Shoulder Joint examination
OverviewIntroductionIntroduction
PresentationPresentation
ExaminationExamination
Anatomy Anatomy
InvestigationsInvestigations
InjectionsInjections
Key pointsKey pointsA J Chakrabarti FRCS(Orth)A J Chakrabarti FRCS(Orth)
Introduction
Shoulder pain is very common
Can be Recalcitrant
Many get better spontaneously without treatment
Costly
Introduction
Prevalence Overall 7%26% in elderly
Rheumatology 2006;45:215–221
Shoulder Pain in Adults
Not getting better spontaneously
What is the actual diagnosis?Are there specific considerations for this particular patient?
When should I refer?
Shoulder examination
Basic steps
History
Examination Clinical tests
Investigations XR/US
What is the diagnosis ?
Don’t be too hasty in simply diagnosing “Frozen shoulder”
Patient factors of importance
Lifestyle
Occupation
Handedness
Sports/Hobbies
PMH / PSH
DH
Expectations
Previous treatments
Shoulder Complaints
Pain
Stiffness
Instability
Weakness/ Functional loss
Swelling
Deformity
Electrical disturbance/ Vascular disturbance
Shoulder Complaints
Pain That keeps patient awake at night
Shoulder Complaints
Pain Keeps partner / spouse up!
Shoulder ComplaintPain
OnsetInjuryDurationSiteSeverityNaturePeriodicityTiming
Night pain
Exacerbating
Relieving factors
Treatments tried
Tablets
Response to Rxs
Shoulder ComplaintPain
Injury Nature
Bleeding/ Bruising
Snap. Crack
“General Feel”
Position of arm
Pre-existing state
Site of Pain
Radiating to forearm/hand infrequent
Radiating to neck Does not arise form intrinsic shoulder problems (except ACJ- to base of neck)
Shoulder ComplaintPain
Open Palm v Finger sign
Deltoid sited pain Subacromial space /
Rotator cuff. GHJ
Superiorly sited pain Acromioclavicular joint
Shoulder Instability
Traumatic
Atraumatic GLL
Muscle patterning disorder
History of fits
Event
Ease
Frequency
Subtle instabilities
Pain
Dead arm
Shoulder Weakness
Pain causes weakness
Weakness of muscles –neural, musculotendinous or other mechanical
Patients exact meaning
Association with any pain.
Painful Shoulder
Remember that pain experienced in the shoulder can arise from outside the shoulder
Shoulder Complaints
NeckBrachial plexus painViscera. Intrathoracic/ subphrenicChronic regional pain syndromes
Shoulder Complaints
NeckBrachial plexus painViscera. Intrathoracic/ subphrenicChronic regional pain syndromes
Shoulder examination
Multiple techniques
No best single way!
Compare sides
Assessing a ShoulderAnatomic sites
Glenohumeral joint
Acromioclavicular joint
Sternoclavicular joint
Subacromial space
Rotator Cuff
Scapulothoracic articulation
Think anatomically !
Three True Joints Three areas
The Rotator cuff
4 muscles with their tendons acting as a functional unit to maintain the humeral head centered on the glenoid
The Rotator
cuff
Clinical Examination
Look
Feel
Move
Stand
Sit
Lie
Clinical Examination
Inspection
Localising Tenderness
Neck Examination
CxSpNeuro exam
Functional assess
•Elevation
•Impingement
•ER
•IR
•Abduction RPA
•Cuff testing 3 pt
•Biceps
Minimum 10 point Clinical Examination
Inspection
Localising Tenderness
Neck Examination
CxSpNeuro exam
Functional assess
•Elevation
•Impingement
•ER
•IR
•Abduction RPA
•Cuff testing 3 pt
•Biceps
Minimum 10 point examination
Cx Spine Elevation Ext Rotation Supraspinatus
Impingement Internal Rotation
Infraspinatus
Abduction Subscapularis
LHB
Non shoulder Functional Glenohumeral Cuff / muscles
Empty can Impingement
• Positive
Comparative increased pain
No pain But slower
Block
The Hallmarks of common diseases
Cx stiffness/ pain: Cervical spondylosis / Cx disc prolapseElevation restriction: RCT lifting with good armImpingement sign: Bursal/cuff disease or ACJ impingementRestrictions of Global GHJ motion: Capsular contracture of Frozen shoulder or OA GHJLoss of resisted muscle power: RCT or pain inhibitionPainful resisted cuff activity: RCT/ impingementLHB signs: Biceps tendinopathy
Clinical Judgement
Neck
Shoulder
ACJ
BURSA
CUFF
BICEPS
CAPSULE AND JOINT SURFACE
10 point examination
Shoulder Scores of function
Oxford Shoulder Score 48
12 Questions – all relate to shoulder in last 4 wks
0-4 per question. Max score 48/48 = Gd shoulder
Worst,Dressing,Car,Knife,Shopping,Tray
Brush,Usual,Robes,Axilla,Housewk,Night
Does it need an XR?
Yes: If referring for surgical opinion
Yes: If you need it to corroborate your diagnosis
Yes: If possibility of calcific disease
Yes: If need to exclude arthrosis
(The arthrosis of ACJ
The arthrosis of the GHJ)
Yes: If concerned re: malignant disease
What XR’s do I find valuable?
AP30° CaudalAxillary Lateral
Stryker Notch view for GHJ instabilityClavicular views for ACJ instability
“Sourcil” sign
30° Caudal view - useful to gauge 3D anatomy of Acromion
30° Caudal view
Ultrasound examination
Examines the rotator cuff
Supraspinatus
Infraspinatus
Subscapularis
Teres Minor
Long Head Biceps
Bursa / Impingement
Ultrasound examination
DO NOT REQUEST
IN PREFERENCE TO
PLAIN XR FILM
MRI?
Access to the films is the most important
The reports may be misleading.
The MRI has a picture that both clinician and patient can understand
Most useful when:
ACJ impingement a possibility
Other pathologies /multiple pathologies are expected
Limited use without contrast: calcific disease/ instability
Treatments
In all cases Conservative.
Analgesia
Physiotherapy: Pendular exercises
Theraband exercises
Eccentric Deltoid exercises
“eccentric means lengthening during loading”
Steroid injections
Other injections / other treatments
Treatments
Theraband exercises
Steroid Injections
Prep the skin and draw up solution with separate needle to one used to inject.
Portal: Soft spot – Below Postero-lateral corner
Aim for Anterior acromion for bursal injection
Aim for Coracoid process for GHJ injection
Superior Summit for ACJ
Cures for shoulder diseases?
Arthritis ACJ: Excision arthroplasty
Arthritis GHJ: Total shoulder replacement/
Hemi
Rotator Cuff Arthropathy: Reverse polarity prosthesis
Acute Rotator Cuff Tears: RCR
Impingement with/without Tears: ASAD
Instabilities: Various stabilizations
Conditions that may not be cured
Chronic Calcific Disease:
Massive Cuff Tears:
Degenerative RCTears without arthritis:
Poor vascularity
Secondary fatty infiltration and neural change to muscle/tendon unit
Patients unfit for surgery:
Conservative management: Steroid injections/ Eccentric Deltoid Training/ Suprascapular Nerve Blocks
Prognosis in shoulder conditions is largely determined by the condition of the rotator cuff
and
The outcome following surgery in most cases largely determined by the condition of the rotator cuff
Top Related