Download - Chiou
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Physical Examination of the Shoulder
Lisa Chiou, MD, MPH
Primary Care Conference
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Goals
Review some of that anatomy from medical school
Discuss common shoulder problemsPractice focused physical exam
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Shoulder pain
Common in all age groupsIntrinsic 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
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Review of shoulder anatomy
Bones Scapula Clavicle Humeral head Posterior rib cage
Joints Sternoclavicular Acromioclavicular Glenohumeral Scapulothoracic
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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
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More shoulder anatomy
Ligaments Coracoclavicular Acromioclavicular Glenohumeral
Superior GH Middle GH Inferior GH Coracohumeral
Subacromial bursaSubdeltoid bursa
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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
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Shoulder exam #1
Visualize from front and backAsymmetry
Pts with rotator cuff tears hold shoulder higher
Atrophy Sign of chronic glenohumeral joint pathology
Effusions Shoulder joint can hide a lot of fluid
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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
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Active range of motion
Forward flexionAbduction/adduction
Painful arc of abduction – sensitive, not specific
External rotationInternal rotation
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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
AbductionInternal and external rotation
Have arm at patient’s side and abducted to 90 degrees
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Rotator cuff strength testing
Supraspinatus “Pour out a Coke”
Infraspinatus and teres minor “Act like a penguin”
Subscapularis “Scratch your back”
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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 forearmNeer’s test
At full elbow extension, internally rotate and flex the arm
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Biceps strength testing
Arms outstretched with palms up at level of shoulder
Forced supination of hand with elbow flexed at 90 degrees
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Impingement syndrome
Compression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromion
Repetitive overhead motionsMain cause of rotator cuff tendonitisCan lead to bursitis, partial or full rotator
cuff tears
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Sx of impingement syndrome
Usually gradual onsetOuter deltoid pain, especially with
reaching or overhead movementsNight painDifficulty sleeping on affected sideNearly identical symptoms as tendonitis
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Exam for impingement
Pain with painful arc maneuverCrepitus above 60 degreesSubacromial tenderness (lateral)No pain with external/internal rotation,
abduction, elbow flexion Distinguishes impingement from tendonitis
Normal glenohumeral ROMNormal strength
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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
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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
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Rotator cuff tendonitis
Some argue this is same as impingementAcute 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 movementsRF – relative overuse, age, osteophytes,
trauma, inflammatory processes (RA)
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Exam for impingement
Painful arc of abduction (active) 60-120 degrees
Impingement signsImpingement test
Subacromial lidocaine injection Can then test again for weakness
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Radiology for tendonitis
Nothing is diagnosticPlain 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
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Tx of tendonitis
RestHeat or iceUltrasound (physical therapy)NSAIDsSubacromial steroid injection
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Rotator cuff tear
50% pts do not have preceding traumaUsually in supraspinatusWide size range, plus partial vs fullShoulder weakness, pain, loss of motion Common mechanisms of injury:
Falling onto outstretched arm, onto outer shoulder directly, heavy pushing/pulling
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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
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Exam for rotator cuff tear
Range of motionStrengthDrop 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
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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
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Rotator cuff tears
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Tx of rotator cuff tears
Ice, NSAIDs, restrict aggravating motionsWeighted pendulumNo arm slingsSteroid injection if persistent sxSurgery – refer if young pts, full/large
tears, dominant arm Best if done within 6 weeks
Acromioplasty and debridement
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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
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Exam for AC joint injuries
Joint enlargement or deformityJoint tendernessPain with crossed body adductionJoint widening with downward arm traction
in pts with 2nd or 3rd degree joint separation
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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 injectionRefer to surgery if no improvement after 2
injections
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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
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Rare associations
Hyper- or hypothyroidismParkinson’s diseaseAntiretrovirals (PPIs)Recent neurosurgery
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Exam for adhesive capsulitis
Clinical diagnosisRange of motion is smooth and pain-free,
then stops suddenlyNo further passive ROM possibleNormal strength in the pain-free rangeCan test strength again after lidocaine
injection
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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
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Arthrogram for adhesive capsulitis
Normal capsule volume
Frozen shoulder (contracted GH capsule)
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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
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Biceps tendonitis
Inflammation of long head of biceps Passes through bicipital groove of anterior
humerus
Usually due to repetitive lifting or reachingInflammation, microtearing, degenerative
changesUp to 10% pts will have spontaneous
rupture
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Sx of biceps tendonitis
Anterior shoulder painWorse with lifting or overhead reachingOften pts point to bicipital grooveUsually no weakness in elbow flexion
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Exam for biceps tendonitis
Bicipital groove tendernessLook for subacromial impingementTendon ruptureTest biceps strengthYergason 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
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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
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Radiology for biceps tendonitis
Usually plain films unnecessaryIf tendon rupture present, then get plain
films, U/S, or MRI Look for rotator cuff tendonitis or tear
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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
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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 activityDistinguish from RA, adhesive capsulitis
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Unusual causes
Hemochromatosis Think of this if patients develop OA in unusual
places at unusually early ages
Hemophilia Blood very erosive to joint
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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
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Imaging for glenohumeral OA
Joint space narrowing (loss of articular cartilage)
Osteophytes Humeral head sclerosis
and flattening Club-like deformity
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Tx of glenohumeral OA
Low impact activities, and heat + stretching Let pain be the guide
NSAIDs, acetaminophen, glucosamine, chondroitin
Intra-articular steroidsIntra-articular hyaluronateArthroplasty or total shoulder replacement
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Polymyalgia rheumatica
Think of this with patients >60, especially if they have bilateral shoulder symptoms
Females>malesEuropeans Rare – 20-50 per 100,000 per year
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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
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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
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Shoulder weakness after viral illness
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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
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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
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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
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Thanks!
And HUGE thanks to Dr. Greg Gardner!!