physical exam of thephysical exam of the shoulder and...
TRANSCRIPT
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Physical Exam of thePhysical Exam of the Shoulder and Hip
and Diagnoses of Common Problems
Pierre Rouzier, MDUniversity of Massachusetts
New England College Health AssociationNovember 8, 2013
Goals and Objectives
• Review shoulder and hipReview shoulder and hip anatomy
• Discuss shoulder and hip exam
• Present cases common in primary care and sports medicinemedicine
• Discuss management of injuries (if time permits –wish me luck!!)
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Case histories• 22 yo tennis player with
“pain serving”• 18 yo hockey player
“crashed shoulder into the boards”
• 21 yo mt. biker “fell on shoulder – came out of place”
Anatomy
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Shoulder Anatomy
• Shoulder Complexp– Glenohumeral– Acromio-clavicular– Scapulo-thoracic– Sterno-clavicular
• Bones– Scapula
• Glenoid• Glenoid• Acromion• Coracoid Process
– Humerus– Clavicle
Static Stabilizers of the Shoulder
• Ligaments– Acomio-clavicularAcomio clavicular– Coracro-clavicular– Coracromial– Sterno-clavicular
• Shoulder Capsule– Gleno-humeral ligaments
• CartilageCartilage– Glenoid Labrum (50%)
• Sub-Acromial Bursa
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Dynamic Stabilizers: Rotator Cuff
• Supraspinatus– Abduction
• Infraspinatus– External Rotation
• Teres MinorExternal Rotation– External Rotation
• Subscapularis– Internal Rotation
Shoulder anatomy
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Physical Exam
• InspectionP l ti• Palpation
• ROM• Strength• Laxity• Special Testsp
Standard Exam
• Inspection: deformity/atrophy/wingingl k l b l• Palpation: neck, para-scapular, sub-acromial
space, AC joint, biceps tendon• ROM: abduction, flexion, internal/external
rotation• Strength: abduction, internal & external g
rotation• Laxity: anterior/posterior/inferior;
apprehension and relocation
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Standard Special Tests• Rotator Cuff Strength
– Scaption/Empty Can/Jobe’s: SupraspinatusE l R i I f i– External Rotation: Infraspinatus
– Internal Rotation: Sub-Scapularis• Impingement
– Neer and Hawkin’s Test• Laxity
– Apprehension, Relocation, Sulcus Sign, Load and Shift• Biceps Tendon
– Speed’s testSpeed s test• Labrum
– Speed’s Test, O’Brien’s test• AC Joint
– Arm Crossover Test
Inspection
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Rotator Cuff Strength Testing
Supraspinatus
Subscapularis
Infraspinatus/teres minor Internal/external rotation
Impingement Tests
• Hawkin’s • Neer
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Impingement
Laxity Exam
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Tests for laxity
Speed’s Test: Biceps Tendon
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O’Brien’s test – SLAPLabral tear (Superior Labrum Anterior to Posterior)
AC Joint Exam: Arm Crossover Test
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Rotator cuff tendonitis - history
• 22 yo female presents ith h ld iwith shoulder pain
after playing tennis on several occasions after long lay off. Lots of overhead smashes and serves.
• Pain with lifting arm, combing hair, sleeping
• Hurts to play tennis!
18 yo hockey player with direct trauma to ac joint, pain and tenderness
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21 yo mountain biker fell onto shoulder, anterior deformity, loss of shoulder “roundness”,
inability to int/ext rotate
Shoulder DislocationSelf-reduction technique
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Case examples - hip• 26 yo female runner with R lateral hip pain after
increasing mileage• 19 yo female runner with deep L hip/groin
pain, hurts with every step• 20 yo male soccer player has anterior R hip pain
after hard kicks• 19 yo male BB player left groin pain for “months”• 55 yo male cyclist has hip pain and trouble
getting on and off his bike
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Hip Anatomy
Hip and pelvis - normal anatomy
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Physical Exam of the Hip
• Inspection• Palpation• Leg length• Range of motion• Strength• Pain against resistancePain against resistance• Impingement signs
Trochanteric Bursitis26 yo female runner with R lateral hip pain after increasing mileage
• Tender directly over greater trochantergreater trochanter
• Tight ITB• Positive Ober sign
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Trochanteric bursitis
• Home rehabPT• PT
• Ice, ice massage• NSAIDs• Corticosteroid injection
Femoral Neck Stress Fracture19 yo female runner with deep L hip/groin pain, hurts with every step
• Increasing mileage, slow progression of painprogression of pain
• Difficulty with weight bearing, limp
• Pain with int/ext rotation• No palpable tenderness• X-Ray• Bone scan, MRI• REST, REST, REST
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Hip Flexor Strain20 yo male soccer player has anterior R hip pain after hard kicks
• Common, can be long-lasting, nuisance
• Rest, ice, rehab
Hip Labral Tear19 yo male basketball player with persistent groin pain
• FrustratingFrustrating• Hip impingement sign
– FADIR (Flexion, Adduction, Internal Rotation)• MRI arthrogram• Arthroscopic surgery
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FAI(femoroacetabular impingement)
Hip Arthritis55 yo male cyclist has hip pain and trouble getting on and off his bike
• DJDNSAID l i• NSAIDs, glucosamine
• Weight loss• Maintain ROM• Appropriate activity• Hip replacement??p p
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Questions??