BYDR MALEY DEEPAK KUMARSENIOR RESIDENT, AIIMS, JODHPUR

• Shoulder pain: a common complaint in primary care• 2nd only to knee pain for

specialist referrals• Most common causes in adults

(peak ages 40-60)• Subacromial impingement

syndrome• Rotator cuff problems

• Athletic injuries• Shoulder: 8-13% of all

athletic injuries

• 3 Bones• Humerus• Scapula• Clavicle

• 3 Joints• Glenohumeral• Acromioclavicular• Sternoclavicular

• 1 “Articulation”• Scapulothoracic

• Glenohumeral joint

• “Ball and socket” vs “Golf ball and tee”

• Very mobile

• Price: instability

• 45% of all dislocations

• Joint stability depends on multiple factors

• Glenohumeral joint

25% of humeral head surface in contact with glenoid.

• Glenoid labrum (50%)

• Joint capsule

• Ligaments

• Rotator Cuff Muscles• S – Supraspinatus

• I – Infraspinatus

• t - Teres minor

• S- Supscapularis

Primary Elevators of ST joint

• Upper fiber of trapezius• Levator scapulae• RhomboidsPrimary Depressor of ST

joint• Lower fiber of trapezius• Latissimus dorsi

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Primary upwards rotators of ST joint

• Upper fiber of trapezius• Lower fiber of trapezius• Serratus anterior

Primary downward rotators of ST joint

• Rhomboids• Pectoralis minor

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Primary protractors of ST joint

• Serratus anterior

Primary retractors of ST joint

• Rhomboids• Middle fiber of

trapezius

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Primary GH Joint Abductors• Anterior fiber of deltoid• Middle fiber of deltoid• Supraspinatus

Primary GH Joint Adductors• Latissimus dorsi• Teres major• Pectoralis major (sternal head)

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Primary GH Joint Flexors• Anterior fiber of deltoid• Pectoralis major (clavicular head)• Coracobrachialis• Biceps brachii

Primary GH Joint Extensors• Latissimus dorsi• Teres major• Pectoralis major (sternal head)• Posterior deltoid• Long head of triceps

12

Primary GH Joint Internal Rotators• Anterior fiber of deltoid• Pectoralis major• Latissimus dorsi• Teres major• Subscapularis

Primary GH Joint External Rotators• Posterior deltoid• infraspinatus• Teres minor

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• Bursae

• Subacromial(Subdeltoid)

• Subscapular

• Coordinated shoulder motion

• Glenohumeral motion

• Acromioclavicular motion

• Sternoclavicular motion

• Scapulothoracic motion Scapular-humeral rhythmScapular-humeral rhythm

• Impingement syndrome• Subacromial bursitis• Rotator cuff tendinopathy• Rotator cuff tear• Biceps tendinopathy

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

• GH dislocation• GH subluxation• Labral tear (e.g. Bankart,

SLAP, etc.)• Clavicle fracture• Proximal humerus fracture• Scapular fracture

Other arthritic diseaseOther arthritic disease– Rheumatoid, Gout, SLERheumatoid, Gout, SLE– Septic, Lyme, etc.Septic, Lyme, etc.

Avascular necrosisAvascular necrosisNeoplastic diseaseNeoplastic diseaseThoracic outlet syndromeThoracic outlet syndromeCRPSCRPSMyofascial painMyofascial painReferred painReferred pain– Cervical radiculopathyCervical radiculopathy– CardiacCardiac– Aortic aneurysmAortic aneurysm– Abdominal / DiaphragmAbdominal / Diaphragm– Other GIOther GI

• Characterize pain• Location of pain• Night pain• Weakness• Deformity • Instability• Locking / Clicking /

Clunking• Sport / Occupation• Previous treatments• Alleviating / Exacerbating • Acute vs. Chronic• Traumatic vs. Overuse• History of prior injury

