H&P Shoulder

Question 1

Shoulder pain

Answer 1

A common complaint in primary care
2nd only to knee pain for referral to ortho
85% is intrinsic in cause
Hx and exam are key to dx

Question 2

Most common causes of shoulder pain in adults

Answer 2

1. Subacromial impingement syndrome

2. Rotator cuff pathology

Question 3

Shoulder accounts for 8-13% of

Answer 3

Athletic injuries

Question 4

Bones of Shoulder

Answer 4

Scapula
Clavicle
Humerus
Posterior Thorax

Question 5

Joints of Shoulder

Answer 5

Sternoclavicular
Acromioclavicular
Glenohumeral: joint where arm articulation occurs
Scapulothoracic

Question 6

Ligaments of Shoulder

Answer 6

Coracoclavicular
Acromioclavicuar
Glenohumeral (Superior, Middle, Inferior)
Coracohumeral

Question 7

Bursa of Shoulder

Answer 7

Subacromial Bursa

Subdeltoid Bursa

Question 8

Glenohumeral Joint: The humeral head contacts the glenoid ?% at any given time

Answer 8

25%

Question 9

Rotator Cuff Muscles

Answer 9

Supraspinatus
Infraspinatus
Teres Minor
Subscapularis

Question 10

Rotator Cuff Functions

Answer 10

Form cuff around humeral head; keep humeral head within joint (counteract deltoid); abduction, external rotation, internal rotation

Question 11

MC Dx of Shoulder Pain in Primary Care

Answer 11

1. Subacromial Impingement Syndrome 48-72%
2. Adhesive Capsulitis (Frozen Shoulder) 16-22%
   Least: Biceps Tendonitis

Question 12

Shoulder Hx: Onset of Pain

Answer 12

When sxs started; Hx of trauma/injury

Question 13

Shoulder Hx: MOI

Answer 13

Try to learn the position the arm was in at the time of pain onset; ~50% of cuff tears occur w/out preceding trauma; if chronic pain, note activity that triggers pain such as the cocking phase of throwing or the pull-through phase of swimming

Question 14

Fall directly onto anterior/superior should

Answer 14

AC joint injury (Shoulder separation)

Question 15

Arm forcefully abducted and externally rotated

Answer 15

Subluxation or anterior dislocation of shoulder

Question 16

Shoulder Hx: Location of pain

Answer 16

Does pain correlate w/specific anatomic structures

Question 17

Shoulder Hx: Radiation of pain

Answer 17

Rotator cuff problems often include pain radiating to upper arm; if pain starts in neck and radiates to shoulder or if numbness is assoc, consider cervical spine disease

Question 18

Shoulder Hx: Consider sources of referred pain

Answer 18

Cervical Spine: arthritis, disc disease, spondylolosis
Cardiac: MI
Diaphragmatic irritation
Thoracic outlet syndrome
Gallbladder disease
Complex regional pain syndrome (AKA relfex sympathetic dystrophy)

Question 19

Shoulder Inspection

Answer 19

Visualize from front and back
Asymmetry: Pts w/rotator cuff tears hold shoulder higher
Atrophy: Sign of chronic glenohumeral joint pathology
Effusion: Shoulder joint can hide a lot of fluid; very difficult to see but may manifest as asymmetry or stiffness

Question 20

Shoulder Palpation: Do both sides at same time

Answer 20

C-spine
Trapezius
Supraspinatus
Infraspinatus/Teres minor
Rhomboids
Sternoclavicular joint
Clavice
Acromioclavicular joint
Subacromial bursa
Coracoid process
Bicipital groove

Question 21

Palpation of the AC Joint

Answer 21

Patient’s arm at side
Follow clavicle distally until you find the joint
Note swelling, tenderness and gapping
Note instability or crepitus
If any abnormality is suspected, compare to opp side

Question 22

Palpation of bicipital groove

Answer 22

Patient sitting, beginning w/arm straight
Patient actively flexes biceps muscle while examiner provides supination and external rotation
Examiner palpates the biciptal groove for tenderness

Question 23

Active Shoulder ROM

Answer 23

Forward flexion
Extension
Abduction
Adduction
External rotation
Internal rotation

Question 24

Passive Shoulder ROM

Answer 24

Immobilize the scapula to prevent rotation
Use one hand to immobilize scapula; Use other hand to do the PROM exercises
For internal and ext rotation have arm at patient’s side and abducted to 90 degrees

Question 25

Abnormal ROM

Answer 25

Differentiates between external rotation problem or frozen shoulder

Question 26

Strength Testing

Answer 26

Flexion Extention External Rotation: Infraspinatus, Teres minor Empty Can test: Supraspinatous (most freq injured in rotator cuff tear) Lift Off Test: Subscapularis Internal Rotation: Subscapularis

Question 27

Compression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromion

Answer 27

Impingement syndrome

Question 28

Impingement Syndrome

Answer 28

Outer deltoid pain, esp w/reaching or overhead movements; pain is freq worse at night; difficulty sleeping on affected side; can lead to chronic bursitis, partial or full-thickness rotator cuff tears; a main cause of cuff tendonitis; freq caused by repetitive overhead movements; usually gradula onset of pain; no pain w/external/internal rotation, adduction or elbow flexion; distinguishes impingement from cuff tendonitis

Question 29

Frequently caused by repetitive overhead motions

Answer 29

Impingement syndrome

Question 30

Impingement signs

Answer 30

Have patient actively abduct the arm at the shoulder; Positive if unable to actively abduct past 90 degrees w/out pain

Question 31

Neer's Impingement Test

Answer 31

At full elbow extension, internally rotate and flex the shoulder forward (palms out, point thumb down); positive if pain w/flexion at or beyond 90 degrees

Question 32

Hawkin's Test for Impingement

Answer 32

At 90 degrees of elbow flexion and 90 degrees of shoulder flexion, do internal rotation by pushing down on pt's forearm; Positive test if significant pain compared to the contralateral side; ~72% sensitivity and 66% specificity

Question 33

Sulcus sign (Testing for shoulder instability)

Answer 33

Patient sits down, hands on lap Push down on antecubital fossa Should be symmetric-affected side will show deep sulci around acromion

Question 34

``` Apprehension Test (Testing for shoulder instability) [Can dislocate should by doing test, so know how to reduce] ```

Answer 34

Patient lies down Put hand under scapula Abduct shoulder and externally rotate at same time Recreate the mechanism for ant shoulder dislocation Should be passive-if subluxation occurs, patient will resist

Question 35

Positive "Popeye" sign

Answer 35

Ruptured biceps tendon

Question 36

Ruptured biceps tendon

Answer 36

Usually rotator cuff tear also present Positive "Popeye" sign Pts rarely get significant weakness: Brachialis and brachioradialis are the other flexors Can be proximal or distal ruptured biceps tendon: Palpate biceps tendon at elbow to determine

Question 37

Glenohumeral OA

Answer 37

No joint space and periosteum looks sclerotic (Normal joint: Should have nice joint space and should be all the same color)

Question 38

Scapular winging

Answer 38

Cervical radiculopathy Consider neurogenic cause: long theracic nerve innervates serratus anterior muscle Hypermobility might cause