Transcript Physical Examination of the Upper Extremity

Physical Examination
of the Shoulder
Lisa Chiou, MD, MPH
Primary Care Conference
Goals
Review some of that anatomy from
medical school
Discuss common shoulder problems
Practice focused physical exam
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
Review of shoulder anatomy
 Bones
Scapula
Clavicle
Humeral head
Posterior rib cage
 Joints
Sternoclavicular
Acromioclavicular
Glenohumeral
Scapulothoracic
Glenohumeral joint
 25% humeral head
surface in contact
with glenoid
 Joint space thinning
seen with OA
 Humeral head
coverage increased to
75% with glenoid
labrum
More shoulder anatomy
Ligaments
Coracoclavicular
Acromioclavicular
Glenohumeral
Superior GH
Middle GH
Inferior GH
Coracohumeral
Subacromial bursa
Subdeltoid bursa
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
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
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
Active range of motion
Forward flexion
Abduction/adduction
Painful arc of abduction – sensitive, not specific
External rotation
Internal rotation
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
Rotator cuff strength testing
Supraspinatus
“Pour out a Coke”
Infraspinatus and teres minor
“Act like a penguin”
Subscapularis
“Scratch your back”
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
Biceps strength testing
Arms outstretched with palms up at level
of shoulder
Forced supination of hand with elbow
flexed at 90 degrees
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
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
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
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
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
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)
Exam for impingement
Painful arc of abduction (active)
60-120 degrees
Impingement signs
Impingement test
Subacromial lidocaine injection
Can then test again for weakness
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
Tx of tendonitis
Rest
Heat or ice
Ultrasound (physical therapy)
NSAIDs
Subacromial steroid injection
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
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
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
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
Rotator cuff tears
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
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
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
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
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
Rare associations
Hyper- or hypothyroidism
Parkinson’s disease
Antiretrovirals (PPIs)
Recent neurosurgery
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
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
Arthrogram for adhesive capsulitis
Normal capsule volume
Frozen shoulder
(contracted GH capsule)
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
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
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
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
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
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
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
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
Unusual causes
Hemochromatosis
Think of this if patients develop OA in unusual
places at unusually early ages
Hemophilia
Blood very erosive to joint
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
Imaging for glenohumeral OA
 Joint space narrowing
(loss of articular
cartilage)
 Osteophytes
 Humeral head sclerosis
and flattening
 Club-like deformity
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
Polymyalgia rheumatica
Think of this with patients >60, especially if
they have bilateral shoulder symptoms
Females>males
Europeans
Rare – 20-50 per 100,000 per year
Symptoms of PMR
 Acute to sub-acute onset
 Morning stiffness
Patients can’t get out of bed
 Night pain
 Proximal muscle involvement
 20% have joint swelling
PMR and giant cell arteritis
 Between 1-16% pts with PMR develop GCA
 Nearly half of pts with GCA have co-existing
PMR
 Watch for jaw
claudication, visual
changes, scalp
tenderness
Shoulder weakness after viral illness
Parsonage-Turner syndrome
 Brachial neuritis
 Thought to be post-viral
 Sudden onset shoulder pain that resolves
 Weakness then develops
 Suprascapular/long thoracic nerve involvement
is common
 Can get atrophy of supra/infraspinatus
 Can have scapular winging
 Months to years to regain strength
Pain patterns #1
Lateral – most common
Impingement syndrome
Rotator cuff tendonitis with tear if also weak
Frozen shoulder if also stiff, loss of movement
Anterior
AC joint
GH joint
Biceps tendon
Pain patterns #2
Posterior – least common
Usually referred pain from C- spine
Can also be referred pain from rotator cuff
tendonitis
Poorly localized
Neck
Nerves
Malingering
Thanks!
And HUGE
thanks to
Dr. Greg
Gardner!!