shoulder scopy for whom emphasis on clinical examination€¦ · •rotator cuff tears •labral...
TRANSCRIPT
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Shoulder examination
P Sripathi Rao Arthroscopy & Sports Injuries Unit
Dean, Kasturba Medical College
Manipal University, Manipal Bone School @ Bangalore
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Pain
Weakness
Loss of movements
Tingling
Numbness
Common symptoms
Bone School @ Bangalore
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Approach Joint
Capsule
Tendon, rotator cuff
Bursa
Arthritis
Tight-
Frozen shoulder
Ruptured-
dislocation
Inflamed/
rupture
Inflamed
Bone School @ Bangalore
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History
Age < 40
Instability
Rotator cuff tendinopathy
Calcific tendinitis
Age >40
Cuff tears
Adhesive capsulits
Arthritis
(GH & ACJ)
Age
Bone School @ Bangalore
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Duration*
Acute: Calcific tendinitis
Infections
Trauma
Chronic:
Rotator cuff tear / Impingement
Frozen shoulder
Arthritis
History
Bone School @ Bangalore
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Trauma (mechanism)*
Instability
Cuff tears
SLAP
History
Bone School @ Bangalore
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Inability to perform certain
activities
Can’t throw: SLAP/ Labral lesion
Can’t lift: RC tear/ Frozen shoulder
History
Bone School @ Bangalore
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Sports participation
Instability & cuff overuse
*Overhead sports: baseball, softball, tennis
*Collision sports: hockey, football, rugby
ACJ arthritis
*weight lifter
History
Bone School @ Bangalore
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Pain*
Pain at night; can’t sleep on shoulder
Rotator cuff tear / Impingement
Frozen shoulder
History
Bone School @ Bangalore
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Pain*
Pain with overhead activity
Rotator cuff disease
ACJ arthritis
Scapular dyskinesia
History
Bone School @ Bangalore
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Pain*
Pain localized to top of shoulder**
ACJ Arthritis
ACJ separation
History
Bone School @ Bangalore
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Pain radiation
Pain over deltoid and lateral arm
Subacromial bursitis
Adhesive capsulitis
GH arthritis
History
Bone School @ Bangalore
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Pain*
Pain &/ tingling sensation; aggravated by
lifting arm or weakness
IVDP; C. spine
History
Bone School @ Bangalore
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Weakness in lifting arm*
Rotator cuff tear
Brachial plexus injury
History
Bone School @ Bangalore
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Passive loss of movement*
GH arthritis
Adhesive capsulitis
History
Bone School @ Bangalore
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History Systemic illness
Diabetes mellitus
Thyroid disorder
Epilepsy
Heart disease
History
Bone School @ Bangalore
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History History
Pain
Pathoanatomy
Biomechanics
Stiffness
Frozen shoulder
Arthritis
Weakness
Cuff tear
Nerve injury
Bone School @ Bangalore
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Examination Examination
Look
Feel
Move
Special test
*Undress upper half
Bone School @ Bangalore
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Examination Inspection (front)
Attitude
Muscle wasting
Deformities
Examination
Bone School @ Bangalore
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Examination Inspection
Examination
Bone School @ Bangalore
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Examination Inspection (back)
Muscle wasting
Deformities
Scapula
Spine
Examination
Bone School @ Bangalore
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Examination
Bone School @ Bangalore
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Examination
Bone School @ Bangalore
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Examination Inspection (scapula)
Examination
Bone School @ Bangalore
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Examination Inspection (scapular dyskinesia)
Examination
Bone School @ Bangalore
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Palpation • Bony prominences: Tenderness
AC joint
Bicipital groove
Coracoid process
Joint line
Tuberosities
Supraspinous fossa
Ligament laxity***
Palpation
Bone School @ Bangalore
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• Range- active &
passive
• Painless or painful
• GH/scapulothoracic
Movements
Bone School @ Bangalore
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• Range- active & passive
Movements
Movements Active Passive Conclusion
+ + Normal / Altered rhythm /
referred pain
- + Not stiff / cuff tears
- - Stiff, arthritic
Bone School @ Bangalore
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Special tests for..
• Acromioclavicular joint
• Impingement tests
• Rotator cuff tears
• Labral lesions
• Bicipital tendon disease
• Stability
• Others..
Special test for..
Bone School @ Bangalore
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Examination Associated condition Sensitivity Specificty
Muscle wasting
(Supra/infraspinatus)
Rotator cuff tear 56 73
Acromio-clavicular
tenderness
ACJ arthiritis / chronic sprain 96 10
Resticted ROM Adhesive capsulitis 86 72
Hawkins Impingement Impingement/ rotator cuff
disorder
72 66
Drop arm test Large rotator cuff tear 27 88
Empty can
supraspinatus
RC involving supraspinatus 44 90
Lift off subscapularis RC involving subscapularis 62 100
External rotation
Infraspinatus strength
RC involving infraspinatus 42 90
Cross body adduction ACJ arthritis 77 79
Apprehension GH instability 72 96
Relocation GH instability 81 92
Bone School @ Bangalore
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ACJ
Bone School @ Bangalore
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Impingement Impingement
Bone School @ Bangalore
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Rotator cuff test
Rotator cuff tear (SS)
Empty & full can test Full can: Specific for Full thickness cuff tear
Negative in tendinitis & Partial cuff tear Bone School @ Bangalore
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Jobe’s supraspinatus test
Rotator cuff test
Rotator cuff tear (SS)
Full can sign
pain + strength
Bone School @ Bangalore
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Rotator cuff test
Rotator cuff tear (SS)
Empty and full can test Bone School @ Bangalore
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Infraspinatus & teres strength
Rotator cuff test
Rotator cuff tear
Bone School @ Bangalore
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• Drop arm test (Codman’s sign) – for massive
rotator cuff tears
Rotator cuff test
Rotator cuff test
Bone School @ Bangalore
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Gerber’s subscapularis liftoff test
Rotator cuff test
Rotator cuff tear
Bone School @ Bangalore
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Napoleon / belly press sign
Rotator cuff tear
Bone School @ Bangalore
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• External & internal rotations in
900 abduction
Crepitus indicates
hypertrophied subacromial bursa
or rotator cuff tear
Rotator cuff test
Rotator cuff test
Bone School @ Bangalore
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Bicipital tendon test
Bicipital tendon test
Bone School @ Bangalore
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SLAP lesions Speed’s and O’Brien test
Bone School @ Bangalore
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Apprehension test
Anterior stability test
Anterior stability test
Bone School @ Bangalore
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Sulcus sign
Anterior stability test
Anterior stability test
Bone School @ Bangalore
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• Supraspinatus and infraspinatus
weakness presents as
cuff tear
• However,
- Neer’s -ve
- Hawkins -ve
- other cuff test -ve
Compression neuropathy
Bone School @ Bangalore
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• Serratus anterior:
Winging (Up & in)
• Trapezius:
Winging (Down & out)
Compression neuropathy
Bone School @ Bangalore
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Still no clues
Bone School @ Bangalore
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Do examine
Cervical spine
Chest
Thoracic outlet
CVS & Abdomen
Do examine
Bone School @ Bangalore
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Do examine Cervical spine
Bone School @ Bangalore
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Do examine Chest
Bone School @ Bangalore
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Do examine Heart
Bone School @ Bangalore
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Do examine Abdomen
Bone School @ Bangalore
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Do examine Investigations
• X-ray
• USG
• MR scan
Bone School @ Bangalore
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Take home message Good history & exam
Do not forget other systems
Conservative tt. is not panacea
Not everything is frozen shoulder !
Bone School @ Bangalore
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Bone School @ Bangalore