1. The Shoulder Exam Jeffrey Rosenberg MD Residency Program in Family Medicine Montefiore Hospital June 2, 2005

2. Objectives  Learn the anatomy of the Shoulder joint so as to better understand shoulder pathology  Review the proper primary care based shoulder examination  Discuss shoulder pathology in relation to age of patient and mechanism of injury

3. Case #1  20 yo male who plays weekend softball p/w pain over the anterior lateral aspect of the rt. shoulder and lateral upper arm. No specific injury noted. C/o pain when combing hair and at nighttime. Exam sig. for nl anatomy, painful arc from 70-130 deg., nl rotator cuff strength. What could his diagnosis be?

4. Case #2  45 yo female p/w gradual onset of pain on top of left shoulder. Pt does remember a sign. fall several years ago onto the left arm and shoulder. C/o pain at night, and with raising arm above head. Exam shows mostly normal AROM and PROM. Tenderness over AC joint with mild protuberance. What could be the cause of this pain

5. Shoulder Bones

6. Glenoid Cavity

7. Acute Pain (<2 weeks)  Fracture if sig fall (esp in >50)  Shoulder Instability: Subluxation/Dislocation-fall with arm outstreched overhead Acute rotator cuff tear-fall with arm abducted Need quick diagnosis/treatment  AC joint separation (if falls onto side of shoulder)

8. Pathology for subacute/chronic often based on age of patient  Middle Aged (30-50): Impingement Syndrome, Partial rotator cuff tears Frozen shoulder  Older patient (>50): Complete RTC tear Degenerative Arthiritis-lots of stiffness Frozen shoulder-lots of stiffness Fracture after fall

9. Shoulder Exam  Start with anatomy. Symmetry of the shoulder, protuberance over AC joint, atrophy of muscles  Tenderness: Biceps Tendon, Lat and Post shoulder, AC joint, SC joint, Clavicle, Scapular Spine

10. Range of Motion  Measure ROM and feel for crepitus  Flexion: move arm forward from body anteriorly 0-165  Extension: move arm backwards from body posteriorly 0-60  Abduction: Abduct arm away from body. 0-170. Note painful arc: 70-120 acromial imping. vs. 130- 160 AC jt imping or arthritis

11. Range of Motion  EXTERNAL ROTATION: (nl 90 degrees) Lack of External Rotation with elbow/shoulder in neutral equal Frozen Shoulder/GH arthritis External Rotation Strength from infraspinatus  REMEMBER for Abduction: Initial 20 degrees of motion from deltoid and ss 20-130 from supraspinatus 130-150 from rotation of scapula

12. Range of Motion  If motion limited, move passively  Drop test: Passively Abduct; let go of arm ?maintain abduction. If not: RTC likely completely torn!! Injection w/ lidocaine and repeat to make sure  Hold scapula and passively abd arm- Decreased movement equals joint restriction from frozen shoulder or GH arthritis.

13. Range of Motion  Cross Body Adduction: adduct arm across body. 0-50: Painful with AC joint pathology.  Internal Rotation: can be done in abduction or extension: measure by vertebrae of t- spine.

14. Rotator Cuff

15. Rotator Cuff Strength  Supraspinatus: Empty can test  Infraspinatus and Teres Minor: Hitch hiker test (ext rotation with elbow next to body)  Subscapularis: with arm internal rotation and extension, have patient move hand away from body

16. Impingement Syndrome  Impingement of RTC or bursa  Inflammation/Swelling increase the size in a tight space OR space gets smaller secondary to bony growth. Can progress to RTC tear.  Swelling ->Tendonitis and Fibrosis- >Degeneration (Tendinosis) and Tears  Often Coexist/continuum

17. Subacromial Bursa

18. Impingement and the ACROMION

19. Impingement Syndrome  Symptoms: gradual onset, anterior-lateral pain, worse overhead, night time pain  Tender over ant or lateral shoulder. Crepitus and Pain with active abduction 60-120 degrees (painful arc). Normal Strength Neer and Hawkins Impingment tests painful.  If positive, could inject with lido,steroids and repeat. If sx resolve, impingement evident

20. Impingement Signs  Neer impingement sign. Forcibly flex arm fully above head to produce pain as humerus compressed Rotator cuff against coracoacromial arch

21. Impingement Signs  Hawkins sign: Abduct arm 90 deg., flex, and forcibly internally rotate arm. Pain sign for subacromial impingement or rotator cuff tendonitis.

22. Gleno-humeral Instability  Inability to keep humeral joint centered in glenoid socket: Sense of Slippage.  TUBS: Traumatic subluxation/dislocation Unilateral, involve tear of glenoid labrum- Bankart Lesion, needs Surgery  AMBRI: Atraumatic dislocation, Multidirectional, Bilateral, Rehab.

23. Gleno-humeral Instability  Sling 6 weeks (external rotation best): Recurrent Dislocation dependant on age/sport  Need lots of PT-if no help-surgery  If occurs > 2 times, reoccurs almost 100%- needs surgery especially if young/active  Subtle instability -> secondary impingement in overuse situation (swimming, pitching, tennis, etc). Fatigue causing migration of head

24. Gleno-humeral instability  Apprehension Test: Abduct shoulder to 90 deg. SLOWLY externally rotate while pushing head of humerus forward with thumb of other hand. Apprehension on the part of the patient is evidence of chronic anterior instability.

25. Gleno-humeral Instability  Sulcus Sign: Pull arm inferiorly and watch for deepening of the acromio-humeral sulcus; sign of inferior instability

26. Don’t Forget about the Neck Investigation of shoulder complaints is not complete without investigation of the cervical spine: Palpate cervical spine Check DTR’s, sensation and strength Spurlinigs Sign

27. Radiography  Acutely: Episode of Dislocation S/p trauma with AC joint/Clavicle Pain After fall in older patient (>60) with decreased ROM

28. Radiography  Chronically: Frozen Shoulder >50 (to see in GH OA) Acromion View : increases likelihood of significant. RTC Pathology

29. Radiography  MRI: Useful for evaluating for Rotator Cuff Tears (partial/complete)-I order them if patient not better with steroid injection/still have weakness  If looking for labral tear-Need intra-articular Gadolinium