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Shoulder Exam Shoulder Exam Kyle Bronsteen DO, MS Sports Medicine Fellow – Western Michigan University School of Medicine – Family Medicine 10/24/2020 Outline - Anatomy Review - Differential Diagnoses - Musculoskeletal exam - Summary - Cases (self review) Shoulder Anatomy - Bones ANTERIOR POSTERIOR Shoulder Anatomy - Joints Shoulder Anatomy - Ligaments Shoulder Anatomy - Muscles Rotator Cuff Muscles Posterior muscles and Anterior Muscles Scapular Stabilizers Shoulder Pain – Differential Diagnoses Shoulder Pain – Differential Diagnoses NON-MUSCULOSKELETAL Derm: herpes zoster, rhus dermatitis, sunburn Cardio: MI, arrhythmia Pulm: Pneumonia, Tumor, Pneumothorax GI: Biliary Rheum: polymyositis/dermatomyositis. Synovitis (RA, SLE) Shoulder Anatomy – Differential Diagnoses MUSCULOSKELETAL - Fracture - Dislocation - Osteoarthritis - Tendonitis / Tendinosis - Muscle strain - Apophysitis - Impingement - Labral tear - Adhesive capsulitis Shoulder Exam Shoulder Exam HISTORY HISTORY HISTORY Trauma - fracture, dislocation, muscle tear/rupture, ligament tear/sprain Insidious onset - tendonitis/tendinosis, bursitis, rheumatologic, osteoarthritis, stress fractures, adhesive capsulitis Musculoskeletal exam I-P-A-S-S Inspection Palpation Active ROM (passive too) Strength Special Tests Shoulder Exam - Inspection Shoulder Exam - Inspection Shoulder Exam - Inspection Posture Shoulder height: level? Arm position: resting at side, abducted and internally rotated Assistive Device: sling, cast/brace, walker/cane Ecchymosis Erythema Rash Open wound/lesion/fracture Scars Atrophy Shoulder Exam - Palpation AC jt. SC jt. Gr. Tuberosity . Coracoid. LH Biceps Shoulder Exam - Palpation Shoulder Exam – Active ROM Shoulder Exam – Active ROM Shoulder Exam – passive ROM Shoulder Exam - ROM Abduction – stresses rotator cuff (Supraspinatus) and deltoid Forward flexion – less rotator cuff, more deltoid External rotation – Infraspinatus, Teres Minor Internal rotation – Subscapularis Others: - Extension - Rotation at 90 degrees (supine or sitting) - Scapular motion (dyskinesia) Shoulder Exam - Strength Infraspinatus Subscapularis Supraspinatus Shoulder Exam – Special Tests Rotator Cuff tendonitis / Impingement - Jobe’s Test / Empty Can - Hawkin’s - Neer’s - Posterior impingement test Special Tests - Impingement Jobe’s Empty Can test Hawkin’s test Neer’s test Posterior Impingement test Shoulder Exam – Special tests Rotator Cuff Tears (*significant*) HALLMARK IS WEAKNESS - Drop arm test - External rotation lag - Lift off - Belly Press - Hornblower’s Special tests – Rotator cuff Hornblower’s test Drop Arm test External rotation Lag sign Belly press test Lift-off test Shoulder Exam – Special tests Labral pathology and Instability (SLAP tear, bankart, subluxation/dislocation) - O’brien’s - Dimple sign - Crank - Load and Shift - Apprehension and Relocation - Posterior apprehension Special Tests – Labral pathology O’Brien’s test Sulcus sign Crank test Special Tests – Labral pathology / Instability Apprehension and Relocation test Posterior Apprehension test Shoulder Exam – Special tests Biceps tendon pathology (SLAP tear, tendonitis, impingement) - O’brien’s - Speed’s - Yergason’s Special Tests - Biceps Red = patient force Yergason’s test Speed’s test Shoulder Exam – Other AC Joint - Cross body test / Compression - Manual translation (anterior to posterior, superior to inferior) Frozen Shoulder / Adhesive capsulitis - Loss of active and passive motion Shoulder Exam – Cervical Spine Cervical Spine - Screening Exam - Active ROM - Flexion / Extension - Rotation - Side bending - Palpation -Tests - Spurling’s - Neural tensioning - Strength, sensation, reflexes Cervical Spine - Tests Spurling’s test Neural tensioning Shoulder Exam – Scapula Fun Fact 17 muscles attach to scapula Scapula evaluation Exam - Inspection - Symmetry? Prominence? Winging? - Active ROM - Abduction, forward