1. Physical Examination of the Shoulder
Lisa Chiou, MD, MPH
Primary Care Conference

2. Goals Review some of that anatomy from medical school
Discuss common shoulder problems
Practice focused physical exam

3. Shoulder pain Common in all age groups
Intrinsic disorder (85%) vs referred pain
C-spine nerve impingement (disc herniation or spinal stenosis)
Peripheral nerve entrapment distal to spinal column (long thoracic, suprascapular)
Diaphragm irritation, intrathoracic tumors, and distension of Gleason’s capsule/gall bladder
Myocardial ischemia
Pancoast tumor
Normal shoulder movement. Also, character of the pain does not change with movement of the shoulder.

4. Review of shoulder anatomy
Bones
Scapula
Clavicle
Humeral head
Posterior rib cage
Joints
Sternoclavicular
Acromioclavicular
Glenohumeral
Scapulothoracic
Sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic joints. Thin capsule. Subacromial bursa. Rotator cuff tendons attach to humeral tuberosities.

5. Glenohumeral joint 25% humeral head surface in contact with glenoid
Joint space thinning seen with OA
Humeral head coverage increased to 75% with glenoid labrum

6. More shoulder anatomy Ligaments Subacromial bursa Subdeltoid bursa
Coracoclavicular
Acromioclavicular
Glenohumeral
Superior GH
Middle GH
Inferior GH
Coracohumeral
Subacromial bursa
Subdeltoid bursa

7. Rotator cuff muscles
Supraspinatus, infraspinatus, teres minor, subscapularis
Form cuff around humeral head
Keep humeral head within joint (counteract deltoid)
Abduction, external rotation, internal rotation
Supraspinatus – abduction (also with deltoid). Infraspinatus and teres – external rotation. Subscapularis – internal rotation.

8. Shoulder exam #1 Visualize from front and back Asymmetry Atrophy
Pts with rotator cuff tears hold shoulder higher
Atrophy
Sign of chronic glenohumeral joint pathology
Effusions
Shoulder joint can hide a lot of fluid
Can see atrophy with chronic RA. Shoulder joint can hide a lot of fluid because of capsule redundancy.

9. Shoulder exam #2 Palpation Along clavicle SC and AC joints
Acromion, subacromial region
Coracoid process (short head of biceps)
Bicipital groove (long head of biceps)
Trigger points in neck, trapezius, scapular region

10. Active range of motion Forward flexion Abduction/adduction
Painful arc of abduction – sensitive, not specific
External rotation
Internal rotation
Flexion – arms outstretched, up in front. Abduction – to the side. External rotation – either the penguin, or putting hands behind back (like relaxing).
Internal rotation – have pt use thumb to touch the highest point on the spine. Apley scratch test does both abduction and external rotation – reach behind head and touch the superior angle of the opposite scapula. Can touch the inferior angle of the opposite scapula for testing of internal rotation and adduction.

11. Passive range of motion
Immobilize the scapula to prevent rotation
Use one arm to push down on shoulder
Use other arm to do the PROM exercises
Abduction
Internal and external rotation
Have arm at patient’s side and abducted to 90 degrees
Preventing scapula from moving isolates the GH joint. When abducted – internal rotation is pointing down, external rotation is pointing up.

12. Rotator cuff strength testing
Supraspinatus
“Pour out a Coke”
Infraspinatus and teres minor
“Act like a penguin”
Subscapularis
“Scratch your back”

13. Impingement maneuvers
Impingement sign
At 90 degrees of abduction with elbow flexed to 90 degrees, do internal (downward) and external (upward) rotation
Hawkins’ test
At 90 degrees of elbow flexion, do internal rotation by pushing down on pt’s forearm
Neer’s test
At full elbow extension, internally rotate and flex the arm

14. Biceps strength testing
Arms outstretched with palms up at level of shoulder
Forced supination of hand with elbow flexed at 90 degrees
Bicipital tendonitis – pain at long head of the biceps.s

15. Will talk about common shoulder problems now.

16. Impingement syndrome
Compression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromion
Repetitive overhead motions
Main cause of rotator cuff tendonitis
Can lead to bursitis, partial or full rotator cuff tears

17. Sx of impingement syndrome
Usually gradual onset
Outer deltoid pain, especially with reaching or overhead movements
Night pain
Difficulty sleeping on affected side
Nearly identical symptoms as tendonitis
Sx = pain over outer deltoid, particularly with overhead activities or reaching. 10% pts have pain over anterior deltoid.

