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The diagnosis-driven physical examination of the shoulder

The diagnosis-driven physical examination of the shoulder. American Medical Society for Sports Medicine – ACP Musculoskeletal Medicine Teaching Group American College of Physicians Meeting. American medical society of sports medicine-ACP Teaching group. Sameer Dixit, MD, FACP

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The diagnosis-driven physical examination of the shoulder

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  1. The diagnosis-driven physical examination of the shoulder American Medical Society for Sports Medicine – ACP Musculoskeletal Medicine Teaching Group American College of Physicians Meeting

  2. American medical society of sports medicine-ACP Teaching group Sameer Dixit, MD, FACP Johns Hopkins University Kevin Eerkes, M.D. New York University Anna Quan, M.D. University of California San Diego David G. Liddle, MD, FACP Vanderbilt University Michal “Kalli” Hose, M.D. University of California San Diego Meg Pearson, MD University of California San Francisco Sara Slattery, MD, FACP University of Pennsylvania Carlin Senter, MD, FACP University of California San Francisco Leslie Yen MD, FACP RMSK Swedish Center for Comprehensive Care Seattle, WA

  3. objectives • Review pertinent shoulder anatomy to inspect • Palpate key structures of the shoulder (ABC’s) • Organize Rotator Cuff ROM/Strength (SITS) • Organize Shoulder Provocative Tests (BIAS) • Practice shoulder exam and cases in small groups

  4. Primary Care Shoulder Exam • Inspection • Palpation: • Range of motion/Strength: Provocative tests: ABC’s SITS BIAS All Shoulder Exam slides courtesy of Drs. Anna Quan and Kalli Hose

  5. Shoulder: Bones & Joints AC Joint Clavicle D A Acromion C Coracoid Process Humerus B E Scapula Glenoid Fossa F GH Joint

  6. Shoulder Bones: Posterior Bones Clavicle Acromion Subacromial Bursa Posterior Scapular Spine

  7. PosteriorRotator Cuff Muscles Supraspinatus Infraspinatus

  8. Primary Care Shoulder Exam • Inspection • Palpation: • Range of motion/Strength: Provocative tests: ABC’s SITS BIAS

  9. Observation: Bony deformitiesPrior Fracture

  10. Observation: Bony deformitiesAc joint separation

  11. Observation: MusclesBiceps Rupture

  12. Observation: MusclesRotator Cuff Atrophy

  13. Shoulder Exam • Inspection • Palpation: • Range of motion/Strength: Provocative tests: ABC’s SITS BIAS

  14. Palpation: ABCs • AC joint • Biceps Tendon • Coracoid • Subacromial Space

  15. Subacromial Space: Contents Subacromial Bursa Supraspinatus Tendon Long head of the Biceps

  16. Palpation: ABCs • AC joint oa/separation • Biceps Tendonitis • Biceps Tendonitis • SA Impingement • AC joint • Biceps Tendon • Coracoid • Subacromial Space S

  17. Shoulder Exam • Inspection • Palpation: • Range of motion/Strength: Provocative tests: ABC’s SITS BIAS

  18. Shoulder Quiz 2: Rotator Cuff Name 4 Rotator cuff muscles and their actions: • S • I • T • S

  19. Rotator Cuff Muscles: SITS Posterior Anterior S I S T

  20. Rotator Cuff SITS: Supraspinatus Abduction Rom: 0-180

  21. Rotator Cuff SITS: Infraspinatus/Teres Minor External Rotation ROM: 0-90 Infraspinatus Teres Minor

  22. Rotator Cuff SITS: Subscapularis Internal Rotation ROM: spinous level

  23. Shoulder exam tip: SITS ROM/Strengthtogether SITS ROM Strength Test: Empty Can SITS: Abduction Resisted ER • SITS: Ext Rotation Gerber Lift Off/ Belly Press • SITS: IntRotation

