the shoulder · 2018-09-14 · • rc cuff becomes inflamed as it is compressed between the humerus...
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The ShoulderJennifer R Marks, MD
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• Skeletal & ligamentous components:The joint is comprised of a confluence of
• Scapula• Clavicle• Humerus
Shoulder Anatomy
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https://www.shoulderdoc.co.uk/article/http/ www.shoulderdoc.co.uk/article/117777
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• Muscles:
Shoulder Anatomy
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Tendons & bursae:https://www.google.com/search?q=shoulder+anatomy&biw=1422&bih=707&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwieo6W5m7HPAhVLVj4KHabHAbsQ_AUIBigB#imgrc=rTBT1HFveBX2nM%3A
Shoulder Anatomy
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• Inspection
• Anterior• Posterior
• Bilateral
Shoulder Physical Exam
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• Palpation
• AC joint• Subacromial space• Musculature• Scapula• Head of biceps tendon
Shoulder Physical Exam
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• ROM
• Flexion• Raise arm (180 degrees)
• Extension (50 degrees)• Lower arm
Shoulder Physical Exam
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• ROM
• Abduction• Arms horizontal
• Adduction• Arms medial
https://www.machinedesign.com/medical/what-s-difference-between-abduction-and-adduction-biomechanics
Shoulder Physical Exam
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• ROM• Internal Rotation, External Rotation
Shoulder Physical Exam
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http://shouldercomplex.weebly.com/movements.htm
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• Provocative testing….
Shoulder Physical Exam
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• 67 yo male presents to clinic for an IV• He has shoulder pain
• What further questions do you want to ask him?
• What is on your DDx?
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• Occurs less often than LE joints since not weight-bearing
• Aspect of worst pain often anterior• Morning stiffness• Pain on ROM• May have prior hx of trauma
Shoulder Osteoarthritis
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• PE• Anterior and/or posterior ttp• Crepitus• Decreased ROM• Cross-Arm test for A-C OA
• Dx/Tx• X-ray• NSAIDs, ice, PT, injection, shoulder
replacement
Shoulder Osteoarthritis
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• Impingement• RC cuff becomes inflamed as it is compressed
between the humerus & choracoacromial arch
• Pain over ant/lat aspect of shoulder• Some radiation down arm• Worse with overhead activity
• Empty can (Jobe’s test)• Neer’s sign
Rotator Cuff Pathologies
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• Tendonitis• Essentially a continuum with impingement
• Painful ROM
Rotator Cuff Pathologies
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• Supraspinatus• Abduction/flexion• Jobe’s or Empty Can test, Neer’s, etc• Drop Arm (tear)
• Infraspinatus• External rotation• Infraspinatus test
Rotator Cuff Pathologies
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• Teres minor• External rotation• Hornblower’s/Patte test
• Subscapularis• Internal rotation• Gerber or Lift off test
Rotator Cuff Pathologies
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• Partial/full tear • Can be due to acute injury in younger patients • Can be traumatic or degenerative in older patients• Pain, weakness esp with overhead activity and often at
night• Most common tear is supraspinatus
• Drop arm test
• Consider MRI• Caution with repeated injections
Rotator Cuff Pathologies
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• Clinically similar to RC tendonitis• Anterior shoulder pain
• TTP in subacromial space
Subacromial bursitis
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• AKA Frozen Shoulder
• Trouble with ADLs• Often painful initially then less so if ROM
regained
Adhesive capsulitis
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• PE• Decreased active and passive ROM (<50% of
normal side)• May have diffuse ttp
• Dx/Tx• X-ray• NSAIDs, moist heat, PT, • Consider injection
Adhesive capsulitis
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• Pain with activity
• Point tenderness at insertion site
Biceps Tendonitis
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https://meded.ucsd.edu/clinicalmed/upper_biceps_rupture.jpg
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• Rupture usually involves long head of the biceps • Often minimal trauma required• Sudden pain, sometimes an audible snap
• Often visible and/or palpable bulge• Usually non-operative, except if pt very active
and/or distal rupture
Biceps Rupture
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• 67 yo male presents to clinic for an IV• He has no particular complaints• On routine exam you find the following:
• Pain on abduction• Palpable and visible deformity• Played football in high school
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Dx = Acromialclavicular Injury
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Dx = Acromialclavicular Injury
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• If acute• X-ray• Type I & II -> sling, NSAIDs, ice• Type III -> controversial so case dependent• Types IV-VI -> operative repair
• If chronic• Becomes degenerative & managed as such
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• Greene, WB. Essentials of Musculo-skeletal Care. 2001• Monica, J, et al. Acute Shoulder Injuries in Adults. Am Fam
Physician, 2016 July 15; 94 (2): 119-127.• Woodward TW, et al. The Painful Shoulder: Part I. Clinical
Evaluation. Am Fam Physician, 2000 May 15;61(10):3079-3088.• Woodward TW, et al. The Painful Shoulder: Part I. Clinical
Evaluation. Am Fam Physician, 2000 June 1;61(11):3291-3300.
References
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