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