe the axilla. View from rear with patient standing straight and look for lateral symmetry, swelling, position of scapula and signs of muscle wasting.
- 43. INSPECTION Swelling, asymmetry,muscle atrophy, scars, ecchymosis and any venous distention Note posture (e.g., shoulder protraction) Deformities Squaring of shoulder - anterior dislocation Scapular "winging" - shoulder instability and serratus anterior or trapezius dysfunction Atrophy - supraspinatus or infraspinatus - consider rotator cuff tear, suprascapular nerve entrapment or neuropathy
- 44. PALPATION Sternoclavicular joint Clavicle Acromioclavicular joint Subacromial bursa Coracoid processBicipital groove Greatertuberosity Lesser tuberosity Scapula (spinatus muscles) TIP: Start medially at the SC joint, proceed laterally, end posteriorly
- 45. ANTERIOR SHOULDER POSTERIORSHOULDER
- 46. 46 Palpation of ACJoint Patient's arm at his/her side Note swelling, pain, and gapping.
- 47. 47 Palpation of BicipitalGroove Patient sitting, beginning with the arm straight Patient actively flexes biceps muscle while examiner provides supination and ER Examiner palpates the bicipital groove for pain
- 48. RANGE OF MOTION(ROM) Evaluate active ROM If movement limited by pain, weakness, or tightness, assist passively Lack of full ROM with active and passive exam is found in adhesive capsulitis and arthropathy Evaluate bilaterally for comparison
- 49. 49 RANGE OF MOTION Movement Forwardflexion Extension (behind back) Abduction Adduction External rotation* Internal rotation* Normal range 0-180° 0-40° 0-180° (with palms up) 0-40° 0-45° (arm at side, elbow flexed) 0-55° (arm at side, elbow flexed)
- 50. 50FORWARD FLEXION Armstraight and brought upward through frontal plane, and move as far as patient can go above his head. 0° is defined as straight down at patient's side, & 180° is straight up.
- 51. 51ABDUCTION Arm straight Hand – palm up (arm supinated) ROM measured in degrees as for forward flexion
- 52. 52 EXTERNAL AND INTERNALROTATION Arm at side, elbow flexed to 90° and held at waist Examiner externally or internally rotates arm
- 53. APLEY SCRATCH TESTFOR ER/IR Internal rotation and adduction Reach for lower scapula Compare bilaterally – note level reached External rotation and abduction Reach for upper scapula Compare bilaterally – note level reached
- 54. OTHER MOVEMENTS Extension-witharm by the patient’s side, lift the arm back wards as far as possible. Adduction-draw the arm across the anterior chest wall as far as possible. Circumduction Shrugging of shoulders
- 55. PAINFUL ARC Inthe evaluation of the active and passive ranges of motion, the patient can often avoid the painful arc by externally rotating the arm while abducting it. This increases the clearance between the acromion and the diseased tendinous portion of the rotator cuff, avoiding impingement in the range between 70° and 120°.
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- 57. STRENGTH TESTS External rotation Infraspinatus Teresminor Internal rotation Subscapularis
- 58. SPECIAL TESTS •Empty cantest •Lift off test •Drop arm test Rotator cuff •Neer’s sign •Hawkin’s test Impingement tests •Speed’s testBiceps tendon •O’Brien’s test •Crank test Labral tear •Apprehension Test •Relocation test •Anterior release test Instability tests
- 59. 59 ROTATOR CUFF Emptycan test Supraspinatus Lift off test Subscapularis
- 60. 60DROP ARM TEST Purpose: tears in the rotator cuff, primarily supraspinatus muscle Method: patient abducts (or examiner passively abducts) arm and then slowly lowers it 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
- 61. GLENOHUMERAL JOINT STABILITY AnteriorGlenohumeral Instability Apprehension test Relocation test Anterior release test
- 62. APPREHENSION TEST -SITTING 90° of abduction Examiner applies slight anterior pressure to humerus and externally rotates arm Positive test = patient expresses apprehension
- 63. APPREHENSION TEST -SUPINE Patient in supine position with affected shoulder at edge of table, arm abducted 90° Examiner externally rotates by pushing forearm posteriorly. Positive test = patient expresses apprehension
- 64. 64RELOCATION TEST Performedafter positive result on anterior apprehension test Patient supine Examiner applies posterior force on proximal humerus while externally rotating patient’s arm Positive test = patient expresses relief
- 65. ANTERIOR RELEASE TEST Patient in supine position, arm abducted 90° Examiner performs Relocation Test, then releases downward pressure Positive test = patient expresses pain or instability when the humeral head is released
- 66. IMPINGEMENT - NEER’SSIGN Patient seated with arm at side, palm down (pronated) Examiner standing Examiner stabilizes scapula and raises the arm (between flexion and abduction) Positive test = pain
- 67. IMPINGEMENT - HAWKIN'STEST Patient standing Examiner forward flexes shoulder to 90°, then forcibly internally rotates the arm Positive test = pain in area of superior GH joint or AC joint
- 68. BICEPS TENDON –SPEED’S TEST Forward flex shoulder against resistance while maintaining elbow in extension and forearm in supination Positive test = tender in bicipital groove (bicipital tendinitis)
- 69. LABRAL TEAR (SLAP)- O'BRIEN'S ACTIVE COMPRESSION TEST Patient standing Arm forward flexed 90°, adducted 15° to 20° with elbow straight Full internal rotation so thumb pointing down Examiner applies downward force on arm - patient resists Patient externally rotates arm so thumb pointing up Examiner applies downward force on arm - patient resists Positive test = Pain or painful clicking elicited with thumb down and decreased or eliminated with thumb up
- 70. 70LABRAL TEAR -CRANK TEST Shoulder elevated to 160° in the scapular plane A gentle axial load is applied through glenohumeral joint with one hand, while other hand does IR and ER Positive test = pain, catching, or clicking in the shoulder
- 71. DUGA’S TEST The patientis seated or standing and touches the contralateral shoulder with the hand of the 90°-flexed arm of the affected side then attempt to lower the elbow to the chest is made. Acromioclavicular joint pain suggests joint disease (osteoarthritis, instability, disk injury, or infection). A differential diagnosis must exclude anterior subacromial impingement and shoulder dislocation
- 72. PROVISIONAL DIAGNOSIS 1. __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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- 79. RADIOLOGY OF SHOULDER ANTERIORSHOULDER DISLOCATION SUBCAPITAL HUMERUS FRACTURE
- 80. DEFINITIVE DIAGNOSIS 1. __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
- 81. CASTS AND SPLINTSFOR SHOULDER SHOULDER BRACE SHOULDER SPLINT
- 82. CASTS AND SPLINTSFOR SHOULDER SHOULDER IMMOBILIZER SHOULDER SPICA
- 83. U SLAB ANDHANGING CAST
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