The Painful Adult Shoulder: evidence based history, exam and approach

Aaron Gray, MDDepartments of Family Medicine and OrthopaedicsUniversity of Missouri

Lecture Objectives

Discuss history and examination of the shoulder and review evidence

Identify evidence based indications for diagnostic imaging tests for shoulder pain

Overview

Taking a History of a Painful Shoulder

Review of Shoulder Anatomy Physical Exam of the Shoulder Imaging of the Shoulder Diagnosis and Treatment of

Specific Shoulder Injuries

History Age

Less than 35 – Impingement, tendonitis, instability

Over 50 – Glenohumeral arthritis, adhesive capsulitis, rotator cuff tear

Onset and Duration of SymptomsAcute vs Gradual

Mechanism of Injury Trauma – fallRepetitive activities such as an overhead motion

Recent increase in activity? Pain at night?

History Location of Pain

Often unhelpful Radiation of pain? Weakness or Stiffness? Activities that worsen pain?

Fixing hair, snapping bra, pulling out a wallet, reaching overhead

Sports, Hobbies, Occupation that involve the shoulder

Shoulder Anatomy3 Bones Humerus ScapulaClavicle

3 Joints Glenohumeral Acromioclavicular Sternoclavicular

1 Articulation Scapular

Golf Ball on a Golf Tee

Bony Anatomy - ScapulaAcromion

Coracoid

Glenoid

Subscapular fossa

Supraspinatus fossa

Scapular spine

Infraspinatus fossa

Glenoid Labrum

Subacromial Space

The area under the acromion and above the glenohumeral joint

Structures• Supraspinatus muscle• Subacromial/subdeltoid

bursa

Subacromial Bursa

Supraspinatus

Sobotta (2002)Small Space • Impingement

Rotator Cuff Muscle Actions

• Supraspinatus o Abduction

• Infraspinatus o External

rotation• Teres Minor

o External rotation Infraspinatus

Teres minor

Supraspinatus

Posterior View

Rotator Cuff Muscle Actions

• Subscapularis:o Internal

rotationo Adduction

SubscapularisAnterior

View

Research on Diagnostic Accuracy of Shoulder Exam IsA Common Story…

Cochrane Database Review 2013 – Hanchard, et al. Physical tests for shoulder

impingements and local lesions of bursa, tendon or labrum that may accompany impingement.

33 studies involving 4002 shoulders

Cochrane Database Review 2013 – Hanchard, et al. There is insufficient evidence upon

which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.

Physical Exam of the Shoulder

• Inspection• Palpation• Range of Motion• Strength• Neurovascular status• Provocative Shoulder Testing• The joint above and below (i.e. neck

and elbow)

Inspection and Examination of Posterior Shoulder

Physical Exam of the Shoulder

• Inspection• Palpation• Range of Motion• Strength• Neurovascular status• Provocative Shoulder Testing• The joint above and below (i.e. neck

and elbow)

ABduction: 180°

ADduction: 0°

Movements at the Shoulder Joint

RotationInternalExternal

(Mid thoracic)(60-80°)

Movements at the Shoulder Joint

Forward Flexion: 180°

Extension: 60°

Movements at the Shoulder Joint

Physical Exam of the Shoulder

• Inspection• Palpation• Range of Motion• Strength• Neurovascular status• Provocative Shoulder Testing• The joint above and below (i.e. neck

and elbow)

Strength Testing Basics

• Compare to unaffected side• Differentiate between true weakness

and weakness secondary to pain

Muscle TestingInfraspinatus/Teres Minor

• Patient’s arms adducted at sides

• Elbows flexed to 90°

• Patient attempts external rotation against examiner’s resistance

Muscle TestingSubscapularis

Lift-off testo Internally rotate

shouldero Dorsum of hand

against lower backo Patient attempts to

push away examiner’s hand

Belly Press TestBear Hug Test

Muscle TestingSupraspinatus

“Jobe’s Test” or “Empty Can Test”

• 90° abduction• 30° forward flexion• Thumbs pointing

downward• Patient attempts

elevation against examiner’s resistance

Physical Exam of the Shoulder• Inspection• Palpation• Range of Motion• Strength• Neurovascular status• Provocative Shoulder Testing• The joint above and below (i.e. neck

and elbow)