• Mechanism of Injury

• Observation• Undress waist → up

• Palpation• Active & passive

ROM• Strength testing• Special tests

• Front & Back• Height of shoulder

& scapulae• Asymmetry• Obvious deformity• Ecchymosis • Muscle atrophy

• Supraspinatus• Infraspinatus• Deltoid

• At rest & with movement

• Bony structures• Joints• Soft tissues

• Surface Anatomy (Anterior)

• Clavicle• SC Joint• Acromion process• AC Joint• Deltoid• Coracoid process• Pectoralis major• Trapezius• Biceps (long head)

AC joint

SC joint

biceps

• Surface Anatomy (Posterior)

• Scapular spine• Acromion process• Supraspinatus• Infraspinatus• Deltoid• Trapezius• Latissumus dorsi• Scapula

• Inferior angle• Medial border

Supraspinatus

InfraspinatusInferior angle of scapula

• Forward flexion:160 - 180°

• Extension: 40 - 60°

• Abduction: 180◦

• Adduction: 45 °

• Internal rotation: 60 - 90 °

• External rotation:80 - 90 °

Apley Scratch TestApley Scratch Test

• Scapular dyskinesis (Scapulothoracic dysfuntion)

• Compare scapular motion through ROM on both sides

• Wall push-ups

• Symmetrical• Smooth• No or minimal winging

• Test & compare both sides• Be specific to muscle or

muscle group

• Grade strength on 0 → 5 scale• 0: no contraction• 1: muscle flicker; no movement• 2: motion, but not against gravity• 3: motion against gravity, but not

resistance• 4: motion against resistance• 5: normal strength

• External rotation

• Tests RTC muscles that ER the shoulder

• Infraspinatus• Teres minor

• Arms at the sides

• Elbows flexed to 90 degrees

• Externally rotates arms against resistance

• Internal rotation

• Tests RTC muscle that IR the shoulder

• Subscapularis

• Arms at the sides• Elbows flexed to 90

degrees• Internally rotates arms

against resistance

• Subscapularis Lift-Off Test

• Other techniques

• Supraspinatus

• “Empty can" test• Jobe’s Test

• Tests Supraspinatus• Attempt to isolate from

deltoid

• Positioned sitting• Arms straight out• Elbows locked straight• Thumbs down• Arm at 30 degrees

(in scapular plane)• Attempts to elevate arms

against resistance

• Impingement Signs• Drop-Arm Test• Speed’s Test• Yergason Test• Cross-Arm Adduction• Sulcus Sign• Apprehension test• Relocation test• O’Brien’s Test• Crank test

Impingement of:Impingement of:– Subacromial bursaSubacromial bursa– Rotator cuff muscles and Rotator cuff muscles and

tendonstendons– Biceps tendonBiceps tendon

BetweenBetween– AcromionAcromion– Coracoacromial ligamentCoracoacromial ligament– AC jointAC joint– Coracoid processCoracoid process– Humeral headHumeral head

Rotator cuff tendonosisRotator cuff tendonosis

Neer’s SignNeer’s Sign

– Arm fully pronated Arm fully pronated and placed in forced and placed in forced flexionflexion

– Trying to impinge Trying to impinge subacromial subacromial structures with structures with humeral headhumeral head

– Pain is positive testPain is positive test

Hawkin’s SignHawkin’s Sign

– Arm is forward Arm is forward elevated to 90 elevated to 90 degrees, then degrees, then forcibly internally forcibly internally rotatedrotated

– Trying to impinge Trying to impinge subacromial subacromial structures with structures with humeral headhumeral head

– Pain is positive testPain is positive test

• Partial thickness tear• Full (Complete)

thickness tear

• May be due to:• Impingement• Degeneration• Overuse• Trauma

• Partial tears• Conservative

• Complete tears• Surgery

Abducted arm slowly Abducted arm slowly lowered lowered – May be able to lower May be able to lower

arm slowly to 90° arm slowly to 90° (deltoid function)(deltoid function)

– Arm will then drop to Arm will then drop to side if rotator cuff side if rotator cuff teartear

