Presentation on theme: "Physical Examination of the Shoulder"— Presentation transcript:
1Physical Examination of the Shoulder Lisa Chiou, MD, MPHPrimary Care Conference
2Goals Review some of that anatomy from medical school Discuss common shoulder problemsPractice focused physical exam
3Shoulder pain Common in all age groups Intrinsic disorder (85%) vs referred painC-spine nerve impingement (disc herniation or spinal stenosis)Peripheral nerve entrapment distal to spinal column (long thoracic, suprascapular)Diaphragm irritation, intrathoracic tumors, and distension of Gleason’s capsule/gall bladderMyocardial ischemiaPancoast tumorNormal shoulder movement. Also, character of the pain does not change with movement of the shoulder.
4Review of shoulder anatomy BonesScapulaClavicleHumeral headPosterior rib cageJointsSternoclavicularAcromioclavicularGlenohumeralScapulothoracicSternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic joints. Thin capsule. Subacromial bursa. Rotator cuff tendons attach to humeral tuberosities.
5Glenohumeral joint 25% humeral head surface in contact with glenoid Joint space thinning seen with OAHumeral head coverage increased to 75% with glenoid labrum
6More shoulder anatomy Ligaments Subacromial bursa Subdeltoid bursa CoracoclavicularAcromioclavicularGlenohumeralSuperior GHMiddle GHInferior GHCoracohumeralSubacromial bursaSubdeltoid bursa
7Rotator cuff musclesSupraspinatus, infraspinatus, teres minor, subscapularisForm cuff around humeral headKeep humeral head within joint (counteract deltoid)Abduction, external rotation, internal rotationSupraspinatus – abduction (also with deltoid). Infraspinatus and teres – external rotation. Subscapularis – internal rotation.
8Shoulder exam #1 Visualize from front and back Asymmetry Atrophy Pts with rotator cuff tears hold shoulder higherAtrophySign of chronic glenohumeral joint pathologyEffusionsShoulder joint can hide a lot of fluidCan see atrophy with chronic RA. Shoulder joint can hide a lot of fluid because of capsule redundancy.
9Shoulder exam #2 Palpation Along clavicle SC and AC joints Acromion, subacromial regionCoracoid process (short head of biceps)Bicipital groove (long head of biceps)Trigger points in neck, trapezius, scapular region
10Active range of motion Forward flexion Abduction/adduction Painful arc of abduction – sensitive, not specificExternal rotationInternal rotationFlexion – arms outstretched, up in front. Abduction – to the side. External rotation – either the penguin, or putting hands behind back (like relaxing).Internal rotation – have pt use thumb to touch the highest point on the spine. Apley scratch test does both abduction and external rotation – reach behind head and touch the superior angle of the opposite scapula. Can touch the inferior angle of the opposite scapula for testing of internal rotation and adduction.
11Passive range of motion Immobilize the scapula to prevent rotationUse one arm to push down on shoulderUse other arm to do the PROM exercisesAbductionInternal and external rotationHave arm at patient’s side and abducted to 90 degreesPreventing scapula from moving isolates the GH joint. When abducted – internal rotation is pointing down, external rotation is pointing up.
12Rotator cuff strength testing Supraspinatus“Pour out a Coke”Infraspinatus and teres minor“Act like a penguin”Subscapularis“Scratch your back”
13Impingement maneuvers Impingement signAt 90 degrees of abduction with elbow flexed to 90 degrees, do internal (downward) and external (upward) rotationHawkins’ testAt 90 degrees of elbow flexion, do internal rotation by pushing down on pt’s forearmNeer’s testAt full elbow extension, internally rotate and flex the arm
14Biceps strength testing Arms outstretched with palms up at level of shoulderForced supination of hand with elbow flexed at 90 degreesBicipital tendonitis – pain at long head of the biceps.s
16Impingement syndromeCompression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromionRepetitive overhead motionsMain cause of rotator cuff tendonitisCan lead to bursitis, partial or full rotator cuff tears
17Sx of impingement syndrome Usually gradual onsetOuter deltoid pain, especially with reaching or overhead movementsNight painDifficulty sleeping on affected sideNearly identical symptoms as tendonitisSx = pain over outer deltoid, particularly with overhead activities or reaching. 10% pts have pain over anterior deltoid.
18Exam for impingement Pain with painful arc maneuver Crepitus above 60 degreesSubacromial tenderness (lateral)No pain with external/internal rotation, abduction, elbow flexionDistinguishes impingement from tendonitisNormal glenohumeral ROMNormal strengthPainful arc maneuver = Neer impingement test. Prevent scapular movement by placing hand down on shoulder. Then with the patient’s elbow flexed at 90 degrees, raise the arm and look for pain/guarding. With impingement, see pain variably from degrees.
