Shoulder Exam: Rapid Exam and Diagnosis
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1 Objectives Shoulder Exam: Rapid Exam and Diagnosis Be able to perform three minute shoulder exam Discuss common MSK diagnoses, and how to rapidly stratify based on history Levi Miller, D.O. University of Washington Departments of Physical Medicine & Rehabilitation Shoulder Overview Shoulder girdle facilitates placement of hand in space. Shoulder is an inherently unstable joint mobility>stability Compare to the hip: stability>mobility It is a non weight bearing joint most problems related to overuse, inflammatory, trauma Anatomy Musculature (major) Rotator cuff: supraspinatus, infraspinatus, subscapularis, teres minor Biceps, triceps, deltoid, rhomboid, trapezium, pec, lats Bones Scapula, clavicle, humerus Anatomy 4 shoulder joints: sternoclavicular (SC), acromioclavicular (AC), glenohumeral (GH), scapulothoracic (ST) Only synovial attachment t to torso through SC articulation Capsule, labrum and ligaments inferior glenohumeral ligament C5, C6 radiculopathy brachial neuritis 1
2 Common Diagnoses Dislocations Rotator cuff tendinopathy and tears Impingements Bursitis AC arthropathy Adhesive capsulitis Neurologic (eg C5 radiculopathy) Referred pain (eg C5-6 facet arthropathy) Uncommon Diagnoses Brachial Neuritis (aka Parsonage-Turner Syndrome) Facioscapulohumeral dystrophy (FSHD) History and Physical Age and activity major predictors of pathology Dislocations Age predicts likelihood of repeat dislocation (>>younger age) Rotator cuff tears Rare in younger patients and athletes More common in >40yo Impingement: Shoulder Instability Traumatic Dislocations Laxity does not equal instability Definitions Instability: symptomatic laxity of the shoulder Apprehension: feeling of impending instability Subluxation: partial loss of articulation (i.e. popping in and out of joint) Dislocation: total loss of articulation Shoulder is most commonly dislocated joint Majority are anterior dislocations (95%) Typically from FOOSH Typically pt presents with arm in a abducted, ER position Axillary nerve commonly injured Risk factors: overhead activities (eg throwing) younger X-ray (common views: A/P, scapular Y view) Bankart lesion (anterior labral avulsion from glenoid) Westpoint view Hill-Sacks lesion (posterior humeral head defect) Striker notch view If posterior dislocation consider electrocution or seizure 2
3 Rotator cuff Rotator cuff What are the four muscles? Fifth muscle? What is tendinopathy? Tendinosis, tendinitis? Rotator cuff disease is a spectrum of pathological changes: Normal tendinosis partial tear full thickness tear Rotator cuff tendinopathy and tears are more common than osteoarthritis in the shoulder X-ray may show superior migration of the humerus due to unopposed deltoid pull Impingement (external) Primary anatomic Narrowing of coracoacromial arch space, resulting in RTC impinging Associated with type 3 hooked acromion Secondary Instability Scapulothoracic dyskinesis (ie poor scapular coordination with arm) Intrinsic RTC abnormality Eg tendinosis, tear, neurologic RTC History & Exam History: Pain location typically lateral arm Pain when lying on that side Worse with overhead activities or reaching behind Exam: + Hawkins + Painful arc (between 60 to 120 degrees) + ER weakness If all 3+, 95% probability RCT pathology Adhesive Capsulitis Facet arthropathy referral patterns Female>male; typically in their 50 s Asso. Thyroid dz, DM, immobilization Limited ROM (especially ER), painful Plain films normal Arthrogram may show reduced capsule volume Typically described as 3 phases Painful stage 1-3 months Freezing stage 3-9 months (< pain, > loss ROM) Thawing stage 9-24 months (slow improved ROM) 3
