clinical examination of shoulder
TRANSCRIPT
BYDR MALEY DEEPAK KUMARSENIOR RESIDENT, AIIMS, JODHPUR
• Shoulder pain: a common complaint in primary care• 2nd only to knee pain for
specialist referrals• Most common causes in adults
(peak ages 40-60)• Subacromial impingement
syndrome• Rotator cuff problems
• Athletic injuries• Shoulder: 8-13% of all
athletic injuries
• 3 Bones• Humerus• Scapula• Clavicle
• 3 Joints• Glenohumeral• Acromioclavicular• Sternoclavicular
• 1 “Articulation”• Scapulothoracic
• Glenohumeral joint
• “Ball and socket” vs “Golf ball and tee”
• Very mobile
• Price: instability
• 45% of all dislocations
• Joint stability depends on multiple factors
• Glenohumeral joint
25% of humeral head surface in contact with glenoid.
• Glenoid labrum (50%)
• Joint capsule
• Ligaments
• Rotator Cuff Muscles• S – Supraspinatus
• I – Infraspinatus
• t - Teres minor
• S- Supscapularis
Primary Elevators of ST joint
• Upper fiber of trapezius• Levator scapulae• RhomboidsPrimary Depressor of ST
joint• Lower fiber of trapezius• Latissimus dorsi
8
Primary upwards rotators of ST joint
• Upper fiber of trapezius• Lower fiber of trapezius• Serratus anterior
Primary downward rotators of ST joint
• Rhomboids• Pectoralis minor
9
Primary protractors of ST joint
• Serratus anterior
Primary retractors of ST joint
• Rhomboids• Middle fiber of
trapezius
10
Primary GH Joint Abductors• Anterior fiber of deltoid• Middle fiber of deltoid• Supraspinatus
Primary GH Joint Adductors• Latissimus dorsi• Teres major• Pectoralis major (sternal head)
11
Primary GH Joint Flexors• Anterior fiber of deltoid• Pectoralis major (clavicular head)• Coracobrachialis• Biceps brachii
Primary GH Joint Extensors• Latissimus dorsi• Teres major• Pectoralis major (sternal head)• Posterior deltoid• Long head of triceps
12
Primary GH Joint Internal Rotators• Anterior fiber of deltoid• Pectoralis major• Latissimus dorsi• Teres major• Subscapularis
Primary GH Joint External Rotators• Posterior deltoid• infraspinatus• Teres minor
13
• Bursae
• Subacromial(Subdeltoid)
• Subscapular
• Coordinated shoulder motion
• Glenohumeral motion
• Acromioclavicular motion
• Sternoclavicular motion
• Scapulothoracic motion Scapular-humeral rhythmScapular-humeral rhythm
• Impingement syndrome• Subacromial bursitis• Rotator cuff tendinopathy• Rotator cuff tear• Biceps tendinopathy
• Adhesive capsulitis• SC joint arthritis, sprain• AC joint arthritis, sprain• Glenohumeral joint OA• Instablity
• GH dislocation• GH subluxation• Labral tear (e.g. Bankart,
SLAP, etc.)• Clavicle fracture• Proximal humerus fracture• Scapular fracture
Other arthritic diseaseOther arthritic disease– Rheumatoid, Gout, SLERheumatoid, Gout, SLE– Septic, Lyme, etc.Septic, Lyme, etc.
