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Physical Examination of the Shoulder Lisa Chiou, MD, MPH Primary Care Conference.

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Presentation on theme: "Physical Examination of the Shoulder Lisa Chiou, MD, MPH Primary Care Conference."— Presentation transcript:

1 Physical Examination of the Shoulder Lisa Chiou, MD, MPH Primary Care Conference

2 Goals Review some of that anatomy from medical school Discuss common shoulder problems Practice focused physical exam

3 Shoulder pain Common in all age groups Intrinsic disorder (85%) vs referred pain  C-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 bladder  Myocardial ischemia  Pancoast tumor

4 Review of shoulder anatomy Bones  Scapula  Clavicle  Humeral head  Posterior rib cage Joints  Sternoclavicular  Acromioclavicular  Glenohumeral  Scapulothoracic

5 Glenohumeral joint 25% humeral head surface in contact with glenoid Joint space thinning seen with OA Humeral head 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 muscles Supraspinatus, infraspinatus, teres minor, subscapularis Form cuff around humeral head Keep humeral head within joint (counteract deltoid) Abduction, external rotation, internal rotation

8 Shoulder exam #1 Visualize from front and back Asymmetry  Pts with rotator cuff tears hold shoulder higher Atrophy  Sign of chronic glenohumeral joint pathology Effusions  Shoulder joint can hide a lot of fluid

9 Shoulder exam #2 Palpation  Along clavicle  SC and AC joints  Acromion, subacromial region  Coracoid process (short head of biceps)  Bicipital groove (long head of biceps)  Trigger points in neck, trapezius, scapular region

10 Active range of motion Forward flexion Abduction/adduction  Painful arc of abduction – sensitive, not specific External rotation Internal rotation

11 Passive range of motion Immobilize the scapula to prevent rotation  Use one arm to push down on shoulder  Use other arm to do the PROM exercises Abduction Internal and external rotation  Have arm at patient’s side and abducted to 90 degrees

12 Rotator cuff strength testing Supraspinatus  “Pour out a Coke” Infraspinatus and teres minor  “Act like a penguin” Subscapularis  “Scratch your back”

13 Impingement maneuvers Impingement sign  At 90 degrees of abduction with elbow flexed to 90 degrees, do internal (downward) and external (upward) rotation Hawkins’ test  At 90 degrees of elbow flexion, do internal rotation by pushing down on pt’s forearm Neer’s test  At full elbow extension, internally rotate and flex the arm

14 Biceps strength testing Arms outstretched with palms up at level of shoulder Forced supination of hand with elbow flexed at 90 degrees


16 Impingement syndrome Compression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromion Repetitive overhead motions Main cause of rotator cuff tendonitis Can lead to bursitis, partial or full rotator cuff tears

17 Sx of impingement syndrome Usually gradual onset Outer deltoid pain, especially with reaching or overhead movements Night pain Difficulty sleeping on affected side Nearly identical symptoms as tendonitis

18 Exam for impingement Pain with painful arc maneuver Crepitus above 60 degrees Subacromial tenderness (lateral) No pain with external/internal rotation, abduction, elbow flexion  Distinguishes impingement from tendonitis Normal glenohumeral ROM Normal strength

19 Radiology for impingement X-rays usually not needed  Reasonable to get if chronic symptoms MRI can rule out other pathology  Wait at least 24 hours after an injection  Osseous abnormalities  Need to clinically correlate MRI findings

20 Tx of impingement Rest Ice Stretching, then strengthening  Pendulum for 5-10 minutes QD  Can increase space under acromion by ½” Don’t use arm sling Subacromial injection Surgical referral if no improvement after 3-6 months

21 Rotator cuff tendonitis Some argue this is same as impingement Acute or chronic  Acute – more likely to have calcific deposits Pain along lateral arm (outer deltoid) Pain with numerous activities, lying on the affected side, overhead movements RF – relative overuse, age, osteophytes, trauma, inflammatory processes (RA)

22 Exam for impingement Painful arc of abduction (active)  60-120 degrees Impingement signs Impingement test  Subacromial lidocaine injection  Can then test again for weakness

23 Radiology for tendonitis Nothing is diagnostic Plain films not necessary  Get if chronic or recurrent  Might see calcifications If significant loss of strength or ROM, get MRI  Rule out tear  Hard to see tendon calcifications

24 Tx of tendonitis Rest Heat or ice Ultrasound (physical therapy) NSAIDs Subacromial steroid injection

25 Rotator cuff tear 50% pts do not have preceding trauma Usually in supraspinatus Wide size range, plus partial vs full Shoulder weakness, pain, loss of motion Common mechanisms of injury:  Falling onto outstretched arm, onto outer shoulder directly, heavy pushing/pulling

26 Sx of rotator cuff tear Shoulder weakness Localized pain over upper back Popping/catching sensation when shoulder is moved Night pain is characteristic Sx vary depending on direction of the torn tendon fibers  Parallel: pain  Transverse: weakness, loss of function

27 Exam for rotator cuff tear Range of motion Strength Drop arm test  Arm abducted with elbow straight  See if pt can smoothly lower arm  If arm drops, then test is positive for tear  Highly specific but only 21% sensitive

28 Radiology for rotator cuff tears Interpret carefully  34% asymptomatic pts (all ages) and 54% pts >60 yo have partial rotator cuff tears  Abnormal rotator cuff signal after trauma may represent strain rather than tear X-rays  Look for high riding humeral head Ultrasound  Highly operator dependent MRI

29 Rotator cuff tears

30 Tx of rotator cuff tears Ice, NSAIDs, restrict aggravating motions Weighted pendulum No arm slings Steroid injection if persistent sx Surgery – refer if young pts, full/large tears, dominant arm  Best if done within 6 weeks Acromioplasty and debridement