Positive testPositive test– patient unable to patient unable to

lower arm further lower arm further with controlwith control

– If able to hold at 90º, If able to hold at 90º, pressure on wrist will pressure on wrist will cause arm to fall cause arm to fall 

• Injury to long head of biceps tendon

• Typically an overuse injury• Repetitive (overhead) lifting

• Impingement

• Forward flex shoulder to about 90°

• Abduct shoulder to about 10°

• Arm in full supination

• Apply downward force to distal arm

• Pain is positive test

• Weakness without pain: muscle weakness or rupture

• Elbow flexed to 90°• Start in pronated

position

• Active supination & flexion against resistance

• Palpate biceps tendon

• Pain or painful pop is positive test• Tendonosis• Subluxation

AC Sprain / AC Sprain / SeparationSeparation

– Typically due to Typically due to fall onto tip of fall onto tip of shoulder shoulder (acromion)(acromion)

– Arm tucked into Arm tucked into sideside

– Treatment Treatment depends on typedepends on type

• Arm flexed to 90°• Arm adducted to > 45°• Hyperadduct shoulder

(down on elbow)

• Positive test is pain in AC joint

• Watch out for false-positives• Where is the pain?

Failure to keep humeral Failure to keep humeral head centered in glenoidhead centered in glenoidDislocationDislocation– Complete disruption of Complete disruption of

joint congruity or joint congruity or alignmentalignment

SubluxationSubluxation– Partial or incomplete Partial or incomplete

dislocationdislocationLaxityLaxity– Slackness or looseness in Slackness or looseness in

jointjoint– May be normal or May be normal or

abnormalabnormal

• Inferior instability

• Arm relaxed in neutral position

• Arm pulled downward at wrist

• Positive test is a visible sulcus at infra-acromial area • Compare to contralateral side

• Anterior instability

• Shoulder abducted to 90°

• Slight stress to humeral head directed in anterior direction

• While externally rotating shoulder

• Positive test is apprehension due to feeling of instability or impending dislocation• Beware if false positives

• Anterior instability

• After a positive apprehension

• Apply posteriorly directed force over externally rotated humeral head

• Positive test is relief of apprehension

• Anterior release test

Tear in glenoid labrumTear in glenoid labrumUsually due to instabilityUsually due to instability

SLAP Tear (Superior Labrum SLAP Tear (Superior Labrum Anterior to Posterior)Anterior to Posterior)– Superior labral tearSuperior labral tear– Fall on outstretched hand or Fall on outstretched hand or

shouldershoulder– Rotator cuff tendonosis or Rotator cuff tendonosis or

tearstears

Bankart LesionBankart Lesion– Anterior-inferior labral tearAnterior-inferior labral tear– Anterior shoulder Anterior shoulder

dislocation / subluxationdislocation / subluxation

• Labral, AC, or biceps pathology

• Arm flexed to 90°• Arm cross-arm adducted

10-15°• Elbow extended• Max pronation• Resist downward force

• Positive test if painful • Beware location of pain

• AC• Biceps• Internal +/- click

• For labral pathology

• Repeat testing with• Max supination• Should be pain free

• Abduct arm to 90-120°

• Stabilize shoulder • Elbow secured with

one hand• Axially load with ER /

IR at shoulder

• Positive test: audible or painful click / catch / grind

• AC joint• Subacromial space• Glenohumeral joint• Biceps tendon (long

head)

FINDING PROBABLE DIAGNOSISScapular winging, trauma, recent viral illness Serratus anterior or trapezius dysfunction

Seizure and inability to passively or actively rotate affected arm externally

Posterior shoulder dislocation

Supraspinatus/infraspinatus wasting Rotator cuff tear; suprascapular nerve entrapment

Pain radiating below elbow; decreased cervical range of motion Cervical disc disease

Shoulder pain in throwing athletes; anterior glenohumeral joint pain and impingement