18. Exam for impingement Pain with painful arc maneuver
Crepitus above 60 degrees
Subacromial tenderness (lateral)
No pain with external/internal rotation, abduction, elbow flexion
Distinguishes impingement from tendonitis
Normal glenohumeral ROM
Normal strength
Painful arc maneuver = Neer impingement test. Prevent scapular movement by placing hand down on shoulder. Then with the patient’s elbow flexed at 90 degrees, raise the arm and look for pain/guarding. With impingement, see pain variably from degrees.

19. Radiology for impingement
X-rays usually not needed
Reasonable to get if chronic symptoms
MRI can rule out other pathology
Wait at least 24 hours after an injection
Osseous abnormalities
Need to clinically correlate MRI findings
XR – loss of space between acromion and humeral head can indicate degenerative thinning or a large rotator cuff tear. Can see erosive changes at greater tubercle. More frequently, can see calcification in the rotator cuff tendone but not specific. MRI – can look for compression of the supraspinatus tendon or the subacromial bursa by spurs, low-lying acromion, osteophytes.

20. Tx of impingement Rest Ice Stretching, then strengthening
Pendulum for 5-10 minutes QD
Can increase space under acromion by ½”
Don’t use arm sling
Subacromial injection
Surgical referral if no improvement after 3-6 months
Pendulum, then weighted pendulum. Injection = pure impingement is mechanical and won’t respond to steroids. Could do a lidocaine injection first. If this works, then could consider steroids. Surgery – acromioplasty (either open or arthroscopic).

21. Rotator cuff tendonitis
Some argue this is same as impingement
Acute or chronic
Acute – more likely to have calcific deposits
Pain along lateral arm (outer deltoid)
Pain with numerous activities, lying on the affected side, overhead movements
RF – relative overuse, age, osteophytes, trauma, inflammatory processes (RA)

22. Exam for impingement Painful arc of abduction (active)
degrees
Impingement signs
Impingement test
Subacromial lidocaine injection
Can then test again for weakness

23. Radiology for tendonitis
Nothing is diagnostic
Plain films not necessary
Get if chronic or recurrent
Might see calcifications
If significant loss of strength or ROM, get MRI
Rule out tear
Hard to see tendon calcifications

24. Tx of tendonitis Rest Heat or ice Ultrasound (physical therapy) NSAIDs
Subacromial steroid injection

25. Rotator cuff tear 50% pts do not have preceding trauma
Usually in supraspinatus
Wide size range, plus partial vs full
Shoulder weakness, pain, loss of motion
Common mechanisms of injury:
Falling onto outstretched arm, onto outer shoulder directly, heavy pushing/pulling

26. Sx of rotator cuff tear Shoulder weakness
Localized pain over upper back
Popping/catching sensation when shoulder is moved
Night pain is characteristic
Sx vary depending on direction of the torn tendon fibers
Parallel: pain
Transverse: weakness, loss of function
If the tear is parallel to the tendon fibers, pt will have shoulder pain, pain with direct pressure, pain aggravated by activities (reaching, lifting, pulling, pushing). If tear is large and transverse in direction, then pt will have weakness, dramatic loss of function.

27. Exam for rotator cuff tear
Range of motion
Strength
Drop arm test
Arm abducted with elbow straight
See if pt can smoothly lower arm
If arm drops, then test is positive for tear
Highly specific but only 21% sensitive

28. Radiology for rotator cuff tears
Interpret carefully
34% asymptomatic pts (all ages) and 54% pts >60 yo have partial rotator cuff tears
Abnormal rotator cuff signal after trauma may represent strain rather than tear
X-rays
Look for high riding humeral head
Ultrasound
Highly operator dependent
MRI
U/S limitations include with fat patients or small tears.

