Shoulder Problem Evaluation MS3 Family Medicine Second most common musculoskeletal complaint Difficult joint to examine Multidirectional range of motion- UNIQUE! Shoulder injury can affect nearly every sport and many daily activities Objectives Review pertinent anatomy Discuss common pathology Discuss historical clues to diagnosis Select cases Physical exam in small group discussions Bony Anatomy Anterior Bony Anatomy Anterior and Posterior Radiographic Anatomy Where do things go wrong?? Fractures Where do things go wrong?? Dislocations and Separations Dislocations and separations are protected by both “static” and “dynamic” stabilizers… Where do things go wrong?? Dislocations and Separations Oh, yeah…Arthritis can happen at these joints, too… Glenohumeral Joint Shallow (“golf ball sitting on a tee”)  Inherently unstable (maximizes ROM) Static stabilizers  glenohumeral ligaments, glenoid labrum and capsule Dynamic stabilizers   Predominantly rotator cuff muscles Also scapular stabilizers Trapezius, leavator scapulae, serratus anterior, rhomboids Bony Anatomy “Static Stabilizers” What goes wrong… Besides separations and dislocations?? Instability!!! LABRUM What goes wrong? Tears and tendonopathies The Rotator Cuff Muscles “dynamic stabilizers” The Rotator Cuff Muscles: SITS  Supraspinatus ABD   Infraspinatus ER  Teres minor ER Supscapularis IR Depress humeral head against glenoid to allow full abduction Finally…the subacromial space What can go wrong??? Impingement!!!!!!! Impingement Other Anatomy    Deltoid Rotator cuff Teres major    Latissimus dorsi Biceps Pectoralis muscles Shoulder Anatomy Don’t forget the scapular stabilizer muscles So…what causes shoulder pain? Impingement Labrum and biceps pathology A-C joint pathology Rotator Cuff Injury Instability Among other things… Clinical Exam History Pain Acute Chronic Weakness Deformity Clinical Exam History Single event Repetitive overload Instability  Does it feel like it’s going to come out? Catching/Locking Clinical Exam History Sport / Occupation Previous injury Previous treatment Other joints involved Disability Physical Exam: Big 6 Inspection Palpation Range of Motion Strength Neurovascular Special Tests Special Tests Impingement Rotator Cuff Integrity Labrum and Biceps AC (SC) Joints Instability Physical Exam The physical exam will be demonstrated during small group discussions… Which rotator cuff muscle(s) are responsible for external rotation 1. Supraspinatus 2. Infraspinatus 3. Subscapularis 4. Teres Minor 5. Both 2 and 4 The apex (bottom) of the scapula is at what level of the spine? 1. 2. 3. 4. 5. C7 T3 T7 T12 L4 Case #1 22-year-old male rugby player falls onto his right shoulder while being tackled Severe pain on top of his right shoulder Case #1 Notable deformity over superior shoulder Painful range of motion  Unable to lift right arm above waist Special Tests?? Diagnosis??? Acromioclavicular (A-C) Sprain Special Tests  Shear Test  Cross Arm Test  A-C Palpation  Resisted Extension  Active compression test Acromioclavicular (A-C) Sprain Damage to A-C joint ligaments Pain and/or deformity over A-C joint Graded I-VI   I-III usually treated nonoperatively IV-VI referred to orthopedic surgery AC Joint Sprain Treatment Analgesics, ice prn Sling for as long as needed Physical Therapy    ROM restoration Gradual strength exercise Return to sport activity as tolerated Case #2 24-year-old male handball player Fell onto his shoulder after being pushed Intense pain Hand is tingling and arm feels like it’s hanging X-rays X RAYS DIAGNOSIS??? Shoulder Dislocation/Anterior Instability Humeral head dislocates from glenoid fossa Almost always anterior (95%) Usually traumatic with injury to capsulelabrum complex Shoulder Dislocation/Anterior Instability Treatment  Reduction of dislocation  Protection & rehab, rehab, rehab  Most will have future dislocations and/or instability At least 70%!!! (young)  May require surgical tightening/repair of the capsule/labrum complex Special Tests Glenoid Labrum and Instability Biceps Load I and II Kim Test Jerk Test Active-Compression Test (O’Brien) Crank Test Apprehension Test Relocation Test Load and Shift Sulcas Sign Which of the following structures can be “impinged”? 