Shoulder Resources

Shoulder examination (R) Shoulder examination (R)


History and physical examination of the shoulder
Age at presentation as an aid to diagnosis
Diagnoses other than instability are rare in patients under 30. Very rare to have a complete cuff tear under 30.
For patients over 45 the most common diagnoses are degenerative joint disease, cuff tears, and frozen shoulders.

History
The four main complaints are pain, weakness, stiffness and instability.

Pain
Position of pain: with rotator cuff disease the pain is usually located anterolaterally and superior; it can also be referred to the deltoid insertion. In patients with bicipital tendinitis pain can be referred to the elbow.
Ask about neck pain, and if the shoulder pain is related to the neck position.
Ask about effect on performance; a pitcher may be able to pitch fewer innings, a swimmer swims less distance.
Ask about the position that increases symptoms, or the phase of throwing that provokes symptoms.
Ask about any trauma, progression of pain
Weakness – trying to identify treatable rotator cuff lesions and distinguish these from neurological problems
Ask about trauma, progression of symptoms (extension of tear)
Ask about neurological symptoms, neck pain (cervical radiculopathy)
Stiffness – attempting to differentiate between frozen shoulder, post traumatic stiffness or stiffness associated with glenohumeral roughness
Ask about previous surgery or injury (post traumatic stiffness)
Ask about any catching or grinding (degenerative disease)
There is often crepitus, clicking, clunking or grinding with the arm overhead or forward flexed.
Instability – trying to distinguish between traumatic unidirectional and atraumatic multidirectional instability
Patients with instability may not be able to throw a ball.
Family history: there may be a family history of ligamentous laxity in MDI.