flexion Tests - ROM - Wall push up (winging) - Scapular assistance Shoulder Exam – Scapula Shoulder Exam – Scapula Wall push up / Scapular assistance Push up Summary Summary Shoulder is a complex structure. multiple joints, ligaments, muscles, and bones. Shoulder pain has broad DDX: both MSK and non-MSK Always inquire about neck pain and radicular symptoms, examine the c-spine ALWAYS examine the skin (shirt off, tank top, sports bra, etc) Special Tests: pick several you are comfortable with for each subgroup of pathology Questions Case 1 45yo male, Left hand dominant CC: left shoulder pain 2 weeks of progressive left anterior and lateral shoulder pain. Denies acute trauma or injury. Sometimes radiates down his lateral arm. Worse with overhead movements, has difficulty brushing his hair and teeth. Uncomfortable at night, has trouble sleeping. Denies swelling, bruising, weakness, tingling/paresthesias. No improvement with naproxen or ice. No neck pain. No prior shoulder injuries or surgeries Works as carpenter, lots of overhead lifting, screwing, hammering, etc Exam Inspection - No swelling, ecchymosis, erythema, skin lesion - slightly elevated left shoulder vs. right ROM - Left Abduction to 150 degrees, pain in mid-arc (full right shoulder) - Normal forward flexion, internal and external rotation Strength - Left abduction 4/5 with pain, External rotation 5-/5 with pain - Left internal rotation, biceps, triceps, grip, finger abduction 5/5. - right strength normal Palpation - pain over greater tuberosity and subacromial space, otherwise none Tests - Positive: Empty can, Hawkin’s, Neer’s, Painful arc - Negative: Speed’s, Crank, Load and shift, O’brien’s Neurovascular - intact Cervical Spine - normal motion, no pain - negative Spurling’s Diagnosis? Rotator Cuff Tendonitis / Impingement Case 2 8yo female, right hand dominant CC: right shoulder pain Last night at cheerleading practice fell onto right shoulder after a jump. Had difficulty moving right arm afterwards. Did not feel a pop or snap. Was uncomfortable overnight, noticed some swelling and bruising over right shoulder this morning. Ice has helped some. No elbow, wrist, or hand pain. Shoulder is very pain full to move. No paresthesias. No prior shoulder injuries or surgeries. Growth and development are normal. Elementary school. Participates in cheerleading. Exam Inspection - Bony deformity/prominence of the distal clavicle. Skin is intact. Faint bruising. - No lateral shoulder bruising or swelling. - Elbow, forearm/wrist, hand appear normal ROM - Limited shoulder motion due to pain - Normal elbow and wrist motion Strength - Actively abducts, forward flexes, and rotates the shoulder with pain - Full elbow and wrist strength Tests - n/a Neurovascular - intact Diagnosis? Clavicle Fracture Case 3 65 female, right hand dominant CC: Left shoulder pain Progressive left shoulder pain for 1 month. Denies trauma or injury. Pain constant but worse with movement in all directions of the arm, is having trouble dressing herself and doing ADL’s. Shoulder feels stiff. No paresthesias, bruising, swelling. She is a diabetic, decided to stop taking her insulin 6-8 weeks ago, does not check blood sugars regularly. No prior shoulder injuries or surgeries. Fractured her right wrist as a child. Works desk job, is not physically active Exam Inspection - Normal alignment, no gross deformity. No swelling, ecchymosis. Skin is normal. ROM - Active abduction to 60 degrees, passive to 70 degrees. + pain - external rotation to 20 degrees, passive to 25 degrees. + pain. - Normal right shoulder motion Strength - Left: 5/5 to abduction, internal and external rotation - Right: Normal Palpation - Diffuse tenderness of the shoulder joint. No gross deformity or step off - no warmth Tests - Restricted passive and active motion Neurovascular - intact Diagnosis? Adhesive Capsulitis / Frozen Shoulder.
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