history & physical examination of the shoulder
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History & Physical History & Physical Examination of the ShoulderExamination of the Shoulder
Garry W. K. Ho, M.D.Garry W. K. Ho, M.D.VCU / Fairfax Family PracticeVCU / Fairfax Family Practice
Sports Medicine FellowSports Medicine FellowJanuary 2007January 2007
ObjectivesObjectives
Review pertinent anatomy of Review pertinent anatomy of the shoulderthe shoulder
Review differential diagnosis Review differential diagnosis of shoulder complaintsof shoulder complaints
Review clinical history and Review clinical history and physical examination of the physical examination of the shoulder shoulder
Review common shoulder Review common shoulder injuries & characteristic injuries & characteristic physical exam findingsphysical exam findings
Brief EpidemiologyBrief Epidemiology
Shoulder pain: a common Shoulder pain: a common complaint in primary carecomplaint in primary care– 22ndnd only to knee pain for only to knee pain for
specialist referralsspecialist referrals– Most common causes in adults Most common causes in adults
(peak ages 40-60)(peak ages 40-60)Subacromial impingement Subacromial impingement syndromesyndrome
Rotator cuff problemsRotator cuff problems
Athletic injuriesAthletic injuries– Shoulder: 8-13% of all Shoulder: 8-13% of all
athletic injuriesathletic injuries
AnatomyAnatomy
3 Bones3 Bones– HumerusHumerus– ScapulaScapula– ClavicleClavicle
3 Joints3 Joints– GlenohumeralGlenohumeral– AcromioclavicularAcromioclavicular– SternoclavicularSternoclavicular
1 “Articulation”1 “Articulation”– ScapulothoracicScapulothoracic
AnatomyAnatomy
HumerusHumerus– Head *Head *– Greater tubercle*Greater tubercle*– Lesser tubercle*Lesser tubercle*– Intertubercular Intertubercular
(bicipital) groove(bicipital) groove– Deltoid tuberosityDeltoid tuberosity
ScapulaScapula– AnglesAngles
SuperiorSuperior
InferiorInferior
Lateral (Head)Lateral (Head)
AnatomyAnatomy
ScapulaScapula– GlenoidGlenoid– AcromionAcromion– CoracoidCoracoid– Subscapular fossaSubscapular fossa– Scapular spineScapular spine– Supraspinatus Supraspinatus
fossafossa– Infraspinatus Infraspinatus
fossafossa
AnatomyAnatomy
Glenohumeral jointGlenohumeral joint
– ““Ball and socket” vs Ball and socket” vs “Golf ball and tee”“Golf ball and tee”
– Very mobileVery mobile
– Price: instabilityPrice: instability
– 45% of all dislocations45% of all dislocations
– Joint stability depends Joint stability depends on multiple factorson multiple factors
AnatomyAnatomy
Glenohumeral jointGlenohumeral joint
– Passive stabilityPassive stability
Joint conformityJoint conformity
Glenoid labrum (50%)Glenoid labrum (50%)
Joint capsuleJoint capsule
LigamentsLigaments
Bony restraintsBony restraints
AnatomyAnatomy
MusclesMuscles– DeltoidDeltoid– Trapezius *Trapezius *– Rhomboids *Rhomboids *– Levator Levator
scapulae *scapulae *– Rotator cuffRotator cuff– Teres majorTeres major– BicepsBiceps– Pectoralis Pectoralis
muscles *muscles *– Serratus Serratus
anterior *anterior ** Scapular stabilizers* Scapular stabilizers
AnatomyAnatomyRotator Cuff Rotator Cuff MusclesMuscles
– SS – Supraspinatus – Supraspinatus
– II – Infraspinatus – Infraspinatus
– tt - Teres minor - Teres minor
– SS- Supscapularis- Supscapularis
AnatomyAnatomy
BursaeBursae
– SubacromialSubacromial
(Subdeltoid)(Subdeltoid)
– SubscapularSubscapular
AnatomyAnatomy
NeurologicNeurologic
– Nerve rootsNerve roots
– Brachial Brachial plexusplexus
– Peripheral Peripheral nervesnerves
AnatomyAnatomyCoordinated Coordinated shoulder motionshoulder motion
– Glenohumeral Glenohumeral motionmotion
– Acromioclavicular Acromioclavicular motionmotion
– Sternoclavicular Sternoclavicular motionmotion
– Scapulothoracic Scapulothoracic motionmotion
Scapular-humeral rhythmScapular-humeral rhythm
Differential DiagnosisDifferential DiagnosisImpingement syndromeImpingement syndrome– Subacromial bursitisSubacromial bursitis– Rotator cuff tendinopathyRotator cuff tendinopathy– Rotator cuff tearRotator cuff tear– Biceps tendinopathyBiceps tendinopathy
Adhesive capsulitisAdhesive capsulitisSC joint aSC joint arthritis, sprainrthritis, sprainAC joint aAC joint arthritis, sprainrthritis, sprainGlenohumeral joint OAGlenohumeral joint OAInstablityInstablity– GH dislocationGH dislocation– GH subluxationGH subluxation– Labral tear (e.g. Bankart, Labral tear (e.g. Bankart,
SLAP, etc.)SLAP, etc.)Clavicle fractureClavicle fractureProximal humerus fractureProximal humerus fractureScapular fractureScapular fracture
Other arthritic diseaseOther arthritic disease– Rheumatoid, Gout, SLERheumatoid, Gout, SLE– Septic, Lyme, etc.Septic, Lyme, etc.
