Chiou

Physical Examination of the Shoulder

Lisa Chiou, MD, MPH

Primary Care Conference

Goals

Review some of that anatomy from medical school

Discuss common shoulder problemsPractice focused physical exam

Shoulder pain

Common in all age groupsIntrinsic disorder (85%) vs referred pain

C-spine nerve impingement (disc herniation or spinal stenosis)

Peripheral nerve entrapment distal to spinal column (long thoracic, suprascapular)

Diaphragm irritation, intrathoracic tumors, and distension of Gleason’s capsule/gall bladder

Myocardial ischemia Pancoast tumor

Review of shoulder anatomy

Bones Scapula Clavicle Humeral head Posterior rib cage

Joints Sternoclavicular Acromioclavicular Glenohumeral Scapulothoracic

Glenohumeral joint

25% humeral head surface in contact with glenoid

Joint space thinning seen with OA

Humeral head coverage increased to 75% with glenoid labrum

More shoulder anatomy

Ligaments Coracoclavicular Acromioclavicular Glenohumeral

Superior GH Middle GH Inferior GH Coracohumeral

Subacromial bursaSubdeltoid bursa

Rotator cuff muscles

Supraspinatus, infraspinatus, teres minor, subscapularis

Form cuff around humeral head

Keep humeral head within joint (counteract deltoid)

Abduction, external rotation, internal rotation

Shoulder exam #1

Visualize from front and backAsymmetry

Pts with rotator cuff tears hold shoulder higher

Atrophy Sign of chronic glenohumeral joint pathology

Effusions Shoulder joint can hide a lot of fluid

Shoulder exam #2

Palpation Along clavicle SC and AC joints Acromion, subacromial region Coracoid process (short head of biceps) Bicipital groove (long head of biceps) Trigger points in neck, trapezius, scapular

region

Active range of motion

Forward flexionAbduction/adduction

Painful arc of abduction – sensitive, not specific

External rotationInternal rotation

Passive range of motion

Immobilize the scapula to prevent rotation Use one arm to push down on shoulder Use other arm to do the PROM exercises

AbductionInternal and external rotation

Have arm at patient’s side and abducted to 90 degrees

Rotator cuff strength testing

Supraspinatus “Pour out a Coke”

Infraspinatus and teres minor “Act like a penguin”

Subscapularis “Scratch your back”

Impingement maneuvers

Impingement sign At 90 degrees of abduction with elbow flexed to

90 degrees, do internal (downward) and external (upward) rotation

Hawkins’ test At 90 degrees of elbow flexion, do internal

rotation by pushing down on pt’s forearmNeer’s test

At full elbow extension, internally rotate and flex the arm

Biceps strength testing

Arms outstretched with palms up at level of shoulder

Forced supination of hand with elbow flexed at 90 degrees

Impingement syndrome

Compression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromion

Repetitive overhead motionsMain cause of rotator cuff tendonitisCan lead to bursitis, partial or full rotator

cuff tears

Sx of impingement syndrome

Usually gradual onsetOuter deltoid pain, especially with

reaching or overhead movementsNight painDifficulty sleeping on affected sideNearly identical symptoms as tendonitis

Exam for impingement

Pain with painful arc maneuverCrepitus above 60 degreesSubacromial tenderness (lateral)No pain with external/internal rotation,

abduction, elbow flexion Distinguishes impingement from tendonitis

Normal glenohumeral ROMNormal strength

Radiology for impingement

X-rays usually not needed Reasonable to get if chronic symptoms

MRI can rule out other pathology Wait at least 24 hours after an injection Osseous abnormalities Need to clinically correlate MRI findings

Tx of impingement

Rest Ice Stretching, then strengthening

Pendulum for 5-10 minutes QD Can increase space under acromion by ½”

