Shoulder Exam Part 2

Question 1

Potential Sources of Shoulder Pain
Origin (local):

Answer 1

Glenohumeral Joint
Scapulothoracic Joint
Acromioclavicular Joint
Sternoclavicular Joint

Question 2

Potential Sources of Shoulder Pain
Non-Shoulder Origin (referred):

Answer 2

Cervical (Radiculopathy) C4-T1
Thoracic Outlet
Vascular (Angina, MI)
Pulmonary
Cancer (Bone, Lung, Breast)
GI (Spleen, Diaphragm, Gallbladder)
Chronic pain (central sensitization)

Question 3

___ is the MOST important part of the examination

Answer 3

Subjective

Question 4

Subjective

Answer 4

Purpose: Understand the problem and develop testable hypotheses

Chief Complaint- Understand the problem

Impairment/Function/Disability- How is the problem inhibiting function?

Question 5

Systems Screening Questions

Answer 5

Health History (Red Flags)- Pain at night? = unrelectant pain-cancer

Recent Trauma (MVA) = pulmonary embolism after major trauma

Cardiac (MI, chest pain, nausea, sweating, jaw pain)

Pulmonary (shoulder pain with cough or deep breath) = rib fracture can mimic signs

GI (GI symptoms associated with shoulder pain)

Question 6

Pain

Answer 6

Location - where is it, does it travel

Quality - sharp, dull, achey

Duration - how long does it last, when does it start

Affect - slow down or speed up

Intensity/Irritability - how aggressive the treatment will be

Pain history - 1st time?

P1, P2, P3….

aggravating/alleviating factors

patient goals

Question 7

Objective

Answer 7

Purpose: Collect objective data to help rule in/out your hypotheses

Outline:
> screening
> observation (static, dynamic, function)
> palpation
> ROM, MMT, muscle length, accessory motion
> special tests

Question 8

You see winging during arm elevation

What possible impairments may be contributing to this atypical movement?

Answer 8

muscle wasting = long thoracic n. (serratus anterior)

tilt = tight pec minor (muscle length)

assess don’t assume

Question 9

Is scapular dyskinesis associated with shoulder pain?

Answer 9

No difference in presence of dyskinesis in those with and without shoulder pain

we have dominant arms! this is going to affect scapula movement

Question 10

When it comes to accessory motion:

____ is a measure
____ is a symptom

Answer 10

laxity
instability

Question 11

doing PROM in supine

Answer 11

pure GHJ motion

takes scapula out - we don’t use scapula much in this position

Question 12

Contractile Assessment

Answer 12

Can differentiate Minor Injury vs Major Injury vs Nerve (resisted isometrics)

MMT (muscle performance)

Selective Tissue Tensioning

Muscle Length Testing

Question 13

Can differentiate Minor Injury vs Major Injury vs Nerve (resisted isometrics)

Answer 13

minor = tendinopathy no substantial weakness

major = usually pain, no strength to do task, substantial pain, muscle or tendon tear

nerve = weakness, symptoms elsewhere, chain is messed up

Question 14

Special Tests
Possibly tells us:

Answer 14

Integrity of Cuff
Integrity of Capsulolabral Complex
Presence of Instability
Subacromial Pain
AC Joint Pathology

Question 15

Specificity (Spin):

Answer 15

Rule in a diagnosis (ratio of false positives and true negatives)

If they test positive they are not negative, they likely DO have it

Question 16

Sensitivity (Snout):

Answer 16

Rule out a diagnosis (ratio of true positives and false negatives)

If they test negative they are not positive, they likely DO NOT have it

Question 17

Need to use tests with good Sensitivity and/or Specificity

Answer 17

Ideally ≥ 80% (50% is a coin flip)

Tests are usually designed to maximize sensitivity or specificity, rarely both

A test that rules in, ONLY rules in. A test that rules out, ONLY rules out

Question 18

Clustering special tests can improve ___

Answer 18

diagnostic accuracy

Question 19

Objective Exam Pro Tips

Answer 19

order matters = save the most provocative tests for the end

Most of our tests are not good enough, cluster!

Assess don’t assume

Walk the fine line between thorough and exhaustive = Enough to confidently rule in/out

Not all impairments or exam findings are contributory

Question 20

Shoulder Imaging

Answer 20

X-ray (Fractures, Tumors, Arthritis, Alignment)

Question 21

AP view

Answer 21

GH joint in natural position

View of entire shoulder complex

Can be done in ER or IR to look at tubercles

Question 22

Lateral (scapular Y) view

Answer 22

Location of humeral head relative to glenoid

Question 23

Stryker view

Answer 23

Articular surfaces

Question 24

MRI (Soft tissues: Contractile tissues, Ligaments, Labrum, Cartilage)

Answer 24

Standard: Contractile tissues, ligaments

Arthrogram: MRI plus contrast dye
(Labrum, joint capsule)

dyes leak out = torn

Ultrasound (Soft tissues: Contractile tissues, Ligaments)