Avascular necrosisAvascular necrosis
Neoplastic diseaseNeoplastic disease
Thoracic outlet syndromeThoracic outlet syndrome
CRPSCRPS
Myofascial painMyofascial pain
Referred painReferred pain– Cervical radiculopathyCervical radiculopathy– CardiacCardiac– Aortic aneurysmAortic aneurysm– Abdominal / DiaphragmAbdominal / Diaphragm– Other GIOther GI
Clinical HistoryClinical HistoryCharacterize painCharacterize painLocation of painLocation of painNight painNight painWeaknessWeaknessDeformity Deformity InstabilityInstabilityLocking / Clicking / Locking / Clicking / ClunkingClunkingSport / OccupationSport / OccupationPrevious treatmentsPrevious treatmentsAlleviating / Exacerbating Alleviating / Exacerbating Acute vs. ChronicAcute vs. ChronicTraumatic vs. OveruseTraumatic vs. OveruseHistory of prior injuryHistory of prior injury
Clinical HistoryClinical HistoryMechanism of InjuryMechanism of Injury
Physical ExamPhysical Exam
ObservationObservation– Undress waist Undress waist → → upup
PalpationPalpation
Active & passive Active & passive ROMROM
Strength testingStrength testing
Special testsSpecial tests
Physical Exam – Observation / Physical Exam – Observation / InspectionInspection
Front & BackFront & Back
Height of shoulder Height of shoulder & scapulae& scapulae
AsymmetryAsymmetry
Obvious deformityObvious deformity
Ecchymosis Ecchymosis
Muscle atrophyMuscle atrophy– SupraspinatusSupraspinatus– InfraspinatusInfraspinatus– DeltoidDeltoid
PalpationPalpation
At rest & with At rest & with movementmovement
Bony structuresBony structures
JointsJoints
Soft tissuesSoft tissues
PalpationPalpationSurface Anatomy Surface Anatomy (Anterior)(Anterior)
– ClavicleClavicle– SC JointSC Joint– Acromion processAcromion process– AC JointAC Joint– DeltoidDeltoid– Coracoid processCoracoid process– Pectoralis majorPectoralis major– TrapeziusTrapezius– Biceps (long head)Biceps (long head)
AC joint
SC joint
biceps
PalpationPalpationSurface Anatomy Surface Anatomy (Posterior)(Posterior)
– Scapular spineScapular spine– Acromion processAcromion process– SupraspinatusSupraspinatus– InfraspinatusInfraspinatus– DeltoidDeltoid– TrapeziusTrapezius– Latissumus dorsiLatissumus dorsi– ScapulaScapula
Inferior angleInferior angleMedial borderMedial border
Supraspinatus
Infraspinatus
Inferior angle of scapula
Range of MotionRange of MotionForward flexion:Forward flexion:160 - 180160 - 180°°
Extension: 40 - 60Extension: 40 - 60°°
Abduction: 180◦Abduction: 180◦
Adduction: 45 °Adduction: 45 °
Internal rotation: Internal rotation: 60 - 90 60 - 90 °°
External rotation:External rotation:80 - 90 80 - 90 °°
Apley Scratch TestApley Scratch Test
Range of MotionRange of Motion
Scapular dyskinesis Scapular dyskinesis (Scapulothoracic (Scapulothoracic dysfuntion)dysfuntion)
– Compare scapular Compare scapular motion through ROM on motion through ROM on both sidesboth sides
– Wall push-upsWall push-ups
– SymmetricalSymmetrical– SmoothSmooth– No or minimal wingingNo or minimal winging
Strength TestingStrength TestingTest & compare both sidesTest & compare both sidesBe specific to muscle or Be specific to muscle or muscle groupmuscle group
Grade strength on 0 Grade strength on 0 → → 5 5 scalescale– 0: no contraction0: no contraction– 1: muscle flicker; no 1: muscle flicker; no
movementmovement– 2: motion, but not against 2: motion, but not against
gravitygravity– 3: motion against gravity, but 3: motion against gravity, but
not resistancenot resistance– 4: motion against resistance4: motion against resistance– 5: normal strength5: normal strength
Strength TestingStrength TestingExternal rotationExternal rotation
