Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
of the Shoulder
Lisa Chiou, MD, MPH
Primary Care Conference
Goals
Palpation
Along clavicle
SC and AC joints
Acromion, subacromial region
Coracoid process (short head of biceps)
Bicipital groove (long head of biceps)
Trigger points in neck, trapezius, scapular
region
Active range of motion
Forward flexion
Abduction/adduction
Painful arc of abduction – sensitive, not specific
External rotation
Internal rotation
Passive range of motion
Supraspinatus
“Pour out a Coke”
Infraspinatus and teres minor
“Act like a penguin”
Subscapularis
“Scratch your back”
Impingement maneuvers
Impingement sign
At 90 degrees of abduction with elbow flexed to
90 degrees, do internal (downward) and
external (upward) rotation
Hawkins’ test
At 90 degrees of elbow flexion, do internal
rotation by pushing down on pt’s forearm
Neer’s test
At full elbow extension, internally rotate and flex
the arm
Biceps strength testing
Nothing is diagnostic
Plain films not necessary
Get if chronic or recurrent
Might see calcifications
If significant loss of strength or ROM, get
MRI
Rule out tear
Hard to see tendon calcifications
Tx of tendonitis
Rest
Heat or ice
Ultrasound (physical therapy)
NSAIDs
Subacromial steroid injection
Rotator cuff tear
Range of motion
Strength
Drop arm test
Arm abducted with elbow straight
See if pt can smoothly lower arm
If arm drops, then test is positive for tear
Highly specific but only 21% sensitive
Radiology for rotator cuff tears
Interpret carefully
34% asymptomatic pts (all ages) and 54% pts >60
yo have partial rotator cuff tears
Abnormal rotator cuff signal after trauma may
represent strain rather than tear
X-rays
Look for high riding humeral head
Ultrasound
Highly operator dependent
MRI
Rotator cuff tears
Tx of rotator cuff tears
Hyper- or hypothyroidism
Parkinson’s disease
Antiretrovirals (PPIs)
Recent neurosurgery
Exam for adhesive capsulitis
Clinical diagnosis
Range of motion is smooth and pain-free,
then stops suddenly
No further passive ROM possible
Normal strength in the pain-free range
Can test strength again after lidocaine
injection
Radiology for adhesive capsulitis
Frozen shoulder
(contracted GH capsule)
Tx of adhesive capsulitis
Watchful waiting
Up to 2 years for resolution
Incomplete recovery more likely in pts with DM, or pts
with >50% loss of external rotation/abduction
Steroid injection
Manipulation under anesthesia
Gentle exercise
Pain medications
Alternative therapies – i.e. acupuncture
Biceps tendonitis
Hemochromatosis
Think of this if patients develop OA in unusual
places at unusually early ages
Hemophilia
Blood very erosive to joint
Exam for glenohumeral OA
And HUGE
thanks to
Dr. Greg
Gardner!!