The Painful Adult Shoulder: evidence based history, exam and approach

1. Aaron Gray, MD
Departments of Family Medicine and
Orthopaedics
University of Missouri

2. Lecture Objectives
 Discuss history and examination of the
shoulder and review evidence
 Identify evidence based indications for
diagnostic imaging tests for shoulder
pain

3. Overview
 Taking a History of a Painful Shoulder
 Review of Shoulder Anatomy
 Physical Exam of the Shoulder
 Imaging of the Shoulder
 Diagnosis and Treatment of Specific
Shoulder Injuries

4. History
 Age
Less than 35 – Impingement, tendonitis, instability
Over 50 – Glenohumeral arthritis, adhesive capsulitis,
rotator cuff tear
 Onset and Duration of Symptoms
Acute vs Gradual
 Mechanism of Injury
Trauma – fall
Repetitive activities such as an overhead motion
 Recent increase in activity?
 Pain at night?

5. History
 Location of Pain
Often unhelpful
 Radiation of pain?
 Weakness or Stiffness?
 Activities that worsen pain?
Fixing hair, snapping bra, pulling out a
wallet, reaching overhead
 Sports, Hobbies, Occupation that
involve the shoulder

6. Shoulder Anatomy
3 Bones
Humerus
Scapula
Clavicle
3 Joints
Glenohumeral
Acromioclavicular
Sternoclavicular
1 Articulation
Scapular

7. Golf Ball on a Golf Tee

8. Bony Anatomy - Scapula
Acromion
Coracoid
Glenoid
Subscapular fossa
Supraspinatus
fossa
Scapular
spine
Infraspinatus
fossa

9. Glenoid Labrum

10. Subacromial Space
The area under the
acromion and above
the glenohumeral joint
Structures
• Supraspinatus muscle
• Subacromial/subdeltoid
bursa
Subacromial Bursa
Supraspinatus
Sobotta (2002)
Small Space • Impingement

11. Rotator Cuff Muscle Actions
• Supraspinatus
o Abduction
• Infraspinatus
o External
rotation
• Teres Minor
o External
rotation
Infraspinatus
Teres
minor
Supraspinatus
Posterior
View

12. Rotator Cuff Muscle Actions
• Subscapularis:
o Internal
rotation
o Adduction
Subscapularis
Anterior
View

13. Research on Diagnostic Accuracy of Shoulder Exam Is
A Common Story…

14. Cochrane Database Review
2013 – Hanchard, et al.
 Physical tests for shoulder
impingements and local lesions of
bursa, tendon or labrum that may
accompany impingement.
 33 studies involving 4002 shoulders

15. Cochrane Database Review
2013 – Hanchard, et al.
 There is insufficient evidence upon which
to base selection of physical tests for
shoulder impingements, and local lesions
of bursa, tendon or labrum that may
accompany impingement, in primary care.
The large body of literature revealed
extreme diversity in the performance and
interpretation of tests, which hinders
synthesis of the evidence and/or clinical
applicability.

16. Physical Exam of the Shoulder
• Inspection
• Palpation
• Range of Motion
• Strength
• Neurovascular status
• Provocative Shoulder Testing
• The joint above and below (i.e. neck
and elbow)

17. Inspection and Examination of Posterior
Shoulder

18. Physical Exam of the Shoulder
• Inspection
• Palpation
• Range of Motion
• Strength
• Neurovascular status
• Provocative Shoulder Testing
• The joint above and below (i.e. neck
and elbow)

19. ABduction: 180°
ADduction: 0°
Movements at the Shoulder Joint

20. Rotation
InternalExternal
(Mid thoracic)(60-80°)
Movements at the Shoulder Joint

21. Forward Flexion: 180°
Extension: 60°
Movements at the Shoulder Joint

22. Physical Exam of the Shoulder
• Inspection
• Palpation
• Range of Motion
• Strength
• Neurovascular status
• Provocative Shoulder Testing
• The joint above and below (i.e. neck
and elbow)

23. Strength Testing Basics
• Compare to unaffected side
• Differentiate between true weakness
and weakness secondary to pain

24. Muscle Testing
Infraspinatus/Teres Minor
• Patient’s arms
adducted at sides
• Elbows flexed to
90°
• Patient attempts
external rotation
against examiner’s
resistance

25. Muscle Testing
Subscapularis
Lift-off test
o Internally rotate
shoulder
o Dorsum of hand
against lower back
o Patient attempts to
push away
examiner’s hand
Belly Press Test
Bear Hug Test

26. Muscle Testing
Supraspinatus
“Jobe’s Test” or “Empty
Can Test”
• 90° abduction
• 30° forward flexion
• Thumbs pointing
downward
• Patient attempts
elevation against
examiner’s resistance

