shoulder exam studentsandresidents

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


– 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


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

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


Biceps tendon (long Biceps tendon (long head)head)

Thanks!Thanks!

Questions?Questions?

Rotator Cuff TearRotator Cuff Tear

History / History / ManeuverManeuver

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


(%)(%)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 / ManeuverManeuver

Study Study QualQual

SensSens

(%)(%)SpecSpec


(%)(%)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

DiagnosisDiagnosis Primary Care Primary Care %%

AgeAge

Subacromial Impingement Subacromial Impingement Syndrome Syndrome

48-7248-72 23-6223-62

Adhesive CapsulitisAdhesive Capsulitis 16-2216-22 5353

Acute BursitisAcute Bursitis 1717 --

Calcific TendonitisCalcific Tendonitis 66 --

Myofascial Pain SyndromeMyofascial Pain Syndrome 55 --

Glenohumeral Joint ArthrosisGlenohumeral Joint Arthrosis 2.52.5 6464

Thoracic Outlet SyndromeThoracic Outlet Syndrome 22 --

Biceps Tendonitis Biceps Tendonitis 0.80.8 --

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