1. Kristine A. Karlson, MD Dartmouth Medical School Community and Family Medicine/ Orthopaedics Physical Examination of the Shoulder

2. 1.Recognize key elements of shoulder pain history and their relation to the physical exam. 2.Describe common pathologies of shoulder disability seen in the outpatient setting and their hallmark physical exam findings. 3.Perform a focused shoulder exam. Objectives

3. ■ Most commonly overuse/tendinitis of rotator cuff ■ Overhead activities - throwing - swimming - racket sports ■ Overhead or reaching occupations ■ Lousy work stations, home or work Shoulder Pain

4. it’s not very stable

5. it’s actually a series of joints

6. ■ supraspinatus ■ infraspinatus ■ teres minor ■ subscapularis Rotator Cuff Anatomy

9.  Downward direction of infraspinatus, teres minor fibers protect supraspinatus, IF they are working right  Gravity helps out in daytime  No gravity help at night…  Night pain The key to understanding night pain…

10. Younger = less stable Multidirectional instability Dislocations without much damage Older = stable, but stiffer Rotator cuff tears, arthritis, frozen shoulder Dislocations, injuries with a lot of damage You can guess what’s wrong based on age

14. ■ A 40 y.o. woman swims a mile almost daily. She noticed anterior shoulder pain after her swims one month ago. More recently, the pain occurs much earlier in her workout. Lately, she has started to have pain when combing her hair. She has been awakened by pain during the past 2 nights. Case

15. ■ progressive increase in pain ■ anterior, but often referred ■ repetitive overhead motions ■ change in activity or technique ■ night pain History - Rotator Cuff

16. ■ active and passive range of motion ■ 3 directions ■ strength testing ■ 3 tests ■ impingement sign ■ apprehension test/ load and shift for instability ■ Scapular stability Physical Exam - Rotator Cuff

20. Impingement Test (Hawkins)

21. Apprehension Test for anterior instability

22. Load and Shift and Sulcus Sign for Instability

23. Scapular Instability

24. ■ Plain x-ray ■ Not necessarily needed immediately except for trauma ■ Ultrasound ■ Shows rotator cuff well, need to be trained  MRI  Think of this as a pre-surgical tool only, not a first line test Studies - Rotator Cuff

25. ■ ice, NSAID ■ modify activities/ relative rest ■ No sling! (except for new dislocation) ■ specific strengthening of rotator cuff ■ injection ■ surgery Treatment - Rotator Cuff

26. ■ AC joint pain/ shoulder separation ■ Fracture – humeral head, scapula, clavicle ■ referred pain – angina (!) ■ other muscle tear - long head of biceps Other causes of shoulder pain

27. How normal is this range of motion? Biomechanics of throwing are complex Extreme external ROM And why I throw like a girl…

28. Observe ROM abduction, ext rotation, int rotation Strength supraspinatus, ext and int rotation Impingement Load and shift or apprehension Scapular stability Shoulder Exam in Brief