shoulder pain and the shoulder exam

33
Shoulder Pain and the Shoulder Exam CHA Ambulatory Didactics Kate Lupton, MD

Upload: terena

Post on 24-Feb-2016

113 views

Category:

Documents


2 download

DESCRIPTION

Shoulder Pain and the Shoulder Exam. CHA Ambulatory Didactics Kate Lupton, MD. Shoulder Overview. Very complex structure with tremendous ROM 4 joints – sternoclavicular , acromioclavicular , glenohumeral , scapulothoracic - PowerPoint PPT Presentation

TRANSCRIPT

Page 1: Shoulder Pain and the Shoulder  Exam

Shoulder Pain and the Shoulder Exam

CHA Ambulatory DidacticsKate Lupton, MD

Page 2: Shoulder Pain and the Shoulder  Exam

Shoulder Overview

• Very complex structure with tremendous ROM• 4 joints – sternoclavicular, acromioclavicular,

glenohumeral, scapulothoracic• Glenohumeral – ball and socket joint (golf ball

on a tee), glenoid only covers 25% of humeral head

Page 3: Shoulder Pain and the Shoulder  Exam

Anatomy

Page 4: Shoulder Pain and the Shoulder  Exam

Shoulder Activity/ROM• Static glenohumeral stability – joint surfaces, capsule and

labrum• Dynamic stability – RC & scapular rotators (trapezius, serratus

anterior, rhomboids, levator scapulae)• Rotator cuff – depress humeral head against glenoid• Internal rotation - Subscapularis• External rotation - Infraspinatus, teres minor • Abduction - supraspinatous• Scapular stability – trapezius, serratus anterior, rhomboids• Upward scapular rotation – trapezius & serratus anterior• Scapular retraction – trapezius & rhomboids

Page 5: Shoulder Pain and the Shoulder  Exam

History

• Background – Handedness, occupation, recreational activities

• CC: Pain vs instability vs decreased movement• Characterize CC: “loose” arm, “dead” arm• Injury? -> Mechanism• Associated Sx – neurovascular, stiffness, crepitus• Function – putting on jacket, overhead activities,

sleeping

Page 6: Shoulder Pain and the Shoulder  Exam

Principles of the MSK Exam

• Good exposure (clothing removed, in gown)

• LOOK• FEEL• MOVE• SPECIAL TESTS

Page 7: Shoulder Pain and the Shoulder  Exam

Look/Feel - Surface Anatomy

Page 8: Shoulder Pain and the Shoulder  Exam

Look • SEADS – swelling, erythema, atrophy, deformity,

scars• Dominant shoulder usually slightly lower than

non-dominant side• Head forward posture, shoulders rolled forward,

scapula protracted• Squaring of shoulder – r/o dislocation• SC joints, clavicle deformity - ?fracture• AC joints – step deformity - ?separation • Atrophy – trapezius, infraspinatus, teres minor

Page 9: Shoulder Pain and the Shoulder  Exam

Feel

• Palpate joints – SC joint, along clavicle, AC joint, coracoid process, along scapula

• Palpate muscles and tendons – trapezius, posterior shoulder, biceps tendon, supraspinatus insertion

• Feel for crepitus while rotating the arm

Page 10: Shoulder Pain and the Shoulder  Exam

Move – Active Range of Motion

Flexion/Extension• Trace arc while reaching

forward with elbow straight

• Normal flexion to 160°-180°, extension to -60°

Abduction/Adduction• Trace arc reaching to

side with straight arm• Normal range is 0°-180°

Page 11: Shoulder Pain and the Shoulder  Exam

Move – Active Range of MotionAbduction & internal

rotation• Should be able to reach

to ~C-7 level (prominent bump on C-spine)

Adduction & external rotation

• Should be able to reach lower border of scapula (~T7 level)

Page 12: Shoulder Pain and the Shoulder  Exam

Move – Passive ROM• If pain or limitation w/ active ROM, assess with

passive ROM testing• Grasp humerus, move through flexion/extension,

abduction, adduction• Feel for crepitus with hand on shoulder• Note movements that precipitate pain –

pain/limitation on active but not passive ROM suggests muscle/tendon problem

• Note limitations in movement – where in arc does it occur? Due to pain or weakness? Symmetric or asymmetric?