19Radiology for impingement X-rays usually not neededReasonable to get if chronic symptomsMRI can rule out other pathologyWait at least 24 hours after an injectionOsseous abnormalitiesNeed to clinically correlate MRI findingsXR – loss of space between acromion and humeral head can indicate degenerative thinning or a large rotator cuff tear. Can see erosive changes at greater tubercle. More frequently, can see calcification in the rotator cuff tendone but not specific. MRI – can look for compression of the supraspinatus tendon or the subacromial bursa by spurs, low-lying acromion, osteophytes.
20Tx of impingement Rest Ice Stretching, then strengthening Pendulum for 5-10 minutes QDCan increase space under acromion by ½”Don’t use arm slingSubacromial injectionSurgical referral if no improvement after 3-6 monthsPendulum, then weighted pendulum. Injection = pure impingement is mechanical and won’t respond to steroids. Could do a lidocaine injection first. If this works, then could consider steroids. Surgery – acromioplasty (either open or arthroscopic).
21Rotator cuff tendonitis Some argue this is same as impingementAcute or chronicAcute – more likely to have calcific depositsPain along lateral arm (outer deltoid)Pain with numerous activities, lying on the affected side, overhead movementsRF – relative overuse, age, osteophytes, trauma, inflammatory processes (RA)
22Exam for impingement Painful arc of abduction (active) degreesImpingement signsImpingement testSubacromial lidocaine injectionCan then test again for weakness
23Radiology for tendonitis Nothing is diagnosticPlain films not necessaryGet if chronic or recurrentMight see calcificationsIf significant loss of strength or ROM, get MRIRule out tearHard to see tendon calcifications
24Tx of tendonitis Rest Heat or ice Ultrasound (physical therapy) NSAIDs Subacromial steroid injection
25Rotator cuff tear 50% pts do not have preceding trauma Usually in supraspinatusWide size range, plus partial vs fullShoulder weakness, pain, loss of motionCommon mechanisms of injury:Falling onto outstretched arm, onto outer shoulder directly, heavy pushing/pulling
26Sx of rotator cuff tear Shoulder weakness Localized pain over upper backPopping/catching sensation when shoulder is movedNight pain is characteristicSx vary depending on direction of the torn tendon fibersParallel: painTransverse: weakness, loss of functionIf the tear is parallel to the tendon fibers, pt will have shoulder pain, pain with direct pressure, pain aggravated by activities (reaching, lifting, pulling, pushing). If tear is large and transverse in direction, then pt will have weakness, dramatic loss of function.
27Exam for rotator cuff tear Range of motionStrengthDrop arm testArm abducted with elbow straightSee if pt can smoothly lower armIf arm drops, then test is positive for tearHighly specific but only 21% sensitive
28Radiology for rotator cuff tears Interpret carefully34% asymptomatic pts (all ages) and 54% pts >60 yo have partial rotator cuff tearsAbnormal rotator cuff signal after trauma may represent strain rather than tearX-raysLook for high riding humeral headUltrasoundHighly operator dependentMRIU/S limitations include with fat patients or small tears.
30Tx of rotator cuff tears Ice, NSAIDs, restrict aggravating motionsWeighted pendulumNo arm slingsSteroid injection if persistent sxSurgery – refer if young pts, full/large tears, dominant armBest if done within 6 weeksAcromioplasty and debridementNo overhead positioning, reaching, lifting. Steroid injection could possibly weaken tendon, but Up to Date says there is no influence on tendon healing. Rotator cuff is NOT necessary for most normal activities of a sedentary life.
31Acromioclavicular injury Arthritic changesAC joint separationAnterior shoulder pain or deformityPreceding traumaOften pts hold arm close to chest and resist rotation and elevationWith OA, may have grinding or popping sensation with reaching overhead/across chest
32Exam for AC joint injuries Joint enlargement or deformityJoint tendernessPain with crossed body adductionJoint widening with downward arm traction in pts with 2nd or 3rd degree joint separationShow how to do the exam: place your arm on their shoulder and rest their affected side on your arm. Then passively push the AC joint together by pushing on the arm. 2nd degree – partial dislocation. 3rd degree – full dislocation.
33Tx of AC joint injuryReduce pressure and traction to allow ligaments to re-attachAcute: ice, NSAIDs, shoulder immobilizer for 3-4 weeksPersistent: steroid injectionRefer to surgery if no improvement after 2 injections
34Adhesive capsulitis Loss of motion +/- pain due to stiff GH joint Is usually reversibleMay have preceding traumaMost common cause (10%) is rotator cuff tendonitisRisk factors:DiabetesDisuse (i.e. pts with arm in sling)Low pain thresholdsPoor compliance with exercise therapyLose abduction and rotation. Loss of GH joint capsule distensibility. Contrast with rotator cuff tendonitis – main sx is pain, not loss of movement.
35Rare associations Hyper- or hypothyroidism Parkinson’s disease Antiretrovirals (PPIs)Recent neurosurgery
36Exam for adhesive capsulitis Clinical diagnosisRange of motion is smooth and pain-free, then stops suddenlyNo further passive ROM possibleNormal strength in the pain-free rangeCan test strength again after lidocaine injectionAfter lidocaine, pts with frozen shoulder still have limited range of movement, unlike tendonitis.
