shoulder pain and the shoulder exam

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Shoulder Pain and the Shoulder Exam. CHA Ambulatory Didactics Kate Lupton, MD. Shoulder Overview. Very complex structure with tremendous ROM 4 joints sternoclavicular , acromioclavicular , glenohumeral , scapulothoracic - PowerPoint PPT Presentation

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Shoulder Pain and the Shoulder Exam

Shoulder Pain and the Shoulder ExamCHA Ambulatory DidacticsKate Lupton, MDShoulder OverviewVery complex structure with tremendous ROM4 joints sternoclavicular, acromioclavicular, glenohumeral, scapulothoracicGlenohumeral ball and socket joint (golf ball on a tee), glenoid only covers 25% of humeral headAnatomy

Shoulder Activity/ROMStatic glenohumeral stability joint surfaces, capsule and labrumDynamic stability RC & scapular rotators (trapezius, serratus anterior, rhomboids, levator scapulae)Rotator cuff depress humeral head against glenoidInternal rotation - SubscapularisExternal rotation - Infraspinatus, teres minor Abduction - supraspinatousScapular stability trapezius, serratus anterior, rhomboidsUpward scapular rotation trapezius & serratus anteriorScapular retraction trapezius & rhomboids

HistoryBackground Handedness, occupation, recreational activitiesCC: Pain vs instability vs decreased movementCharacterize CC: loose arm, dead armInjury? -> MechanismAssociated Sx neurovascular, stiffness, crepitusFunction putting on jacket, overhead activities, sleepingPrinciples of the MSK ExamGood exposure (clothing removed, in gown)

LOOKFEELMOVESPECIAL TESTSLook/Feel - Surface Anatomy

Look SEADS swelling, erythema, atrophy, deformity, scarsDominant shoulder usually slightly lower than non-dominant sideHead forward posture, shoulders rolled forward, scapula protractedSquaring of shoulder r/o dislocationSC joints, clavicle deformity - ?fractureAC joints step deformity - ?separation Atrophy trapezius, infraspinatus, teres minorFeelPalpate joints SC joint, along clavicle, AC joint, coracoid process, along scapulaPalpate muscles and tendons trapezius, posterior shoulder, biceps tendon, supraspinatus insertionFeel for crepitus while rotating the armMove Active Range of Motion

Flexion/ExtensionTrace arc while reaching forward with elbow straightNormal flexion to 160-180, extension to -60Abduction/AdductionTrace arc reaching to side with straight armNormal range is 0-180Move Active Range of Motion

Abduction & internal rotationShould be able to reach to ~C-7 level (prominent bump on C-spine)

Adduction & external rotationShould be able to reach lower border of scapula (~T7 level)Move Passive ROMIf pain or limitation w/ active ROM, assess with passive ROM testingGrasp humerus, move through flexion/extension, abduction, adductionFeel for crepitus with hand on shoulderNote movements that precipitate pain pain/limitation on active but not passive ROM suggests muscle/tendon problemNote limitations in movement where in arc does it occur? Due to pain or weakness? Symmetric or asymmetric?MovePainful arc on abduction? Glenohumeral joint from 60-120, AC joint 170-180Watch scapular motion look for asymmetry, jerky motionWall push-up for scapular wingingRotator Cuff Anatomy and Function4 Major MusclesDepress humeral head, keep it in contact with glenoid throughout wide ROMSupraspinatus abducts shoulder (to ~80)Infraspinatus external rotationTeres minor external rotationSubscapularis internal rotation

Special Tests - SupraspinatusEmpty/Full Can TestHold arms at 1:00 and 11:00, abducted 30 Internally rotate so thumbs point down (empty can), pt lifts up against resistance. Repeat with thumbs pointed upNote pain (tendinopathy, partial tear), weakness (tear)Deltoid is responsible for abduction beyond 70-80

Special Tests InfraspinatusExternal RotationFully adduct arm, flex elbow to 90 , medially rotate humerus 45 (hand at 12:00)Have pt try to externally rotate while you resist against their forearms

Special Tests - SubscapularisPosterior (Gerbers)Lift OffPt places hand behind back, palm facing outPt lifts hand away from the backNote pain, weaknessBelly PressPlace hands on abdomen, elbows outPress in on abdomen or keep elbows out while posteriorly directed force is applied to elbowsPositive test if unable to keep elbows out

Shoulder Impingement/Bursitis4 tendons of the RC pass under the acromion and coracoacromial ligament and insert in the humeral headSpace between arcromion, coracoacromial ligament and tendons can narrow, causing impingement of tendons (esp supraspinatus)Resulting friction inflames tendons and subacromial bursaCauses shoulder pain, esp with reaching overhead

Special Tests - ImpingementNeers TestPlace hand on pts scapula, other on forearmPt fully internally rotates (thumb pointed down)Passively forward flex arm through full range of motionPain = impingement

Special Tests - ImpingementHawkins-Kennedy TestFlex arm to 90Stabilize shoulder with one handForcibly internally rotate shoulder, thumb pointed downPain = impingement

Special Tests - BursitisSubacromial PalpationIdentify acromion by following scapular spine to distal endPalpate in subacromial spacePain = inflamed bursa and/or tendons

Biceps TendonLong head of biceps tendon runs in the bicipital groove of humerus, inserts at superior glenoidBiceps flexes and supinates forearmSubject to similar stresses as RC tendonsInflammation causes pain in top and anterior shoulder, especially with flexion/supination

Special Tests Biceps TendonPalpationPalpate along biceps tendon/bicipital grooveConfirm location by having pt supinate while palpatingYergasons TestFlex elbow to 90with arm adducted (elbow against side)Grasp pts hand, resist while they supinatePain = tendinopathy

Special Tests AC JointPalpationPalpate point at which distal clavicle articulates with acromionOBrienFlex shoulder to 90 while internally rotated (thumb down)Adduct arm 10-15 from 12:00Apply downward force to arm while pt resistsRepeat with thumb pointed upIf there is pain with first maneuver and not second, indicates labral or AC joint pathologyCross Arm /Forced FlexionFlex shoulder to 90, flex elbow, then actively adduct

Special Tests Shoulder InstabilityApprehension/RelocationWith patient supine, abduct shoulder 90, flex elbow 90Externally rotate shoulder by moving forearm from perpendicular to parallel with bodyPain or sense of instability with further external rotation is a positive test, indicating anterior shoulder instabilityIf sx are relieved with posterior force applied to proximal humerus, that is a positive relocation test and further supports dxSulcus SignArm hangs relaxed at the sidePull arm straight down, look for step-off under lateral acromionIndicates inferior instability

Many ThanksAnthony Luke, MD UCSFCharlie Goldberg, MD - UCSD