Avascular necrosisAvascular necrosisNeoplastic diseaseNeoplastic diseaseThoracic outlet syndromeThoracic outlet syndromeCRPSCRPSMyofascial painMyofascial painReferred painReferred pain– Cervical radiculopathyCervical radiculopathy– CardiacCardiac– Aortic aneurysmAortic aneurysm– Abdominal / DiaphragmAbdominal / Diaphragm– Other GIOther GI
• Characterize pain• Location of pain• Night pain• Weakness• Deformity • Instability• Locking / Clicking /
Clunking• Sport / Occupation• Previous treatments• Alleviating / Exacerbating • Acute vs. Chronic• Traumatic vs. Overuse• History of prior injury
• Mechanism of Injury
• Observation• Undress waist → up
• Palpation• Active & passive
ROM• Strength testing• Special tests
• Front & Back• Height of shoulder
& scapulae• Asymmetry• Obvious deformity• Ecchymosis • Muscle atrophy
• Supraspinatus• Infraspinatus• Deltoid
• At rest & with movement
• Bony structures• Joints• Soft tissues
• Surface Anatomy (Anterior)
• Clavicle• SC Joint• Acromion process• AC Joint• Deltoid• Coracoid process• Pectoralis major• Trapezius• Biceps (long head)
AC joint
SC joint
biceps
• Surface Anatomy (Posterior)
• Scapular spine• Acromion process• Supraspinatus• Infraspinatus• Deltoid• Trapezius• Latissumus dorsi• Scapula
• Inferior angle• Medial border
Supraspinatus
InfraspinatusInferior angle of scapula
• Forward flexion:160 - 180°
• Extension: 40 - 60°
• Abduction: 180◦
• Adduction: 45 °
• Internal rotation: 60 - 90 °
• External rotation:80 - 90 °
Apley Scratch TestApley Scratch Test
• Scapular dyskinesis (Scapulothoracic dysfuntion)
• Compare scapular motion through ROM on both sides
• Wall push-ups
• Symmetrical• Smooth• No or minimal winging
• Test & compare both sides• Be specific to muscle or
muscle group
• Grade strength on 0 → 5 scale• 0: no contraction• 1: muscle flicker; no movement• 2: motion, but not against gravity• 3: motion against gravity, but not
resistance• 4: motion against resistance• 5: normal strength
• External rotation
• Tests RTC muscles that ER the shoulder
• Infraspinatus• Teres minor
• Arms at the sides
• Elbows flexed to 90 degrees
• Externally rotates arms against resistance
• Internal rotation
• Tests RTC muscle that IR the shoulder
• Subscapularis
• Arms at the sides• Elbows flexed to 90
degrees• Internally rotates arms
against resistance
• Subscapularis Lift-Off Test
• Other techniques
• Supraspinatus
• “Empty can" test• Jobe’s Test
• Tests Supraspinatus• Attempt to isolate from
deltoid
• Positioned sitting• Arms straight out• Elbows locked straight• Thumbs down• Arm at 30 degrees
(in scapular plane)• Attempts to elevate arms
against resistance
• Impingement Signs• Drop-Arm Test• Speed’s Test• Yergason Test• Cross-Arm Adduction• Sulcus Sign• Apprehension test• Relocation test• O’Brien’s Test• Crank test
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
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
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
• Partial thickness tear• Full (Complete)
thickness tear
• May be due to:• Impingement• Degeneration• Overuse• Trauma
• Partial tears• Conservative
• Complete tears• Surgery
Abducted 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
• Injury to long head of biceps tendon
• Typically an overuse injury• Repetitive (overhead) lifting
• Impingement
• 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
• Elbow flexed to 90°• Start in pronated
position
• Active supination & flexion against resistance
• Palpate biceps tendon
• Pain or painful pop is positive test• Tendonosis• Subluxation
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
• Arm flexed to 90°• Arm adducted to > 45°• Hyperadduct shoulder
(down on elbow)
• Positive test is pain in AC joint
• Watch out for false-positives• Where is the pain?