29. Rotator cuff tears

30. Tx of rotator cuff tears
Ice, NSAIDs, restrict aggravating motions
Weighted pendulum
No arm slings
Steroid injection if persistent sx
Surgery – refer if young pts, full/large tears, dominant arm
Best if done within 6 weeks
Acromioplasty and debridement
No overhead positioning, reaching, lifting. Steroid injection could possibly weaken tendon, but Up to Date says there is no influence on tendon healing. Rotator cuff is NOT necessary for most normal activities of a sedentary life.

31. Acromioclavicular injury
Arthritic changes
AC joint separation
Anterior shoulder pain or deformity
Preceding trauma
Often pts hold arm close to chest and resist rotation and elevation
With OA, may have grinding or popping sensation with reaching overhead/across chest

32. Exam for AC joint injuries
Joint enlargement or deformity
Joint tenderness
Pain with crossed body adduction
Joint widening with downward arm traction in pts with 2nd or 3rd degree joint separation
Show how to do the exam: place your arm on their shoulder and rest their affected side on your arm. Then passively push the AC joint together by pushing on the arm. 2nd degree – partial dislocation. 3rd degree – full dislocation.

33. Tx of AC joint injury
Reduce pressure and traction to allow ligaments to re-attach
Acute: ice, NSAIDs, shoulder immobilizer for 3-4 weeks
Persistent: steroid injection
Refer to surgery if no improvement after 2 injections

34. Adhesive capsulitis Loss of motion +/- pain due to stiff GH joint
Is usually reversible
May have preceding trauma
Most common cause (10%) is rotator cuff tendonitis
Risk factors:
Diabetes
Disuse (i.e. pts with arm in sling)
Low pain thresholds
Poor compliance with exercise therapy
Lose abduction and rotation. Loss of GH joint capsule distensibility. Contrast with rotator cuff tendonitis – main sx is pain, not loss of movement.

35. Rare associations Hyper- or hypothyroidism Parkinson’s disease
Antiretrovirals (PPIs)
Recent neurosurgery

36. Exam for adhesive capsulitis
Clinical diagnosis
Range of motion is smooth and pain-free, then stops suddenly
No further passive ROM possible
Normal strength in the pain-free range
Can test strength again after lidocaine injection
After lidocaine, pts with frozen shoulder still have limited range of movement, unlike tendonitis.

37. Radiology for adhesive capsulitis
X-rays have limited use
Might see calcifications or degenerative changes that would lead to frozen shoulder
MRI
Enhancement of joint capsule and synovial membrane
4 mm thickening is 70% sensitive and 95% specific
X-rays: could see evidence of calcific tendonitis or degenerative changes that would suggest problems that could eventually lead to frozen shoulder.

38. Arthrogram for adhesive capsulitis
Normal capsule volume
Frozen shoulder (contracted GH capsule)

39. Tx of adhesive capsulitis
Watchful waiting
Up to 2 years for resolution
Incomplete recovery more likely in pts with DM, or pts with >50% loss of external rotation/abduction
Steroid injection
Manipulation under anesthesia
Gentle exercise
Pain medications
Alternative therapies – i.e. acupuncture
Exercise – (1) weighted pendulum exercises, (2) passive stretching. Up to 50% will respond to exercise therapy.

40. Biceps tendonitis Inflammation of long head of biceps
Passes through bicipital groove of anterior humerus
Usually due to repetitive lifting or reaching
Inflammation, microtearing, degenerative changes
Up to 10% pts will have spontaneous rupture
Biceps – elbow flexion and supination.

41. Sx of biceps tendonitis
Anterior shoulder pain
Worse with lifting or overhead reaching
Often pts point to bicipital groove
Usually no weakness in elbow flexion
Bicipital groove is about 1” below the anterolateral tip of the acromion. Pts can seem weak because of pain.

