Evaluation of the Painful Shoulder J. Lindsay Quade, MD Clinical Instructor Internal Medicine/Pediatrics, Sports Medicine Michigan Medicine Objectives • To improve physician comfort with obtaining relevant history in the evaluation of the painful shoulder • To improve physician comfort with physical examination of the shoulder, including special testing • To improve physician comfort with diagnosis and management of common causes of shoulder pain The Shoulder • Shoulder pain is common in the primary care setting, responsible for 16% of all musculoskeletal complaints. • Taking a good history can help tailor the physical exam and narrow the diagnosis. • Knowledge of common shoulder disorders is important as they can often be treated with conservative measures and without referral to a subspecialist. Shoulder Anatomy Shoulder Anatomy Shoulder Anatomy Shoulder Anatomy MSK Shoulder Pain Differential • Articular Causes • Periarticular Causes • Glenohumeral (GH) and acromoclavicular • Chronic impingement and rotator cuff (AC) arthritis tendinitis • Ligamentous and labral lesions • Bicep tendinitis • GH and AC joint instability • Rotator cuff and long biceps tendon tears • Osseus: fracture, osteonecrosis, neoplasm, • Subacromial bursitis infection • Adhesive capsulitis Taking Your History • Age • Duration • Grinding or clicking • Hand dominance • Radiation • Weakness • Occupation • Aggravating/relieving • Numbness/tingling factors • Sports/physical activities • Pain • Night pain • Trauma • Effect on shoulder • Onset function • Location • Stiffness/restriction of • Character movement The Physical Exam • Inspection • Asymmetry • Bony deformity or abnormal contour • Muscle atrophy or bulge • Scapular winging The Physical Exam • Range of Motion • Active • Passive • Apley’s “scratch” test • Scapular movement •Strength Testing The Rotator Cuff Muscles • Supraspinatus • Abduction • Infraspinatus • External rotation • Subscapularis • Internal rotation • Teres minor • External rotation The Physical Exam • Palpation • AC, SC, and GH joints • Biceps tendon • Coracoid process • Acromion • Scapula Special Tests • Rotator Cuff • “Drop-arm” • “Empty can,” push-off, and resistance testing • Impingement • Neer’s • Hawkins Special Tests • Biceps • Speed’s • Yergason’s • AC Joint • Cross-arm Special Tests • Shoulder Instability • Sulcus sign • Apprehension, relocation, release • Load and shift Special Tests • Labrum • O’Brien’s • Crank test • SLAPprehension Specific Examples • Rotator Cuff Pathology • “Frozen Shoulder” Main points: • Shoulder Instability Presenting symptoms • AC Joint Separation PE findings • Arthritis Diagnosis • Labral Tear Conservative treatment or refer? • “SICK Scapula” Rotator Cuff Pathology • Presentation & symptoms: • PAIN • +/- weakness • Age? trauma vs chronic • Physical exam findings: • Pain with ROM & resistance testing (+empty can, +push-off) • +/- weakness • + drop arm if full-thickness tear, • + Neer’s and Hawkins if impingement Rotator Cuff Pathology • Diagnosis: • Xray – often negative or “cortical irregularity” • Ultrasound • Consider MRI if planning for surgery • Management: • Tendinopathy or impingement – conservative treatment, PT, subacromial GC injection • Partial-thickness tear – PT, possibly subacromial GC injection • Full-thickness tear – PT versus Ortho referral “Frozen Shoulder” (Adhesive Capsulitis) • Presentation & symptoms: • Pain, often >3 months • Progressive loss of ROM • Age >40yo • Risk factors: immobility, DM, hypothyroidism • Physical exam findings: • Limited active ROM, external rotation often 50% normal • Endpoint with passive ROM “Frozen Shoulder” (Adhesive Capsulitis) • Diagnosis: • CLINICAL! • Xray if need to rule-out fracture or OA • US later if concerned for RC pathology • Management: • Set expectations • Pain control, gentle ROM exercises/PT • IG capsular distention +/- intra-articular GC injection PT within 24 hours Shoulder (GH) Instability • Presentation & symptoms: • Pain • Instability • Age < 40yo • Transient neurologic symptoms • History of dislocation or subluxation •Physical exam findings: • + sulcus sign • + apprehension & relocation • + load & shift testing Shoulder (GH) Instability • Diagnosis: • Clinical • Xrays often normal • MR arthrogram if no improvement • Management: • Activity modification • PT focused on aggressive strengthening • Refer to Ortho if no improvement with PT or if recurrent dislocation Acute Shoulder Dislocation • Physical Exam: • External rotation & abduction, palpable humeral head • Check innervation of skin over lateral deltoid! (Axillary nerve) • Diagnosis: • Clinical • Xray • Management: • Relocate & immobilize • ROM exercises within 7-10 days aggressive rehab program AC Joint Separation • Presentation & symptoms: • Direct blow to shoulder or FOOSH • Male contact sport athlete, ~20yo • Pain/swelling • Physical exam findings: • Pain and swelling over AC joint • “Stepped” deformity if more severe • + cross-arm test • + painful arc AC Joint Separation • Diagnosis: • Clinical + • Xray • Management: • Types I-III: Non-operative (rest, ice, analgesics, sling for immobilization, PT) • Types IV+: Ortho referral for surgery Shoulder Arthritis • Presentation & symptoms: • Age >50 • Progressive pain with activity • Decreased ROM • Impingement symptoms • History of rotator cuff injury, previous trauma, or shoulder surgery • Physical exam findings: • AC joint: tenderness over AC joint, pain at extreme internal rotation, + cross-arm test • GH joint: decreased ROM, pain and crepitus at extremes of motion Shoulder Arthritis • Diagnosis: • Clinical + • Xray • Management: • AC joint: • Activity modification, NSAIDs, GC injection • GH joint: • Goal = maintain function with adequate pain control • PT, activity modification, intra-articular GC injection • Referral to Ortho if conservative treatment fails or if severe Labral Tear • Presentation & Symptoms: • Pain +/- instability • Clicking/popping • Overhead athlete, history of dislocation, history of trauma • Physical Exam: • Pain with passive external rotation • Pain with palpation of bicipital groove • + Apprehension/relocation, O’Brien’s, SLAPprehension, crank tests • Can also have + biceps testing Labral Tear • Diagnosis: • Xrays usually normal but may show Hills-Sach lesion • MRI or MR arthrogram • Management: • Conservative: rest, NSAIDs PT • Operative: Ortho referral • If conservative measures fail, larger tears, concomitant RC tear “SICK Scapula” • Presentation & Symptoms: • Pain • Repetitive overhead activity • Drooping shoulder on dominant side • Physical Exam: • Scapular malposition • Inferior medial border prominence • Coracoid pain and malposition • Kinesis abnormalities of scapula “SICK Scapula” • Diagnosis: • Clinical • Management: • PT& kinetic-chain based rehabilitation • Pain free ROM Strengthening Proprioception exercises Take-Home Points • Shoulder pain is common • Taking a good history can help narrow both your differential and your physical exam • Having a good grasp of shoulder anatomy is necessary for interpreting physical exam findings • Develop your own shoulder exam approach and follow it consistently • Aim to know at least one special test for each category of shoulder pain Take-Home Points • Rotator cuff pathology can often be diagnosed with US • Frozen shoulder is a clinical diagnosis • Arthritis diagnosis requires an abnormal xray • Shoulder instability or history of dislocations should warrant PT referral •Most chronic shoulder pain can be treated conservatively • If patient is not improving clinically, refer to Sports Medicine YouTube! “Complete Musculoskeletal Exam of the Shoulder” by University of Michigan Family Medicine Questions? 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