37Radiology for adhesive capsulitis X-rays have limited useMight see calcifications or degenerative changes that would lead to frozen shoulderMRIEnhancement of joint capsule and synovial membrane4 mm thickening is 70% sensitive and 95% specificX-rays: could see evidence of calcific tendonitis or degenerative changes that would suggest problems that could eventually lead to frozen shoulder.
38Arthrogram for adhesive capsulitis Normal capsule volumeFrozen shoulder (contracted GH capsule)
39Tx of adhesive capsulitis Watchful waitingUp to 2 years for resolutionIncomplete recovery more likely in pts with DM, or pts with >50% loss of external rotation/abductionSteroid injectionManipulation under anesthesiaGentle exercisePain medicationsAlternative therapies – i.e. acupunctureExercise – (1) weighted pendulum exercises, (2) passive stretching. Up to 50% will respond to exercise therapy.
40Biceps tendonitis Inflammation of long head of biceps Passes through bicipital groove of anterior humerusUsually due to repetitive lifting or reachingInflammation, microtearing, degenerative changesUp to 10% pts will have spontaneous ruptureBiceps – elbow flexion and supination.
41Sx of biceps tendonitis Anterior shoulder painWorse with lifting or overhead reachingOften pts point to bicipital grooveUsually no weakness in elbow flexionBicipital groove is about 1” below the anterolateral tip of the acromion. Pts can seem weak because of pain.
42Exam for biceps tendonitis Bicipital groove tendernessLook for subacromial impingementTendon ruptureTest biceps strengthYergason testElbows flexed with forearms in frontPt actively resisting external rotationTendon may pop out of bicipital groove when downward pressure applied to forearm
43Ruptured biceps tendon Usually rotator cuff tear also presentGet the “popeye” signRarely get significant weaknessBrachioradialis and short head of biceps provide 80-85% elbow flexor strengthTx is supportiveUsually proximal end of the long head ruptures.
44Radiology for biceps tendonitis Usually plain films unnecessaryIf tendon rupture present, then get plain films, U/S, or MRILook for rotator cuff tendonitis or tear
45Tx of biceps tendonitis Reduce inflammationStrengthen biceps muscle and tendonPrevent ruptureIce, NSAIDs, avoid aggravating motions5-10% risk of rupture with noncomplianceWeighted pendulumElbow flexion toning exercisesSteroid injectionSurgical referral if sx persist >3 monthsSurgery rarely necessary since flexion strength only minimally decreased and it usually ends up being a cosmetic issue. Can get slight improvement in elbow flexion and supination.
46Glenohumeral osteoarthritis Same risk factors as with OA in other areasTrauma, obesity, ageLess common than OA in weight bearing joints or spinePain, stiffness over months to yearsAnterior shoulder is most painful areaWorse with activityDistinguish from RA, adhesive capsulitisRA – morning stiffness, better with activity. Shoulder sx in RA is common, especially in late stages of dse.
47Unusual causes Hemochromatosis Hemophilia Think of this if patients develop OA in unusual places at unusually early agesHemophiliaBlood very erosive to joint
48Exam for glenohumeral OA GH joint line tenderness and swellingJust below coracoid processUse outward and upward pressureEffusion may be very hard to seeDecreased ROMExternal rotation, abductionEndpoint stiffnessCrepitus
49Imaging for glenohumeral OA Joint space narrowing (loss of articular cartilage)OsteophytesHumeral head sclerosis and flatteningClub-like deformity
50Tx of glenohumeral OA Low impact activities, and heat + stretching Let pain be the guideNSAIDs, acetaminophen, glucosamine, chondroitinIntra-articular steroidsIntra-articular hyaluronateArthroplasty or total shoulder replacement
51Polymyalgia rheumatica Think of this with patients >60, especially if they have bilateral shoulder symptomsFemales>malesEuropeansRare – per 100,000 per year
52Symptoms of PMR Acute to sub-acute onset Morning stiffness Night pain Patients can’t get out of bedNight painProximal muscle involvement20% have joint swelling
53PMR and giant cell arteritis Between 1-16% pts with PMR develop GCANearly half of pts with GCA have co-existing PMRWatch for jaw claudication, visual changes, scalp tenderness
55Parsonage-Turner syndrome Brachial neuritisThought to be post-viralSudden onset shoulder pain that resolvesWeakness then developsSuprascapular/long thoracic nerve involvement is commonCan get atrophy of supra/infraspinatusCan have scapular wingingMonths to years to regain strength
56Pain patterns #1 Lateral – most common Anterior Impingement syndrome Rotator cuff tendonitis with tear if also weakFrozen shoulder if also stiff, loss of movementAnteriorAC jointGH jointBiceps tendon
57Pain patterns #2 Posterior – least common Poorly localized Usually referred pain from C- spineCan also be referred pain from rotator cuff tendonitisPoorly localizedNeckNervesMalingering