Shoulder & NeckExam

Tiffany Bohon MDAssistant Professor of Family Medicine

& Orthopedics/Sports Medicine

History• Duration• Location• Radicular• Injury/trauma• Aggravating/alleviating factors• Night pain• Numbness/tingling/weakness• Occupation/activities• Dominant hand• Hx of shoulder issues

Shoulder

Physical Exam

• Inspection• Palpation• ROM• Strength• Special tests• Neurovascular exam• **Always examine c-spine w/ shoulder**

http://snoworthopaedics.com/portfolio/biceps-tendon-rupture/

Inspection

• Atrophy• Shoulder asymmetry• Swelling• Ecchymosis• Erythema• Posture

http://www.foundrysportsmedicine.com/our-blog/bid/109741/Anterior-Shoulder-Instability

http://hotchsibgrp.wordpress.com/2014/09/14/anatomy-of-the-shoulder-joint-human-atlas-of-anatomy-netter-download/

Palpation

Bony:• SC joint• Clavicle• AC joint• Acromion• Greater tuberosity• Coracoid process• Spine of scapula• Humerus• C-spine

Soft tissue:• Short/long head of biceps• Subacromial bursa• Muscles of shoulder• Periscapular muscles• Anterior/posterior capsule

Range of Motion

Passive= 0% effort by patientActive= 100% effort by patient

• Forward flexion: 160-180°• Lateral abduction: 160-180°• External rotation arm at side: ~90°• External rotation w/ arm abducted 90°: ~90°• Internal rotation w/ arm abducted 90°: ~70°• Internal rotation: ~T7

Rotator Cuff

http://orthoinfo.aaos.org/topic.cfm?topic=a00064

RC Strength

• Teres minor/infraspinatus: External rotation w/ 90 ° elbow flexion

• Subscapularis : Internal rotation w/ 90 ° elbow flexion

• Subscapularis: lift off or belly press• Supraspinatus: empty can; 90° abduction, 30°

forward flexion w/ thumb down

Teres minor/infraspinatus: External rotation w/ 90 ° elbow flexion

http://classconnection.s3.amazonaws.com/522/flashcards/1066522/png/shoulder_test1330050731990.png

Subscapularis: Internal rotation w/ 90 °elbow flexion

http://classconnection.s3.amazonaws.com/522/flashcards/1066522/png/shoulder_test1330050731990.png

Subscapularis: lift off or belly press

http://classconnection.s3.amazonaws.com/443/flashcards/1607443/jpg/1-s20-s1058274608001730-gr91359771717358.jpg

Supraspinatus: empty can; 90°abduction, 30° forward flexion w/

thumbs down

http://www.aafp.org/afp/2000/0515/afp20000515p3079-f3.jpg

Signs/Special Tests:Impingement

Neer: abduction of pronated arm

w/ GH joint in plane of scapula

Hawkins: shoulder in 90 ° of forward

flexion w/ elbow in 90 °flexion & forcibly internally

rotating the shoulder

http://www.aafp.org/afp/2005/0901/afp20050901p811-f5.jpghttp://www.aafp.org/afp/2005/0901/afp20050901p811-f4.jpg

Signs/Special Tests• Joint stability– Load & shift: pt supine, 90 ° abduction/90 ° external

rotation position, apply anterior & posterior force to humeral head; for anterior/posterior laxity

– Sulcus sign: seated w/ downward traction on elbow; += >2cm displacement; inferior laxity

– Apprehension test: seated, 90/90 position w/ anterior pressure on humerus; += ‘apprehension’ that it’s going to dislocate

– Relocation test: supine, 90/90, have pt ‘throw’ against your hand; += less pain/apprehension when examiner is applying posterior force to humeral head

Signs/Special Tests

• Labral pathology– Cross over test– O’Brien’s

http://painmuse.org/wp-content/uploads/obrienac.jpg Biceps pathologySpeed’s: resisted forward flexion of shoulder with elbow extended and forearm supinated; += pain at bicipitalgroove

Yergasons: elbow flexed to 90°w/ forearm pronated; += pain in bicipital groove w/ resisted supination

http://www.mhhe.com/hper/physed/athletictraining/illustrations/ch22/22-17b.jpg

http://www.aafp.org/afp/2000/0515/afp20000515p3079-f4.jpg

Neck

Physical Exam

• Inspection• Palpation• ROM• Strength• Special tests• Neurovascular exam• **Always examine c-spine w/ shoulder**

Inspection

• Atrophy• Shoulder asymmetry• Swelling• Ecchymosis• Erythema• Posture

Palpation

• Spinous processes:– C2 is 1st palpable process– C7 is larger than those above them

• Muscles:– Sternocleidomastoid– Trapezius

• Lymph nodes

ROM

• Flexion: 60 °• Extension: 70°• Lateral flexion: 20-45°• Rotation: 90°

https://www.google.com/search?q=neck+rom&rls=com.microsoft:en-US:IE-

Address&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiuy63vmKbaAhVFzoMKHaE9CB4Q_AUICigB&biw=1920&bih=963#imgrc=pAmLOaE3oX8u

eM:&spf=1523036443110

Strength & Neuro Exam

UpToDate

Special Tests

• Spurling’s maneuver– Extend & rotate the neck to

side of the pain and apply axial load on head

– + test= limb pain or parathesiasproduced

– Specific, not sensitive

Special Tests

• Adson’s– Loss of the radial pulse when the

arm is abducted, extended backward, the head is turned ipsilaterally, and the patient inspires (UpToDate)

– + test = loss of radial pulse

– Common in Thoracic Outlet Syndrome

https://www.google.com/search?rls=com.microsoft%3Aen-US%3AIE-

Address&biw=1024&bih=651&tbm=isch&sa=1&ei=h63HWp_iOoXljwThwLOQCw&q=adsons+test&oq=adsons+test&gs_l=

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Special Tests

• Roo’s– repetitive and vigorous hand grip while the arms

are abducted overhead for 3 min (UpToDate)– += paresthesias, inability to complete– Common in Thoracic Outlet Syndrome

https://www.google.com/search?q=roos+sign&rls=com.microsoft:en-US:IE-Address&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjEie_Tk6baAhXMqYMKHV-

mAycQ_AUICigB&biw=1024&bih=651

References• Griffin, L.Y. (2005). Essentials of Musculoskeletal Care

3rd Ed. Rosemont, IL: American Academy of Orthopaedic Surgeons.

• Hoppenfeld, S (1976). Physical Examination of the Spine & Extremeties. Upper Saddle River, NJ: Prentice Hall.

• Puffer, J.C. (2002). Twenty Common Problems in Sports Medicine. McGraw-Hill.

• Woodward, T.W. (2000). The Painful Shoulder: Part I. Clinical Evaluation. American Family Physician

2000 May 15;61(10):3079-3088.• UpToDate