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Chiou
- 1. Physical Examination of the Shoulder Lisa Chiou, MD, MPH Primary Care Conference
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Notes de l'éditeur
- Normal shoulder movement. Also, character of the pain does not change with movement of the shoulder.
- Sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic joints. Thin capsule. Subacromial bursa. Rotator cuff tendons attach to humeral tuberosities.
- Supraspinatus – abduction (also with deltoid). Infraspinatus and teres – external rotation. Subscapularis – internal rotation.
- Can see atrophy with chronic RA. Shoulder joint can hide a lot of fluid because of capsule redundancy.
- Flexion – arms outstretched, up in front. Abduction – to the side. External rotation – either the penguin, or putting hands behind back (like relaxing). Internal rotation – have pt use thumb to touch the highest point on the spine. Apley scratch test does both abduction and external rotation – reach behind head and touch the superior angle of the opposite scapula. Can touch the inferior angle of the opposite scapula for testing of internal rotation and adduction.
- Preventing scapula from moving isolates the GH joint. When abducted – internal rotation is pointing down, external rotation is pointing up.
- Bicipital tendonitis – pain at long head of the biceps.s
- Will talk about common shoulder problems now.
- Sx = pain over outer deltoid, particularly with overhead activities or reaching. 10% pts have pain over anterior deltoid.
- Painful arc maneuver = Neer impingement test. Prevent scapular movement by placing hand down on shoulder. Then with the patient’s elbow flexed at 90 degrees, raise the arm and look for pain/guarding. With impingement, see pain variably from 45-120 degrees.
- XR – loss of space between acromion and humeral head can indicate degenerative thinning or a large rotator cuff tear. Can see erosive changes at greater tubercle. More frequently, can see calcification in the rotator cuff tendone but not specific. MRI – can look for compression of the supraspinatus tendon or the subacromial bursa by spurs, low-lying acromion, osteophytes.
- Pendulum, then weighted pendulum. Injection = pure impingement is mechanical and won’t respond to steroids. Could do a lidocaine injection first. If this works, then could consider steroids. Surgery – acromioplasty (either open or arthroscopic).
- If the tear is parallel to the tendon fibers, pt will have shoulder pain, pain with direct pressure, pain aggravated by activities (reaching, lifting, pulling, pushing). If tear is large and transverse in direction, then pt will have weakness, dramatic loss of function.
- U/S limitations include with fat patients or small tears.
- No overhead positioning, reaching, lifting. Steroid injection could possibly weaken tendon, but Up to Date says there is no influence on tendon healing. Rotator cuff is NOT necessary for most normal activities of a sedentary life.
- Show how to do the exam: place your arm on their shoulder and rest their affected side on your arm. Then passively push the AC joint together by pushing on the arm. 2 nd degree – partial dislocation. 3 rd degree – full dislocation.
- Lose abduction and rotation. Loss of GH joint capsule distensibility. Contrast with rotator cuff tendonitis – main sx is pain, not loss of movement.
- After lidocaine, pts with frozen shoulder still have limited range of movement, unlike tendonitis.
- X-rays: could see evidence of calcific tendonitis or degenerative changes that would suggest problems that could eventually lead to frozen shoulder.
- Exercise – (1) weighted pendulum exercises, (2) passive stretching. Up to 50% will respond to exercise therapy.
- Biceps – elbow flexion and supination.
- Bicipital groove is about 1” below the anterolateral tip of the acromion. Pts can seem weak because of pain.
- Usually proximal end of the long head ruptures.
- Surgery rarely necessary since flexion strength only minimally decreased and it usually ends up being a cosmetic issue. Can get slight improvement in elbow flexion and supination.
- RA – morning stiffness, better with activity. Shoulder sx in RA is common, especially in late stages of dse.