The Shoulder. Jennifer R Marks, MD

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1 The Shoulder Jennifer R Marks, MD

2 Shoulder Anatomy Skeletal & ligamentous components: The joint is comprised of a confluence of Scapula Clavicle Humerus http/ 2

3 Shoulder Anatomy Muscles: 3

4 Shoulder Anatomy Tendons & bursae: q=shoulder+anatomy&biw=1422&bih=707&source=lnms&tbm=isch&sa=x&sqi=2&ved=0ahukewieo6w5m7hpahvlvj4khabhabsq_auibigb#imgrc=rtbt1hfvebx2nm%3a 4

5 Shoulder Physical Exam Inspection Anterior Posterior Bilateral 5

6 Shoulder Physical Exam Palpation AC joint Subacromial space Musculature Scapula Head of biceps tendon 6

7 Shoulder Physical Exam ROM Flexion Raise arm (180 degrees) Extension (50 degrees) Lower arm 7

Shoulder Physical Exam ROM Abduction Arms horizontal Adduction Arms medial https://www.

8 Shoulder Physical Exam ROM Abduction Arms horizontal Adduction Arms medial 8

9 Shoulder Physical Exam ROM Internal Rotation, External Rotation 9

10 Shoulder Physical Exam Provocative testing. 10

11 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? 11

12 Shoulder Osteoarthritis 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 12

13 Shoulder Osteoarthritis 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 13

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15 Rotator Cuff Pathologies 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 15

16 Rotator Cuff Pathologies Tendonitis Essentially a continuum with impingement Painful ROM 16

17 Rotator Cuff Pathologies Supraspinatus Abduction/flexion Jobe s or Empty Can test, Neer s, etc Drop Arm (tear) Infraspinatus External rotation Infraspinatus test 17

18 Rotator Cuff Pathologies Teres minor External rotation Hornblower s/patte test Subscapularis Internal rotation Gerber or Lift off test 18

19 Rotator Cuff Pathologies 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 19

20 Subacromial bursitis Clinically similar to RC tendonitis Anterior shoulder pain TTP in subacromial space 20

21 Adhesive capsulitis AKA Frozen Shoulder Trouble with ADLs Often painful initially then less so if ROM regained 21

22 Adhesive capsulitis PE Decreased active and passive ROM (<50% of normal side) May have diffuse ttp Dx/Tx X-ray NSAIDs, moist heat, PT, Consider injection 22

23 Biceps Tendonitis Pain with activity Point tenderness at insertion site 23

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25 Biceps Rupture 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 25

26 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 26

27 Dx = Acromialclavicular Injury 27

28 Dx = Acromialclavicular Injury 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 28

29 References Greene, WB. Essentials of Musculo-skeletal Care Monica, J, et al. Acute Shoulder Injuries in Adults. Am Fam Physician, 2016 July 15; 94 (2): Woodward TW, et al. The Painful Shoulder: Part I. Clinical Evaluation. Am Fam Physician, 2000 May 15;61(10): Woodward TW, et al. The Painful Shoulder: Part I. Clinical Evaluation. Am Fam Physician, 2000 June 1;61(11):

Review shoulder anatomy Review the physical exam of the shoulder Discuss some common causes of acute shoulder pain Discuss some common causes of

Review shoulder anatomy Review the physical exam of the shoulder Discuss some common causes of acute shoulder pain Discuss some common causes of chronic shoulder pain Review with some case questions Bones: