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History and Physical Examination of the Shoulder PowerPoint Presentation

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Description : Check out this medical presentation on Orthopedic Surgery, which is titled "History & Physical Examination of the Shoulder", to know about the history and physical examination of the shoulder.

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Published on : Jul 20, 2021 | Views : 2216 | Downloads : 16

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Slide 1-

History & Physical Examination of the Shoulder
Slide 2-

Objectives Review pertinent anatomy of the shoulder Review differential diagnosis of shoulder complaints Review clinical history and physical examination of the shoulder Review common shoulder injuries & characteristic physical exam findings
Slide 3-

Brief Epidemiology Shoulder pain: a common complaint in primary care 2nd only to knee pain for specialist referrals Most common causes in adults (peak ages 40-60) Subacromial impingement syndrome Rotator cuff problems Athletic injuries Shoulder: 8-13% of all athletic injuries
Slide 4-

Anatomy 3 Bones Humerus Scapula Clavicle 3 Joints Glenohumeral Acromioclavicular Sternoclavicular 1 “Articulation” Scapulothoracic
Slide 5-

Anatomy Humerus Head * Greater tubercle* Lesser tubercle* Intertubercular (bicipital) groove Deltoid tuberosity Scapula Angles Superior Inferior Lateral (Head)
Slide 6-

Anatomy Scapula Glenoid Acromion Coracoid Subscapular fossa Scapular spine Supraspinatus fossa Infraspinatus fossa
Slide 7-

Anatomy Glenohumeral joint “Ball and socket” vs “Golf ball and tee” Very mobile Price: instability 45% of all dislocations Joint stability depends on multiple factors
Slide 8-

Anatomy Glenohumeral joint Passive stability Joint conformity Glenoid labrum (50%) Joint capsule Ligaments Bony restraints
Slide 9-

Anatomy Muscles Deltoid Trapezius * Rhomboids * Levator scapulae * Rotator cuff Teres major Biceps Pectoralis muscles * Serratus anterior * * Scapular stabilizers
Slide 10-

Anatomy Rotator Cuff Muscles S – Supraspinatus I – Infraspinatus t - Teres minor S- Supscapularis
Slide 11-

Anatomy Bursae Subacromial (Subdeltoid) Subscapular
Slide 12-

Anatomy Neurologic Nerve roots Brachial plexus Peripheral nerves
Slide 13-

Anatomy Coordinated shoulder motion Glenohumeral motion Acromioclavicular motion Sternoclavicular motion Scapulothoracic motion Scapular-humeral rhythm
Slide 14-

Differential Diagnosis Impingement syndrome Subacromial bursitis Rotator cuff tendinopathy Rotator cuff tear Biceps tendinopathy Adhesive capsulitis SC joint arthritis, sprain AC joint arthritis, sprain Glenohumeral joint OA Instablity GH dislocation GH subluxation Labral tear (e.g. Bankart, SLAP, etc.) Clavicle fracture Proximal humerus fracture Scapular fracture Other arthritic disease Rheumatoid, Gout, SLE Septic, Lyme, etc. Avascular necrosis Neoplastic disease Thoracic outlet syndrome CRPS Myofascial pain Referred pain Cervical radiculopathy Cardiac Aortic aneurysm Abdominal / Diaphragm Other GI
Slide 15-

Clinical History Characterize pain Location of pain Night pain Weakness Deformity Instability Locking / Clicking / Clunking Sport / Occupation Previous treatments Alleviating / Exacerbating Acute vs. Chronic Traumatic vs. Overuse History of prior injury
Slide 16-

Clinical History Mechanism of Injury
Slide 17-

Physical Exam Observation Undress waist → up Palpation Active & passive ROM Strength testing Special tests
Slide 18-

Physical Exam – Observation / Inspection Front & Back Height of shoulder & scapulae Asymmetry Obvious deformity Ecchymosis Muscle atrophy Supraspinatus Infraspinatus Deltoid
Slide 19-

Palpation At rest & with movement Bony structures Joints Soft tissues
Slide 20-

Palpation Surface Anatomy (Anterior) Clavicle SC Joint Acromion process AC Joint Deltoid Coracoid process Pectoralis major Trapezius Biceps (long head) AC joint SC joint biceps
Slide 21-

Palpation Surface Anatomy (Posterior) Scapular spine Acromion process Supraspinatus Infraspinatus Deltoid Trapezius Latissumus dorsi Scapula Inferior angle Medial border Supraspinatus Infraspinatus Inferior angle of scapula
Slide 22-

Range of Motion Forward flexion: 160 – 180° Extension: 40 - 60° Abduction: 180◦ Adduction: 45 ° Internal rotation: 60 - 90 ° External rotation: 80 - 90 ° Apley Scratch Test
Slide 23-

Range of Motion Scapular dyskinesis (Scapulothoracic dysfuntion) Compare scapular motion through ROM on both sides Wall push-ups Symmetrical Smooth No or minimal winging
Slide 24-

Strength Testing Test & compare both sides Be specific to muscle or muscle group Grade strength on 0 → 5 scale 0: no contraction 1: muscle flicker; no movement 2: motion, but not against gravity 3: motion against gravity, but not resistance 4: motion against resistance 5: normal strength
Slide 25-

