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Physical Exam > The Shoulder > Flashcards

The Shoulder Flashcards

1
Q

Exam guided by history…

  • Lateral deltoid
  • Peri-scapular
  • Anterior shoulder pain
  • One finger sign
  • Burning pain
  • Clicking
A

Lateral deltoid- rotator cuff
Peri-scapular- myofascial pain/C-spine
Anterior shoulder pain- bicipital tendonitis
One finger sign- AC joint
Burning pain- nerve injury, radiculopathy
Clicking- instability/labral pathology

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2
Q

Dislocation

A

Anterior dislocation- abduction and ER

Posterior dislocation- adduction and IR

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3
Q

Dropped shoulder

A

spinal accessory neuropathy

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4
Q

Use of accessory muscles

A

scapular substitution

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5
Q

Shoulder separation

A

falling on an adducted arm

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6
Q

Normal ROM

A
  • Forward flexion: 0-180
  • Abduction: 0-180
  • Extension: 0-45/60
  • External rotation: 0-90
  • Internal rotation 0-70/90
  • ER and IR values with arm abducted 90 degrees and elbow flexed at 90 degrees in horizontal plane
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7
Q

ROM assessment

A
  1. Assess active ROM first (“touchdown sign”). If abnormal, proceed to passive ROM.
  2. Apply scratch tests
    - Superior: abduction, ER–> T4 (scapular spine)
    - Inferior: adduction, IR–> T8 (inferior angle of scapula)
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8
Q

GIRD: Glenohumeral Internal Rotation Deficit

A
  • 20-25 degree side to side difference in internal rotation between dominant and non-dominant arms
  • Commonly seen in throwing athletes, swimmers
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9
Q

What is the cause of GIRD?

A

Posterior capsule tightness–> posterior capsule stretch is helpful in reducing rates on injuries
*Loss of IR may predispose athletes to rotator cuff impingement/tears and labral injuries

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10
Q

Scapulothoracic Motion Ratio

A
  • 2:1 ratio of glenohumeral to scapular motion for abduction
  • 180 degrees abduction: 120 degrees from GH, 60 degrees from scapular rotation
  • With intrinsic pathology of the shoulder this ratio is decreased leading to “scapular substitution”–> scapulorthoracic motion can provide 90 degrees of abduction if necessary
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11
Q

Scapulothoracic motion

A
  • Observe patient from behind with abduction and forward flexion
  • “Push off” test: patient pushes on wall to look for winging
  • “Stabilization” test: compression of scapula leads to improved pain and ROM
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12
Q

Positive push off test or stabilization test

A

Imply scapular muscle weakness/dyskinesis is contributing to clinical presentation, and therefore, a scapular stabilization therapy program should be of benefit.

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13
Q

Scapular winging

A
  • Due to weakness of Trapezius, rhomboids, or serratus anterior
  • May be primary, secondary, or voluntary
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14
Q

Innervation of muscles a/w scapular winging

A
  • Trapezius: spinal accessory
  • Rhomboids: dorsal scapular nerve
  • Serratus anterior: long thoracic nerve
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15
Q

Lateral winging vs. Medial winging–> look where the inferior angle goes

A
  • Lateral: rhomboid or trapezius–> inferior angle is rotated laterally due to unopposed serratus anterior
  • Medial: serratus anterior (“SAM”)–> inferior angle is rotated laterally due to unopposed rhomboid and trapezius
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16
Q

Sensation of UE

A 
C4- distal clavicle
C5- lateral epicondyle
C6- thumb
C7- middle finger
C8- little finger
17
Q

Reflexes of UE

A

C5- biceps
C6- pronator
C7- triceps

18
Q

Suprascapular Neuropathy

A
  • Rare cause of refractory shoulder pain in young patients, esp volleyball players and overthrowing athletes
  • Suprascapular nerve- provides motor innervation to supraspinatus/infraspinatus and provides deep sensation/proprioception to about 70% of shoulder joint

Think PAINLESS WEAKNESS

19
Q

What are the 2 main sites of compression/traction for the suprascapular nerve?

