shoulder 2shoulder
TRANSCRIPT
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MusculoskeletalCurriculum
History &Physical Examof the Shoulder
Copyright 2005
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Authors
Kathleen Carr, MD
Madison Residency [email protected]
Dennis Breen, MD
Eau Claire Residency [email protected]
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Goal
Learn a standardized, evidence-based historyand physical examination of patients withshoulder problems
WHICH WILL:
Enable family medicine resident physicians toaccurately diagnose common shoulderproblems throughout the full age spectrum ofpatients seen in family medicine
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Competency-Based Objectives
Patient carefocused history and exam
Professionalismrespect, compassion
Interpersonal and communication skillsdifferential diagnosis
Medical knowledge baseanatomy, injury
mechanisms
Systems based practiceaccuracy, time-efficiency
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Shoulder Pain Key Points Shoulder pain is a common complaint in primary
care 2nd only to knee pain for referral to Ortho or primary care sports
med
Most common causes in adults (peak ages 40-60) Subacromial impingement syndrome
Rotator cuff problems
Athletic injuries Shoulder accounts for 8-13% of athletic injuries
History and examination are keys to diagnosis
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Assessing shoulder pain
Components of the assessment
include
1. Focused history2. Attentive physical examination
3. Thoughtfully ordered tests/studies
for future discussion
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Focused History
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Focused History Questions
Onset of Pain
When symptoms started*
History of trauma/injury
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Focused History Questions
Mechanism of Injury
Helps predict injured structure
Example: Fall directly onto anterior/superiorshoulderAC joint injury (shoulder separation)
Example: Arm forcefully abducted and externallyrotated subluxation or anterior dislocation
Example: If chronic pain, note activity that triggerspain, such as the cocking phase of throwing or thepull-through phase of swimming
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Focused History Questions
Mechanism of Injury, continued
Can determine radiological needs
Likelihood of specific conditions varies Setting (work, recreation, sports, traumatic,
atraumatic)
Age of the patient*
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Focused History Questions Location of pain*
Anterior
Lateral
Superior Posterior
Radiation of pain
Rotator cuff problems often include painradiating to upper arm
If pain starts in neck and radiates toshoulder, consider cervical spine disease
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Consider sources of referred pain
Cervical spine spondylolysis, arthritis, disc
disease Cardiac - myocardial ischemia
Diaphragmatic irritation
Thoracic outlet syndrome
Gallbladder disease
Complex regional pain syndrome (a.k.a, reflex
sympathetic dystrophy)
Focused History Questions
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Characteristics of pain
Focused History Questions
Night pain when lying on affected
side, muscle atrophy
Rotator cuff tear
< 30 yo Biomechanical, inflammatory
> 45 yo, Hx of trauma Rotator cuff tear - 35% of pts
Painful arc (60-120abduction) Subacromial impingement
Pain > 120 abduction Acromioclavicular joint
Catching, popping, clicking GH or AC joint arthritis, labral
tear
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Focused History Questions
History of instability
Glenohumeral subluxation or dislocation
Aggravating factors Overhead work, repetitive movements, sports
Relieving factors/treatments tried
Rest, immobility, medications, other treatments
History of Prior Shoulder Problems or
Surgeries
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Differential Diagnosis
Diagnosis Primary Care % Age
Subacromial Impingement Syndrome 48-72 23-62
Adhesive Capsulitis 16-22 53
Acute Bursitis 17 -
Calcific Tendonitis 6 -
Myofascial Pain Syndrome 5 -
Glenohumeral Joint Arthrosis 2.5 64
Thoracic Outlet Syndrome 2 -
Biceps Tendonitis 0.8 -
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Physical Exam
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Physical Exam - General
Develop a standard routine
Alleviate the patient's fears
Adequate exposure - bilateral Males shirtless
Females tank top or sports bra
Compare shoulders
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Physical Exam Steps*
Inspection
Palpation
Range of motion (ROM) Strength testing
Special tests
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Inspection
Swelling, asymmetry, muscle atrophy, scars,ecchymosis and any venous distention
Note posture (e.g., shoulder protraction)
Deformities Squaring of shoulder - anterior dislocation
Scapular "winging" - shoulder instability andserratus anterior or trapezius dysfunction
Atrophy - supraspinatus or infraspinatus -consider rotator cuff tear, suprascapular nerveentrapment or neuropathy
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Palpation
Sternoclavicular joint
Clavicle
Acromioclavicular joint
Subacromial bursa
Coracoid process
Bicipital groove
Greater tuberosity Lesser tuberosity
Scapula (spinatus muscles)
TIP: Start medially atthe SC joint, proceed
laterally, end posteriorly
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Anterior Shoulder
http://www.nismat.org/orthocor/exam/shoulder.html#Functions
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Posterior Shoulder
http://www.nismat.org/orthocor/exam/shoulder.html#Functions
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Palpation of AC Joint
Patient's arm at his/her
side
Note swelling, pain, and
gapping.