– Tests RTC muscles that Tests RTC muscles that ER the shoulderER the shoulder
InfraspinatusInfraspinatus
Teres minor Teres minor
– Arms at the sidesArms at the sides
– Elbows flexed to 90 Elbows flexed to 90 degreesdegrees
– Externally rotates arms Externally rotates arms against resistance against resistance
Strength TestingStrength TestingInternal rotationInternal rotation
– Tests RTC muscle that IR Tests RTC muscle that IR the shoulderthe shoulder
SubscapularisSubscapularis
– Arms at the sidesArms at the sides– Elbows flexed to 90 Elbows flexed to 90
degreesdegrees– Internally rotates arms Internally rotates arms
against resistance against resistance
– Subscapularis Lift-Off Subscapularis Lift-Off TestTest
– Other techniquesOther techniques
Strength TestingStrength TestingSupraspinatusSupraspinatus
– ““Empty can" testEmpty can" test– Jobe’s TestJobe’s Test
– Tests SupraspinatusTests Supraspinatus– Attempt to isolate from Attempt to isolate from
deltoiddeltoid
– Positioned sittingPositioned sitting– Arms straight outArms straight out– Elbows locked straightElbows locked straight– Thumbs downThumbs down– Arm at 30 degrees Arm at 30 degrees
(in scapular plane)(in scapular plane)– Attempts to elevate Attempts to elevate
arms against resistancearms against resistance
Special Provocative TestsSpecial Provocative Tests
Impingement SignsImpingement Signs
Drop-Arm TestDrop-Arm Test
Speed’s TestSpeed’s Test
Yergason TestYergason Test
Cross-Arm AdductionCross-Arm Adduction
Sulcus SignSulcus Sign
Apprehension testApprehension test
Relocation testRelocation test
O’Brien’s TestO’Brien’s Test
Crank testCrank test
Subacromial Impingement Subacromial Impingement SyndromeSyndrome
Impingement of:Impingement of:– Subacromial bursaSubacromial bursa– Rotator cuff muscles and Rotator cuff muscles and
tendonstendons– Biceps tendonBiceps tendon
BetweenBetween– AcromionAcromion– Coracoacromial ligamentCoracoacromial ligament– AC jointAC joint– Coracoid processCoracoid process– Humeral headHumeral head
Rotator cuff tendonosisRotator cuff tendonosis
Impingement SignsImpingement Signs
Neer’s SignNeer’s Sign
– Arm fully pronated Arm fully pronated and placed in forced and placed in forced flexionflexion
– Trying to impinge Trying to impinge subacromial subacromial structures with structures with humeral headhumeral head
– Pain is positive testPain is positive test
Impingement SignsImpingement Signs
Hawkin’s SignHawkin’s Sign
– Arm is forward Arm is forward elevated to 90 elevated to 90 degrees, then degrees, then forcibly internally forcibly internally rotatedrotated
– Trying to impinge Trying to impinge subacromial subacromial structures with structures with humeral headhumeral head
– Pain is positive testPain is positive test
Rotator Cuff TearRotator Cuff Tear
Partial thickness tearPartial thickness tearFull (Complete) Full (Complete) thickness tearthickness tear
May be due to:May be due to:– ImpingementImpingement– DegenerationDegeneration– OveruseOveruse– TraumaTrauma
Partial tearsPartial tears– ConservativeConservative
Complete tearsComplete tears– SurgerySurgery
Rotator Cuff Tear: Drop-Arm TestRotator Cuff Tear: Drop-Arm TestAbducted arm slowly Abducted arm slowly lowered lowered – May be able to lower May be able to lower
arm slowly to 90° arm slowly to 90° (deltoid function)(deltoid function)
– Arm will then drop to Arm will then drop to side if rotator cuff side if rotator cuff teartear
Positive testPositive test– patient unable to patient unable to
lower arm further lower arm further with controlwith control
– If able to hold at 90º, If able to hold at 90º, pressure on wrist will pressure on wrist will cause arm to fall cause arm to fall