  24. Muscle: • Supraspinatus • Motion: • Abduction • Full tear test: • Drop Arm • Strength test: • Empty Can SITS

  25. Muscle: • Infraspinatus/TM • Motion: • Ext Rotation • Full tear test: • ER Lag • Strength test: • Resisted ER Infraspinatus SITS Teres Minor

  26. Muscle: • Subscapularis • Motion: • Int Rotation • Full tear test: • IR Lag • Strength test: • Gerber Lift off • Belly Press SITS

  27. Shoulder Exam: ROM/StrengthSITS • Supraspinatus • ROM: Abduction Active/Passive (if limited) • Strength: Empty Can • Full tear test: Drop Arm • Infraspinatus/Teres Minor • ROM: External Rotation Active/Passive (if limited) • Strength: ER Strength • Full tear test: ER Lag test • Subscapularis • ROM: Internal Rotation Spinous process level Active/Passive (if limited) • Strength: Gerber lift off • Full tear test: IR Lag

  28. Shoulder: range of motion is key Active ROM Normal Decreased Provocative tests: Biceps tendinitis Impingement AC joint OA Stability Passive ROM Normal Decreased Adapted from: O'Kane and Toresdahl. The evidenced-based shoulder evaluation. Cur Sports Med Rep. 2014. Frozen shoulder GH joint arthritis Xray Abnormal Normal

  29. Shoulder Exam • Inspection • Palpation: • Range of motion/Strength: Provocative tests: ABC’s SITS BIAS

  30. Shoulder Provocative Signs: BIAS A • Biceps Tests • Impingement Tests: • Acromioclavicular Tests • Stability Tests I S B

  31. Shoulder Exam: Provocative Signs: BIAS • Stability Tests: • Apprehension • Relocation • Load & Shift • Sulcus • O’Brien’s • Biceps tests • Yergason’s • Speed’s • Impingement Tests: • Neer’s • Hawkin’s • Acromioclaviculartests • Scarf test • Cross arm

  32. BIAS: Biceps Tests Yergason’s Test • Resisted SUPINATION • Speed’s Test • Resisted Biceps • FLEXION

  33. BIAS: Impingement Neer’sTest • Elbow extended • Internally rotated • Forward flexion, • Hawkin’sTest • 90o forward flexion, elbow flexed, • internal rotation

  34. BIAS:AC JointTests • Scarf test • Active adduction • Cross arm test • Resisted adduction

  35. BIAS: Stability • Anterior • Apprehension/relocation • Load & Shift • Posterior • Load & Shift • Inferior • Sulcussign • Labrum • O’Brien’s Test

  36. Shoulder Glenohumeral Stabilizers:Labrum Glenoid Fossa Labrum

  37. Shoulder Glenohumeral Stabilizers:Capsule • Prevents anterior, inferior and posterior displacement

  38. Shoulder Glenohumeral Stabilizers:Rotator Cuff: Dynamic Stabilizers Supraspinatus Infraspinatus Subscapularis Teres Minor

  39. Shoulder Exam • Inspection • Palpation: • Range of motion/Strength: Provocative tests: ABCS SITS BIAS

  40. The essential shoulder exam for internists • Provocative Tests: BIAS • Biceps • Yergason’s • Speeds • Impingement • Neer’s • Hawkins • AC Joint • Scarf • Cross Arm • Stability—Next layer • Inspection– Bony abnormalities, muscle atrophy • PalpationABC’s: AC joint, Biceps tendon, Coracoid, Subacromial space • ROM/Strength: SITS • Supraspinatus • Abduction • Drop Arm/Empty Can • Infraspinatus/Teres Minor • External Rotation • ER Lag test/ Resisted ER • Subscapularis • Internal Rotation Spinous process level • IR Lag/Gerber lift off

  41. The End! All Shoulder Exam slides courtesy of Drs. Anna Quan and Kalli Hose Please do not reproduce withouth permission

  42. Key Features of Top Shoulder Problems

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