adam meakins shoulder exam

Examining the

Shoulder

Adam Meakins

Clinical Lead Physiotherapist

Shoulder Pain

Is commonhellip

bull 3rd most common MSK complaint

bull Prevalence rates between 6-30

bull lsquoImpingementrsquo most common

Luime JJ (2004) Prevalence and incidence of shoulder pain in the general population

a systematic review Scand J Rheumatol 33(2)73-81

ldquoThe shoulder complex often

renders the clinician with frustrating uncertaintyrdquo Joslashrgen Jevne

httpblogsbmjcombjsm20150106the-sexy-scalpel-unnecessary-shoulder-surgery-on-the-rise

Whyhellip

Shoulders can be complicated bull Many pathologies cause shoulder pain

bull Many clinical tests are not specific or sensitive

bull Pain is a complex phenomenon

Dean BJ (2013) Why does my shoulder hurt A review of the neuroanatomical and biochemical basis of shoulder pain

Br J Sports Med Nov47(17)1095-104

Hegedus EJ (2012) Which physical examination tests provide clinicians with the most value when examining the shoulder

Update of a systematic review with meta-analysis of individual tests Br J Sports Med Nov46(14)964-78

Melzack R and Katz J (2013) Pain Cognitive Science Vol 4 Issue 1 1ndash15 DOI 101002wcs1201

But shoulders donrsquot

have to be complicated

Painful Shoulders

Are eitherhellip

1 Stiff and painful

2 Weak and painful

3 Unstable and painful

Three criteriahellip

Can help plan best Mxhellip

1 Hx of trauma

2 Age

3 Shoulder External Rotation Test

But Firsthellip

Is it even the shoulderhellip bull RED FLAGS

bull Pain on neck movement

bull Pain below the elbow

bull Neural symptoms

bull +ve Spurling Test

The Stiff

and

Painful Shoulder

Stiff and painfulhellip

1 Trauma = No

2 Age = gt50

3 Ext Rot = Reduced both

ACTIVE and PASSIVE

Dx = OA or Frozen Shoulder

Mx = X-ray (not US) Physio


1 Trauma = Yes

2 Age = Any


ACTIVE and PASSIVE

Dx = Missed Frac Disloc

Mx = X-ray (not US) Ortho

The Weak

and

Painful Shoulder

Weak and painfulhellip

1 Trauma = No

2 Age = 30+

3 Ext Rot = Weakpainful

on RESISTED testing

Dx = Rotator Cuff Tendinopathy

Mx = Refer to Physio

Rotator Cuff Tendinopathy Other Signs

bull +ve Painful arc sign

bull +ve Hawkins Kennedy test

bull +ve Neers test

bull PainWeak fullempty can

bull PainWeak resisted ER

gt3 +ve tests = +LR293 (95 CI 16-53)

Michener LA (2009) Reliability and diagnostic accuracy of 5 physical examination tests and

combination of tests for subacromial impingement Arch Phys Med Rehabil Nov90(11)1898-903



1 Trauma = Yes

2 Age = lt50


on RESISTED testing

Dx = Rotator cuff tear

Mx = Refer to Ortho


Rotator Cuff Tears Other Signs SP 77 +ve test can NOT rule in a tear

SN 73 -ve test FAIR to rule out a tear

SP 94 +ve test CAN rule in a tear

SN 46 -ve test can NOT rule out a tear

SP 84 +ve test FAIR to rule in a tear

SN 100 -ve test CAN rule out a tear

bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test

Miller CA (2008) The validity of the lag signs in diagnosing full-thickness tears of the

rotator cuff a preliminary investigation Arch Phys Med Rehabil Jun89(6)1162-8

The Unstable

and

Painful Shoulder

Unstable and Painfulhellip

1 Trauma = No

2 Age = 20+

3 Ext Rot in Abd = Painful

andor APPREHENSIVE

Dx = Congenital Instability



1 Trauma = Yes (gt652+)

2 Age = Any


andor APPREHENSIVE

Dx = Structural defect

Mx = Refer to Ortho if had physio


Posterior Apprehension Test

bull Rare lt 10

bull Usually fitselectrocution

bull Can be traumatic


Inferior Hyperabduction Test

bull Even rarer lt 5

bull Usually hypermobile

Summary

Is the painful shoulderhellip ndash Stiff think OA Frozen missed dislocation

ndash Weak think Rotator Cuff Tendinopathy Tear

ndash Unstable think congenital structural defect

Use three simple criteria to decide Mxhellip

ndash Trauma

ndash Age

ndash Shoulder External Rotation

Thank You

Questions

Shoulder Pain

Is commonhellip

bull 3rd most common MSK complaint

bull Prevalence rates between 6-30

bull lsquoImpingementrsquo most common

Luime JJ (2004) Prevalence and incidence of shoulder pain in the general population

a systematic review Scand J Rheumatol 33(2)73-81




Whyhellip











Painful Shoulders

Are eitherhellip

1 Stiff and painful

2 Weak and painful




1 Hx of trauma

2 Age


But Firsthellip






The Stiff

and

Painful Shoulder


1 Trauma = No

2 Age = gt50


ACTIVE and PASSIVE




1 Trauma = Yes

2 Age = Any


ACTIVE and PASSIVE



The Weak

and

Painful Shoulder


1 Trauma = No

2 Age = 30+


on RESISTED testing






bull +ve Neers test



gt3 +ve tests = +LR293 (95 CI 16-53)





