The Shoulder Examination:

Supporting your differential

COURTNEY DAWLEY, DO MAJOR, USAF, MC DIRECTOR SPORTS MEDICINE TRAVIS AFB FAMILY MEDICINE RESIDENCY

Objectives
Review important anatomy

Emphasize the interplay between the dynamic

stabilizers Review the shoulder examination Refine the differential diagnosis based on exam findings

Shoulder Anatomy

Bony Anatomy of the Shoulder

Coracoid Process Intertubercular Groove

Glenohumeral Joint and the Labrum

Ball (humeral head) and

socket (glenoid fossa) joint

Glenoid fossa is shallow allowing large ROM at the expense of skeletal instability

Static Stabilizers Glenohumeral ligaments Labrum Bony structure Capsule

Dynamic Stabilizers

Rotator Cuff Muscles/Tendons

Scapular Stabilizers Long Head of the Biceps

17 Muscles Create the Movement of the Shoulder

The Rotator Cuff

Case
Chief Complaint 54 y/o RHD female with 2 months left shoulder pain History of Present Illness

Worse with overhead motion and at night Pain is lateral and radiates distally to a few cm No weakness or instability Improved slightly with ice and NSAIDs

Had similar pain on right several years ago that improved with
a steroid shot

Differential Diagnosis
Impingement syndrome

Adhesive capsulitis SC joint arthritis, sprain AC joint arthritis, sprain Glenohumeral joint OA Instablity

Subacromial bursitis Rotator cuff tendinopathy Rotator cuff tear Biceps tendinopathy

Other arthritic disease

Rheumatoid, Gout, SLE Septic, Lyme, etc.

Clavicle fracture Proximal humerus fracture Scapular fracture

GH dislocation GH subluxation Labral tear (e.g. Bankart, SLAP, etc.)

Avascular necrosis Neoplastic disease Thoracic outlet syndrome CRPS Myofascial pain Referred pain

Cervical radiculopathy Cardiac Aortic aneurysm Abdominal / Diaphragm Other GI

Physical Exam
Inspection Normal Rounded shoulder posture? Arm in sling? Atrophy?
Supraspinatus/infraspinatus fossa(e) Deltoid atrophy?

Prominence of Acromioclavicular (AC) joint? Normal, rounded shoulder posture

Physical Exam
Palpation Tender? Non-tender? AC Joint Anterior rotator cuff Clavicle Biceps Tendon Soft tissues

Tender along anterior and lateral shoulder

Physical Exam
Range Of Motion Elbow at side
Forward flexion-elevation 180 Deg Abduction 180 Deg External Rotation 45 Deg Internal Rotation 45 Deg Apley scratch test to: T7, T5, Sacrum, Hip Pocket, etc

Shoulder Abducted to 90 degrees

External Rotation 90 Deg; Internal Rotation 90 Deg Total arc of motion 180

Physical Exam
Range of Motion Scapular motion symmetric/asymmetric? Dyskinesis on the R/L? Exaggerated scapulo-thoracic motion with ROM?

Full Active ROM, pain with forward flexion and abduction, slight dyskinesis on the left

The Rotator Cuff

Why do We care?
-17 MUSCLES HAVE ACTIONS ACROSS THE SHOULDER -NEARLY IMPOSSIBLE TO ISOLATE INDIVIDUAL MUSCLES -ROTATOR CUFF IS AFFECTED BY MOST DISORDERS OF THE SHOULDER -DISRUPTION CAN CAUSE SYMPTOMS THAT MIMIC SUBACROMIAL IMPINGEMENT, INSTABILITY, GLENOID LABRUM TEAR, ADHESIVE CAPSULITIS -ROTATOR-CUFF INTEGRITY SHOULD BE TESTED IN ALL SHOULDER EXAMINATIONS

The Rotator Cuff Revealed

Supraspinatus

Teres Minor

ABDuction

External Rotation Internal Rotation

Infraspinatus

Subscapularis

External Rotation

Physical Exam
Strength Testing Supraspinatus: 5/5 Drop arm External Rotation: 5/5 Subscapular lift-off: 5/5 Tummy press Bear Hug

5/5

Strength but painful with supraspinatus and subscapularis

Physical Exam
Neurovascular Upper extremity distal pulses Upper extremity sensory

Grossly Normal

And last, but not least..

