Shoulder 101
…and Then Some
Evan D. Ellis MD
Rebound Orthopaedics and
Sports Medicine
Why Shoulder 101?

Multiple studies: High percentage of visits
to see PCP are for musculoskeletal pain

2 studies*: Large gap in PCP confidence in
evaluating and treating musculoskeletal
injuries

Studies in both a rural and tertiary academic
setting
*Lynch et al JBJS AM 2006 and AJO 2005
The Shoulder

ANATOMY

HISTORY

PHYSICAL EXAM

IMAGING

CASES/TREATMENT
Anatomy




Not a ball and
socket
More of a ball on a
dish
Static Restraints
Dynamic Restraints
Anatomy
Glenoid Concavity:
• Bone
• Cartilage
• Labrum
Anatomy

Labrum:
 Deepens glenoid by 50%

9 mm superoinferior*

5 mm anteroposterior*

Contributes to 20% of
stability in A-P direction

Loss of labral integrity
may result in instability
*McMahon et al. JSES. 2004. Jan-Feb;13(1):39-44.
*Howell SM, Galinat BJ. The glenoid-labral socket: a constrained articular surface. Clin Orthop. 1989
Anatomy
Static Restraints
 Glenohumeral Ligaments

Superior: Prevents inferior
translation with arm at side

Middle: Important for midrange abduction

Inferior: Critical for ABD/ER

Anterior band prevents anterior
inferior translation
Anatomy
• Ligaments do not center
the head.
• Limit its translation and
rotation.
• Think Check-Rains
Anatomy
Dynamic Restraints
 Muscular Stabilizers
 Anterior: Subscapularis

Superior: Supraspinatus

Posterior: Teres minor and
Infraspinatus

Lateral: Deltoid

Scapular stabilizers
History Basics
 Painful
shoulders can be:
 Unstable
 Stiff
 Weak
 Rough/Pain
“What bothers you about your
shoulder?”
History



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
Age
Gender
Was there an
injury?
Injury mechanism
Prior problem
Dominant arm
History





Chronicity
Location of Pain
Pain at night
Stiffness/Unstable
Prior treatment
Physical Exam

Goal: Reproduce Symptoms

Inspection, Palpation, ROM,
neurovascular exam, special
tests

Compare to contralateral side

Cervical spine

Note provocative positions
Physical Exam
 EXPOSE:
Neck
 Shoulders
 Arms

Physical Exam
 EXPOSE:
Neck
 Shoulders
 Arms


Women need gown
or tank top!
Physical Exam
Motion: Active/Passive






Forward Elevation
External Rotation
ER in Abduction
Internal Rotation
IR in Abduction
X-Body
Range of Motion
FE: 180
 ERS: 60
 ERA: 90
 IRA: 70
 IRB: T-spine
 X-Body: 60

Range of Motion
FE: 180
 ERS: 60
 ERA: 90
 IRA: 70
 IRB: T-spine
 X-Body: 60

Range of Motion
FE: 180
 ERS: 60
 ERA: 90
 IRA: 70
 IRB: T-spine
 X-Body: 60

Range of Motion
FE: 180
 ERS: 60
 ERA: 90
 IRA: 70
 IRB: T-spine
 X-Body: 60

Range of Motion
FE: 180
 ERS: 60
 ERA: 90
 IRA: 70
 IRB: T-spine
 X-Body: 60

Range of Motion
FE: 180
 ERS: 60
 ERA: 90
 IRA: 70
 IRB: T-spine
 X-Body: 60

Rotator Cuff Exam
 MOTOR
Subscapularis
 Supraspinatus
 Infraspinatus
 Teres Minor

Rotator Cuff Exam
 MOTOR
Subscapularis
 Supraspinatus
 Infraspinatus
 Teres Minor

Rotator Cuff Exam
 MOTOR
Subscapularis
 Supraspinatus
 Infraspinatus
 Teres Minor

Rotator Cuff Exam
 MOTOR
Subscapularis
 Supraspinatus
 Infraspinatus
 Teres Minor

Rotator Cuff Exam
 MOTOR
Subscapularis
 Supraspinatus
 Infraspinatus
 Teres Minor

Neurologic Exam
 NEURO
Sensation
 Motor
 Reflexes
 Spurling’s

Neurologic Exam
 NEURO
Sensation
 Motor
 Reflexes
 Spurling’s

Special Tests - Cuff
 CUFF

Neer Impingement
Sign
 Neer Impingement
Test
 Subacromial
injection

Hawkins Test
Special Tests - Cuff
 CUFF

Neer Impingement
Sign
 Neer Impingement
Test
 Subacromial
injection

Hawkins Test
Special Tests - Cuff
 CUFF
Neer Impingement
Sign
 Neer Impingement
Test
Subacromial
injection
 Hawkins Test

Special Tests - Instability

Apprehension/Relocation
 Supine position
 Stabilizes scapula
 Abduct to 90°
 Increase ER gradually

