shoulder Flashcards
examination of the shoulder - look
Asymmetry of shoulders
skin: scars, erythema, lacerations
soft tissue: loss of muscle bulk, swelling
bone: bony deformity
Deformity near the middle of the clavicle may suggest a previous clavicular fracture
Protrusion of the distal end of the clavicle may suggest AC joint subluxation
The side of the shoulder: athroscopy scars
Scapula: wasting of muscles, wasting of supra and infraspinatus appear as hollow grooves above and below the spine
examination of the shoulder - feel
Deformity, tenderness, temperature, swelling
Tenderness over acromioclavicular joint may indicate osteoarthritis
Tenderness over the greater tuberosity may indicate impingement or rotator cuff pathology
palpate longhead of biceps tendon
flexion and extension
do active movement first
180 degrees of flexion and 50 degrees of extension
impingement syndrome is typically a painful arc of abduction between 60 and 120 degrees (normal range is 180)
also assess from behind to visualise scapular movement
external rotation
with elbows bent assess
usually about 60 degrees
external rotation: most severely affected in frozen shoulder, affected most early in glenohumeral joint arthritis
internal rotation
internal rotation: how far the patient is able to reach up their back with their thumb
should be able to reach to the inferior border of the scapula
since they’re in this position, you can do the lift off test
lift off test
assesses subscapularis strength
if the patient can’t reach up their back, you can do the belly press test instead
how to test infraspinatus
(and teres minor)
external rotation against resistance
how to test supraspinatus
30 degrees of flexion and abduction
press down and compare the two shoulders
types of shoulder special tests
tests for rotator cuff strength
tests for impingement
cross arm test for AC joint arthritis
tests for instability
special tests for rotator cuff strength
sub scapularis lift off test: patient should try to lift their arm off their back against resistance, use the belly press test if the patient can’t reach behind their back
Infraaspinatus and (teres minor) external rotation against resistance
supraspinatus test: 30 degrees of flexion and abduction, compare the two shoulders, vast majority of tears occur in the supraspinatus tendon
empty can/jobe’s test
abduct to 90 degrees
thumb pointing up
push up agianst resistance
point thumb down and again push against resistance
both actions are typically painful in impingement but it is typically more painful when pushing down as internal rotation brings the greater tuberosity of the humerus under the acromion process compressing the supraspinatus tendon
hawkin’s test
abduct the shoulder and flex the elbow 90 degrees
rotate the arm downward and repeat while adducting the humerus
performing the test in varying degrees of adduction increases sensitivity
internal rotation of the shoulder exacerbates impingement pain
cross arm test
test for AC joint arthritis
forcibly adduct the arm across the chest
pain over the acromioclavicular joint is indicative of osteoarthritis
special tests for impingement
Empty can test
- flex shoulder to 90 degrees and abduct
- patient pushes up against resistance with thumbs up
- patient pushes up against resistance with thumbs down
- typically more painful wehn thumbs are pointing down as internal rotation brings the greater tuberosity of the humerous under the acromion process compressing the supraspinatus tendon
Hawkins test
- abduct the shoulder 90 degrees and flex the elbow 90 degrees
- passively rotate the patients arm while adducting the humerous
Neer’s test
- patient internally rotates arm with thumb down
- patient forward flexes internally rotated arm, test is positive if this elicits pain
tests for AC joint arthritis
cross arm test
- forward flex to 90 ddegrees and adduct across the chest
positive test is pain over the AC joint and may indicate OA
interior and posterior draw test
apply anterior and posterior traction force to the humerus to assess the laxity of the humerus
compare the the other side
sulcus test
to demonstrate inferior instability of the glenohumeral joint
downward traction force to the humerus
in a positive test, a sulus will be visible under the acromion process
apprehension test
either upight or supine
abduct the shoulder and flex the elbow to 90 degrees
externally rotate the shoulder while watching the patient’s face carefully
a positive sign is apprehension on the patients face as the shoulder is about to dislocate
this feeling may be relieved by applying pressure to the front of the humerus
special tests for shoulder instability
inferior and posterior draw test (laxity)
- stabilise the shoulder with one hand and grip the humerus with the other and apply anterior and posterior pressure
sulcus test
- apply downward force on the humerus, if positive a sulcus will appear under the acromion process
apprehension test
- abduct the shoulder and flex the elbow to 90 degrees, externally rotate the arm, a positive sign is a look of apprehension on the patient’s face
relocation test
- after the apprehension test, place direct pressure on the anterior aspect of the humeral head
tests for biceps tendon pathology
speed’s test
- forward flex the arm to 60 degrees and flex the elbow 20-30 degrees, attempt to flex the elbow against resistance
yergason’s test
- arm abducted and elbow flexed 90 degrees, have patient supinate (turn inward) against resistance
special shoulder tests for labral tears
O’brian’s test
- arm internally rotated, forward flexed and in adduction, attempt to resist downard force
- pain indicates labral tear
- if it is more difficult pronated, this my indicate biceps pathology more so than a labral tear
the rotator cuff is made up of
subscapularis
infrapsinatus
supraspinatus
teres minor
things to ask on history
stability symptoms: clicks or jerks when arm is held over head
