Evaluation of Shoulder Pain

Differential Diagnosis

Most Common

1. Rotator Cuff strain or tendinopathy

2. Glenohumeral Dislocation: Usually Anterior but occassionaly Posterior

3. Glenohumeral instability: Anterior, Posterior, or Multidirectional

4. Glenoid Labrum Tears

5. Referred pain from (cervical spine, Thoracic Spine, or Soft Tissues)

6. Fracture of the Clavicle: Midshaft or Distal

7. AcromioClavicular Joint Sprain

8. Levator Scapulae Syndrome

9. Muscle Tears (Pectoralis Major, Long head of biceps)

10. Brachial Plexus Pathology (Stingers or Neuritis)

11. Thoracic Outlet Syndrome

Less Common

1. Rotator Cuff Tear or Calcific Tendinitis

2. Adhesive Capsulitis

3. Biceps Tendinitis

4. Nerve Entrapment (Suscapular or Long Thoracic)

5. Fracture (Scapula,Humerus, or Corocoid Process)

Not to be Missed

1. Tumor

2. Referred pain (diaphragm, gall bladder, dudodenal ulcer, spleen, lungs)

3. Thoracic Outlet Syndromes

4. Axillary Vein Thrombosis

History

• Exact site of pain

• Acute or insidious Onset

• Aggravating or alleviating factors

• Numbness / tingling / paresthesias

• Dead Arm Syndromes

• Spinal or lower limb problems.

Examination

Always remember to examine the joint above (cervical spine) and joint below (elbow).

Inspection

1. Scars or stretch marks

2. Wasting of muscles

3. Deformity of shoulder girdle or spine

Palpation

1. Scapula: Superior angle/medial border/inferior angle/spine/lateral border acromion/coracoid process

2. Clavicle: A-C joint/body of clavicle/sternoclavicular joint/sternal manubrian

3. Humerus: Greater tuberosity/lesser tuberosity/bicepital groove

4. If considering infection or tumor: cervical triangle and axilla for nodes

5. Supraspinatus and Subacromian Bursae: Internally rotate the shoulder, with the athletes hand placed on the small of the back. This can deliver the bursae forward and allow examination under the acromion

6. Tenderness along the long head of biceps may suggest biceps impingement.

Motion

Note that range of movement is measured determined actively first, if there is a deficiency, move on to passive range of motion. Any deficits should be measured with a goniometer. Note should be made of discrepence between active and passive movement.

Muscles

Measurement of muscle strength using the Oxford (MRC) Scale.

1. Shoulder Shrug for Trapezius (C2 C3 C4)

2. Protraction of Scapula and Pressure against wall for serratus anterior

3. Retraction of Scapula for rhomboids (C5 C6 C7)

4. Glenohumeral abduction for deltoid (C5 C6 C7)

5. Glenohumeral foreward flexion for anterior fibers of deltoid (C5 C6 C7)

6. Glenohumeral extension for posterior fibers of deltoid (C5 C6 C7)

7. Glenohumeral internal rotation for subscapularis (C5)

8. Glenohumeral external rotation for infraspinatus (C5 C6)

9. Specific test for supraspinatus: arm abducted to 90degrees, brought forward by 30degrees, and thumbs pointed to the floor. Athlete pushes up against resistance provided by examiner.

10. Flexion of elbow to assess biceps brachii (C5 C6)

NeuroVascular

1. Test Distal pules including radial, ulnar, brachial.

2. Assess signs of distal circulation, color/warmth/capillary refill.

3. Check sensation in three areas:

1. Radial Nerve: First Webspace

2. Median Nerve: Distal second digit, radial aspect

3. Ulnar Nerve: Ulnar aspect fifth digit.

4. Check and Grade Reflexes

1. Bicep's Jerk: C5-C6

2. Tricep's Jerk: C7

3. Wrist Jerk: (brachioradialis): C6

Special Tests for Impingement

The presence of a painful arc of abduction during test of movement may suggest impingement. Use the following tests to look for impingement:

• Forced Cross Flexion

• Anterior impingement may be examined by the Painful Arc Sign and its varients (Supplemented Painful Arc and Codman's Drop Arm Test).

• Hawkin's sign

• Impingement injection test

• Speed's Test and Yergason's Test for bicep impingement.

• Neer Test

Special Tests for Instability

• Load and Shift Test

• Apprehension Test which includes Fowler's Sign or the Relocation Test for anterior instability

• Posterior Subluxation Flexion Test

• Feagin Maneuver for anterior instability

• Glenoid Labrum Clunk Test

• Long Axis Glenoid Traction Test and the Sulcus Sign

Special Tests for SLAP Lesions

Injuries to the labrum are divided into SLAP (superior labrum anterior to posterior) and Non-SLAP injuries. SLAP lesions extend from anterior to the biceps to posterior to the tendon.

• Anterior Slide Test

• O'Brien Test

• Crank Test

Special Tests for Thoracic Outlet Syndrome

• Adson Test

• Hyperabduction Test

• Overhead Exercise Test

• Wright's Maneuver

Investigations

1. Plain Xrays: AP and lateral views should be considered in any case. If there is a history of trauma, an axillary view is necessary.

2. Special Views for Impingement: Consider Supraspinatus Outlet Views and Down-Tilted acromial views for cases of impingement.

3. Special Views for Instability: Consider the West Point View or the Stryker Notch View to detect Bankhart for Hill-Sachs lesions.

4. Arthrography: Once considered the Gold Standard for instability and rotator cuff damage, this test can reliably detect only complete cuff tears. Its use has largely been superseded by MRI and CT.

5. Computed Tomography: Especially helpful when CT arthrography is performed.

6. Ultrasound: In appropriate hands, this can reliably detect tendon swelling, thickeneing of the bursa, abnormal fluid collection, or cuff tears. This may be a static exam or a dynamic exam with the patient moving the arm.

7. Magnetic Resonance Imaging: Excellent for detection of rotator cuff tear. Bone detail is not as well defined as with CT. To evaluate for Labral Tears or Instability, contrast is needed.

8. Arthroscopy: This is particularly useful in cases of instability. It can be a diagnostic and therapeutic procedure.

9. Examination Under Anesthesia: Used to assess the presence, severity, and direction of laxity.

Appendix I: Scapula-Thoracic Joint Movers

Appendix II: Gleno-Humeral Joint Movers

+++ Primary Mover

+ Secondary Mover

Index

Whois Dr Frankenstein

Search Judy