Milestones in Musculoskeletal Medicine: The Shoulder Exam A Project of the STFM Group on Musculoskeletal/Sports Medicine Jacob J. Miller, MD Mike Petrizzi, MD Amy Kratz, MD Rob Rutherford, MD Amity Rubeor, DO Alec O. DeCastro, MD

The Problem Providers lack confidence in their MSK exams Abou-Raya and Abou-Raya; Clinical Rheumatology, Oct 2010 Up to 80% report “low level of confidence” Knowledge deficits begin in med school/residency Matheny, et al; American Journal of Orthopedics, Dec 2000 79% of FM residents had reduced ≤5 fractures Average 5 weeks of orthopedic surgery training Express more confidence in treating non-MSK conditions

The Problem Specialties play larger role in MSK medicine Hsu, Schwend, and Julia; Journal of Pediatric Orthopedics, Oct-Nov 2012 Only 14% of referrals met AAP Surgery Advisory Panel guidelines for pediatric orthopedic evaluation Liddell, Carmichael, and McHugh; Rheumatology, Aug 2005 51% of joint injections done by 15% of GP’s 26% referred primary care joint injections to a colleague Lack of specialist training associated with referral

Bulletin of the WHO, 2003 “Improved Education in Musculoskeletal Conditions is Necessary for all Doctors” Cited disproportional allotment of time in training vs. importance to practice Only 3% of time in preclinical curriculum spent on MSK disorders Electives focus on specialty care (surgery) rather than primary care 3.5% of residents choose rotations in ortho, <1% in sports med, rheum, or physical med

Bulletin of the WHO, 2003 Outlined necessity for standards and defined outcomes Preclinical “Consecutive building of knowledge and skills” Every new doctor should be able to: Differentiate normal from abnormal Choose and interpret relevant tests Formulate differential diagnosis Recognize disease impact on the patient Make appropriate management plan Clinical Catered to local needs and disease prevalence “Minimum competence…combined with basic knowledge” Focused on appropriate attitude in managing chronic conditions/pain

Bulletin of the WHO, 2003 Suggested effective teaching methods Methods should be molded to shape objectives Formal instruction (lecture, discussion) Problem-based learning Hands-on workshops Real-life situations

Milestones in MSK Education Curriculum resource for med students, residents, and evaluating faculty Why? Recognized need for increased competency in MSK care Current Fam Med Milestones do not address specific abilities or skills needed for clinical care Requirement for evidence-based PE skills Standardize expectations

The Shoulder Exam ~1% of all complaints presenting to primary care Major component of overhead sporting injuries (swimming, baseball, football, etc.) Common in work-related injuries (overhead work, heavy lifting, etc.) Frequent injury of the elderly (transitioning, falls, etc.) Most common diagnosis: Rotator Cuff Tendinopathy

Which tests to use? Mazion Maneuver Codman Sign Palm Sign Finger Sign Dugas Calloways Bryants Sign Anterior Load and Shift Anterior Drawer Anterior Apprehension Jobe Relocation Rowe Throwing Leffert Surprise/Release Dynamic Anterior Jerk Dynamic Relocation Dynamic Anterior Stability Kinetic Medial Rotation Posterior Load and Shift Posterior Apprehension Jerk Fukuda Gagey’s Hyperabduction Sulcus Sign Inferior Apprehension Kibler’s Corkscrew O’Brien’s Anterior Slide Posterior Slide Luddington’s Curtain’s Kibler’s Grind LaFosse AERS SLAPprehension Feagin Biceps Load Crank O’Driscoll’s Slap Pain Provocation Resisted Supination External Rotation Passive Compression Passive Distraction Supine Flexion Resistance Yergason’s Speed’s Abbot-Saunders Transverse Humeral Ligament Snap Hueter Sign Duga Sign Beru Sign Traction Compression Anterior/Posterior AC Shear Cross Chest Adduction Forced Adduction AC Distraction Paxino’s Neer Sign Hawkins-Kennedy Empty Can Copeland Impingement Horizontal Impingement Dawburn’s

Very few physical exam tests are diagnostic.