4 Approach to MSK exam Inspection Inspection Palpation and ROM Neuromuscular exam Special & Functional Tests View gowned pt from back Posture Typical modern posture shoulders protracted, increase thoracic kyphosis, anterior head carriage Position of scapula It scapula equidistant from spine? Subluxation? Scapular winging? Serratus anterior, trapezoid, or rhomboid weakness each presents with specific pattern of winging Atrophy Especially look for supraspinatus, infraspinatus, and deltoid atrophy Range of Motion Shoulder ROM Active ROM: Still viewing from behind Bilateral shoulder abduction Painful arc? consider RTC pathology Observe smoothness of scapular motion Symmetric? Delayed? Flex elbows to 90 degrees (external rotation) Rotate arms 180 degrees (internal rotation) Standing exam of IR and ER is a gross test ideal test is with pt supine on table, scapula is fixed and true GH rotation observed. Palpation From behind supraspinatus, infraspinatus, deltoid atrophy? Compare to contralateral side - palpation more sensitive for atrophy than visual inspection From front SC joint, move along clavicle to AC joint drop off acromion to RTC Lateral is supraspinatus Posterior is infraspinatus External rotate arm palpate long head of biceps and subscapularis Neuro exam Strength Shoulder abduction, elbow flexion, elbow extension, external rotation, internal rotation, lift off test (subscapula) Always compare sides Reflexes DTRs biceps, triceps, brachioradialis Hoffman s Sensation dermatomal a/o peripheral nerves 4
5 Special tests Apprehension test (instability) Tons of them we ll go over just a few Pt sitting or supine Gently abduct shoulder 90 deg, ER 90 deg Gentle anterior force at posterior shoulder + test: t if signs or symptoms of apprehension Relocation & Surprise tests (instability) Relocation test Continue apprehension maneuver, however change examiners force by placing posterior pressure on anterior shoulder + test: relief of anxiety/apprehension Surprise test subsequently letting go of the posteriorly directed pressure + test: with sudden fear/apprehension of dislocation Sulcus Sign (Subluxation, inferior instability/labral tear) Pt sits/stands with relaxed shoulder. Examiner distracts arm inferiorly, + test: increased space between humerus and acrominon Load & Shift (A/P instability, labral tears) Pt sitting or supine, the scapula is stabilized (secure coracoid and scapular spine) with one hand The humeral head is then grasped, translated anteriorly and posteriorly Palpate for movement of head along or over glenoid 3 grades (0-25%, 25-50%, >50% respectively) Neer and Foster s study: PPV 93.8%, 90.9% sensitive, 93.3% specific for Bankart lesion (antieroinferior labral tear) Empty Can (aka Jobe Test, aka Supraspinatus Test) first assess the deltoid by pt abducting arm to 90 degrees with neutral rotation Supraspinatus is then assessed by internally rotating arm (thumb towards floor) and moving the arm (horizontal adduction) 30 degrees Examiner then provides resistance + test: pain and or weakness 5
6 O Brien s Test (labral tear vs AC arthropathy) Drop Arm Neer s test (impingement) Hawkin s Test (impingement) Passively flex the shoulder to maximal forward flexion, pt s thumb towards ear + test: pain in shoulder at maximal forward flexion Forward flex pt s shoulder to 90 degrees with elbow flexed 90 degrees Internally rotate shoulder Check at several locations by horizontally adducting arm and dthen internally rotating ti + test: pain in shoulder Scapular assistance test (secondary impingement) Lift Off Test (weak/torn subscapularis) Internally rotate arm behind pt s back Pt presses hand posteriorly + test: Inability to lift/press arm backwards 6
7 Yergason s test (biceps tendinopathy) Speed s test (biceps tendinopathy) Pt s elbow flexed 90 degrees, forearm pronated Pt resists supination + test: pain at bicipital groove (ie anterior shoulder) Shoulder forward flexed about 30 degrees, elbow full extended and supinated Doc puts downward d force on arm, pt asked to resist + test: pain along biceps long head Yocum s test (AC arthopathy) Conclusion Pt places hand on opposite shoulder and raises elbow against examiner s resistance + test: pain at AC joint There are many should exams try to quickly determine a differential diagnosis from the history and customize your exam to rule in/out for diagnosis 7
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