Don’t use arm sling Subacromial injection Surgical referral if no improvement after 3-6

months

Rotator cuff tendonitis

Some argue this is same as impingementAcute or chronic

Acute – more likely to have calcific deposits

Pain along lateral arm (outer deltoid)Pain with numerous activities, lying on the

affected side, overhead movementsRF – relative overuse, age, osteophytes,

trauma, inflammatory processes (RA)

Exam for impingement

Painful arc of abduction (active) 60-120 degrees

Impingement signsImpingement test

Subacromial lidocaine injection Can then test again for weakness

Radiology for tendonitis

Nothing is diagnosticPlain films not necessary

Get if chronic or recurrent Might see calcifications

If significant loss of strength or ROM, get MRI Rule out tear Hard to see tendon calcifications

Tx of tendonitis

RestHeat or iceUltrasound (physical therapy)NSAIDsSubacromial steroid injection

Rotator cuff tear

50% pts do not have preceding traumaUsually in supraspinatusWide size range, plus partial vs fullShoulder weakness, pain, loss of motion Common mechanisms of injury:

Falling onto outstretched arm, onto outer shoulder directly, heavy pushing/pulling

Sx of rotator cuff tear

Shoulder weakness Localized pain over upper back Popping/catching sensation when shoulder is

moved Night pain is characteristic

Sx vary depending on direction of the torn tendon fibers Parallel: pain Transverse: weakness, loss of function

Exam for rotator cuff tear

Range of motionStrengthDrop arm test

Arm abducted with elbow straight See if pt can smoothly lower arm If arm drops, then test is positive for tear Highly specific but only 21% sensitive

Radiology for rotator cuff tears

Interpret carefully 34% asymptomatic pts (all ages) and 54% pts >60

yo have partial rotator cuff tears Abnormal rotator cuff signal after trauma may

represent strain rather than tear X-rays

Look for high riding humeral head Ultrasound

Highly operator dependent MRI

Rotator cuff tears

Tx of rotator cuff tears

Ice, NSAIDs, restrict aggravating motionsWeighted pendulumNo arm slingsSteroid injection if persistent sxSurgery – refer if young pts, full/large

tears, dominant arm Best if done within 6 weeks

Acromioplasty and debridement

Acromioclavicular injury

Arthritic changes AC joint separation

Anterior shoulder pain or deformity Preceding trauma Often pts hold arm close to chest and resist

rotation and elevation With OA, may have grinding or popping

sensation with reaching overhead/across chest

Exam for AC joint injuries

Joint enlargement or deformityJoint tendernessPain with crossed body adductionJoint widening with downward arm traction

in pts with 2nd or 3rd degree joint separation

Tx of AC joint injury

Reduce pressure and traction to allow ligaments to re-attach

Acute: ice, NSAIDs, shoulder immobilizer for 3-4 weeks

Persistent: steroid injectionRefer to surgery if no improvement after 2

injections

Adhesive capsulitis

Loss of motion +/- pain due to stiff GH joint Is usually reversible May have preceding trauma Most common cause (10%) is rotator cuff

tendonitis Risk factors:

Diabetes Disuse (i.e. pts with arm in sling) Low pain thresholds Poor compliance with exercise therapy

Rare associations

Hyper- or hypothyroidismParkinson’s diseaseAntiretrovirals (PPIs)Recent neurosurgery

Exam for adhesive capsulitis

Clinical diagnosisRange of motion is smooth and pain-free,

then stops suddenlyNo further passive ROM possibleNormal strength in the pain-free rangeCan test strength again after lidocaine

injection

Radiology for adhesive capsulitis

X-rays have limited use Might see calcifications or degenerative

changes that would lead to frozen shoulder

MRI Enhancement of joint capsule and synovial

membrane 4 mm thickening is 70% sensitive and 95%

specific

Arthrogram for adhesive capsulitis

Normal capsule volume

Frozen shoulder (contracted GH capsule)

Tx of adhesive capsulitis

Watchful waiting Up to 2 years for resolution Incomplete recovery more likely in pts with DM, or pts

with >50% loss of external rotation/abduction Steroid injection Manipulation under anesthesia

