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

Download Report

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

Physical Examination
of the Shoulder
Lisa Chiou, MD, MPH
Primary Care Conference
Goals
Review some of that anatomy from
medical school
Discuss common shoulder problems
Practice focused physical exam
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
Review of shoulder anatomy
 Bones
Scapula
Clavicle
Humeral head
Posterior rib cage
 Joints
Sternoclavicular
Acromioclavicular
Glenohumeral
Scapulothoracic
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
More shoulder anatomy
Ligaments
Coracoclavicular
Acromioclavicular
Glenohumeral
Superior GH
Middle GH
Inferior GH
Coracohumeral
Subacromial bursa
Subdeltoid bursa
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
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
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
Active range of motion
Forward flexion
Abduction/adduction
Painful arc of abduction – sensitive, not specific
External rotation
Internal rotation
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
Rotator cuff strength testing
Supraspinatus
“Pour out a Coke”
Infraspinatus and teres minor
“Act like a penguin”
Subscapularis
“Scratch your back”
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
Biceps strength testing
Arms outstretched with palms up at level
of shoulder
Forced supination of hand with elbow
flexed at 90 degrees
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
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
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
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
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
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)
Exam for impingement
Painful arc of abduction (active)
60-120 degrees
Impingement signs
Impingement test
Subacromial lidocaine injection
Can then test again for weakness
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
Tx of tendonitis
Rest
Heat or ice
Ultrasound (physical therapy)
NSAIDs
Subacromial steroid injection
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
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
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
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
Rotator cuff tears
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
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
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 2nd or 3rd degree joint
separation
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
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
Rare associations
Hyper- or hypothyroidism
Parkinson’s disease
Antiretrovirals (PPIs)
Recent neurosurgery
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
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
Arthrogram for adhesive capsulitis
Normal capsule volume
Frozen shoulder
(contracted GH capsule)
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
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
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
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
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
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
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
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
Unusual causes
Hemochromatosis
Think of this if patients develop OA in unusual
places at unusually early ages
Hemophilia
Blood very erosive to joint
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
Imaging for glenohumeral OA
 Joint space narrowing
(loss of articular
cartilage)
 Osteophytes
 Humeral head sclerosis
and flattening
 Club-like deformity
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
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
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
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
Shoulder weakness after viral illness
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
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
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
Thanks!
And HUGE
thanks to
Dr. Greg
Gardner!!