Special Tests
Impingement Hawkin's Sign Neer's Sign Neer's Test: Lidocaine injected into the subacromial space to see if pain is relieved

Hawkins and Neers Signs positive

Special Tests
Cross-body adduction Painful in AC joint? Anterior joint? Posterior joint?

Negative

Labral OBrien or Active Compression test

Painful over top of shoulder vs inside the joint? Improved symptoms with external rotation? Painful clicking?

Crank Test Negative

Special Tests
Biceps Tendinopathy Tendon is difficult to palpate

Externally rotate the arm 20 deg and flex and extend the elbow

Biceps tendon is rarely affected without coexisting rotator cuff tendinopathy

Speed's Test
Yergason's Test

Both Negative

Special Tests
Instability Sulcus Sign Apprehension Relocation Load and shift All Negative

Physical Exam Continued

Cervical Radiculopathy should be ruled out in

patients over 35 by performing a neck exam

Neck Neck ROM Spurling's Test

Full ROM, Negative Spurlings

So What do we Know?
Not a full-thickness rotator cuff tear

Not likely to be labral

Not likely to be AC joint sprain/OA Not likely to be glenohumeral OA

No evidence of instability
Does not appear to involve the biceps

And the diagnosis is..

1. Subacromial bursitisAssociated Diagnoses

with Signs of impingement 2. Rotator cuff tendonopathy

-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

Time to Practice

Closing Thoughts
Large differential for shoulder pain with tests that have

varying degrees of sensitivity and specificity Clinical history and mechanism of injury can be very helpful Consider diagnostic injections

AC joint Subacromial space Glenohumeral joint Biceps tendon (long head)

Questions?

http://espn.go.com/photo/2007/0221/nba_ap_wade_268x400.jpg

References
Griffin LY: Essentials in Musculoskeletal Care.

Rosemont, IL, American Academy of Orthopedic Surgeons, 2005. McFarlan ED, Garzon-Muvdi J, Jia X, Desai P, Petersen SA: Clinical and diagnostic tests for shoulder disorders: a critical review. Br J Sports Med. 2010; 44: 328-332. Moen MH, de Vos R-J, Ellenbecker TS, et al: Clinical tests in shoulder examination: how to perform them. Br J Sports Med. 2010; 44: 370-375. Seidenberg PH, Beutler AI: The Sports Medicine Resource Manual. Chapters 9. Philadelphia, PA, Saunders, 2008.

Case 2
-45 Y/O RIGHT HAND DOMINANT MALE -2 WEEKS OF ACUTE ONSET RIGHT SHOULDER PAIN AFTER

GRABBING A LADDER WHILE FALLING

-DECREASED RANGE OF MOTION -HURTS TO LAY ON THAT SHOULDER AT NIGHT -PAIN ALONG ANTERIOR JOINT

-WEAKNESS WITH OVERHEAD MOTIONS, NO INSTABILITY

-IMPROVED SLIGHTLY WITH ICE AND NSAIDS AND PERCOCET HE HAD LEFT OVER

Physical Exam
Inspection

Normal, no ecchymosis Standing exam: right shoulder sits lower than the left Atrophy of supraspinatus/infraspinatus fossa(e) or deltoid atrophy? Prominence of Acromioclavicular (AC) joint?

Palpation Tender diffusely across anterior shoulder and wrapping back around

AC Joint Anterior rotator cuff Clavicle Biceps Tendon Soft tissues

Physical Exam
Range Of Motion (elbow at side)

Forward flexion-elevation painful after 30 degrees, can passively get to 180 Deg Abduction painful after 30 degrees, can passively get to 180 Deg External Rotation 45 Deg Internal Rotation some pain, 45 Deg Apley scratch test to: T5 Scapular motion symmetric/asymmetric? Dyskinesis on the R/L? Exaggerated scapulo-thoracic motion with ROM?
External Rotation 90 Deg; Internal Rotation 90 Deg

Range of Motion (shoulder abducted to 90 deg)

Physical Exam
Strength Testing Supraspinatus: 0/5, painful Drop arm Positive External Rotation: 5/5 Subscapular lift-off: 5/5 with pain Tummy press Bear Hug Neurovascular Upper extremity distal pulses: normal Upper extremity sensory: grossly normal

Special Tests
Impingement Hawkin's Sign: positive Neer's Sign: positive Neer's Test: not performed (lidocaine injected into the subacromial space to see if pain is relieved

Cross-body adduction: negative Painful in AC joint? Anterior joint? Posterior joint?