Page 13: Shoulder Pain and the Shoulder  Exam

Move

• Painful arc on abduction? Glenohumeral joint from 60-120°, AC joint 170-180°

• Watch scapular motion – look for asymmetry, jerky motion

• Wall push-up for scapular winging

Page 14: Shoulder Pain and the Shoulder  Exam

Rotator Cuff Anatomy and Function• 4 Major Muscles• Depress humeral head, keep it

in contact with glenoid throughout wide ROM

• Supraspinatus – abducts shoulder (to ~80°)

• Infraspinatus – external rotation

• Teres minor – external rotation• Subscapularis – internal

rotation

Page 15: Shoulder Pain and the Shoulder  Exam

Special Tests - Supraspinatus

Empty/Full Can Test• Hold arms at 1:00 and 11:00,

abducted 30 °• Internally rotate so thumbs

point down (“empty can”), pt lifts up against resistance. Repeat with thumbs pointed up

• Note pain (tendinopathy, partial tear), weakness (tear)

• Deltoid is responsible for abduction beyond 70-80 °

Page 16: Shoulder Pain and the Shoulder  Exam

Special Tests – Infraspinatus

External Rotation• Fully adduct arm, flex

elbow to 90 °, medially rotate humerus 45 ° (hand at 12:00)

• Have pt try to externally rotate while you resist against their forearms

Page 17: Shoulder Pain and the Shoulder  Exam

Special Tests - SubscapularisPosterior (Gerber’s)Lift Off• Pt places hand behind back,

palm facing out• Pt lifts hand away from the back• Note pain, weaknessBelly Press• Place hands on abdomen, elbows

out• Press in on abdomen or keep

elbows out while posteriorly directed force is applied to elbows

• Positive test if unable to keep elbows out

Page 18: Shoulder Pain and the Shoulder  Exam

Shoulder Impingement/Bursitis• 4 tendons of the RC pass under

the acromion and coracoacromial ligament and insert in the humeral head

• Space between arcromion, coracoacromial ligament and tendons can narrow, causing impingement of tendons (esp supraspinatus)

• Resulting friction inflames tendons and subacromial bursa

• Causes shoulder pain, esp with reaching overhead

Page 19: Shoulder Pain and the Shoulder  Exam

Special Tests - Impingement

Neer’s Test• Place hand on pt’s

scapula, other on forearm• Pt fully internally rotates

(thumb pointed down)• Passively forward flex

arm through full range of motion

• Pain = impingement

Page 20: Shoulder Pain and the Shoulder  Exam

Special Tests - Impingement

Hawkins-Kennedy Test• Flex arm to 90°• Stabilize shoulder with

one hand• Forcibly internally

rotate shoulder, thumb pointed down

• Pain = impingement

Page 21: Shoulder Pain and the Shoulder  Exam

Special Tests - Bursitis

Subacromial Palpation• Identify acromion by

following scapular spine to distal end

• Palpate in subacromial space

• Pain = inflamed bursa and/or tendons

Page 22: Shoulder Pain and the Shoulder  Exam

Biceps Tendon• Long head of biceps tendon

runs in the bicipital groove of humerus, inserts at superior glenoid

• Biceps flexes and supinates forearm

• Subject to similar stresses as RC tendons

• Inflammation causes pain in top and anterior shoulder, especially with flexion/supination

Page 23: Shoulder Pain and the Shoulder  Exam

Special Tests – Biceps TendonPalpation• Palpate along biceps

tendon/bicipital groove• Confirm location by having pt

supinate while palpatingYergason’s Test• Flex elbow to 90°with arm

adducted (elbow against side)• Grasp pt’s hand, resist while

they supinate• Pain = tendinopathy

Page 24: Shoulder Pain and the Shoulder  Exam

Special Tests – AC JointPalpation• Palpate point at which distal clavicle

articulates with acromionO’Brien• Flex shoulder to 90° while internally

rotated (thumb down)• Adduct arm 10-15° from 12:00• Apply downward force to arm while pt

resists• Repeat with thumb pointed up• If there is pain with first maneuver and

not second, indicates labral or AC joint pathology

Cross Arm /Forced Flexion• Flex shoulder to 90°, flex elbow, then

actively adduct

Page 25: Shoulder Pain and the Shoulder  Exam

Special Tests – Shoulder InstabilityApprehension/Relocation• With patient supine, abduct shoulder 90°,

flex elbow 90°• Externally rotate shoulder by moving

forearm from perpendicular to parallel with body

• Pain or sense of instability with further external rotation is a positive test, indicating anterior shoulder instability

• If sx are relieved with posterior force applied to proximal humerus, that is a positive relocation test and further supports dx

Sulcus Sign• Arm hangs relaxed at the side• Pull arm straight down, look for step-off

under lateral acromion• Indicates inferior instability

Page 26: Shoulder Pain and the Shoulder  Exam

Many Thanks

• Anthony Luke, MD – UCSF• Charlie Goldberg, MD - UCSD

Page 27: Shoulder Pain and the Shoulder  Exam
Page 28: Shoulder Pain and the Shoulder  Exam
Page 29: Shoulder Pain and the Shoulder  Exam
Page 30: Shoulder Pain and the Shoulder  Exam
Page 31: Shoulder Pain and the Shoulder  Exam
Page 32: Shoulder Pain and the Shoulder  Exam
Page 33: Shoulder Pain and the Shoulder  Exam