1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

8. 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

9. 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

10. 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

11. Very few physical exam tests are diagnostic.

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

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

14. Ligaments and Tendons

15. Posterior Muscles Supraspinatus Infraspinatus Teres Minor Teres Major
Deltoid

16. Anterior Muscles

17. Shoulder Capsule

18. Shoulder Bursae

19. Exam: Inspection
Inspect
Asymmetry
Atrophy
Bruising
Swelling

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

21. 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°

22. 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

23. 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

24. 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)

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

26. 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

27. 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

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

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

30. 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

31. 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+

32. 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

33. 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+

34. 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

35. 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.

36. And now, a story about shoulders…

37. References
Abou-Raya, A. and Abou-Raya, S. The inadequacies of musculoskeletal education. Clinical Rheumatology Oct. 29(10):
Akesson, K., Dreinhofer, K., and Woolf, A.D. Improved musculoskeletal education is necessary for all doctors. Bulletin of the World Health Organization :
Breckler, J., Joun, D., and Ngo, H. Learning styles of physiology students interested in the health professions. Advances in Physiology Education :30-36.
Fleming, N.D. I’m different; not dumb. Modes of presentation (VARK) in the tertiary classroom, in Zelmer, A., (ed). Research and Development in Higher Education, Proceedings of the 1995 Annual Conference of the Higher Education and Research Development Society of Australasia (HERDSA). HERDSA, Volume 18, pp
Hegedus, E.J. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. British Journal of Sports Medicine :
Hsu, E.Y., Schwend, R.M., and Julia, L. How many referrals to a pediatric orthopaedic hospital specialty clinic are primary care problems? Journal of Pediatric Orthopedics Oct.-Nov. 32(7):
Kharb, P., Samanta, P.R., Jindal, M., and Singh, V. The learning styles and the preferred teaching-learning strategies of first year medical students. Journal of Clinical and Diagnostic Research June 7(6):
Liddel, W.G., Carmichael, C.R., and McHugh, N.J. Joint and soft tissue injections. Rheumatology (Oxford) Aug. 44(8):
Matheny, J.M., et al. Confidence of graduating family practice residents in their management of musculoskeletal conditions. American Journal of Orthopedics Dec. 29(12):
O’Kane, J. Evidence based shoulder exam. Presentation given at the 2014 AMSSM Annual Conference, New Orleans, LA.
Truntzer, J., et al. Musculoskeletal education: an assessment of the clinical confidence of medical students. Perspectives in Medical Education :
Woodward, T. and Best, T. The painful shoulder: part I. Clinical evaluation. American Family Physician May 15 61(10):
Wright, A., et al. Diagnostic accuracy of scapular physical examination tests for shoulder disorders: a systematic review. British Journal of Sports Medicine :