Strength Testing External rotation Tests RTC muscles that ER the shoulder Infraspinatus Teres minor Arms at the sides Elbows flexed to 90 degrees Externally rotates arms against resistance
Slide 26-

Strength Testing Internal rotation Tests RTC muscle that IR the shoulder Subscapularis Arms at the sides Elbows flexed to 90 degrees Internally rotates arms against resistance Subscapularis Lift-Off Test Other techniques
Slide 27-

Strength Testing Supraspinatus “Empty can" test Jobe’s Test Tests Supraspinatus Attempt to isolate from deltoid Positioned sitting Arms straight out Elbows locked straight Thumbs down Arm at 30 degrees (in scapular plane) Attempts to elevate arms against resistance
Slide 28-

Special Provocative Tests Impingement Signs Drop-Arm Test Speed’s Test Yergason Test Cross-Arm Adduction Sulcus Sign Apprehension test Relocation test O’Brien’s Test Crank test
Slide 29-

Subacromial Impingement Syndrome Impingement of: Subacromial bursa Rotator cuff muscles and tendons Biceps tendon Between Acromion Coracoacromial ligament AC joint Coracoid process Humeral head Rotator cuff tendonosis
Slide 30-

Impingement Signs Neer’s Sign Arm fully pronated and placed in forced flexion Trying to impinge subacromial structures with humeral head Pain is positive test
Slide 31-

Impingement Signs Hawkin’s Sign Arm is forward elevated to 90 degrees, then forcibly internally rotated Trying to impinge subacromial structures with humeral head Pain is positive test
Slide 32-

Rotator Cuff Tear Partial thickness tear Full (Complete) thickness tear May be due to: Impingement Degeneration Overuse Trauma Partial tears Conservative Complete tears Surgery
Slide 33-

Rotator Cuff Tear: Drop-Arm Test Abducted arm slowly lowered May be able to lower arm slowly to 90° (deltoid function) Arm will then drop to side if rotator cuff tear Positive test patient unable to lower arm further with control If able to hold at 90º, pressure on wrist will cause arm to fall
Slide 34-

Biceps Tendonosis Injury to long head of biceps tendon Typically an overuse injury Repetitive (overhead) lifting Impingement
Slide 35-

Biceps Tendonosis: Speed’s Test Forward flex shoulder to about 90° Abduct shoulder to about 10° Arm in full supination Apply downward force to distal arm Pain is positive test Weakness without pain: muscle weakness or rupture
Slide 36-

Biceps Tendonosis: Yergason’s Test Elbow flexed to 90° Start in pronated position Active supination & flexion against resistance Palpate biceps tendon Pain or painful pop is positive test Tendonosis Subluxation
Slide 37-

AC Separation AC Sprain / Separation Typically due to fall onto tip of shoulder (acromion) Arm tucked into side Treatment depends on type
Slide 38-

AC Separation AC Sprain / Separation Typically due to fall onto tip of shoulder (acromion) Arm tucked into side Treatment depends on type
Slide 39-

AC Arthritis / DJD
Slide 40-

AC Joint: Cross-Arm Adduction Test Arm flexed to 90° Arm adducted to > 45° Hyperadduct shoulder (down on elbow) Positive test is pain in AC joint Watch out for false-positives Where is the pain?
Slide 41-

Shoulder Instability Failure to keep humeral head centered in glenoid Dislocation Complete disruption of joint congruity or alignment Subluxation Partial or incomplete dislocation Laxity Slackness or looseness in joint May be normal or abnormal
Slide 42-

Instability: Sulcus Sign Inferior instability Arm relaxed in neutral position Arm pulled downward at wrist Positive test is a visible sulcus at infra-acromial area Compare to contralateral side
Slide 43-

Instability: Apprehension Test Anterior instability Shoulder abducted to 90° Slight stress to humeral head directed in anterior direction While externally rotating shoulder Positive test is apprehension due to feeling of instability or impending dislocation Beware if false positives
Slide 44-

Instability: Relocation Test Anterior instability After a positive apprehension Apply posteriorly directed force over externally rotated humeral head Positive test is relief of apprehension Anterior release test
Slide 45-

Glenoid Labral Tear Tear in glenoid labrum Usually due to instability SLAP Tear (Superior Labrum Anterior to Posterior) Superior labral tear Fall on outstretched hand or shoulder Rotator cuff tendonosis or tears Bankart Lesion Anterior-inferior labral tear Anterior shoulder dislocation / subluxation
Slide 46-

O’Brien’s Active Compression Test Labral, AC, or biceps pathology Arm flexed to 90° Arm cross-arm adducted 10-15° Elbow extended Max pronation Resist downward force Positive test if painful Beware location of pain AC Biceps Internal +/- click
Slide 47-

O’Brien’s Active Compression Test For labral pathology Repeat testing with Max supination Should be pain free
Slide 48-

Labral Tear: Crank Test Abduct arm to 90-120° Stabilize shoulder Elbow secured with one hand Axially load with ER / IR at shoulder Positive test: audible or painful click / catch / grind
Slide 49-

Diagnostic Injection AC joint Subacromial space Glenohumeral joint Biceps tendon (long head)