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.