1. Biceps tendon 2. Subacromial Bursa 3. Rotator Cuff Tendons 4. All of the above 25% 25% 25% 25% 30 10 0 0 1 2 3 4 Case #3 35-year-old male tennis player Shoulder pain exacerbated by practicing serves Develops dull, aching pain in right shoulder SHOULDER PAIN Physical Exam Tenderness to palpation anterior shoulder Pain with abduction starting around 90 degrees Unable to lift arm past 120 degrees Pain with forward flexion at 90-120 degrees Special Tests??? Diagnosis??? Shoulder Pain Physical Exam Hawkin’s positive Neer’s positive IMPINGEMENT??? Impingement as a Clinical Sign Repetitive overhead activities Subacromial bursa and/or rotator cuff impinged between acromion & humerus Physical therapy, activity modification +/medications Diagnoses associated with clinical sign of Rotator Cuff Impingement: Subacromial bone spurs and / or bursal hypertrophy AC joint arthrosis and /or bone spurs Rotator cuff disease Superior labral injury Glenohumeral instability Scapular dyskinesis Biceps tendinopathy A diagnostic injection sometimes helps to clarify the diagnosis Case #4 45-year-old weight lifter Caught bar as it was falling off his shoulder Sudden pain Severe weakness left shoulder Worse with overhead activities; while sleeping at night Pain in anterior lateral shoulder Special tests? Case #4 Drop Arm Test Positive External Rotation Lag Sign positive Weakness with Empty Can Sign Normal bear hug and belly press tests… Diagnosis????? Rotator Cuff Tear Supraspinatus tendon most common Acute trauma or chronic tendinopathy Treatment dependent upon age/activity   Young, active usually require operative treatment Older, low-activity usually respond to nonoperative treatment Case #5 42-year-old female with dull pain right shoulder Pain is diffuse in nature Sometimes spreads to between shoulder blades Seems worse at night Physical Exam Obese, pleasant female Diffuse pain Normal shoulder exam Not able to reproduce pain during exam What else do you want to do??? Shoulder pain isn’t always the shoulder!! Get more history… Gall bladder disease Peptic Ulcer Disease Cervical radiculopathy Cardiac ischemia Pulmonary conditions  ie Pancoast’s tumor, Pneumonia In the human body, which is the most incredible joint? 1. 2. 3. 4. 5. PIP Knee Ankle Shoulder None of the above 20% 1 20% 2 20% 20% 3 4 20% 5 Case #6 40-year-old male Recently shoveled 16” of snow Can hardly lift left arm due to pain Special Tests? Diagnosis? Biceps Tendonopathy Speed Test Yergason Test Direct palpation Biceps Tendonopathies Repetitive overhead activity Repetitive forearm flexion/supination Difficult to discern from rotator cuff tendinopathy or impingement Conclusion Shoulder injuries are common. Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis. Impingement is a clinical sign, not a diagnosis. Don’t forget about medical causes. QUESTIONS? Physical Exam Inspection Front & back Height of shoulder and scapulae Muscle atrophy, asymmetry Physical Exam Range of Motion Abduction 0-180o Physical Exam Range of Motion Forward flexion:  0o – 180o Physical Exam Range of Motion Extension  0o – 40 to 60o Physical Exam Range of Motion Internal rotation  T5 segment External rotation  80-90o Physical Exam Strength Empty can test    30o angle Steady downward pressure Tests supraspinatus strength and pain Physical Exam Strength Resisted external rotation  Tests infraspinatus, teres minor strength Physical Exam Strength of Subscapularis Liftoff test Belly press test Cross-Arm Adduction Test AC joint pathology Arm flexed to 90° Hyperadduct arm across body as far as possible Pain in AC = (+) test A-C Shear Test Interlock fingers with hand on distal clavicle and spine of scapula Pain in A-C joint when hands squeezed together = (+) test Sulcus Sign Inferior instability Arm relaxed in neutral position, pull downward at elbow (+) test = sulcus at infra-acromial area  compare to unaffected side Apprehension Test Anterior instability Shoulder at 90° abducted, slight anterior pressure & External rotation (+) test = dislocation apprehension  some false (+) Relocation Test Perform after positive apprehension test Apply post force over humeral head during external rotation (ER) (+) test = increased ER tolerance Load & Shift Test Test for multidirectional instability Grasp humeral head, slide anteriorly and posteriorly while securing rest of shoulder (+) if greater than 50% displacement (graded 1-3) Impingement Signs Hawkins Neer Drop Arm Test Suggestive of Rotator Cuff Tear Passive abduction to 90° Instruct patient to slowly lower arm At 90° abducted arm will suddenly drop, may need to add slight pressure (+) drop = (+) test Speed’s Test Biceps Tendinopathy Long head of biceps tendonitis Fwd flex to 90°, abd 10°, full supination Apply downward force to distal arm Pain = (+) test  weakness w/o pain = muscle weakness or rupture O’Brien’s Active Compression SLAP lesion (Superior Labrum Antero-Posterior) Labral/AC pathology Arm flexed to 90°, elbow extended, adduct 10-15°, resist downward force + if AC pain or internal pain/click O’Brien’s Active Compression SLAP lesion Supination should be pain free (decreased pain) Crank Test Labral injury Glenoid labrum tear Abduct arm to 160°, pt is supine or upright, elbow secured with one hand axial load at shoulder with other (+) if audible/painful catch/grind is noted