27. Physical Exam of the Shoulder
• Inspection
• Palpation
• Range of Motion
• Strength
• Neurovascular status
• Provocative Shoulder Testing
• The joint above and below (i.e. neck
and elbow)

28. Neurovascular Testing
• Distal pulses
• Capillary refill
• Sensation
www.swipnet.se, accessed 10/2005

29. Physical Exam of the Shoulder
• Inspection
• Palpation
• Range of Motion
• Strength
• Neurovascular status
• Provocative Shoulder Testing
• The joint above and below (i.e. neck
and elbow)

30. Impingement Signs
Neer Test
• Scapula stabilized
• Arm fully pronated
• Examiner brings
shoulder into
maximal forward
flexion
• Pain suggests
Subacromial
Impingement

31. Impingement Signs
Hawkins Test
• Patient’s arm
forward flexed to
90°
• Elbow flexed to
90°
• Shoulder forcibly
internally rotated
by examiner
• Pain suggests
Subacromial
Impingement

32. AC joint
Crossover Test
• Patient forward
flexes affected arm
to 90°
• Actively adducts
arm across body
• Forces acromion
into distal end of
clavicle
• Suggests AC joint
pathology if
painful

33. Sensitivity/Specificity
 Neer Impingement
Sensitivity: 72%
Specificity: 60%
 Hawkins-Kennedy Impingement
Sensitivity: 79%
Specificity: 59%
Hegedus. British J Sports Med, 2012.

34. Biceps Tendon/Labrum
Speed’s Test
• Elbow flexed 20°-
30°
• Forearm supinated
• Arm in 60° flexion
• Patient forward
flexes arm against
examiner’s
resistance

35. Biceps Tendon/Labrum
Yergason’s Test
• Elbow flexed to 90°
with thumb up
• Grasp hand (hand
shake)
• Patient supinates
against resistance

36. Labral signs
O’Brien Test
• Arm forward flexed to 90°
• Elbow fully extended
• Arm adducted 10° across
body with thumb down
• Apply downward pressure
against patient resistance
• Repeat with thumb up
• Suggestive of labral
tear if more pain with
thumb down

37. Sensitivity/Specificity for SLAP
Tear
 Speeds Test
Sensitivity: 20%
Specificity: 78%
 Yergason’s Test
Sensitivity: 12%
Specificity: 95%
 O’Brien’s Test
Sensitivity: 67%
Specificity: 37%
Hegedus. British J Sports Med, 2012.

38. • Arm abducted to 90°
• Apply slight anterior
pressure and slowly
externally rotate
• Apprehension may
indicate anterior
instability
• High Diagnostic Odds
Ratio of 53.6

39. • Supine
• Shoulder abducted and
externally rotated
• Posteriorly directed force
applied to shoulder
• Positive if apprehension
decreases and indicates
anterior instability

40. Physical Exam of the Shoulder
• Inspection
• Palpation
• Range of Motion
• Strength
• Neurovascular status
• Provocative Shoulder Testing
• The joint above and below (i.e. neck
and elbow)

41. Cervical Spine
Spurling’s Maneuver
• Neck extended
• Head rotated toward
affected shoulder
• Axial load placed on the
cervical spine
• Reproduction of
patient’s shoulder/arm
pain indicates possible
nerve root compression

42. Hegedus. British J Sports Med, 2012.

43. Indications and Guidelines for
Diagnostic Imaging

44. Be Wise When Ordering Imaging
 Analysis of 459 elective outpatient CT
and MRIs from PCPs
 37% of shoulder MRIs were considered
inappropriate
 Examples of inappropriate indications
Shoulder pain with no conservative therapy
Osteoarthritis in older patients
Lehnert & Bruce. J Am Coll Radiol , 2010.

45. Asymptomatic Rotator Cuff
Tears Increase with Age
Tempelhof et al. J Shoulder Elbow Surg, 1999.

46. American College of Radiology
Appropriateness Criteria
 Evidence based guidelines developed by
a multidisciplinary panel
 Reviewed every two years
Wise et al. J Am Coll Radiol 2011.

47. ACR Appropriateness Criteria
Wise et al. J Am Coll Radiol 2011.

48. MRI
 Superior for most soft tissues in
shoulder
Rotator Cuff Tear
Cartilage
Bursae
 Identifies tendon retraction, muscle
atrophy and fatty infiltration
Suggests chronic tear & poor prognosis

49. MR Arthrogram
 Main use – instability in those <35 y/o
 Injection of gadolinium enhances view
of labrum
 Typical History of Shoulder Instability
or Labral Tear

50. Glenoid Labrum

51. CT Scan
 Useful for characterizing fractures
 Consider CT arthrography in evaluation
of rotator cuff in setting of previous
shoulder replacement
 Otherwise… not many uses

52. Ultrasound
 Very operator dependent
 Can be used to evaluate
acromioclavicular joint, rotator cuff
tendons, long head of bicep tendon
 Increased accuracy of injections into
glenohumeral joint/biceps tendon
sheath