31 Acromioclavicular injury Arthritic changes AC joint separation Anterior shoulder pain or deformity Preceding trauma Often pts hold arm close to chest and resist rotation and elevation With OA, may have grinding or popping sensation with reaching overhead/across chest

32 Exam for AC joint injuries Joint enlargement or deformity Joint tenderness Pain with crossed body adduction Joint widening with downward arm traction in pts with 2 nd or 3 rd degree joint separation

33 Tx of AC joint injury Reduce pressure and traction to allow ligaments to re-attach Acute: ice, NSAIDs, shoulder immobilizer for 3-4 weeks Persistent: steroid injection Refer to surgery if no improvement after 2 injections

34 Adhesive capsulitis Loss of motion +/- pain due to stiff GH joint Is usually reversible May have preceding trauma Most common cause (10%) is rotator cuff tendonitis Risk factors:  Diabetes  Disuse (i.e. pts with arm in sling)  Low pain thresholds  Poor compliance with exercise therapy

35 Rare associations Hyper- or hypothyroidism Parkinson’s disease Antiretrovirals (PPIs) Recent neurosurgery

36 Exam for adhesive capsulitis Clinical diagnosis Range of motion is smooth and pain-free, then stops suddenly No further passive ROM possible Normal strength in the pain-free range Can test strength again after lidocaine injection

37 Radiology for adhesive capsulitis X-rays have limited use  Might see calcifications or degenerative changes that would lead to frozen shoulder MRI  Enhancement of joint capsule and synovial membrane  4 mm thickening is 70% sensitive and 95% specific

38 Arthrogram for adhesive capsulitis Normal capsule volume Frozen shoulder (contracted GH capsule)

39 Tx of adhesive capsulitis Watchful waiting  Up to 2 years for resolution  Incomplete recovery more likely in pts with DM, or pts with >50% loss of external rotation/abduction Steroid injection Manipulation under anesthesia Gentle exercise Pain medications Alternative therapies – i.e. acupuncture

40 Biceps tendonitis Inflammation of long head of biceps  Passes through bicipital groove of anterior humerus Usually due to repetitive lifting or reaching Inflammation, microtearing, degenerative changes Up to 10% pts will have spontaneous rupture

41 Sx of biceps tendonitis Anterior shoulder pain Worse with lifting or overhead reaching Often pts point to bicipital groove Usually no weakness in elbow flexion

42 Exam for biceps tendonitis Bicipital groove tenderness Look for subacromial impingement Tendon rupture Test biceps strength Yergason test  Elbows flexed with forearms in front  Pt actively resisting external rotation  Tendon may pop out of bicipital groove when downward pressure applied to forearm

43 Ruptured biceps tendon Usually rotator cuff tear also present Get the “popeye” sign Rarely get significant weakness  Brachioradialis and short head of biceps provide 80-85% elbow flexor strength Tx is supportive

44 Radiology for biceps tendonitis Usually plain films unnecessary If tendon rupture present, then get plain films, U/S, or MRI  Look for rotator cuff tendonitis or tear

45 Tx of biceps tendonitis Reduce inflammation Strengthen biceps muscle and tendon Prevent rupture Ice, NSAIDs, avoid aggravating motions  5-10% risk of rupture with noncompliance Weighted pendulum Elbow flexion toning exercises Steroid injection Surgical referral if sx persist >3 months

46 Glenohumeral osteoarthritis Same risk factors as with OA in other areas  Trauma, obesity, age Less common than OA in weight bearing joints or spine Pain, stiffness over months to years  Anterior shoulder is most painful area Worse with activity Distinguish from RA, adhesive capsulitis

47 Unusual causes Hemochromatosis  Think of this if patients develop OA in unusual places at unusually early ages Hemophilia  Blood very erosive to joint

48 Exam for glenohumeral OA GH joint line tenderness and swelling  Just below coracoid process  Use outward and upward pressure  Effusion may be very hard to see Decreased ROM  External rotation, abduction  Endpoint stiffness Crepitus

49 Imaging for glenohumeral OA Joint space narrowing (loss of articular cartilage) Osteophytes Humeral head sclerosis and flattening Club-like deformity

50 Tx of glenohumeral OA Low impact activities, and heat + stretching  Let pain be the guide NSAIDs, acetaminophen, glucosamine, chondroitin Intra-articular steroids Intra-articular hyaluronate Arthroplasty or total shoulder replacement

51 Polymyalgia rheumatica Think of this with patients >60, especially if they have bilateral shoulder symptoms Females>males Europeans Rare – 20-50 per 100,000 per year

52 Symptoms of PMR Acute to sub-acute onset Morning stiffness  Patients can’t get out of bed Night pain Proximal muscle involvement 20% have joint swelling

53 PMR and giant cell arteritis Between 1-16% pts with PMR develop GCA Nearly half of pts with GCA have co-existing PMR Watch for jaw claudication, visual changes, scalp tenderness

54 Shoulder weakness after viral illness

55 Parsonage-Turner syndrome Brachial neuritis Thought to be post-viral Sudden onset shoulder pain that resolves Weakness then develops Suprascapular/long thoracic nerve involvement is common Can get atrophy of supra/infraspinatus Can have scapular winging Months to years to regain strength

56 Pain patterns #1 Lateral – most common  Impingement syndrome  Rotator cuff tendonitis with tear if also weak  Frozen shoulder if also stiff, loss of movement Anterior  AC joint  GH joint  Biceps tendon

57 Pain patterns #2 Posterior – least common  Usually referred pain from C- spine  Can also be referred pain from rotator cuff tendonitis Poorly localized  Neck  Nerves  Malingering

58 Thanks! And HUGE thanks to Dr. Greg Gardner!!

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