Biceps TendonosisBiceps Tendonosis
Injury to long head Injury to long head of biceps tendonof biceps tendon
Typically an Typically an overuse injuryoveruse injury– Repetitive Repetitive
(overhead) lifting(overhead) lifting– ImpingementImpingement
Biceps Tendonosis: Speed’s TestBiceps Tendonosis: Speed’s Test
Forward flex shoulder to about 90°Abduct shoulder to about 10°Arm in full supination
Apply downward force to distal arm
Pain is positive test
Weakness without pain: muscle weakness or rupture
Biceps Tendonosis: Yergason’s TestBiceps Tendonosis: Yergason’s Test
Elbow flexed to 90Elbow flexed to 90°°Start in pronated Start in pronated positionposition
Active supination & Active supination & flexion against flexion against resistanceresistancePalpate biceps tendonPalpate biceps tendon
Pain or painful pop is Pain or painful pop is positive testpositive test– TendonosisTendonosis– SubluxationSubluxation
AC SeparationAC Separation
AC Sprain / AC Sprain / SeparationSeparation
– Typically due to Typically due to fall onto tip of fall onto tip of shoulder shoulder (acromion)(acromion)
– Arm tucked into Arm tucked into sideside
– Treatment Treatment depends on typedepends on type
AC Arthritis / DJDAC Arthritis / DJD
AC Joint: Cross-Arm Adduction TestAC Joint: Cross-Arm Adduction Test
Arm flexed to 90Arm flexed to 90°°
Arm adducted to > 45Arm adducted to > 45°°
Hyperadduct shoulder Hyperadduct shoulder (down on elbow)(down on elbow)
Positive test is pain in Positive test is pain in AC jointAC joint
Watch out for false-Watch out for false-positivespositives– Where is the pain?Where is the pain?
Shoulder InstabilityShoulder Instability
Failure to keep humeral Failure to keep humeral head centered in glenoidhead centered in glenoid
DislocationDislocation– Complete disruption of Complete disruption of
joint congruity or joint congruity or alignmentalignment
SubluxationSubluxation– Partial or incomplete Partial or incomplete
dislocationdislocation
LaxityLaxity– Slackness or looseness in Slackness or looseness in
jointjoint– May be normal or May be normal or
abnormalabnormal
Instability: Sulcus SignInstability: Sulcus SignInferior instabilityInferior instability
Arm relaxed in Arm relaxed in neutral positionneutral positionArm pulled Arm pulled downward at wristdownward at wrist
Positive test is a Positive test is a visible sulcus at visible sulcus at infra-acromial area infra-acromial area – Compare to Compare to
contralateral sidecontralateral side
Instability: Apprehension TestInstability: Apprehension TestAnterior instabilityAnterior instability
Shoulder abducted to Shoulder abducted to 9090°°Slight stress to humeral Slight stress to humeral head directed in head directed in anterior directionanterior directionWhile externally While externally rotating shoulder rotating shoulder
Positive test is Positive test is apprehension due to apprehension due to feeling of instability or feeling of instability or impending dislocationimpending dislocation– Beware if false positivesBeware if false positives
Instability: Relocation TestInstability: Relocation Test
Anterior instabilityAnterior instability
After a positive After a positive apprehensionapprehensionApply posteriorly Apply posteriorly directed force over directed force over externally rotated externally rotated humeral headhumeral head
Positive test is relief Positive test is relief of apprehensionof apprehension
Anterior release testAnterior release test
Glenoid Labral TearGlenoid Labral Tear
Tear in glenoid labrumTear in glenoid labrum
Usually due to instabilityUsually due to instability