53. Diagnosis and Treatment of
Selected Specific Conditions

54. Shoulder Impingement
 Hx: Gradual onset of pain worsened with
overhead activities. Often with night pain
 PE: +impingement tests, weakness and pain
with resisted supraspinatous testing, ROM
usually NL
 Imaging: Xray – usually NL. Can see acromion
spurs.
 Treatment: PT for strengthening of scapula
stabilizers and rotator cuff, consider injection
if severe pain
 Referral - Consider if not improved after 6
months of adequate rehab

55. Rotator Cuff Injuries
 Continuum of edema/hemorrhage >
tendonitis and fibrosis > partial or complete
tear
 Rotator cuff tears are uncommon under the
age of 40 but strains do occur
 Hx: pain in lateral shoulder, night pain is
common, +/- history of trauma
 PE: pain and weakness of affected muscles.
 Differentiating weakness because of pain
versus a tear can be difficult. Consider
diagnostic lidocaine injection.

56. Rotator Cuff Injuries
 Imaging: Xray usually normal. Tears
are best evaluated with U/S or MRI.
 Treatment: Complete tears in an active
person should be referred for surgical
consult. Partial tears and strains can
often successfully be rehabilitated.
Consider injection if severe pain does
not allow physical therapy.

57. Adhesive Capsulitis (Frozen Shoulder)
 Hx: pain and decreased range of active and
passive motion, night pain (early in condition)
 At Risk: Diabetics, women, post surgical
immobilization, 40-60 y/o
 PE: decreased active and passive ROM
 Imaging: Xrays- NL, used to differentiate
glenohumeral arthritis
 Treatment: NSAIDS and corticosteroid
injections beneficial during painful stage. PT
ROM and exercise. Increase aggressiveness as
pain resolves
 Refer when: conservative treatment has
failed

58. Biceps Tendonitis
 Often occurs in combination with
rotator cuff pathology
 Hx: Pain in anterior aspect of shoulder
that radiates to biceps
 PE: TTP in bicipital groove, +Speed’s &
Yergason’s test
 Imaging: Xrays – NL, US/MRI – fluid
around tendon

59. Shoulder Dislocation
 72-95% recurrence in <20 y/o patients
 20-30% in 25-40 yo
 10-15% in >40 yo
 Shoulder dislocations in patients <25
y/o should have surgical stabilization

60. Glenoid Labral Tear
 Hx: Multiple mechanisms
Atraumatic
Traction in overhead throwing athletes
Sudden pull from catching oneself from falling
Compression from falling onto outstretched
arm
 Hx: Pain with overhead activities;
sometimes will have popping, clicking, or
catching with motion. Often will have
failed rehab with continued discomfort.

61. Glenoid Labral Tear
 PE: All tests have poor +LR
 Imaging: MR arthrogram
 Treatment: start with PT, however,
most patients will need surgical
treatment to resume full function

62. 67 yo male w/ decreased ROM

64. Glenohumeral Arthritis
 Hx: decreased and painful ROM, hx of
previous injury or arthritis in other
joints
 PE: Decreased active and passive ROM
 Imaging: degenerative changes of
glenohumeral joint
 Treatment: glenohumeral
corticosteroid injection, shoulder
replacement
 Refer when: pain has become severe
despite conservative treatment

65. Biceps Tendon Rupture

66. Biceps Tendon Rupture
 Hx: forceful elbow extension against
resistance, pain, ecchymosis
 PE: “Popeye” deformity, decrease
flexion and supination strength
 Imaging: MRI will show rupture
 Treatment: Quick referral to a surgeon
in active patients. Pain control and PT
in elderly

67. Take Home Pearls
 Don’t order an MRI for an arthritic
shoulder
 ~50% of patients 80 years or older have
asymptomatic rotator cuff tears
 Glenohumeral arthritis is often rarely
helped by physical therapy

68. Take Home Pearls
 Refer all first time shoulder dislocations
under age of 25 for surgical repair
 Order an MR Arthrogram for a pt <35
y/o with shoulder instability when
there is concern for labral tear

69. References
 Madden, Chris, et al. Netter’s Sports
Medicine. 1st Ed. Saunders, 2009.
 Puffer, James. 20 Common Problems in Sports
Medicine. 1st Ed. McGraw-Hill, 2001.
 Esenyel CZ, et al. Arch Orthop Trauma Surg ,
2010. Mar;130(3):297-300.
 Hegedus EJ, et al. British Journal of Sports
Medicine 2008;42:80-92.
 Sethi PM, Arthroscopy. 2005 Jan;21(1):77-80.
 Tallia A & Cardone D. Diagnostic and Theraputic
Injection of the Shoulder. Am Fam
Physician. 2003 Mar 15;67(6):1271-1278.