Physical Examination of the Shoulder

1. Physical Examination of the Shoulder Lisa Chiou, MD, MPH Primary Care Conference

2. Goals • Review some of that anatomy from medical school • Discuss common shoulder problems • Practice focused physical exam

3. Shoulder pain • Common in all age groups • Intrinsic 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

4. Review of shoulder anatomy • Bones • Scapula • Clavicle • Humeral head • Posterior rib cage • Joints • Sternoclavicular • Acromioclavicular • Glenohumeral • Scapulothoracic

5. 25% humeral head surface in contact with glenoid Joint space thinning seen with OA Humeral head coverage increased to 75% with glenoid labrum Glenohumeral joint

6. More shoulder anatomy • Ligaments • Coracoclavicular • Acromioclavicular • Glenohumeral • Superior GH • Middle GH • Inferior GH • Coracohumeral • Subacromial bursa • Subdeltoid bursa

7. 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

8. Shoulder exam #1 • Visualize from front and back • Asymmetry • Pts with rotator cuff tears hold shoulder higher • Atrophy • Sign of chronic glenohumeral joint pathology • Effusions • Shoulder joint can hide a lot of fluid

9. 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

10. Active range of motion • Forward flexion • Abduction/adduction • Painful arc of abduction – sensitive, not specific • External rotation • Internal rotation

11. 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 • Abduction • Internal and external rotation • Have arm at patient’s side and abducted to 90 degrees

12. Rotator cuff strength testing • Supraspinatus • “Pour out a Coke” • Infraspinatus and teres minor • “Act like a penguin” • Subscapularis • “Scratch your back”

13. 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 forearm • Neer’s test • At full elbow extension, internally rotate and flex the arm

14. Biceps strength testing • Arms outstretched with palms up at level of shoulder • Forced supination of hand with elbow flexed at 90 degrees

16. Impingement syndrome • Compression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromion • Repetitive overhead motions • Main cause of rotator cuff tendonitis • Can lead to bursitis, partial or full rotator cuff tears

17. Sx of impingement syndrome • Usually gradual onset • Outer deltoid pain, especially with reaching or overhead movements • Night pain • Difficulty sleeping on affected side • Nearly identical symptoms as tendonitis

18. Exam for impingement • Pain with painful arc maneuver • Crepitus above 60 degrees • Subacromial tenderness (lateral) • No pain with external/internal rotation, abduction, elbow flexion • Distinguishes impingement from tendonitis • Normal glenohumeral ROM • Normal strength

19. 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

20. 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

21. Rotator cuff tendonitis • Some argue this is same as impingement • Acute 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 movements • RF – relative overuse, age, osteophytes, trauma, inflammatory processes (RA)

22. Exam for impingement • Painful arc of abduction (active) • 60-120 degrees • Impingement signs • Impingement test • Subacromial lidocaine injection • Can then test again for weakness

23. Radiology for tendonitis • Nothing is diagnostic • Plain 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

24. Tx of tendonitis • Rest • Heat or ice • Ultrasound (physical therapy) • NSAIDs • Subacromial steroid injection

25. Rotator cuff tear • 50% pts do not have preceding trauma • Usually in supraspinatus • Wide size range, plus partial vs full • Shoulder weakness, pain, loss of motion • Common mechanisms of injury: • Falling onto outstretched arm, onto outer shoulder directly, heavy pushing/pulling

26. 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

27. Exam for rotator cuff tear • Range of motion • Strength • Drop 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

28. 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

29. Rotator cuff tears

30. Tx of rotator cuff tears • Ice, NSAIDs, restrict aggravating motions • Weighted pendulum • No arm slings • Steroid injection if persistent sx • Surgery – refer if young pts, full/large tears, dominant arm • Best if done within 6 weeks • Acromioplasty and debridement

31. 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

32. Exam for AC joint injuries • Joint enlargement or deformity • Joint tenderness • Pain with crossed body adduction • Joint widening with downward arm traction in pts with 2nd or 3rd degree joint separation

33. 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 injection • Refer to surgery if no improvement after 2 injections

34. 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

35. Rare associations • Hyper- or hypothyroidism • Parkinson’s disease • Antiretrovirals (PPIs) • Recent neurosurgery

36. Exam for adhesive capsulitis • Clinical diagnosis • Range of motion is smooth and pain-free, then stops suddenly • No further passive ROM possible • Normal strength in the pain-free range • Can test strength again after lidocaine injection

37. 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

38. Arthrogram for adhesive capsulitis Normal capsule volume Frozen shoulder (contracted GH capsule)

39. 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

40. Biceps tendonitis • Inflammation of long head of biceps • Passes through bicipital groove of anterior humerus • Usually due to repetitive lifting or reaching • Inflammation, microtearing, degenerative changes • Up to 10% pts will have spontaneous rupture

41. Sx of biceps tendonitis • Anterior shoulder pain • Worse with lifting or overhead reaching • Often pts point to bicipital groove • Usually no weakness in elbow flexion

42. Exam for biceps tendonitis • Bicipital groove tenderness • Look for subacromial impingement • Tendon rupture • Test biceps strength • Yergason 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

43. 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

44. Radiology for biceps tendonitis • Usually plain films unnecessary • If tendon rupture present, then get plain films, U/S, or MRI • Look for rotator cuff tendonitis or tear

45. 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

46. 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 activity • Distinguish from RA, adhesive capsulitis

47. Unusual causes • Hemochromatosis • Think of this if patients develop OA in unusual places at unusually early ages • Hemophilia • Blood very erosive to joint

48. 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

49. Joint space narrowing (loss of articular cartilage) Osteophytes Humeral head sclerosis and flattening Club-like deformity Imaging for glenohumeral OA

50. Tx of glenohumeral OA • Low impact activities, and heat + stretching • Let pain be the guide • NSAIDs, acetaminophen, glucosamine, chondroitin • Intra-articular steroids • Intra-articular hyaluronate • Arthroplasty or total shoulder replacement