the painful shoulder part i: evaluation1).pdf · physical examination of patients presenting with...

The Painful Shoulder Part I: Evaluation© Jackson Orthopedic Foundation www.jacksonortho.org

• 1. Describe 6 key components of the history and physical examination of patients presenting with shoulder pain

• 2. Relate anatomical structures and landmarks to pain and dysfunction of the shoulder

• 3. Perform specialized provocative testing on the shoulder and appropriately interpret findings to support a probable diagnosis.

Objectives

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Common Sites of Shoulder Pain

A good place for a chart

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Superficial Musculature of the Shoulder


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Bony Anatomy of the Shoulder


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Glenohumeral Joint


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Right Shoulder – A/P View

Left Shoulder Axillary View

Y-View

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Acromion Types


ACROMION

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BURSAE


A A good place for a chart

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Vascular Supply

Nerve Supply

Rotator Cuff Muscles

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Rotator Cuff


A

Adhesive Capsulitis


A

Tendinitis


A

AC Joint DJD/Rotator Cuff Tear


PRINT THIS SLIDE!

• Onset• Location• Duration• Character• Aggravators• Relievers• Timing• Severity

• Overhead• Look down• Dislocation• Clunking• Anterior/posterior• Rotator Cuff• Throwing• Sleep

HISTORY

IMPINGEMENT SYNDROME

– Most often associated with overhead activities– Washing hair; reaching up to cabinets/shelves– Repetitive use– Wake at night when rolling onto an extended arm

HISTORY: Overhead?

• Full neck flexion – r/o radiculopathy– C5, C6, Suprascapular & Axillary nerves

• Supraspinatus, Infraspinatus, Subscapularis– C7 – below elbow

• Referred pain from– Chest (lungs, diaphragm)– Abdomen (liver, gall bladder, colon)

HISTORY: Look down!

• Previous history raises risk

• “Something slipping out of place.”

• May be chronic

History: Dislocation

•NORMAL: –Clicking, popping, snapping

• TENDINOSIS:–Deeper, heavier clunk

LABRALTEAR: –Severe pain with –Movement blocked

History: Clunking

Anterior:– Biceps tendon groove– AC Joint

Posterior- Supraspinatus

- Teres Minor

History: Anterior/Posterior

• Tendinitis: – Subacromial pain– Worse w activity; better w rest

• Rotator Cuff Tear- Dull, relentless, “toothache” pain- Severe at night; prevents sleep- Can’t sleep on affected side

History: Rotator Cuff

• Pain with COCKING– Anterior cuff tendinitis– Instability or anterior dislocation

• Pain with ACCELERATION– Rotator cuff tear– Impingement

• Pain with RELEASE/DECELRATION– Posterior cuff tendinitis– Posterior dislocation (rare)

History: Throwing

• Impingement– Wake in pain w arm overhead

• Tendinitis– Sleep may be interrupted when rolling to

affected side• Rotator Cuff Tear

– Relentless pain makes sleep difficult; cannot lie on affected side


History: Sleep

• Onset• Location• Duration• Character• Aggravators• Relievers• Timing• Severity

• Overhead• Look down• Dislocation• Clunking• Anterior/posterior• Rotator Cuff• Throwing• Sleep

HISTORY

*

• Inspection• Palpation• Range of Motion• Resisted Strength• Provocative Testing* One joint above; one below


Musculoskeletal Exam

Inspection• Movement• Alignment• Swelling• Asymmetry• Scars• Bruising• Venuos Distention

• Squaring of the shoulder:– dislocation

• Scapular winging:– Instability/dislocation– Serratus anterior or

trapezius dysfunction• Atrophy

– RCT– Nerve entrapment– Radiculopathy

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What do you see?


What do you see?

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What do you see?


• What do you see? • What do you see?

What do you see?

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What do you see?