Glenohumeral joint instability

Pain or “clunking” sound with overhead motion Labral disorder

Nighttime shoulder pain Impingement

Generalized ligamentous laxity Multidirectional instability

Key Findings in the History and Physical Examination

TEST MANEUVERDIAGNOSIS SUGGESTED BY POSITIVE RESULT

Apley scratch test Patient touches superior and inferior aspects of opposite scapula

Loss of range of motion: rotator cuff problem

Neer's sign Arm in full flexion Subacromial impingement

Hawkins' test Forward flexion of the shoulder to 90 degrees and internal rotation

Supraspinatus tendon impingement

Drop-arm test Arm lowered slowly to waist Rotator cuff tear

Cross-arm test Forward elevation to 90 degrees and active adduction

Acromioclavicular joint arthritis

Spurling's test Spine extended with head rotated to affected shoulder while axially loaded

Cervical nerve root disorder

Tests Used in Shoulder Evaluation and Significance of Positive Findings

Apprehension test Anterior pressure on the humerus with external rotation

Anterior glenohumeral instability

Relocation test Posterior force on humerus while externally rotating the arm

Anterior glenohumeral instability

Sulcus sign Pulling downward on elbow or wrist

Inferior glenohumeral instability

Yergason test Elbow flexed to 90 degrees with forearm pronated

Biceps tendon instability or tendonitis

Speed's maneuver Elbow flexed 20 to 30 degrees and forearm supinated

Biceps tendon instability or tendonitis

“Clunk” sign Rotation of loaded shoulder from extension to forward flexion

Labral disorder

History / History / Maneuver Maneuver

Study Study QualQual

SensSens(%)(%)

SpecSpec(%)(%)

LR+LR+ LR-LR- PV+PV+(%)(%)

PV-PV-(%)(%)

History of History of trauma trauma

2b2b 3636 7373 1.31.3 0.880.88 7272 3737

Night pain Night pain 2b2b 8888 2020 1.11.1 0.60.6 7070 4343

Painful arc Painful arc 2b2b 3333 8181 1.71.7 0.830.83 8181 3333

Empty can Empty can test test

1b1b 84 84 8989

50505858

1.71.722

0.220.220.280.28

36369898

22229393

Drop arm Drop arm 1b1b 2121 100100 >25>25 0.790.79 100100 3232

TestTest Study Study QualQual

SensSens(%)(%)

SpecSpec(%)(%)

LR+LR+ LR-LR- PV+PV+(%)(%)

PV-PV-(%)(%)

ImpingementImpingementHawkin’sHawkin’s 1b1b 8787

89896060 2.22.2 0.180.18 7171 8383

InstabilityInstabilityRelocationRelocation 2b2b 5757 100100 >25>25 0.430.43 100100 7373

ApprehensionApprehension 2b2b 6868 100100 >25>25 0.320.32 100100 7878

History / History / Maneuver Maneuver

Study Study QualQual

SensSens(%)(%)

SpecSpec(%)(%)

LR+LR+ LR-LR- PV+PV+(%)(%)

PV-PV-(%)(%)

AC JointAC JointActiveActivecompressioncompression

1b1b 100100 9797 >25>25 0.010.01 8989 100100

SLAP TearSLAP TearCrankCrank 2b2b 9191 9393 1313 0.100.10 9494 9090

ActiveActivecompressioncompression

1b1b 100100 9999 >25>25 0.010.01 9595 100100

Diagnosis Diagnosis Primary Care Primary Care %%

AgeAge

Subacromial Impingement Subacromial Impingement Syndrome Syndrome

48-7248-72 23-6223-62

Adhesive Capsulitis Adhesive Capsulitis 16-2216-22 5353Acute Bursitis Acute Bursitis 1717 --Calcific Tendonitis Calcific Tendonitis 66 --Myofascial Pain Syndrome Myofascial Pain Syndrome 55 --Glenohumeral Joint Arthrosis Glenohumeral Joint Arthrosis 2.52.5 6464Thoracic Outlet Syndrome Thoracic Outlet Syndrome 22 --Biceps Tendonitis Biceps Tendonitis 0.80.8 --