42. Exam for biceps tendonitis
Bicipital groove tenderness
Look for subacromial impingement
Tendon rupture
Test biceps strength
Yergason test
Elbows flexed with forearms in front
Pt actively resisting external rotation
Tendon may pop out of bicipital groove when downward pressure applied to forearm

43. Ruptured biceps tendon
Usually rotator cuff tear also present
Get the “popeye” sign
Rarely get significant weakness
Brachioradialis and short head of biceps provide 80-85% elbow flexor strength
Tx is supportive
Usually proximal end of the long head ruptures.

44. Radiology for biceps tendonitis
Usually plain films unnecessary
If tendon rupture present, then get plain films, U/S, or MRI
Look for rotator cuff tendonitis or tear

45. Tx of biceps tendonitis
Reduce inflammation
Strengthen biceps muscle and tendon
Prevent rupture
Ice, NSAIDs, avoid aggravating motions
5-10% risk of rupture with noncompliance
Weighted pendulum
Elbow flexion toning exercises
Steroid injection
Surgical referral if sx persist >3 months
Surgery rarely necessary since flexion strength only minimally decreased and it usually ends up being a cosmetic issue. Can get slight improvement in elbow flexion and supination.

46. Glenohumeral osteoarthritis
Same risk factors as with OA in other areas
Trauma, obesity, age
Less common than OA in weight bearing joints or spine
Pain, stiffness over months to years
Anterior shoulder is most painful area
Worse with activity
Distinguish from RA, adhesive capsulitis
RA – morning stiffness, better with activity. Shoulder sx in RA is common, especially in late stages of dse.

47. Unusual causes Hemochromatosis Hemophilia
Think of this if patients develop OA in unusual places at unusually early ages
Hemophilia
Blood very erosive to joint

48. Exam for glenohumeral OA
GH joint line tenderness and swelling
Just below coracoid process
Use outward and upward pressure
Effusion may be very hard to see
Decreased ROM
External rotation, abduction
Endpoint stiffness
Crepitus

49. Imaging for glenohumeral OA
Joint space narrowing (loss of articular cartilage)
Osteophytes
Humeral head sclerosis and flattening
Club-like deformity

50. Tx of glenohumeral OA Low impact activities, and heat + stretching
Let pain be the guide
NSAIDs, acetaminophen, glucosamine, chondroitin
Intra-articular steroids
Intra-articular hyaluronate
Arthroplasty or total shoulder replacement

51. Polymyalgia rheumatica
Think of this with patients >60, especially if they have bilateral shoulder symptoms
Females>males
Europeans
Rare – per 100,000 per year

52. Symptoms of PMR Acute to sub-acute onset Morning stiffness Night pain
Patients can’t get out of bed
Night pain
Proximal muscle involvement
20% have joint swelling

53. PMR and giant cell arteritis
Between 1-16% pts with PMR develop GCA
Nearly half of pts with GCA have co-existing PMR
Watch for jaw claudication, visual changes, scalp tenderness

54. Shoulder weakness after viral illness

55. Parsonage-Turner syndrome
Brachial neuritis
Thought to be post-viral
Sudden onset shoulder pain that resolves
Weakness then develops
Suprascapular/long thoracic nerve involvement is common
Can get atrophy of supra/infraspinatus
Can have scapular winging
Months to years to regain strength

56. Pain patterns #1 Lateral – most common Anterior Impingement syndrome
Rotator cuff tendonitis with tear if also weak
Frozen shoulder if also stiff, loss of movement
Anterior
AC joint
GH joint
Biceps tendon

57. Pain patterns #2 Posterior – least common Poorly localized
Usually referred pain from C- spine
Can also be referred pain from rotator cuff tendonitis
Poorly localized
Neck
Nerves
Malingering

58. Thanks!
And HUGE thanks to Dr. Greg Gardner!!