How I do a 5 minute Comprehensive Examination of the Shoulder C. - - PDF document

▶
how i do a 5 minute comprehensive examination of the
SMART_READER_LITE
LIVE PREVIEW

How I do a 5 minute Comprehensive Examination of the Shoulder C. - - PDF document

Dec 11, 2023 40 likes •172 views

11/27/2017 How I do a 5 minute Comprehensive Examination of the Shoulder C. Benjamin Ma, M.D. Professor in Residence UCSF Department of Orthopaedic Surgery Chief, Sports Medicine and Shoulder Physical Examination-5 minute office exam

slide-1
SLIDE 1

11/27/2017 1

How I do a 5 minute Comprehensive Examination of the Shoulder

  • C. Benjamin Ma, M.D.

Professor in Residence UCSF Department of Orthopaedic Surgery Chief, Sports Medicine and Shoulder

Physical Examination-5 minute office exam

  • Visual inspection
  • Palpation
  • Motion
  • Cuff-Specific testing
  • Biceps Testing
slide-2
SLIDE 2

11/27/2017 2

Shoulder examination

  • Inspection
  • Patient in gown
  • Palpation
  • ROM
  • Strength
  • Supraspinatus
  • Infraspinatus & Teres minor
  • Subscapularis
  • Biceps
  • Other tests

Visual Inspection

  • Remove shirt
  • Systematic
  • Deltoid
  • Supraspinatus
  • Infraspinatus
  • Biceps
  • AC joint
  • Skin changes
  • Scars
slide-3
SLIDE 3

11/27/2017 3

Shoulder examination

  • Inspection
  • Palpation
  • ROM
  • Strength
  • Supraspinatus
  • Infraspinatus & Teres

minor

  • Subscapularis
  • Biceps
  • Other tests

Palpation

Press where it hurts

Location Diagnosis Clavicle Clavicle fracture AC joint AC joint arthritis Trapezius/Neck Muscle strain Front of shoulder Biceps pathology Back of shoulder Arthritis

slide-4
SLIDE 4

11/27/2017 4

RANGE OF MOTION

Active Range of Motion “What can you do?” Active Range of Motion “What can you do?” Difficulty with active

  • check passive

Difficulty with active

  • check passive

No problem With AROM No problem With AROM No arthritis No cuff tear No frozen shoulder No arthritis No cuff tear No frozen shoulder No problem with passive Think CUFF TEAR No problem with passive Think CUFF TEAR Problem with passive Think Shoulder OA or Frozen Shoulder Problem with passive Think Shoulder OA or Frozen Shoulder

Rotator Cuff Testing

Im pingem ent

  • -Neer’s/ Hawkins tests

Muscle Strength

  • -Teres Minor
  • -Infraspinatus
  • -Supraspinatus
  • -Subscapularis
slide-5
SLIDE 5

11/27/2017 5

Pain test: Painful arc

  • JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

If painful, positive LR 3.7 for RCD. If not painful, negative LR 0.36 for RCD.

Pain test: Impingement signs

Hawkin’s Neer’s

Photos from Dr. Christina Allen

slide-6
SLIDE 6

11/27/2017 6

Rotator Cuff Impingement

Park, et al. JBJS 2012

  • Hawkins’ Test
  • 75% sensitive
  • 49% specific
  • Neer’s Test
  • 85% sensitive
  • 44% specific

Supraspinatus

  • Jobe’s test
  • 90º abduction
  • 30º anterior flexion
  • Internal rotation (palms down)
  • Pain/weakness
  • 53% sensitive/82% spec.
  • (Park, et al. JBJS 12)

30°

slide-7
SLIDE 7

11/27/2017 7

Infraspinatus

  • External rotation strength
  • 0º abduction & 45º ER

Infraspinatus

Pain/strength test: Drop arm test

  • JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

Positive LR 3.3, negative LR 0.82 for rotator cuff disease.

slide-8
SLIDE 8

11/27/2017 8

Subscapularis

Lift off test About 70% reliable (JAMA 2013) Bear Hug test About 70% reliable (JAMA 2013)

Pain & Strength test: Subscapularis = internal rotation lag test aka ‘lift

  • ff’
  • JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

Positive LR 5.6, negative LR 0.04 for full thickness rotator cuff tear.

slide-9
SLIDE 9

11/27/2017 9

Biceps

  • Bicipital Tendonitis
  • TTP at biceps groove

‒ Compare to other side

AC arthritis

  • Pain with palpation
  • Pain with cross chest

adduction tests

  • Pain located at the AC

joint

slide-10
SLIDE 10

11/27/2017 10

Superior Labrum Anterior Posterior Lesion

  • O’ Brien’s Test
  • Adduction 15-20 deg
  • Forward Flexion 90 deg
  • Thumbs down
  • Resisted forward flexion
  • Positive test only when:
  • Pain with the above position
  • Pain diminishes when palm is

supinated

  • Otherwise equivocal test

Superior Labrum Anterior Posterior Lesion

  • SLAP lesion is a disease of the young individual
  • Sensitive test
  • Not a specific test
  • Labral pathology
  • Rotator cuff tendon tears
slide-11
SLIDE 11

11/27/2017 11

Stability examination

  • Translational tests
  • Anterior translation
  • Posterior translation
  • Inferior translation
  • Grading
  • I – to the rim not over
  • II – over the rim but spontaneously reduce
  • III – locked dislocation

Load and Shift test

  • Slight joint

compression

  • Anterior / posterior

translation

  • Inferior pull for

sulcus sign

  • Relax patient
slide-12
SLIDE 12

11/27/2017 12

Instability tests

  • Apprehension sign
  • Arm 90 deg abducted, 90 deg external rotation
  • Dislocation position for anterior instability
  • Relocation sign
  • Relieve of pain with a posteriorly directed force
  • ‘Jerk’ sign
  • Posteriorly directed force of the shoulder
  • Pain with posterior instability

Physical examination

  • Examine the cervical spine
  • Referred pain!!
  • Range of motion
  • Strength
  • Examine distal motor strength
  • Peripheral nerve examination
  • Remember zebras
  • Pain out of proportion

‒ Lung CA – Pancoast tumor

slide-13
SLIDE 13

11/27/2017 13

Thank you

  • C. Benjamin Ma, M.D.

Professor in Residence UCSF Department of Orthopaedic Surgery Chief, Sports Medicine and Shoulder (415) 353-7566 maben@ucsf.edu