Shoulder Pain and the Shoulder Exam
CHA Ambulatory DidacticsKate Lupton, MD
Shoulder Overview
• Very complex structure with tremendous ROM• 4 joints – sternoclavicular, acromioclavicular,
glenohumeral, scapulothoracic• Glenohumeral – ball and socket joint (golf ball
on a tee), glenoid only covers 25% of humeral head
Anatomy
Shoulder Activity/ROM
• Static glenohumeral stability – joint surfaces, capsule and labrum
• Dynamic stability – RC & scapular rotators (trapezius, serratus anterior, rhomboids, levator scapulae)
• Rotator cuff – depress humeral head against glenoid• Internal rotation - Subscapularis• External rotation - Infraspinatus, teres minor • Abduction - supraspinatous• Scapular stability – trapezius, serratus anterior, rhomboids• Upward scapular rotation – trapezius & serratus anterior• Scapular retraction – trapezius & rhomboids
History
• Background – Handedness, occupation, recreational activities
• CC: Pain vs instability vs decreased movement• Characterize CC: “loose” arm, “dead” arm• Injury? -> Mechanism• Associated Sx – neurovascular, stiffness, crepitus• Function – putting on jacket, overhead
activities, sleeping
Principles of the MSK Exam
• Good exposure (clothing removed, in gown)
• LOOK• FEEL• MOVE• SPECIAL TESTS
Look/Feel - Surface Anatomy
Look • SEADS – swelling, erythema, atrophy, deformity,
scars• Dominant shoulder usually slightly lower than
non-dominant side• Head forward posture, shoulders rolled
forward, scapula protracted• Squaring of shoulder – r/o dislocation• SC joints, clavicle deformity - ?fracture• AC joints – step deformity - ?separation • Atrophy – trapezius, infraspinatus, teres minor
Feel
• Palpate joints – SC joint, along clavicle, AC joint, coracoid process, along scapula
• Palpate muscles and tendons – trapezius, posterior shoulder, biceps tendon, supraspinatus insertion
• Feel for crepitus while rotating the arm
Move – Active Range of Motion
Flexion/Extension• Trace arc while reaching
forward with elbow straight
• Normal flexion to 160°-180°, extension to -60°
Abduction/Adduction• Trace arc reaching to
side with straight arm• Normal range is 0°-180°
Move – Active Range of MotionAbduction & internal
rotation• Should be able to reach
to ~C-7 level (prominent bump on C-spine)
Adduction & external rotation
• Should be able to reach lower border of scapula (~T7 level)
Move – Passive ROM• If pain or limitation w/ active ROM, assess with
passive ROM testing• Grasp humerus, move through flexion/extension,
abduction, adduction• Feel for crepitus with hand on shoulder• Note movements that precipitate pain –
pain/limitation on active but not passive ROM suggests muscle/tendon problem
• Note limitations in movement – where in arc does it occur? Due to pain or weakness? Symmetric or asymmetric?
Move
• Painful arc on abduction? Glenohumeral joint from 60-120°, AC joint 170-180°
• Watch scapular motion – look for asymmetry, jerky motion
• Wall push-up for scapular winging
Rotator Cuff Anatomy and Function
• 4 Major Muscles• Depress humeral head, keep it
in contact with glenoid throughout wide ROM
• Supraspinatus – abducts shoulder (to ~80°)
• Infraspinatus – external rotation
• Teres minor – external rotation
• Subscapularis – internal rotation
Special Tests - Supraspinatus
Empty/Full Can Test• Hold 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 up
• Note pain (tendinopathy, partial tear), weakness (tear)
• Deltoid is responsible for abduction beyond 70-80 °
Special Tests – Infraspinatus
External Rotation• Fully 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 (Gerber’s)Lift Off• Pt places hand behind back,
palm facing out• Pt lifts hand away from the back• Note pain, weaknessBelly Press• Place hands on abdomen,
elbows out• Press in on abdomen or keep
elbows out while posteriorly directed force is applied to elbows
• Positive test if unable to keep elbows out
Shoulder Impingement/Bursitis
• 4 tendons of the RC pass under the acromion and coracoacromial ligament and insert in the humeral head
• Space between arcromion, coracoacromial ligament and tendons can narrow, causing impingement of tendons (esp supraspinatus)
• Resulting friction inflames tendons and subacromial bursa
• Causes shoulder pain, esp with reaching overhead
Special Tests - Impingement
Neer’s Test• Place hand on pt’s
scapula, other on forearm• Pt fully internally rotates
(thumb pointed down)• Passively forward flex
arm through full range of motion
• Pain = impingement
Special Tests - Impingement
Hawkins-Kennedy Test• Flex arm to 90°• Stabilize shoulder with
one hand• Forcibly internally
rotate shoulder, thumb pointed down
• Pain = impingement
Special Tests - Bursitis
Subacromial Palpation• Identify acromion by
following scapular spine to distal end
• Palpate in subacromial space
• Pain = inflamed bursa and/or tendons
Biceps Tendon
• Long head of biceps tendon runs in the bicipital groove of humerus, inserts at superior glenoid
• Biceps flexes and supinates forearm
• Subject to similar stresses as RC tendons
• Inflammation causes pain in top and anterior shoulder, especially with flexion/supination
Special Tests – Biceps Tendon
Palpation• Palpate along biceps
tendon/bicipital groove• Confirm location by having pt
supinate while palpatingYergason’s Test• Flex elbow to 90°with arm
adducted (elbow against side)
• Grasp pt’s hand, resist while they supinate
• Pain = tendinopathy
Special Tests – AC JointPalpation• Palpate point at which distal clavicle
articulates with acromionO’Brien• Flex shoulder to 90° while internally
rotated (thumb down)• Adduct arm 10-15° from 12:00• Apply downward force to arm while pt
resists• Repeat with thumb pointed up• If there is pain with first maneuver and
not second, indicates labral or AC joint pathology
Cross Arm /Forced Flexion• Flex shoulder to 90°, flex elbow, then
actively adduct
Special Tests – Shoulder InstabilityApprehension/Relocation• With patient supine, abduct shoulder 90°,
flex elbow 90°• Externally rotate shoulder by moving
forearm from perpendicular to parallel with body
• Pain or sense of instability with further external rotation is a positive test, indicating anterior shoulder instability
• If sx are relieved with posterior force applied to proximal humerus, that is a positive relocation test and further supports dx
Sulcus Sign• Arm hangs relaxed at the side• Pull arm straight down, look for step-off
under lateral acromion• Indicates inferior instability
Many Thanks
• Anthony Luke, MD – UCSF• Charlie Goldberg, MD - UCSD