Neurovascular Testing

• Distal pulses• Capillary refill• Sensation

www.swipnet.se, accessed 10/2005

Physical Exam of the Shoulder

• Inspection• Palpation• Range of Motion• Strength• Neurovascular status• Provocative Shoulder Testing• The joint above and below (i.e. neck

and elbow)

Impingement SignsNeer Test

• Scapula stabilized• Arm fully pronated• Examiner brings

shoulder into maximal forward flexion

• Pain suggests Subacromial Impingement

Impingement SignsHawkins Test• Patient’s arm

forward flexed to 90°

• Elbow flexed to 90°

• Shoulder forcibly internally rotated by examiner

• Pain suggests Subacromial Impingement

AC jointCrossover Test

• Patient forward flexes affected arm to 90°

• Actively adducts arm across body

• Forces acromion into distal end of clavicle

• Suggests AC joint pathology if painful

Sensitivity/Specificity

Neer Impingement Sensitivity: 72%Specificity: 60%

Hawkins-Kennedy Impingement Sensitivity: 79%Specificity: 59%

Hegedus. British J Sports Med, 2012.

Biceps Tendon/LabrumSpeed’s Test

• Elbow flexed 20°-30°

• Forearm supinated • Arm in 60° flexion• Patient forward

flexes arm against examiner’s resistance

Biceps Tendon/LabrumYergason’s Test

• Elbow flexed to 90° with thumb up

• Grasp hand (hand shake)

• Patient supinates against resistance

Labral signsO’Brien Test

• Arm forward flexed to 90°• Elbow fully extended• Arm adducted 10° across

body with thumb down• Apply downward

pressure against patient resistance

• Repeat with thumb up• Suggestive of labral

tear if more pain with thumb down

Sensitivity/Specificity for SLAP Tear Speeds Test

Sensitivity: 20%Specificity: 78%

Yergason’s TestSensitivity: 12%Specificity: 95%

O’Brien’s TestSensitivity: 67%Specificity: 37%

Hegedus. British J Sports Med, 2012.

• Arm abducted to 90° • Apply slight anterior

pressure and slowly externally rotate

• Apprehension may indicate anterior instability

• High Diagnostic Odds Ratio of 53.6

• Supine • Shoulder abducted and

externally rotated• Posteriorly directed force

applied to shoulder• Positive if apprehension

decreases and indicates anterior instability

Physical Exam of the Shoulder

• Inspection• Palpation• Range of Motion• Strength• Neurovascular status• Provocative Shoulder Testing• The joint above and below (i.e. neck

and elbow)

Cervical SpineSpurling’s Maneuver

• Neck extended• Head rotated toward

affected shoulder• Axial load placed on the

cervical spine• Reproduction of

patient’s shoulder/arm pain indicates possible nerve root compression

Hegedus. British J Sports Med, 2012.

Indications and Guidelines for Diagnostic Imaging

Be Wise When Ordering Imaging

Analysis of 459 elective outpatient CT and MRIs from PCPs

37% of shoulder MRIs were considered inappropriate

Examples of inappropriate indicationsShoulder pain with no conservative

therapyOsteoarthritis in older patients

Lehnert & Bruce. J Am Coll Radiol , 2010.

Asymptomatic Rotator Cuff Tears Increase with Age

Tempelhof et al. J Shoulder Elbow Surg, 1999.

American College of Radiology Appropriateness Criteria Evidence based guidelines

developed by a multidisciplinary panel

Reviewed every two years

Wise et al. J Am Coll Radiol 2011.

ACR Appropriateness Criteria

Wise et al. J Am Coll Radiol 2011.

MRI

Superior for most soft tissues in shoulderRotator Cuff TearCartilageBursae

Identifies tendon retraction, muscle atrophy and fatty infiltration Suggests chronic tear & poor

prognosis

MR Arthrogram

Main use – instability in those <35 y/o

Injection of gadolinium enhances view of labrum

Typical History of Shoulder Instability or Labral Tear

Glenoid Labrum

CT Scan

Useful for characterizing fractures Consider CT arthrography in

evaluation of rotator cuff in setting of previous shoulder replacement

Otherwise… not many uses

Ultrasound

Very operator dependent Can be used to evaluate

acromioclavicular joint, rotator cuff tendons, long head of bicep tendon

Increased accuracy of injections into glenohumeral joint/biceps tendon sheath

Diagnosis and Treatment of Selected Specific Conditions

Shoulder Impingement Hx: Gradual onset of pain worsened with

overhead activities. Often with night pain

PE: +impingement tests, weakness and pain with resisted supraspinatous testing, ROM usually NL

Imaging: Xray – usually NL. Can see acromion spurs.