PALPATIONLooking for:

• Deformity

• Spasm

• Tenderness

• Sternoclavicular joint• Clavicle• AC joint• Coracoid• Anterior Glenohumeral Joint• Biceps tendon• Acromion• Posterior GH joint• Scapula• Trapezius• Paracervicals

• Sterno-clavicular joint• Clavicle• AC joint• Coracoid• Anterior Glenohumeral Joint• Biceps tendon• Acromion• Posterior GH joint• Scapula• Trapezius• Paracervicals

DislocationFracture, dislocationDislocation, arthritis Biceps tendinitisTendinits, labral tear, dislocationTendinitis, ruptureArthritis, bursitis, Dislocation, tendinitsNeuropathy, atrophySpasm, trigger points Spasm, degenerative disease

Positive TTP Consider

Biceps

Triceps

Distal Sensation

Distal Circulation

Percussion/Neuro/Circulatory

• Flexion• Extension• Internal Rotation• External Rotation• Abduction

AROM loss with normal PROM:? Rotator Cuff Tear? Impingement

• 180• 45-60• 90• 90• 150

PROM loss w abnormal AROM? Adhesive Capsulitis? GH Osteoarthritis

Range of Motion

• Neer Test: With the arm fully pronated, raise the patient’s arm fully overhead in full flexion. Stabilize the scapula to prevent scapulo-thoracic motion.

Subacromial Impingement

A

Supraspinatus Testing


Infraspinatus TestingPatient has pain when externally rotating the shoulder against resistance with elbow flexed to 90 degrees.

• Lift-Off Test: Position patient’s hand behind the back at waist level with palm facing out. Ask patient to move arm away from body against examiner resistance.

Subscapularis Injury

• Yergason Test: Position patient’s elbow at 90 degrees with thumb up. Have the patient supinate and flex elbow against examiner’s resistance (holding at wrist.)

Biceps: Shoulder External Rotation; Elbow Flexion & Supination

Labrum

• Position patient’s arm in 90 degree flexion and external rotation. Push humerus into glenohumeral joint while internally and externally rotating.

Labral Tear – Crank (Clunk) Test

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Bony Anatomy of the Shoulder


O’ Brien’s Test: Position shoulder in 90 deg flexion, elbow extended, and 15 deg. Adducted. Point thumb down. Apply downward force. Repeat with thumb up.

With thumb up only: DEEP pain = Labral tearTOP OF SHOULDER pain = AC Joint

Labral Tear vs. AC Joint

• The patient actively flexes the shoulder to 90 degrees then actively adducts it.

• AC joint dysfunction (arthritis, spurring, etc.) indicated by pain

AC Joint Dysfunction

• SPEED’S ManeuverFlex patient’s elbow 20-30

degrees with forearm supinated and elbow flexed 20-30 degrees, arm in 60 degrees flexion. Resist forward flexion of the arm while palpating biceps tendon at anterior shoulder.

Biceps Tendon – Long Head

Dislocation Tests

With patient’s arm in neutral, pull downward on elbow or wrist while observing shoulder area for a depression lateral or inferior to the acromion. Many asymptomatic patients, especially adolescents normally have some degree of instability.

Sulcus Sign – Inferior Dislocation

OA Impingement

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Posterior Dislocation


Headline

Anterior Dislocation

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Common Sites of Shoulder Pain


• Woodward, T. W., & Best, T. M. (2000). The painful shoulder: part I. Clinical evaluation. American family

physician, 61(10), 3079-3089.• Woodward, T. W., & Best, T. M. (2000). The painful

shoulder: part II. Acute and chronic disorders. American

family physician, 61(11), 3291-3300.• Zuckerman, J. D., Mirabello, S. C., Newman, D.,

Gallagher, M., & Cuomo, F. (1991). The painful shoulder: Part II. Intrinsic disorders and impingement syndrome. American family physician, 43(2), 497.

REFERENCES

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•We call this approach Orthopedic Primary Care.

About JOF

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•JOF’s vision is to be the Bay Area’s pre-eminent resource for information, collaboration and innovation affecting musculoskeletal health and common orthopedic conditions.

About JOF

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Oakland, CA 94609Phone (510) 238-4851


the painful shoulder part i: evaluation1).pdf · physical examination of patients presenting with...

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