Shoulder 2shoulder

7/29/2019 Shoulder 2shoulder

1/60

MusculoskeletalCurriculum

History &Physical Examof the Shoulder

Copyright 2005


2/60

2

Authors

Kathleen Carr, MD

Madison Residency [email protected]

Dennis Breen, MD

Eau Claire Residency [email protected]


3/60

3

Goal

Learn a standardized, evidence-based historyand physical examination of patients withshoulder problems

WHICH WILL:

Enable family medicine resident physicians toaccurately diagnose common shoulderproblems throughout the full age spectrum ofpatients seen in family medicine


4/60

4

Competency-Based Objectives

Patient carefocused history and exam

Professionalismrespect, compassion

Interpersonal and communication skillsdifferential diagnosis

Medical knowledge baseanatomy, injury

mechanisms

Systems based practiceaccuracy, time-efficiency


5/60

5

Shoulder Pain Key Points Shoulder pain is a common complaint in primary

care 2nd only to knee pain for referral to Ortho or primary care sports

med

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


6/60

6

Assessing shoulder pain

Components of the assessment

include

1. Focused history2. Attentive physical examination

3. Thoughtfully ordered tests/studies

for future discussion


7/60

Focused History


8/60

8

Focused History Questions

Onset of Pain

When symptoms started*

History of trauma/injury


9/60

9


Mechanism of Injury

Helps predict injured structure

Example: Fall directly onto anterior/superiorshoulderAC joint injury (shoulder separation)

Example: Arm forcefully abducted and externallyrotated subluxation or anterior dislocation

Example: If chronic pain, note activity that triggerspain, such as the cocking phase of throwing or thepull-through phase of swimming


10/60

10


Mechanism of Injury, continued

Can determine radiological needs

Likelihood of specific conditions varies Setting (work, recreation, sports, traumatic,

atraumatic)

Age of the patient*


11/60

11

Focused History Questions Location of pain*

Anterior

Lateral

Superior Posterior

Radiation of pain

Rotator cuff problems often include painradiating to upper arm

If pain starts in neck and radiates toshoulder, consider cervical spine disease


12/60

12

Consider sources 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)



13/60

13

Characteristics of pain


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 (60-120abduction) Subacromial impingement

Pain > 120 abduction Acromioclavicular joint

Catching, popping, clicking GH or AC joint arthritis, labral

tear


14/60

14


History of instability

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


15/60

15

Differential Diagnosis

Diagnosis Primary Care % Age

Subacromial Impingement Syndrome 48-72 23-62

Adhesive Capsulitis 16-22 53

Acute Bursitis 17 -

Calcific Tendonitis 6 -

Myofascial Pain Syndrome 5 -

Glenohumeral Joint Arthrosis 2.5 64

Thoracic Outlet Syndrome 2 -

Biceps Tendonitis 0.8 -


16/60

Physical Exam


17/60

17

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


18/60

18

Physical Exam Steps*

Inspection

Palpation

Range of motion (ROM) Strength testing

Special tests


19/60

19

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 andserratus anterior or trapezius dysfunction

Atrophy - supraspinatus or infraspinatus -consider rotator cuff tear, suprascapular nerveentrapment or neuropathy


20/60

20

Palpation

Sternoclavicular joint

Clavicle

Acromioclavicular joint

Subacromial bursa

Coracoid process

Bicipital groove

Greater tuberosity Lesser tuberosity

Scapula (spinatus muscles)

TIP: Start medially atthe SC joint, proceed

laterally, end posteriorly


21/60

21

Anterior Shoulder

http://www.nismat.org/orthocor/exam/shoulder.html#Functions


22/60

22

Posterior Shoulder

http://www.nismat.org/orthocor/exam/shoulder.html#Functions


23/60

23

Palpation of AC Joint

Patient's arm at his/her

side

Note swelling, pain, and

gapping.


24/60

24

Palpation of Bicipital Groove

Patient sitting,beginning with the armstraight

Patient actively flexesbiceps muscle whileexaminer providessupination and ER

Examiner palpates the

bicipital groove for pain


25/60

25

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


26/60

26

Range of Motion

Movement

Forward flexion

Extension (behind back)

Abduction

Adduction

External rotation*

Internal rotation*

Normal range

180

40

180(with palms up)

0

45(arm at side, elbow flexed)

55(arm at side, elbow flexed)


27/60

27

Forward Flexion

Arm straight andbrought upwardthrough frontal plane,and move as far aspatient can go abovehis head

0 is defined as straightdown at patient's side,

& 180 is straight up


28/60

28

Abduction

Arm straight

Hand palm up (arm

supinated)

ROM measured indegrees as for forward

flexion


29/60

29

External and Internal Rotation

Arm at side, elbow flexed to 90 and held at waist

Examiner externally or internally rotates arm


30/60

30

Apley scratch test for 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


31/60

31

Strength Tests

Flexion

Extension


32/60

32

Strength Tests*

External rotation

Infraspinatus

Teres minor

Internal rotationSubscapularis


33/60

33

Strength tests

Empty can test*

Supraspinatus

Lift off test*

Subscapularis


34/60

34

Special Tests

Rotator cuff

Drop arm test

Impingement tests Neers sign

Hawkins test

Speeds test Biceps tendon

Labral tear

OBriens test

Crank test

Instability tests

Anterior release

Relocation test


35/60

35

Rotator Cuff

Empty Can Test

Supraspinatus

Lift off test

Subscapularis integrity

Drop Arm Test

Rotator cuff tear or supraspinatus dysfunction


36/60

36

Drop Arm Test Purpose: tears in the rotator

cuff, primarily supraspinatusmuscle

Method: patient abducts (orexaminer 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 cufftear

