1. Shoulder Pathology and Examination For Finals
Sarah White
FY1 RLBUHT

2. To be covered
Anatomy
Common pathology
Examination
MCQs

3. Anatomy- Bones

4. Anatomy- Muscles Rotator cuff (SITS): Supraspinatus Infraspinatus
Teres minor
Subscapularis

5. Anatomy- Nerves

6. Pathology- Arthritis Osteoarthritis most likely to affect shoulder
Acromioclavicular joint >glenohumeral
Symptoms:
Pain
Stiffness
Reduced range of movement
Rheumatoid arthritis in shoulder uncommon
Septic arthritis possible
Avascular necrosis
Causes
Trauma
Sickle cell disease

7. LOSS Vs. LESS LOSS LESS Loss of bone space Osteophytes
Subchondral sclerosis
Subchondral cysts
LESS
Loss of joint space
Erosions
Soft tissue swelling
Soft bones (osteopenia)

8. Pathology- Dislocation
Aetiology
Traumatic
(Rare: connective tissue disorders i.e. Ehlers Danlos)
Presentation
Symptoms: pain, inability to move joint, tenderness, swelling
Examination: classical posturing of slight abduction and external rotation (anterior dislocation=95%)
Management
Analgesia
Rule out fracture
Reduce dislocation
Higher risk for future dislocation, joint instability

9. Pathology- Impingement Syndrome
Clinical sign not a diagnosis
Aetiology
Repetitive pinching of supraspinatus tendon as it passes through subchromial space causing irritation and inflammation- supraspinatus tendonitis
Presentation
Painful arc
Management
Rest and ice
NSAIDS
Steroids injected in subchromial space

10. Pathology- Rotator Cuff Tear
Aetiology
Atraumatic in older patients, attrition from bony spurs
Traumatic in younger patients
Presentation
Pain
Restricted mobility in pattern dependent on which muscle is torn- special tests to isolate muscles
Management
Rehab and NSAIDS
Surgical repair
Physiotherapy

11. Pathology- Frozen Shoulder
AKA adhesive capsulitis
Aetiology
Spontaneous
Following rotator cuff injury
Following period of immobility i.e. CVA or plaster immobilisation
Presentation
Non-dominant shoulder more often affected
Pain followed by stiffness
Restriction of all shoulder movements both active and passive
Management
Difficult.
Analgesia
Physio
Corticosteroid injections

12. Pathology- Long thoracic nerve injury
Aetiology
Trauma to ribs
Damage during surgery i.e. radical mastectomy
Presentation
Winged scapula
Shoulder pain
Management
Physio
Surgical repair of nerve

13. Examination Explanation and consent Inspection Palpation
Movement: active and passive
Special tests
Neurovascular integrity
Concluding remarks

14. Examination- Explanation and Consent
Introduce self
What examination you want to do
Why you want to do it
What the examination involves
Chaperone
Gain consent

15. Examination- Inspection
From front/side/back
Compare side to side for:
Symmetry
Muscle wasting
Scars
Erythema
Swelling
Check for long thoracic nerve injury
Ask pt to stand, face wall, place hands on wall at shoulder height to illicit winged scapula

16. Examination- Palpation
Temperature, compare side to side
Bony anatomy
Sternoclavicular joint
Clavicle
Acromioclavicular joint
Head of humerus
Spine of scapula
What are you feeling for:
warmth
tenderness
loss of bony continuity
bony abnormality (osteophytes)

17. Examination- Movement
Active range of movement, both shoulders at once to compare side to side.
From side
Flexion (180 degrees)
Extension (60 degrees)
External rotation (70 degrees)
From back
Internal rotation (reach up back)
Abduction (180)
Adduction (180)
Repeat all movements passively, hand on shoulder feel for crepitus.
Slow abduction for painful arc (impingement syndrome, pain at degrees)

18. Examination- Functional Movement
Both hands behind head- washing hair, dressing
Both hands up to mouth- eating
Both hands down to bottom- cleaning after toilet

19. Examination- Special Tests
Shoulder apprehension test- for shoulder instability
Young patients
Pt lies supine
Abduct shoulder to 90 degrees
Flex elbow 90 degrees
Externally rotate shoulder by holding humerus and pushing pt’s hand up
Positive test- pt is “apprehensive”, feels like shoulder will dislocate

20. Examination- Special Tests
Hawkin’s test- Impingement syndrome
Middle aged patients
Flex shoulder 90 degrees
Flex elbow 90 degrees
Passive internal rotation- stabilise humerus and push down hand
Positive test- pain in shoulder

21. Examination- Special Tests
Jobe’s test (empty can)- rotator cuff injury/tear SUPRASPINATUS
Older patients
Straight arm abducted to 90 degrees, angle forwards by 30 degrees, fist with thumbs down
Force adduction, ask pt to resist you
Positive test- pain/difficulty with resistance
May also be positive in impingement syndrome

22. Examination- Special Tests
Gerber’s lift off test- rotator cuff injury/tear SUBSCAPULARIS
Older patients
Stand behind pt, ask pt to put dorsum of hand on mid lumbar spine
Apply some pressure to pt’s palm
Ask pt to push hand away from spine
Positive test- pain or difficulty

23. Examination- Special Tests
Resisted external rotation- rotator cuff injury/tear TERES MINOR AND INFRASPINATUS
Older patients
Arms by side
Elbows flexed to 90 degrees
Ask pt to externally rotate shoulders against resistance
Positive test- pain or difficulty

24. Examination- Neurovascular
Sensation
Axillary- regimental badge
Median- lateral aspect index finger
Ulnar- medial aspect little finger
Radial- dorsal 1st interosseous space
Vascular
Radial pulse
CRT in finger

25. Examination- Concluding remarks
Examine other shoulder to compare
Joint above and below (neck, elbow)
Investigations
X ray (AP, modified axillary view)
MRI
Joint aspiration

26. MCQ 1- Which direction is the shoulder most likely to dislocate in?
a) Superior
b) Inferior
c) Anterior
d) Posterior

27. MCQ
2- Which muscle of the rotator cuff is implicated in impingement syndrome?
a) Supraspinatus
b) Infraspinatus
c) Teres minor
d) Subscapularis

28. MCQ 3- Which nerve is implicated in winged scapula?
a) Long thoracic nerve
b) Axillary
c) Ulnar
d) Radial

29. MCQ
4- Which nerve is most vulnerable to damage as a complication of anterior shoulder dislocation?
a) Long thoracic nerve
b) Axillary
c) Ulnar
d) Radial