MSK Milestones Level 1: Medical Student Shoulder Anatomy Basic Physical Exam Inspection Palpation Range of Motion Strength

Shoulder Bones Ball-and-socket joint Scapula Humerus Clavicle Spine Glenoid Fossa Acromion Coracoid Humerus Head Greater Tubercle Clavicle

Ligaments and Tendons

Posterior Muscles Supraspinatus Infraspinatus Teres Minor Teres Major Deltoid

Anterior Muscles

Shoulder Capsule

Shoulder Bursae

Exam: Inspection Inspect Asymmetry Atrophy Bruising Swelling

Exam: Palpation Examine for crepitus and tenderness Sternoclavicular Joint Clavicle Acromioclavicular Joint Bicipital Groove Glenohumeral Joint Line Subacromial Space Scapular Spine

Exam: Range of Motion Assess both active and passive ROM Forward Flexion 180° Extension 45° Abduction 150° External Rotation 90° Internal Rotation 90° Horizontal Adduction 130°

Exam: Strength Testing Internal/External Rotation Abduction Empty Can Test: 90° shoulder abduction, 30° horizontal adduction, thumbs down, downward pressure Isolates supraspinatus Speed’s Test: Forearm supinated, 15° elbow flexion, resisted shoulder flexion Isolates biceps

Level 2: Resident Impingement: Compression of rotator cuff tendons Hawkins-Kennedy Sign: 90° shoulder flexion, forearm pronated, 90° elbow flexion; perform internal/external rotation Pain = + test Most sensitive Inpingement test: If subacromial space lidocaine injection relieves pain, diagnostic for impingement

Joint Instability Apprehension Test: 90° shoulder abduction, 90° elbow flexion, 90° external rotation; apply posterior pressure on humeral head while externally rotating shoulder Apprehension about shoulder dislocation = + test Increase LR+ Relocation Test (anterior humeral pressure relieves fear) Surprise Test (quickly releasing anterior pressure causes fear recurrence)

Shrug Sign: 90° shoulder abduction; elevating scapula or shoulder girdle during maneuver = + sign Indicative of frozen shoulder, glenohumeral OA, or RC tendonopathy

Level 3: Fellow Less evidence for clinical utility or few supporting studies More specific pathology Labral Tears Crank Test: 160° shoulder abduction, 90° elbow flexion; place axial load on humerus and rotate iternally/externally. Click + pain = + test

SLAP Lesion “Superior Labral Anterior/Posterior” injury Occurs during forced internal rotation Yergason’s Test: 90° elbow flexion, thumb up; patient attempts to supinate forearm and flex elbow against resistance Most specific Pain = + test

SLAP Lesion Tests: Passive Distraction Patient supine, 150° shoulder abduction, forearm supinated Examiner stabilizes humerus and pronates forearm Pain in glenohumeral joint = + test

Modified Dynamic Labral Shear 120° shoulder abduction, 90° elbow flexion, 90° external rotation Examiner places axial load and moves shoulder from 60-120° abduction Pain/clicking between 90-120° = + test LR+ 31.57

Active Compression (O’Brien’s) Test 90° shoulder flexion, 10° horizontal adduction, maximum internal rotation Examiner applies downward force Pain + click = SLAP injury Pain alone = AC joint pathology

Subscapularis Tendon Tear “Belly Off Test” Examiner flexes and maximally internally rotates shoulder, patient’s hand on stomach Wrist support removed Hand elevating from stomach/wrist flexion = + test High LR+

Full-Thickness Rotator Cuff Tear External Rotation Lag Sign 90° passive elbow flexion, 20° shoulder abduction, maximal external shoulder rotation Remove external rotation support Internal rotation = + test The greater internal rotation, thicker the tear Greatest LR+ for full-thickness supraspinatus tear

Bony Instability Bony apprehension test Detects: Bankart lesion (injury to anterior/inferior labrum or glenoid fossa fracture due to anterior shoulder dislocation) Hill-Sachs lesion (cortical depression in posterolateral humeral head) 45° shoulder abduction and external rotation, 90° elbow flexion Apprehensive about dislocation = + test High LR+

A Note on Teaching People learn in a variety of ways Visual: Viewing images, graphs, etc. Auditory: Listening to music or lectures Read/Write: Reading text and writing notes Kinesthetic: Moving, doing, touching VARK questionnaire developed by Neil Fleming at Lincoln University, New Zealand 16 questions used to determine how a person takes in information “I’m different; not dumb” presented at 1995 HERDSA Conference

Preferred Modes: Breckler, Joun, and Ngo (2008) Some people prefer one mode over all others, while some use a combination to obtain information Studies of undergraduate and graduate students show a majority are multimodal 60% show a significant kinesthetic component Of unimodal students, kinesthetic and read/write were most preferred.

And now, a story about shoulders…

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