stiffness
swelling
deformity: muscle wasting, prominence of AC joint
difficulty dressing, inability to lift objects over should height
differential diagnosis of shoulder pain
Referred pain syndromes
oCervical spondylosis
oMediastinal pathology
oCardiac ischaemia
Joint disorders
oGlenohumeral arthritis
oAcromioclavicular arthritis
Bone lesions
oInfection
oTumours
Rotator cuff disorders
oTendinitis
oRupture
oFrozen shoulder
Instability
oDislocation
oSubluxation
Nerve injury
oSuprascapular nerve entrapment
Examination findings of rotator cuff pathology
rain with ROM
+empty can, +push off test
drop arm if full-thickness tear
if there is impingement, +neers and +hawkins
investigations for rotator cuff pathology
x-ray for all patients
US and MRI for imaging of the cuff
MRI is gold standard
acromial morphology
x-ray with supraspinatus outlet view will allow you to see the acromial morphology
Bigliani classification: type 2 and 3 is associated with impingement of supraspinatus as the arm goes into abduction
superior migration of the humeral head is seen in
chronic cuff tears
there is nothing to hold the humeral head in the joint so it slowly migrates superiorly and arthritis develops
humeral head starts to articulate with the acromion and wears the acromion
how will MRI help diagnose a rotator cuff tear
will show size and extent of the tear and amount of retraction and atrophy of the muscles
management of rotator cuff pathology
tendinopathy or impingement: concervative treatment, physio, subacromial cortisone injections
partial thickness tear: physio (up to 12 weeks), possibly subacromial cortisone injection
full thickness tear: ortho referral for consideration of surgery, rotator cuff repair
types of shoulder impingement
two patterns
- acute subacromial impingemnt: under 40, tenndinosus/busitis
- chronic - over 40, tendinosus, tendon tear, recurrent episodes with acute on chronic symptoms
symptoms of impingment
painful arc
management of impingement
rest, nsaids, physio, steroid injections
subacromial decompression (acromioplasty)
acromioplasty
acromial spur is burred back
ligament is released and bursectomy
this provides space for the tendonn in the subacromial space during shoulder abduction
frozen shoulder symptoms
adhesive capsulitis
joint capsule becomes inflamed and thickens and constricts
pain for >3 months
progressive loss of ROM
age >40, female risk factor
immobility, hypothyroidism, diabetes, adjacent surgery eg. mastectomy
2 year time course, not full resolution in all patients by many content without surgery
exam findings in adhesive capsulitits
limited active and passive range of motion
external rotation is often 50% of normal, often the first to be affected
differs for other cuff pathology where passive range is usually maintained, if frozen shoulder there is definite end point in ROM
stages of frozen shoulder
freezing stage
- the pain will be the most severe in the outer shoulder, range of motion is lessened
frozen stage
- pain is less intense but the shoulder is stiff
thawing stage
- range of motion returns and adhesive capsulitis resolves
diagnosis of adhesive capsulitis
clinical, most investigations are usually normal
x-ray to rule out fracture of OA
US/MRI if concerned about rotator cuff pathology
management of adhesive capsulitis
set expectations
some patients are not willing to wait 2 years for this to resolve on its own
pain control, gentle ROM exercises, hydrotherapy
intra-articular cortisone injection under cT guidance: injection needs to be in the joint itself or it wont work
MUA
- manipulation under aneasthetic, tearing through the capsule to release the tight thickened capsule
arthroscopic release
- surgeon divides the capsule using arthroscopic instraments
shoulder dislocation
reduce and immobilise for 3-10 days in a sling
after a short period of immobilisation, most patients are referral to physio with focus on restoring strength of the dynamic glenohumeral stabilisers
early rehab to achieve full pain free motion (you shouldnt immobilise or too long)
how soon can you return to sport after shoulder dislocation
21 days
recurrent shoulder dislocation
with recurrent dislocations, glenoid bone loss increases
bankart tear of anterior inferior labrum (because more than 95% of shoulder dislocations are anterior dislocations)
hall-sachs lesion - bony lesion produced by the posterior humeral head hitting the anterior glenoid rim, this lesion will become bigger with repeated dislocations
surgical options for recurrent shoulder dislocations
arthroscopic stabilisation/bankhart repair
- repair the torn labrum back onto the glenoid using suture anchors
laterjet procedure
- transfer of the chorocoid to the glenoid through a split in the subscapularis tendon, creates a sling effect
shoulder dislocation in the older patient
beware
very high incidence of cuff tear, often massive tear
have low threshold for imaging in >60
osteoarthritis
age >50
progressive pain with activity
decreased ROM
impingement symptoms
history of rotator cuff injury, previous trauma, or shoulder injury
OA on examination
decreased ROM
pain and crepitus at extreme of motion
4 cardinal findings on x-ray of OA
loss of joint space
osteophyte formation
subchondral sclerosis
subchondral cysts
cuff tear arthropathy
different to classic OA
caused by a large or massive tear of the cuff
disrupts the balance of the shoulder joint
leads to superior migration of the humeral head
superior glenoid erosion and erosion of the acromion
management of OA
non operative: physio, simple analgesics, cortisone injections
rest and activity modification
surgery
- total shoulder arthroplasty, best for active patients
types of shoulder arthoplasty
anatomical arthroplasty
- patient needs a functioning rotator cuff for this to work
reverse arthroplasty
- used for patient with a deficient rotator cuff such as those with cuff tear arthropathy