Failure to keep humeral Failure to keep humeral head centered in glenoidhead centered in glenoidDislocationDislocation– Complete disruption of Complete disruption of
joint congruity or joint congruity or alignmentalignment
SubluxationSubluxation– Partial or incomplete Partial or incomplete
dislocationdislocationLaxityLaxity– Slackness or looseness in Slackness or looseness in
jointjoint– May be normal or May be normal or
abnormalabnormal
• Inferior instability
• Arm relaxed in neutral position
• Arm pulled downward at wrist
• Positive test is a visible sulcus at infra-acromial area • Compare to contralateral side
• Anterior instability
• Shoulder abducted to 90°
• Slight stress to humeral head directed in anterior direction
• While externally rotating shoulder
• Positive test is apprehension due to feeling of instability or impending dislocation• Beware if false positives
• Anterior instability
• After a positive apprehension
• Apply posteriorly directed force over externally rotated humeral head
• Positive test is relief of apprehension
• Anterior release test
Tear in glenoid labrumTear in glenoid labrumUsually 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
• Labral, AC, or biceps pathology
• Arm flexed to 90°• Arm cross-arm adducted
10-15°• Elbow extended• Max pronation• Resist downward force
• Positive test if painful • Beware location of pain
• AC• Biceps• Internal +/- click
• For labral pathology
• Repeat testing with• Max supination• Should be pain free
• Abduct arm to 90-120°
• Stabilize shoulder • Elbow secured with
one hand• Axially load with ER /
IR at shoulder
• Positive test: audible or painful click / catch / grind
• AC joint• Subacromial space• Glenohumeral joint• Biceps tendon (long
head)
FINDING PROBABLE DIAGNOSISScapular winging, trauma, recent viral illness Serratus anterior or trapezius dysfunction
Seizure and inability to passively or actively rotate affected arm externally
Posterior shoulder dislocation
Supraspinatus/infraspinatus wasting Rotator cuff tear; suprascapular nerve entrapment
Pain radiating below elbow; decreased cervical range of motion Cervical disc disease
Shoulder pain in throwing athletes; anterior glenohumeral joint pain and impingement
Glenohumeral joint instability
Pain or “clunking” sound with overhead motion Labral disorder
Nighttime shoulder pain Impingement
Generalized ligamentous laxity Multidirectional instability
Key Findings in the History and Physical Examination
TEST MANEUVERDIAGNOSIS SUGGESTED BY POSITIVE RESULT
Apley scratch test Patient touches superior and inferior aspects of opposite scapula
Loss of range of motion: rotator cuff problem
Neer's sign Arm in full flexion Subacromial impingement
Hawkins' test Forward flexion of the shoulder to 90 degrees and internal rotation
Supraspinatus tendon impingement
Drop-arm test Arm lowered slowly to waist Rotator cuff tear
Cross-arm test Forward elevation to 90 degrees and active adduction
Acromioclavicular joint arthritis
Spurling's test Spine extended with head rotated to affected shoulder while axially loaded
Cervical nerve root disorder
Tests Used in Shoulder Evaluation and Significance of Positive Findings
Apprehension test Anterior pressure on the humerus with external rotation
Anterior glenohumeral instability
Relocation test Posterior force on humerus while externally rotating the arm
Anterior glenohumeral instability
Sulcus sign Pulling downward on elbow or wrist
Inferior glenohumeral instability
Yergason test Elbow flexed to 90 degrees with forearm pronated
Biceps tendon instability or tendonitis
Speed's maneuver Elbow flexed 20 to 30 degrees and forearm supinated
Biceps tendon instability or tendonitis
“Clunk” sign Rotation of loaded shoulder from extension to forward flexion
Labral disorder
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 8989
50505858
1.71.722
0.220.220.280.28
36369898
22229393
Drop arm Drop arm 1b1b 2121 100100 >25>25 0.790.79 100100 3232
TestTest Study Study QualQual
SensSens(%)(%)
SpecSpec(%)(%)
LR+LR+ LR-LR- PV+PV+(%)(%)
PV-PV-(%)(%)
ImpingementImpingementHawkin’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
History / History / Maneuver Maneuver
Study Study QualQual
SensSens(%)(%)
SpecSpec(%)(%)
LR+LR+ LR-LR- PV+PV+(%)(%)
PV-PV-(%)(%)
AC JointAC JointActiveActivecompressioncompression
1b1b 100100 9797 >25>25 0.010.01 8989 100100
SLAP TearSLAP TearCrankCrank 2b2b 9191 9393 1313 0.100.10 9494 9090
ActiveActivecompressioncompression
1b1b 100100 9999 >25>25 0.010.01 9595 100100
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 5353Acute 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 6464Thoracic Outlet Syndrome Thoracic Outlet Syndrome 22 --Biceps Tendonitis Biceps Tendonitis 0.80.8 --