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Palpation of Bicipital Groove
Patient sitting,beginning with the armstraight
Patient actively flexesbiceps muscle whileexaminer providessupination and ER
Examiner palpates the
bicipital groove for pain
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Range of Motion (ROM)
Evaluate active ROM
If movement limited by pain, weakness, or
tightness, assist passively
Lack of full ROM with active and passive exam
is found in adhesive capsulitis and arthropathy
Evaluate bilaterally for comparison
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Range of Motion
Movement
Forward flexion
Extension (behind back)
Abduction
Adduction
External rotation*
Internal rotation*
Normal range
180
40
180(with palms up)
0
45(arm at side, elbow flexed)
55(arm at side, elbow flexed)
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Forward Flexion
Arm straight andbrought upwardthrough frontal plane,and move as far aspatient can go abovehis head
0 is defined as straightdown at patient's side,
& 180 is straight up
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Abduction
Arm straight
Hand palm up (arm
supinated)
ROM measured indegrees as for forward
flexion
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External and Internal Rotation
Arm at side, elbow flexed to 90 and held at waist
Examiner externally or internally rotates arm
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Apley scratch test for ER/IR*
Internal rotation and adduction
Reach for lower scapula
Compare bilaterally note level
reached
External rotation and abduction
Reach for upper scapula
Compare bilaterally note level
reached
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Strength Tests
Flexion
Extension
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Strength Tests*
External rotation
Infraspinatus
Teres minor
Internal rotationSubscapularis
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Strength tests
Empty can test*
Supraspinatus
Lift off test*
Subscapularis
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Special Tests
Rotator cuff
Drop arm test
Impingement tests Neers sign
Hawkins test
Speeds test Biceps tendon
Labral tear
OBriens test
Crank test
Instability tests
Anterior release
Relocation test
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Rotator Cuff
Empty Can Test
Supraspinatus
Lift off test
Subscapularis integrity
Drop Arm Test
Rotator cuff tear or supraspinatus dysfunction
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Drop Arm Test Purpose: tears in the rotator
cuff, primarily supraspinatusmuscle
Method: patient abducts (orexaminer passively abducts)arm and then slowly lowers it May be able to lower arm slowly to 90
(deltoid function)
Arm will then drop to side if rotator cufftear
Positive test: patient unable tolower arm further with control If able to hold at 90, pressure on
wrist will cause arm to fall
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Video of Drop Arm Test
Click onimage for video
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Impingement - Neers Sign*
Patient seated with armat side, palm down(pronated)
Examiner standing Examiner stabilizes
scapula and raises thearm (between flexion
and abduction) Positive test = pain
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Video of Neers Sign
Click onimage for video
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Impingement - Hawkin's Test*
Patient standing
Examiner forward
flexes shoulder to 90,
then forcibly internallyrotates the arm
Positive test = pain in
area of superior GH
joint or AC joint
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Video of Hawkins Test
Click onimage for video
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Speeds Test - Biceps tendon
Forward flex shoulder
against resistance
while maintaining
elbow in extensionand forearm in
supination
Positive test = tender
in bicipital groove(bicipital tendinitis)
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Video of Speeds Test
Click onimage for video
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Labral Tear (SLAP) - O'Brien's
Active Compression Test Patient standing
Arm forward flexed 90, adducted15 to 20 with elbow straight