Examination
• Look
• Eyes for Horner's
• Inspect in front for muscle symmetry; deltoids, pectoral and biceps muscles
• Look for scars, sinuses; don't forget to look in the armpits
• Look at the posture of the arm; if it is internally rotated consider posterior dislocation
• Look at the back for trapezius, supraspinatus and infraspinatus symmetry
• i. Look at position of scapulae: small, high, asymmetry
• ii. Mild scapular winging is often seen with posterior instability
• Look at the shape of the spine
• i. Low hairline and short neck: Klippel Feil syndrome
• Feel
• Feel each bony structure, starting with sternoclavicular joint, then length of clavicle, AC joint, acromion, coracoid process, biceps (with shoulder externally rotated), greater tuberosity, spine of scapula. If GT tender, forward flex the shoulder and see if this decreases the pain.
• Move and special signs
• Note: if there is any limitation of movement it must be established whether the limitation is at the glenohumeral joint or at the scapulothoracic articulation
• Forward flexion
• i. Observe initially posteriorly for scapulothoracic rhythm; patients with unstable shoulders tend to have problems with the arm descending, whereas patients with cuff tears have problems with the arm ascending. Pain at the end of elevation can signify AC arthritis.
• ii. Active
• While performing this inspect the head of the humerus for superolateral escape. This normally indicates a massive cuff tear although it may represent a small posteriorly placed acromion. Patients with superolateral escape must not have an acromioplasty.
• Pain in mid arc is suggestive of rotator cuff pathology; at the end of the range it implies AC arthritis. If the patient has pain in mid arc get them to repeat the movement with the arm externally rotated throughout; this should be less painful
• iii. Passive
• iv. Impingement sign
The “impingement sign” is elicited with the patient seated and the examiner standing. Scapular rotation is prevented with one hand while the other hand raises the arm in forced forward elevation (somewhere between flexion and abduction), causing the greater tuberosity to impinge against the acromion. This maneuver produces pain in patients with impingement lesions of all stages. It also causes pain in many other shoulder conditions . In the case of impingement lesions, however, the pain caused by this maneuver is relieved by the injection of 10.0cc of 1% xylocaine beneath the anterior acromion. This test is useful in separating impingement lesions of all stages from other causes of shoulder pain. CORR March 1983
• v. If positive perform impingement test
• Abduction
• i. Perform drop arm test at this stage; if the patient can only get to 80-90 degrees of active abduction, then passively abduct fully, then lower the arm. At about 100 degrees the arm will suddenly drop. This is indicative of either a major rotator cuff tear or an axillary nerve palsy
• Supraspinatus power (thumbs turned down)
• i. Jobe talks about first assessing the deltoid with the arm at 90 degrees of abduction and neutral rotation. The shoulder is then internally rotated so the thumbs point down towards the floor and the humerus is horizontally adducted 30 degrees – this makes the subscap, infraspinatus and teres minor comparatively electrically silent
• ii. Note on cuff examination – be wary of pronouncing cuff intact in patients with RA – remember San case
• O'Brien's test
• i. Stephen O'Brien Am J Sports Med 1998
• ii. “The standing patient forward flexed the arm to 90 degrees with the elbow in full extension and then adducted the arm 10-15 degrees medial to the sagittal plane of the body and internally rotated it so that the thumb pointed downward. The examiner, standing behind the patient, applied a uniform downward force to the arm. (A picture shows the examiners hand on the patient' elbow). With the arm in the same position the palm was then fully supinated and the maneuver was repeated. The test was considered positive if pain was elicited during the first maneuver and was reduced or eliminated with the second. Pain localized to the AC joint or “on top” was diagnostic of AC joint abnormality, whereas pain or painful clicking described as inside the shoulder was considered indicative of labral abnormality.
The position of the arm leads to medial and inferior displacement of the biceps tendon which tensions the bicipital labral complex. It also locks and loads the ACJ and creates the greatest possible tension within the joint.
O'Brien emphasizes that the patient is resisting the examiner's downward force, rather than trying to actively forward flex the arm.
• Hawkins sign
• i. “Another less reliable method of demonstrating this impingement involves forward flexing the humerus to 90 degrees and forcibly internally rotating the shoulder. This maneuver drives the greater tuberosity farther under the coraco-acromial ligament, similarly reproducing the impingement pain. This affect may be important if consideration is given to resecting the coraco-acromial ligament”
• Cross body adduction
• i. Performed with internal rotation also, to jam the AC joint together
• External rotation
• i. Active
• ii. Passive
• An increase in ER and a decrease in IR is often seen with posterior instability
• Internal rotation in adduction
• Lift off test
• i. Reported by Christian Gerber in JBJS(B) 1991
• ii. The patient is “unable to lift the dorsum of his hand off his back”. The ability to passively lift the hand off the back should be tested if the patient is unable to do so himself
• iii. In Gerber's 1996 article there are photos showing the arm being lifted passively away from the body, and then released; patients with a normal subscapularis are able to maintain the arm there but in patients with a subscapularis tear the hand drops to the back and cannot be lifted off actively. “The result of this test is considered normal if the patient maintains maximum internal rotation after the examiner releases the patient's hand”.
• Belly press test (if unable to do lift off test)
• i. Described in Gerber's 1996 article.
• ii. Performed when passive internal rotation is limited. The patient places his hand flat on the abdomen. The patient exerts pressure on the abdomen with his hand. If maximum internal rotation is maintained (the elbow remains in front of the trunk and the wrist is not flexed) while pressure is exerted the subscapularis tendon is functional.
• Slide test of Kibler: use if suspicious of superior labral tears
• i. The patient is examined standing with the hands on the hips with the thumbs pointing backwards.
• ii. One of the examiner's hands is on the shoulder, the other behind the elbow
• iii. A force is applied anteriorly and superiorly on the shoulder, and the patient is asked to push back against this force
• iv. A positive test is when the pain is localized to the anterosuperior aspect of the shoulder, if there is a pop or click in the anterosuperior region, or if the test reproduces the symptoms
• Biceps signs
• Speed's test
• i. The forearm is supinated and the elbow extended. Flexion to approximately 60 degrees is attempted against resistance
• Yergasun's test
• i. The elbow is flexed and the forearm pronated. Pain occurs when supination is attempted against resistance
• Instability signs (lying down) ALWAYS CHECK FOR LIGAMENTOUS LAXITY
• Sulcus sign – Cleeman and Flatow
• i. The shoulder is held in the neutral position and downward traction is placed on the arm
• ii. The acromiohumeral distance is palpated and the amount of translation is graded
• iii. A grade of 1+ indicates an acromiohumeral interval of 1cm
• iv. A grade of 2+ indicates an acromiohumeral interval of 1-2cm
• v. A grade of 3+ indicates an acromiohumeral interval of >2cm
• vi. Performing this test with arm adducted stresses the superior glenohumeral ligament and rotator interval
• vii. Performing this test with the arm abducted 90 degrees stresses the IGHL.
• viii. If there is inferior translation without symptoms the patient has inferior laxity; if there are symptoms the patient has inferior instability
• Apprehension/relocation/release test
• i. Has four phases
• ii. Bokor places the patient on their back with a stool under his foot
• iii. The maximally abducts and externally rotates the arm
• iv. When the patient is uncomfortable firm pressure is applied to “relocate” the shoulder
• v. At this point little of significance has been established; it is important to proceed with further ER and abduction then release which should again reproduce symptoms
• Jerk test for posterior instability
• i. Arm is at 90 degrees forward flexion and flexed at the elbow to 90 degrees
• ii. A pressure is applied posteriorly to translate the shoulder back, then the arm is brought around to abduction and the shoulder relocated
• iii. The scapula is stabilized with the other hand during this manouver.
• Load and shift test
• i. A compressive force is delivered to the humeral head to reduce it into the glenoid. The arm is positioned in 20 degrees of abduction, 20 degrees of forward flexion and neutral rotation. Anterior and posterior forces are then placed on the proximal humerus and direction and degree of translation are determined.
• ii. A grade of 1+ indicates head translation up to the glenoid rim that is greater than the other side
• iii. A grade of 2+ means that the head translates over the glenoid rim but spontaneously reduces when the force is removed.
• iv. A 3+ grade indicates humeral head translation over the glenoid rim which remains locked when the force is removed. In Cleeman and Flatow
• If relevant, signs of ligamentous laxity
• Neurovascular exam
• Further
• Neck
• i. ROM
• ii. Tenderness
• iii. Spurling's test
• Ask for X-rays
• Ultrasound
• May reveal
• i. Nonvisualization of the cuff: Indicative of a large cuff tear. There is no cuff tendon visualized, and the subdeltoid bursa is in contact with the humeral head. The bursa can be quite thickened, up to 5mm in width
• ii. Focal nonvisualization of the cuff: indicative of a small rotator cuff tear
• iii. Discontinuity: Observed when small tendon defects fill with joint fluid
• iv. Abnormal echogenicity: diffuse echogenicity is non-specific; focal abnormal echogenicity is associated with small rotator cuff tears and partial thickness tears.
• Sensitivity and specificity in the order of 90% for RCT prior to surgery
• Biggest problem is the operator dependant nature of the test
• MRI
• The patient is positioned supine, with the arm extended by the side and externally rotated. Placing the arm on the chest will cause motion artifact
• Images are acquired in the coronal plane for the supraspinatus, sagittal plane with respect to the supraspinatus, and axially
• Surface coils are mandatory for adequate imaging
• Cuff tears have an increased signal on T1 images that is brighter still on T2 images
• There is focal discontinuity and sometimes tendon retraction
• Gadolinium MRA can enhance pickup of articular surface PTRCT.
• Big problem with MRI is its sensitivity, with signal changes in the vast majority of normal patients with no symptomatic rotator cuff pathology.

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