Positive test: patient unable tolower arm further with control If able to hold at 90, pressure on

wrist will cause arm to fall


37/60

37

Video of Drop Arm Test

Click onimage for video


38/60

38

Impingement - Neers Sign*

Patient seated with armat side, palm down(pronated)

Examiner standing Examiner stabilizes

scapula and raises thearm (between flexion

and abduction) Positive test = pain


39/60

39

Video of Neers Sign



40/60

40

Impingement - Hawkin's Test*

Patient standing

Examiner forward

flexes shoulder to 90,

then forcibly internallyrotates the arm

Positive test = pain in

area of superior GH

joint or AC joint


41/60

41

Video of Hawkins Test



42/60

42

Speeds Test - Biceps tendon

Forward flex shoulder

against resistance

while maintaining

elbow in extensionand forearm in

supination

Positive test = tender

in bicipital groove(bicipital tendinitis)


43/60

43

Video of Speeds Test



44/60

44

Labral Tear (SLAP) - O'Brien's

Active Compression Test Patient standing

Arm forward flexed 90, adducted15 to 20 with elbow straight

Full internal rotation so thumb

pointing down Examiner applies downward force on

arm - patient resists

Patient externally rotates arm sothumb pointing up

Examiner applies downward force on

arm - patient resists Positive test = Pain orpainful

clicking elicited with thumb downand decreased or eliminated withthumb up


45/60

45

Video of OBriens Test



46/60

46

Labral Tear - Crank Test

Shoulder elevated to 160

in the scapular plane

A gentle axial load is

applied throughglenohumeral joint with

one hand, while other

hand does IR and ER

Positive test = pain,catching, or clicking in the

shoulder


47/60

47

Video of the Crank Test



48/60

48

Glenohumeral Joint Stability

Anterior Glenohumeral Instability

Apprehension test

Relocation test Anterior release test


49/60

49

Apprehension Test - Sitting

90 of abduction

Examiner applies slight

anterior pressure to humerusand externally rotates arm

Positive test = patient

expresses apprehension


50/60

50

Apprehension Test

Patient in supineposition with affectedshoulder at edge oftable, arm abducted

90 Examiner externally

rotates by pushingforearm posteriorly.

Positive test = patientexpressesapprehension


51/60

51

Relocation Test

Performed after positiveresult on anteriorapprehension test

Patient supine

Examiner appliesposterior force onproximal humerus whileexternally rotating

patients arm Positive test = patient

expresses relief


52/60

52

Video of the Apprehension &

Relocation Tests Seated & Supine



53/60

53

Anterior Release Test Patient in supine

position, arm abducted90

Examiner performs

Relocation Test, thenreleases downwardpressure

Positive test = patient

expresses pain orinstability when thehumeral head isreleased


54/60

54

Video of Anterior Release Test



55/60

55

The Current Evidence Base

for History Questions andPhysical Exam Tests


56/60

56

Rotator Cuff Tear

History /Maneuver

StudyQual

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 cantest

1b 8489

5058

1.72

0.220.28

3698

2293

Drop arm 1b 21 100 >25 0.79 100 32


57/60

57

Impingement / Instability

Test Study

Qual

Sens

(%)

Spec

(%)

LR+ LR- PV+

(%)

PV-

(%)

Impingement

Hawkins 1b 87

89

60 2.2 0.18 71 83

Instability

Relocation 2b 57 100 >25 0.43 100 73

Apprehension 2b 68 100 >25 0.32 100 78


58/60

58

AC / SLAP

History /Maneuver

StudyQual

Sens

(%)

Spec

(%)

LR+ LR- PV+

(%)

PV-

(%)

AC

Activecompression

1b 100 97 >25 0.01 89 100

SLAP

Crank 2b 91 93 13 0.10 94 90

Active

compression

1b 100 99 >25 0.01 95 100


59/60

59

References

Luime JJ, Verhagen AP, Miedema HS, et al. Does This Patient Have an Instability of the

Shoulder or a Labrum Lesion? JAMA. 2004;292:1989-1999.

Stetson WB, Templin K. The crank test, the OBrien test, and routine magnetic resonance

imaging scans in the diagnosis of labral tears.Am J Sports Med. 2002;30:806-809.

Stevenson JH, Trojian T. Evaluation of shoulder pain. Journal of Family Practice.

2002;51:605-11.

Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with

Shoulder Examination Part I: The Rotator Cuff Tests.Am J Sports Med. 2003;31:154-

160.

Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with

Shoulder Examination Part II: Laxity, Instability, and Superior Labral Anterior and

Posterior (SLAP) Lesions.Am J Sports Med. 2003;31:301-307.


60/60

60

Video of Shoulder Exam

http://www.fammed.wisc.edu/our-department/media/musculoskeletal
http://inside.fammed.wisc.edu/education/musculo

Shoulder 2shoulder

Documents

Transcript of Shoulder 2shoulder