Full internal rotation so thumb
pointing down Examiner applies downward force on
arm - patient resists
Patient externally rotates arm sothumb pointing up
Examiner applies downward force on
arm - patient resists Positive test = Pain orpainful
clicking elicited with thumb downand decreased or eliminated withthumb up
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Video of OBriens Test
Click onimage for video
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Labral Tear - Crank Test
Shoulder elevated to 160
in the scapular plane
A gentle axial load is
applied throughglenohumeral joint with
one hand, while other
hand does IR and ER
Positive test = pain,catching, or clicking in the
shoulder
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Video of the Crank Test
Click onimage for video
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Glenohumeral Joint Stability
Anterior Glenohumeral Instability
Apprehension test
Relocation test Anterior release test
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Apprehension Test - Sitting
90 of abduction
Examiner applies slight
anterior pressure to humerusand externally rotates arm
Positive test = patient
expresses apprehension
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Apprehension Test
Patient in supineposition with affectedshoulder at edge oftable, arm abducted
90 Examiner externally
rotates by pushingforearm posteriorly.
Positive test = patientexpressesapprehension
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Relocation Test
Performed after positiveresult on anteriorapprehension test
Patient supine
Examiner appliesposterior force onproximal humerus whileexternally rotating
patients arm Positive test = patient
expresses relief
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Video of the Apprehension &
Relocation Tests Seated & Supine
Click onimage for video
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Anterior Release Test Patient in supine
position, arm abducted90
Examiner performs
Relocation Test, thenreleases downwardpressure
Positive test = patient
expresses pain orinstability when thehumeral head isreleased
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Video of Anterior Release Test
Click onimage for video
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The Current Evidence Base
for History Questions andPhysical Exam Tests
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Rotator Cuff Tear
History /Maneuver
StudyQual
Sens
(%)
Spec
(%)
LR+ LR- PV+
(%)
PV-
(%)
History of
trauma
2b 36 73 1.3 0.88 72 37
Night pain 2b 88 20 1.1 0.6 70 43
Painful arc 2b 33 81 1.7 0.83 81 33
Empty cantest
1b 8489
5058
1.72
0.220.28
3698
2293
Drop arm 1b 21 100 >25 0.79 100 32
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Impingement / Instability
Test Study
Qual
Sens
(%)
Spec
(%)
LR+ LR- PV+
(%)
PV-
(%)
Impingement
Hawkins 1b 87
89
60 2.2 0.18 71 83
Instability
Relocation 2b 57 100 >25 0.43 100 73
Apprehension 2b 68 100 >25 0.32 100 78
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AC / SLAP
History /Maneuver
StudyQual
Sens
(%)
Spec
(%)
LR+ LR- PV+
(%)
PV-
(%)
AC
Activecompression
1b 100 97 >25 0.01 89 100
SLAP
Crank 2b 91 93 13 0.10 94 90
Active
compression
1b 100 99 >25 0.01 95 100
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References
Luime JJ, Verhagen AP, Miedema HS, et al. Does This Patient Have an Instability of the
Shoulder or a Labrum Lesion? JAMA. 2004;292:1989-1999.
Stetson WB, Templin K. The crank test, the OBrien test, and routine magnetic resonance
imaging scans in the diagnosis of labral tears.Am J Sports Med. 2002;30:806-809.
Stevenson JH, Trojian T. Evaluation of shoulder pain. Journal of Family Practice.
2002;51:605-11.
Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with
Shoulder Examination Part I: The Rotator Cuff Tests.Am J Sports Med. 2003;31:154-
160.
Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with
Shoulder Examination Part II: Laxity, Instability, and Superior Labral Anterior and
Posterior (SLAP) Lesions.Am J Sports Med. 2003;31:301-307.
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Video of Shoulder Exam
http://www.fammed.wisc.edu/our-department/media/musculoskeletal
http://inside.fammed.wisc.edu/education/musculo