A
  • Suprascapular notch- supraspinatus and infraspinatus affected
  • Spinoglenoid notch- only infraspinatus affected “infraspinatus syndrome”
20
Q

Rotator cuff impingement tests (2)

A
  1. Neers- passive forward flexion; examiner holds shoulder down to prevent scapular substitution
  2. Hawkins- passive IR with arm abducted and flexed 90 degrees

Positive test- pain on lateral shoulder/arm

21
Q

Rotator cuff muscle testing (SITS muscles)

A
  1. Supraspinatus- empty can test, pt resists downward force
  2. Infraspinatus/Teres minor- resisted ER with arms adducted and elbow flexes 90 degrees
    - others include hornblowers test (may isolate teres minor)
  3. Subscapularis-
    - “lift-off test”: hand behind back, resist push off
    - Belly press test: may isolate the upper part of the subscapularis better than the lift off
  • **Pain with preserved strength implies tendonitis/tendinopathy.
  • **Pain with weakness may imply rotator cuff tear
22
Q

What test implies complete tear of supraspinatus?

A

Drop arm test:

  • patient slowly lowers both arms from full abduction
  • positive test when patient unable to lower slowly or affected arm “drops”

***Highly specific but not sensitive.

23
Q

Bicipital Tendonitis (2 tests)

A
  • Speeds: arms flexed 30 degrees, elbow extended, arm supinated–> patient resisted downward force
  • Yergasons- arm adducted, elbow flexed 90 degrees–> patient supinates hand against resistance

***Positive test if pain reproduced in bicipital groove and/or painful subluxation of long head biceps tendon

24
Q

AC Joint

A
  • Cross arm/scarf test: arm adducted across chest
  • Dugar test: patient touches opposite shoulder with affected arm
  • AC distraction (bad cop): arm maximally internally rotated while upward force is applied

***Positive test is when pain is reproduced over AC joint

25
Q

AC separation/ shoulder separation

A
  • Grade 1: AC sprain
  • Grade 2: AC ligament torn
  • Grade 3: AC and CC ligament torn

Graded 4-6 referring to the direction/degree of clavicle displacement

  • Grade 4: posterior clavicle displacement
  • Grade 5: superior clavicle displacement
  • Grade 6: inferior clavicle displacement under coracoid process
26
Q

Acromion Types

A
  1. Type I- smooth
  2. Type 2- curved
  3. Type 3- hooked

***People with type 3 acromion have increased incidence of rotator cuff injury/impingement

27
Q

Labral Pathology (3 tests)

A
  1. Obrien test- empty can except arm is adducted past neutral
  2. Anterior slide test- patient sitting with hands on hips,, examiner applies superior and forward force on elbow
  3. Crank test- arm abducted 90 degrees with elbow flexed at 90; axial load applied while arm is ER, IR, and circumducted

***Positive test is pain or clicking with labral pathology

28
Q

SLAP lesion

A
  • Superior labral tear in Anterior to Posterior direction (types I-IV)
  • SLAP lesion is a labral tear where the biceps inserts
  • type 3 & 4 are surgical
29
Q

Signs of Instability (4 tests)

A
  • Sulcus sign: downward force on arm >1/2 inch movement c/w hypermobility
  • Apprehension/Relocation test: patient supine, arm in throwing position, anterior force applied to shoulder while holding elbow (feeling of impending dislocation is positive); relocation is when force applied in opposite direction improves symptoms
  • Release test: at end of relocation test, examiner abruptly stops applying force and symptoms recur
  • Load and shift test: arm adducted, axial load applied to humerus (grab the bone) while attempting to move in anterior and posterior direction
30
Q

Types of shoulder dislocations/instability

A
  • MC direction is anterior and inferior
  • May see posterior dislocation in seizures or electrocution
  • Axillary nerve susceptible to injury in anterior dislocations
31
Q

What happens if axillary nerve is damaged?

A

Think of what it innervates!

  • Deltoid and teres minor–> weakness with abduction and internal rotation
  • Sensory deficit on lateral shoulder
32
Q

TUBS vs. AMBRII for shoulder dislocation

A

TUBS
-traumatic, unidirectional, bankart lesion, surgery is treatment of choice

AMBRII
-atraumatic, multidirectional, bilateral involvement, rehab is treatment of choice, inferior capsule shift if surgery required, interval lesion

33
Q

Bankart Lesion

A
  • Anterior inferior labral tear, usually a/w anterior shoulder dislocation
  • Occurs in the LOWER part of the labrum (inferior)
34
Q

Hill Sachs Lesion

A

-Compression fracture/deformity of posterior lateral humeral head related to repeated subluxation/instability

35
Q

Which imaging to order?

A
  • AP of shoulder w/ axillary lateral or trans-scapular view for suspected shoulder dislocation
  • West point view- evaluates bony bankart lesion
  • Stryker notch view- evaluates humeral head and/or Hill Sachs lesion
  • Serendipity- evals SC joint and medial 1/3 of clavicle
  • MRI: suspected rotator cuff pathology
  • MR arthrogram- suspected labral injuries

Physical Exam (7 decks)

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