Bursitis
Impingement (with its complications of tendinitis and
rotator cuff tears)
Frozen shoulder and fracture
Dislocated or unstable shoulder
Osteoarthritis
Medical Zone |
|
What are the most common musculoskeletal causes of shoulder pain?
Bursitis Impingement (with its complications of tendinitis and rotator cuff tears) Frozen shoulder and fracture Dislocated or unstable shoulder Osteoarthritis
0 Comments
What is the general approach to the shoulder exam?
Always expose both shoulders (and watch while the patient removes the shirt). Then carry out a systematic exam: inspect, palpate, assess ROM, measure strength, evaluate neurologically, and perform special shoulder tests. Also, examine the cervical spine and upper extremity. 1. Inspect for scars, color, edema, deformities, muscle atrophy, asymmetry, and guarding. 2. Palpate for pain or point tenderness (the presence of either narrows the exam): Bony and soft-tissue structures, such as coracoid process, acromioclavicular joint, greater tubercle Subdeltoid and subacromial bursae Supraspinatus muscle and its insertion (anteriorly, with arm externally rotated and flexed) Infraspinatus muscle (with arm hyperextended) Major muscle groups and biceps tendon Sternum and sternoclavicular joint 3. Assess active and passive ROM, especially in regard to elicited pain and reduced movement. 4. Determine muscle strength. This is an essential part of the exam, and comparing side to side may help you locate the area of concern. Always carry it out with and without resistance. To isolate the various muscles, use the following maneuvers: Supraspinatus: arm forward 90 degrees in the scapular plane and forearm pronated (thumbs down, “empty can” maneuver). Drooping of this position suggests full-thickness rotator cuff tears. Subscapularis is tested by internal rotation. Arm is rotated internally with the dorsum against the buttock. Actively lift the hand from the buttocks against resistance. External rotators, teres minor, and infraspinatus are primarily tested by external rotation (arm on the side and in 90 degrees of abduction). Deltoids are primarily assessed by abduction. Biceps is primarily tested by elbow flexion and supination. Can history identify the cause of a shoulder ailment?
Yes. For instance, recurrent subluxation in young individuals usually indicates multidirectional instability; constant shoulder pain and decreased range of movement (ROM) in diabetics classically reflect adhesive capsulitis; pain and weakness in workers whose jobs require recurrent overhead action suggest rotator cuff pathology; shoulder pain after a fall on an outstretched arm argues for acromioclavicular (AC) lesions. What areas of the shoulder girdle should be palpated?
Acromioclavicular joint (top of shoulder, radiating toward the neck) Long head of the biceps tendon (anterior shoulder, in the bicipital groove) Coracoid process (anterior shoulder) Rotator cuff (lateral aspect of shoulder, radiating toward the deltoid insertion) Glenohumeral joint What are the shoulder’s
movements? How do you test its ROM? The shoulder can actively abduct, adduct, externally and internally rotate, flex, and extend. It has the largest ROM of any joint, since it provides mobility not only to the girdle but also to the hand. ROM is tested as follows: Abduction: Ask patients to raise the arms laterally and away from the body: first, to the level of the shoulder and with palms facing down (90 degrees of glenohumeral motion), and then above the head and with palms facing each other (another 90 degrees, of which 60 degrees are scapulothoracic motion and 30 degrees are combined glenohumeral and scapulothoracic). Normal individuals should complete a smooth 180-degree arc. Average, however, is a little less (150 degrees). Abduction and external rotation: Ask patients to place the hand behind the head, trying to reach as far down into the spine as possible. Normal individuals should reach C7. Average range of external rotation with the arm in abduction is 70–90 degrees. Adduction and internal rotation: Ask patients to place the hand behind the back, trying to reach with the thumb as far up into the scapula and spine as possible (Apley’s scratch test). Normal adduction is 45 degrees; normal range of internal rotation is above T8 (i.e., the lower border of the scapula and the T7 level). Forward flexion: Ask patients to trace an arc forward while keeping the elbow straight, ultimately raising the hands above the head. Normal range is 0–180 degrees. Extension: Ask patients to trace an arc backwards, with the elbow straight, arms at the side, and palms facing each other. Normal subjects should place the hand behind their back to 40–50 degrees. If active ROM elicits pain, evaluate the same movements through passive ROM. To provide your patient with adequate support (and thus ensure maximal relaxation), gently rest one hand on his/her shoulder while using your other hand to move the humerus through the same ROM as previously discussed. Look for pain and crepitus. Pain and limitation on active, but not passive, ROM indicate muscular or tendinous problems. Crepitus suggests instead degenerative joint disease. Describe the muscles and tendons of the shoulder
The rotator cuff consists of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis (mnemonic, SITS). Their tendons converge on the humerus, thus allowing for most of the joint movements (abduction of the arm and rotation of the shoulder, both internal and external). They also hold the humeral head in the glenoid cavity, thus stabilizing the joint. The deltoid is the largest and strongest muscle, responsible for the later part of abduction and flexion once the arm has been lifted by the supraspinatus. It is visible but rarely injured. The biceps has two proximal heads (hence, the name), which insert into the shoulder: (1) the long head tendon and (2) the short head of the biceps. The long head tendon lies in the bicipital groove of the humerus, between the greater and lesser tuberosities and under the transverse humeral ligament. This arrangement prevents the humeral head from sliding too far during abduction and external rotation. At the upper end of the groove, the long head of the biceps angles 90 degrees inward, crossing the humeral head and eventually inserting itself into the upper edge of the glenoid labrum and supraglenoid tubercle. The short head of the biceps connects instead on the coracoid process. Distally, the two heads of the biceps merge to form the body of the biceps brachii muscle, which inserts itself into the radius through its common distal head. The biceps is a powerful flexor and supinator of the forearm (i.e., it rotates forearm and hand so that the palm faces upward). What is the anatomy of the shoulder?
It results from the confluence of three bones (humerus, clavicle, and scapula) and four joints (glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic). Everything is kept in place by various static and dynamic stabilizers: the “static” being labrum, capsule, and three ligaments (acromioclavicular, coracoclavicular, and coracoacromial); the “dynamic” being the scapular stabilizers (trapezius, rhomboid, and teres major) plus two muscles: rotator cuff and deltoid. What are the findings of joint hypermobility?
Ability to oppose the thumb passively to the forearm Hyperextension of fingers >10 degrees of hyperextension of the elbows and knees Ability to touch the palms to the floor with flexion at the waist Note that joint hypermobility can be benign or associated with Ehlers-Danlos. |