The ShoulderJennifer R Marks, MD

•  Skeletal & ligamentous components:The joint is comprised of a confluence of

•  Scapula•  Clavicle•  Humerus

Shoulder Anatomy

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https://www.shoulderdoc.co.uk/article/http/ www.shoulderdoc.co.uk/article/117777

•  Muscles:

Shoulder Anatomy

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Tendons & bursae:https://www.google.com/search?q=shoulder+anatomy&biw=1422&bih=707&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwieo6W5m7HPAhVLVj4KHabHAbsQ_AUIBigB#imgrc=rTBT1HFveBX2nM%3A

Shoulder Anatomy

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•  Inspection

•  Anterior•  Posterior

•  Bilateral

Shoulder Physical Exam

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•  Palpation

•  AC joint•  Subacromial space•  Musculature•  Scapula•  Head of biceps tendon

Shoulder Physical Exam

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•  ROM

•  Flexion•  Raise arm (180 degrees)

•  Extension (50 degrees)•  Lower arm

Shoulder Physical Exam

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•  ROM

•  Abduction•  Arms horizontal

•  Adduction•  Arms medial

https://www.machinedesign.com/medical/what-s-difference-between-abduction-and-adduction-biomechanics

Shoulder Physical Exam

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•  ROM•  Internal Rotation, External Rotation

Shoulder Physical Exam

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http://shouldercomplex.weebly.com/movements.htm

•  Provocative testing….

Shoulder Physical Exam

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•  67 yo male presents to clinic for an IV•  He has shoulder pain

•  What further questions do you want to ask him?

•  What is on your DDx?

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•  Occurs less often than LE joints since not weight-bearing

•  Aspect of worst pain often anterior•  Morning stiffness•  Pain on ROM•  May have prior hx of trauma

Shoulder Osteoarthritis

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•  PE•  Anterior and/or posterior ttp•  Crepitus•  Decreased ROM•  Cross-Arm test for A-C OA

•  Dx/Tx•  X-ray•  NSAIDs, ice, PT, injection, shoulder

replacement

Shoulder Osteoarthritis

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•  Impingement•  RC cuff becomes inflamed as it is compressed

between the humerus & choracoacromial arch

•  Pain over ant/lat aspect of shoulder•  Some radiation down arm•  Worse with overhead activity

•  Empty can (Jobe’s test)•  Neer’s sign

Rotator Cuff Pathologies

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•  Tendonitis•  Essentially a continuum with impingement

•  Painful ROM

Rotator Cuff Pathologies

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•  Supraspinatus•  Abduction/flexion•  Jobe’s or Empty Can test, Neer’s, etc•  Drop Arm (tear)

•  Infraspinatus•  External rotation•  Infraspinatus test

Rotator Cuff Pathologies

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•  Teres minor•  External rotation•  Hornblower’s/Patte test

•  Subscapularis•  Internal rotation•  Gerber or Lift off test

Rotator Cuff Pathologies

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•  Partial/full tear •  Can be due to acute injury in younger patients •  Can be traumatic or degenerative in older patients•  Pain, weakness esp with overhead activity and often at

night•  Most common tear is supraspinatus

•  Drop arm test

•  Consider MRI•  Caution with repeated injections

Rotator Cuff Pathologies

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•  Clinically similar to RC tendonitis•  Anterior shoulder pain

•  TTP in subacromial space

Subacromial bursitis

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•  AKA Frozen Shoulder

•  Trouble with ADLs•  Often painful initially then less so if ROM

regained

Adhesive capsulitis

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•  PE•  Decreased active and passive ROM (<50% of

normal side)•  May have diffuse ttp

•  Dx/Tx•  X-ray•  NSAIDs, moist heat, PT, •  Consider injection

Adhesive capsulitis

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•  Pain with activity

•  Point tenderness at insertion site

Biceps Tendonitis

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https://meded.ucsd.edu/clinicalmed/upper_biceps_rupture.jpg

•  Rupture usually involves long head of the biceps •  Often minimal trauma required•  Sudden pain, sometimes an audible snap

•  Often visible and/or palpable bulge•  Usually non-operative, except if pt very active

and/or distal rupture

Biceps Rupture

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•  67 yo male presents to clinic for an IV•  He has no particular complaints•  On routine exam you find the following:

•  Pain on abduction•  Palpable and visible deformity•  Played football in high school

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Dx = Acromialclavicular Injury

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Dx = Acromialclavicular Injury

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•  If acute•  X-ray•  Type I & II -> sling, NSAIDs, ice•  Type III -> controversial so case dependent•  Types IV-VI -> operative repair

•  If chronic•  Becomes degenerative & managed as such

•  Greene, WB. Essentials of Musculo-skeletal Care. 2001•  Monica, J, et al. Acute Shoulder Injuries in Adults. Am Fam

Physician, 2016 July 15; 94 (2): 119-127.•  Woodward TW, et al. The Painful Shoulder: Part I. Clinical

Evaluation. Am Fam Physician, 2000 May 15;61(10):3079-3088.•  Woodward TW, et al. The Painful Shoulder: Part I. Clinical

Evaluation. Am Fam Physician, 2000 June 1;61(11):3291-3300.

References

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