Gentle exercise Pain medications Alternative therapies – i.e. acupuncture

Biceps tendonitis

Inflammation of long head of biceps Passes through bicipital groove of anterior

humerus

Usually due to repetitive lifting or reachingInflammation, microtearing, degenerative

changesUp to 10% pts will have spontaneous

rupture

Sx of biceps tendonitis

Anterior shoulder painWorse with lifting or overhead reachingOften pts point to bicipital grooveUsually no weakness in elbow flexion

Exam for biceps tendonitis

Bicipital groove tendernessLook for subacromial impingementTendon ruptureTest biceps strengthYergason test

Elbows flexed with forearms in front Pt actively resisting external rotation Tendon may pop out of bicipital groove when

downward pressure applied to forearm

Ruptured biceps tendon

Usually rotator cuff tear also present

Get the “popeye” sign Rarely get significant

weakness Brachioradialis and

short head of biceps provide 80-85% elbow flexor strength

Tx is supportive

Radiology for biceps tendonitis

Usually plain films unnecessaryIf tendon rupture present, then get plain

films, U/S, or MRI Look for rotator cuff tendonitis or tear

Tx of biceps tendonitis

Reduce inflammation Strengthen biceps muscle and tendon Prevent rupture

Ice, NSAIDs, avoid aggravating motions 5-10% risk of rupture with noncompliance

Weighted pendulum Elbow flexion toning exercises Steroid injection Surgical referral if sx persist >3 months

Glenohumeral osteoarthritis

Same risk factors as with OA in other areas Trauma, obesity, age

Less common than OA in weight bearing joints or spine

Pain, stiffness over months to years Anterior shoulder is most painful area

Worse with activityDistinguish from RA, adhesive capsulitis

Unusual causes

Hemochromatosis Think of this if patients develop OA in unusual

places at unusually early ages

Hemophilia Blood very erosive to joint

Exam for glenohumeral OA

GH joint line tenderness and swelling Just below coracoid process Use outward and upward pressure Effusion may be very hard to see

Decreased ROM External rotation, abduction Endpoint stiffness

Crepitus

Imaging for glenohumeral OA

Joint space narrowing (loss of articular cartilage)

Osteophytes Humeral head sclerosis

and flattening Club-like deformity

Tx of glenohumeral OA

Low impact activities, and heat + stretching Let pain be the guide

NSAIDs, acetaminophen, glucosamine, chondroitin

Intra-articular steroidsIntra-articular hyaluronateArthroplasty or total shoulder replacement

Polymyalgia rheumatica

Think of this with patients >60, especially if they have bilateral shoulder symptoms

Females>malesEuropeans Rare – 20-50 per 100,000 per year

Symptoms of PMR

Acute to sub-acute onset Morning stiffness

Patients can’t get out of bed

Night pain Proximal muscle involvement 20% have joint swelling

PMR and giant cell arteritis

Between 1-16% pts with PMR develop GCA Nearly half of pts with GCA have co-existing

PMR Watch for jaw

claudication, visual changes, scalp tenderness

Shoulder weakness after viral illness

Parsonage-Turner syndrome

Brachial neuritis Thought to be post-viral Sudden onset shoulder pain that resolves Weakness then develops Suprascapular/long thoracic nerve involvement

is common Can get atrophy of supra/infraspinatus Can have scapular winging Months to years to regain strength

Pain patterns #1

Lateral – most common Impingement syndrome Rotator cuff tendonitis with tear if also weak Frozen shoulder if also stiff, loss of movement

Anterior AC joint GH joint Biceps tendon

Pain patterns #2

Posterior – least common Usually referred pain from C- spine Can also be referred pain from rotator cuff

tendonitis

Poorly localized Neck Nerves Malingering

Thanks!

And HUGE thanks to Dr. Greg Gardner!!