Treatment: PT for strengthening of scapula stabilizers and rotator cuff, consider injection if severe pain

Referral - Consider if not improved after 6 months of adequate rehab

Rotator Cuff Injuries Continuum of edema/hemorrhage >

tendonitis and fibrosis > partial or complete tear

Rotator cuff tears are uncommon under the age of 40 but strains do occur

Hx: pain in lateral shoulder, night pain is common, +/- history of trauma

PE: pain and weakness of affected muscles.

Differentiating weakness because of pain versus a tear can be difficult. Consider diagnostic lidocaine injection.

Rotator Cuff Injuries

Imaging: Xray usually normal. Tears are best evaluated with U/S or MRI.

Treatment: Complete tears in an active person should be referred for surgical consult. Partial tears and strains can often successfully be rehabilitated. Consider injection if severe pain does not allow physical therapy.

Adhesive Capsulitis (Frozen Shoulder) Hx: pain and decreased range of active and

passive motion, night pain (early in condition)

At Risk: Diabetics, women, post surgical immobilization, 40-60 y/o

PE: decreased active and passive ROM Imaging: Xrays- NL, used to differentiate

glenohumeral arthritis Treatment: NSAIDS and corticosteroid

injections beneficial during painful stage. PT ROM and exercise. Increase aggressiveness as pain resolves

Refer when: conservative treatment has failed

Biceps Tendonitis

Often occurs in combination with rotator cuff pathology

Hx: Pain in anterior aspect of shoulder that radiates to biceps

PE: TTP in bicipital groove, +Speed’s & Yergason’s test

Imaging: Xrays – NL, US/MRI – fluid around tendon

Shoulder Dislocation

72-95% recurrence in <20 y/o patients

20-30% in 25-40 yo 10-15% in >40 yo

Shoulder dislocations in patients <25 y/o should have surgical stabilization

Glenoid Labral Tear Hx: Multiple mechanisms

AtraumaticTraction in overhead throwing athletesSudden pull from catching oneself from

fallingCompression from falling onto outstretched

arm Hx: Pain with overhead activities;

sometimes will have popping, clicking, or catching with motion. Often will have failed rehab with continued discomfort.

Glenoid Labral Tear

PE: All tests have poor +LR Imaging: MR arthrogram Treatment: start with PT, however,

most patients will need surgical treatment to resume full function

67 yo male w/ decreased ROM

Glenohumeral Arthritis Hx: decreased and painful ROM, hx of

previous injury or arthritis in other joints

PE: Decreased active and passive ROM

Imaging: degenerative changes of glenohumeral joint

Treatment: glenohumeral corticosteroid injection, shoulder replacement

Refer when: pain has become severe despite conservative treatment

Biceps Tendon Rupture

Biceps Tendon Rupture

Hx: forceful elbow extension against resistance, pain, ecchymosis

PE: “Popeye” deformity, decrease flexion and supination strength

Imaging: MRI will show rupture Treatment: Quick referral to a

surgeon in active patients. Pain control and PT in elderly

Take Home Pearls

Don’t order an MRI for an arthritic shoulder

~50% of patients 80 years or older have asymptomatic rotator cuff tears

Glenohumeral arthritis is often rarely helped by physical therapy

Take Home Pearls

Refer all first time shoulder dislocations under age of 25 for surgical repair

Order an MR Arthrogram for a pt <35 y/o with shoulder instability when there is concern for labral tear

References Madden, Chris, et al.  Netter’s Sports

Medicine.  1st Ed. Saunders, 2009.  Puffer, James.  20 Common Problems in

Sports Medicine. 1st Ed.  McGraw-Hill, 2001.  Esenyel CZ, et al. Arch Orthop Trauma Surg ,

2010.  Mar;130(3):297-300. Hegedus EJ, et al. British Journal of Sports

Medicine 2008;42:80-92. Sethi PM, Arthroscopy. 2005 Jan;21(1):77-80. Tallia A & Cardone D. Diagnostic and

Theraputic Injection of the Shoulder. Am Fam Physician. 2003 Mar 15;67(6):1271-1278.