SLAP Tear (Superior Labrum SLAP Tear (Superior Labrum Anterior to Posterior)Anterior to Posterior)– Superior labral tearSuperior labral tear– Fall on outstretched hand or Fall on outstretched hand or
shouldershoulder– Rotator cuff tendonosis or Rotator cuff tendonosis or
tearstears
Bankart LesionBankart Lesion– Anterior-inferior labral tearAnterior-inferior labral tear– Anterior shoulder Anterior shoulder
dislocation / subluxationdislocation / subluxation
O’Brien’s Active Compression TestO’Brien’s Active Compression Test
Labral, AC, or biceps Labral, AC, or biceps pathologypathology
Arm flexed to 90Arm flexed to 90°°Arm cross-arm Arm cross-arm adducted adducted 10-1510-15°°Elbow extendedElbow extendedMax pronationMax pronationResist downward forceResist downward force
Positive test if painful Positive test if painful Beware location of painBeware location of pain– ACAC– BicepsBiceps– Internal +/- clickInternal +/- click
O’Brien’s Active Compression TestO’Brien’s Active Compression Test
For labral For labral pathologypathology
– Repeat testing Repeat testing withwith
– Max supinationMax supination– Should be pain Should be pain
freefree
Labral Tear: Crank TestLabral Tear: Crank Test
Abduct arm to 90-Abduct arm to 90-120120°°
Stabilize shoulder Stabilize shoulder
Elbow secured with Elbow secured with one handone hand
Axially load with ER / Axially load with ER / IR at shoulder IR at shoulder
Positive test: audible Positive test: audible or painful click / or painful click / catch / grind catch / grind
Diagnostic InjectionDiagnostic Injection
AC jointAC joint
Subacromial spaceSubacromial space
Glenohumeral jointGlenohumeral joint
Biceps tendon (long Biceps tendon (long head)head)
Thanks!Thanks!
Questions?Questions?
Rotator Cuff TearRotator Cuff Tear
History / History / Maneuver Maneuver
Study Study QualQual
SensSens
(%)(%)SpecSpec
(%)(%)LR+LR+ LR-LR- PV+PV+
(%)(%)PV-PV-
(%)(%)
History of History of trauma trauma
2b2b 3636 7373 1.31.3 0.880.88 7272 3737
Night pain Night pain 2b2b 8888 2020 1.11.1 0.60.6 7070 4343
Painful arc Painful arc 2b2b 3333 8181 1.71.7 0.830.83 8181 3333
Empty can Empty can test test
1b1b 84 84
89895050
58581.71.7
220.220.22
0.280.283636
98982222
9393
Drop arm Drop arm 1b1b 2121 100100 >25>25 0.790.79 100100 3232
Impingement / InstabilityImpingement / Instability
TestTest Study Study QualQual
SensSens
(%)(%)SpecSpec
(%)(%)LR+LR+ LR-LR- PV+PV+
(%)(%)PV-PV-
(%)(%)
ImpingementImpingement
Hawkin’sHawkin’s 1b1b 8787
89896060 2.22.2 0.180.18 7171 8383
InstabilityInstabilityRelocationRelocation 2b2b 5757 100100 >25>25 0.430.43 100100 7373
ApprehensionApprehension 2b2b 6868 100100 >25>25 0.320.32 100100 7878
AC Joint / SLAP TearAC Joint / SLAP Tear
History / History / Maneuver Maneuver
Study Study QualQual
SensSens
(%)(%)SpecSpec
(%)(%)LR+LR+ LR-LR- PV+PV+
(%)(%)PV-PV-
(%)(%)
AC JointAC Joint
ActiveActive
compressioncompression1b1b 100100 9797 >25>25 0.010.01 8989 100100
SLAP TearSLAP Tear
CrankCrank 2b2b 9191 9393 1313 0.100.10 9494 9090
ActiveActive
compressioncompression1b1b 100100 9999 >25>25 0.010.01 9595 100100
Differential DiagnosisDifferential Diagnosis
Diagnosis Diagnosis Primary Care Primary Care %%
AgeAge
Subacromial Impingement Subacromial Impingement Syndrome Syndrome
48-7248-72 23-6223-62
Adhesive Capsulitis Adhesive Capsulitis 16-2216-22 5353
Acute Bursitis Acute Bursitis 1717 --
Calcific Tendonitis Calcific Tendonitis 66 --
Myofascial Pain Syndrome Myofascial Pain Syndrome 55 --
Glenohumeral Joint Arthrosis Glenohumeral Joint Arthrosis 2.52.5 6464
Thoracic Outlet Syndrome Thoracic Outlet Syndrome 22 --
Biceps Tendonitis Biceps Tendonitis 0.80.8 --
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