1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions




Whyhellip











Painful Shoulders

Are eitherhellip

1 Stiff and painful

2 Weak and painful




1 Hx of trauma

2 Age


But Firsthellip






The Stiff

and

Painful Shoulder


1 Trauma = No

2 Age = gt50


ACTIVE and PASSIVE




1 Trauma = Yes

2 Age = Any


ACTIVE and PASSIVE



The Weak

and

Painful Shoulder


1 Trauma = No

2 Age = 30+


on RESISTED testing






bull +ve Neers test



gt3 +ve tests = +LR293 (95 CI 16-53)





1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions



Painful Shoulders

Are eitherhellip

1 Stiff and painful

2 Weak and painful




1 Hx of trauma

2 Age


But Firsthellip






The Stiff

and

Painful Shoulder


1 Trauma = No

2 Age = gt50


ACTIVE and PASSIVE




1 Trauma = Yes

2 Age = Any


ACTIVE and PASSIVE



The Weak

and

Painful Shoulder


1 Trauma = No

2 Age = 30+


on RESISTED testing






bull +ve Neers test



gt3 +ve tests = +LR293 (95 CI 16-53)





1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions



1 Hx of trauma

2 Age


But Firsthellip






The Stiff

and

Painful Shoulder


1 Trauma = No

2 Age = gt50


ACTIVE and PASSIVE




1 Trauma = Yes

2 Age = Any


ACTIVE and PASSIVE



The Weak

and

Painful Shoulder


1 Trauma = No

2 Age = 30+


on RESISTED testing






bull +ve Neers test



gt3 +ve tests = +LR293 (95 CI 16-53)





1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions

But Firsthellip






The Stiff

and

Painful Shoulder


1 Trauma = No

2 Age = gt50


ACTIVE and PASSIVE




1 Trauma = Yes

2 Age = Any


ACTIVE and PASSIVE



The Weak

and

Painful Shoulder


1 Trauma = No

2 Age = 30+


on RESISTED testing






bull +ve Neers test



gt3 +ve tests = +LR293 (95 CI 16-53)





1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions

The Stiff

and

Painful Shoulder


1 Trauma = No

2 Age = gt50


ACTIVE and PASSIVE




1 Trauma = Yes

2 Age = Any


ACTIVE and PASSIVE



The Weak

and

Painful Shoulder


1 Trauma = No

2 Age = 30+


on RESISTED testing






bull +ve Neers test



gt3 +ve tests = +LR293 (95 CI 16-53)





1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions


1 Trauma = No

2 Age = gt50


ACTIVE and PASSIVE




1 Trauma = Yes

2 Age = Any


ACTIVE and PASSIVE



The Weak

and

Painful Shoulder


1 Trauma = No

2 Age = 30+


on RESISTED testing






bull +ve Neers test



gt3 +ve tests = +LR293 (95 CI 16-53)





1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions


1 Trauma = Yes

2 Age = Any


ACTIVE and PASSIVE



The Weak

and

Painful Shoulder


1 Trauma = No

2 Age = 30+


on RESISTED testing






bull +ve Neers test



gt3 +ve tests = +LR293 (95 CI 16-53)





1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions

The Weak

and

Painful Shoulder


1 Trauma = No

2 Age = 30+


on RESISTED testing






bull +ve Neers test



gt3 +ve tests = +LR293 (95 CI 16-53)





1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions


1 Trauma = No

2 Age = 30+


on RESISTED testing






bull +ve Neers test



gt3 +ve tests = +LR293 (95 CI 16-53)





1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions




bull +ve Neers test



gt3 +ve tests = +LR293 (95 CI 16-53)





1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions


1 Trauma = Yes

2 Age = lt50


on RESISTED testing


Mx = Refer to Ortho








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions








bull Drop Arm Test

bull ER Lag Test

bull IR Lag Test



The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions

The Unstable

and

Painful Shoulder


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions


1 Trauma = No

2 Age = 20+


andor APPREHENSIVE





2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions



2 Age = Any


andor APPREHENSIVE





bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions



bull Rare lt 10







Summary





ndash Trauma

ndash Age


Thank You

Questions





Summary





ndash Trauma

ndash Age


Thank You

Questions

Thank You

Questions

adam meakins shoulder exam

Health & Medicine