Labral OBrien or Active Compression test: positive?

Painful over top of shoulder vs inside the joint? Improved symptoms with external rotation? Painful clicking?

Crank: negative

Special Tests
Biceps Tendon Rupture? Tendon is difficult to palpate

Externally rotate the arm 20 deg and flex and extend the elbow

Popeye deformity?

Speed's Test: negative Yergason's Test: negative

Physical Exam Continued

Cervical Radiculopathy should be ruled out in

patients over 35 by performing a neck exam

Neck Neck ROM: Full Spurling's Test: Negative

And the diagnosis is..

1. Rotator cuff tear/tendonopathy

2. Subacromial bursitis
3. Frozen shoulder

Most Commonly torn rotator cuff muscle/tendon is?

Supraspinatus
Acutely or with chronic tendonopathy

Case 3
-32 Y/O LEFT HAND DOMINANT MALE -ACUTE ONSET OF LEFT SHOULDER PAIN AFTER SKIING 3

DAYS AGO; FELL ON LEFT SHOULDER WITH IMMEDIATE

PAIN -IS NOT SURE BUT MAY HAVE COME OUT OF SOCKET -PAIN DIFFUSELY ALONG ANTERIOR JOINT AND LATERALLY -PAIN WITH OVERHEAD MOTIONS, UNSURE ABOUT INSTABILITY -NO PRIOR DISLOCATIONS -PAIN SOMEWHAT IMPROVED WITH ICE AND NSAIDS

Physical Exam
Inspection Normal, no ecchymosis Arm in sling? Auto-splinting? Prominence of Acromioclavicular (AC) joint? Palpation Tender diffusely across anterior shoulder and wrapping back around AC Joint Anterior rotator cuff Clavicle Biceps Tendon Soft tissues

Physical Exam
Range Of Motion (elbow at side) Forward flexion-elevation painful after 90 degrees, can actively get to 180 Deg Abduction painful after 45 degrees, can actively get to 180 Deg External Rotation 45 Deg with some pain Internal Rotation 45 Deg with pain Apley scratch test to: T7 Scapular motion symmetric/asymmetric? Dyskinesis on the R/L? Exaggerated scapulo-thoracic motion with ROM? Range of Motion (shoulder abducted to 90 deg) External Rotation 90 Deg; Internal Rotation 90 Deg

Physical Exam
Strength Testing Supraspinatus: 4/5, painful Drop arm Negative External Rotation: 5/5, painful Subscapular lift-off: 4/5, painful Tummy press Bear Hug Neurovascular Upper extremity distal pulses: normal Upper extremity sensory: grossly normal

Special Tests
Impingement Hawkin's Sign: positive Neer's Sign: positive Neer's Test: not performed (lidocaine injected into the subacromial space to see if pain is relieved

Cross-body adduction: painful-inside joint Painful in AC joint? Anterior joint? Posterior joint?
Labral OBrien or Active Compression test: painful inside joint

Painful over top of shoulder vs inside the joint? Improved symptoms with external rotation? Painful clicking?

Crank: negative

Special Tests
Biceps Tendonopathy No ttp over biceps tendon Speed's Test: negative Yergason's Test: negative Sulcus Sign: positive Apprehension: positive What about Relocation: positive Load and shift: positive

But wait!!!!!!
the films?

Closing Thoughts
Large differential for shoulder pain with tests that have

varying degrees of sensitivity and specificity Clinical history and mechanism of injury can be very helpful Consider diagnostic injections

AC joint Subacromial space Glenohumeral joint Biceps tendon (long head)

References
Griffin LY: Essentials in Musculoskeletal Care.

Rosemont, IL, American Academy of Orthopedic Surgeons, 2005. McFarlan ED, Garzon-Muvdi J, Jia X, Desai P, Petersen SA: Clinical and diagnostic tests for shoulder disorders: a critical review. Br J Sports Med. 2010; 44: 328-332. Moen MH, de Vos R-J, Ellenbecker TS, et al: Clinical tests in shoulder examination: how to perform them. Br J Sports Med. 2010; 44: 370-375. Seidenberg PH, Beutler AI: The Sports Medicine Resource Manual. Chapters 9. Philadelphia, PA, Saunders, 2008.