Positive:
 Apprehension w/
increasing amounts of
ER
 Apprehension relieved
by posterior force on
the humerus
Special Tests - Instability

Seated Load & Shift

Assess A & P translation
 Grade
 1+: to rim
 2+: over rim
w/reduction
 3+: over rim & locked

Compare to other side

Assess for pain, click, &
instability
Special Tests - Instability

Supine Load & Shift

Arm position:
 45-60° abduction

Ant/Post directed force
applied to humerus
 Assess
 Stability
 Pain
 Palpable click
Special Tests - Instability

Sulcus Sign:


Arm at side
To look for multi-directional
instability

Grade

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1+ = 1 cm
2+ = 1-2 cm
3+ = > 2 cm
Look for generalized
hypermobility
Radiographs

Never order an MRI before X-Rays

Everyone deserves a normal set of X-Rays!

Most important X-Rays: True AP (Grashey)
and Axillary Lateral

These two X-Rays are almost always omitted
from a “shoulder series”!
Radiographs
True AP or Grashey View:
• Arthritis
• Fracture
• Massive Rotator Cuff tear
Radiographs

True AP
Radiographs

Axillary Lateral
 Arthritis
 Instability
 Fracture
Radiographs

Axillary Lateral
Radiographs
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Additional Views
 Outlet
 Internal/External
 Stryker Notch
 West Point View
The Shoulder
Diagnosable & Treatable
A.

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Rotator cuff tears
Shoulder instability
Arthritis
SLAP tear
Diagnosable & Untreatable
B.

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Brachial neuritis
Voluntary instability/MDI
Rib fractures
Age is Key
Age is Key
Case #1
History:
 16 year old RHD
male football player
 Shoulder “popped”
out of place while
getting tackled
 To ER for reduction
 Has happened 2
previous times
Case #1
Physical Exam:
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Full Range of Motion
Full rotator cuff
strength
+ Apprehension Test
+ Relocation Test
+ Anterior Load &
Shift
Case #1
Case #1

What do you do?
Place him in a sling
 Refer to Ortho
 If first time dislocater – Physical
Therapy
 If 2 or more dislocations – MRI and
surgery

Sling
Regular Sling vs. External Rotation

Which is better?

Itoi, JBJS 2007
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159 patients
Avg follow up of 25.6 months
74 immobilized in IR
 31 recurred (42%)
85 immobilized in ER
 22 recurred (26%)
 *Effect on labral position for
healing
Case #1
Case #1
Arthroscopic Repair
Case #2
History:
 41 yo female with gradual onset
pain/stiffness over 6 weeks
 No history of trauma
 Similar problem with other shoulder 2 years
prior
 Hx of Diabetes
 Can’t brush hair or fasten bra
Case #2
Physical Exam:
 Forward Elevation – 80
 External Rotation – Neutral
 Internal Rotation – Back Pocket
 Full strength of rotator cuff
 Can’t get arm to side to check for
instability
Case #2
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Radiographs
Case #2
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Diagnosis???
Adhesive Capsulitis/Frozen Shoulder
Treatment???
If nothing done, may take 2 years to resolve
PT, PT, PT
If fails: Intraarticular cortisone shot and
more PT
If fails: Manipulation under anesthesia
If fails: Arthroscopic capsular release
Case #2

What would MRI show with adhesive
capsulitis?

Normal
Case #2
Case #3
History:
 49 yo male fell down stairs and grabbed
railing on way down.
 Felt ripping sensation in shoulder
 Pain on lateral aspect of shoulder
 Pain with overhead activity
 Night pain
 Popping
 Feels weak
Case #3
Physical Exam:
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Pain/crepitus with
forward elevation
Positive Impingement
Sign
Positive Hawkins Test
Weakness with
supraspinatus testing
No instability
Case #3
Case #3
Case #3
Diagnosis??
 Acute rotator cuff tear
Treatment??
 Refer to ortho
 Acute, full-thickness
cuff tear in a “young”
patient = surgical
repair
Case #4
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History:
48 yo RHD male
6 months shoulder pain
No injury
Pain at night
Pain with reaching overhead
NSAIDS no help
No neck pain/numbness/tingling
Case #4
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Physical Exam:
Full ROM
+ Impingement Sign
+ Hawkins Test
Full Strength of Cuff
Pain with
supraspinatus
testing
Case #4
Case #4
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Diagnosis?
Rotator Cuff Tendonitis vs. Partial
Thickness Tear
Treatment?
Physical Therapy
If no improvement = Refer to Ortho
Case #4
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What do we do?
MRI
If MRI =
Cortisone injection
If MRI =
Possible Surgery
Partial Thickness Cuff Tears

Increasing prevalence with age
30 – 60% Incidence in Age > 60
 Over 80% Incidence in Age > 70


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Often asymptomatic
If painful and fail therapy = Surgery
Supraspinatus is 11 mm thick
If < 50% torn = Debridement + Decompression
 If > 50% torn = Complete the tear and Repair

Case #5
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History:
66 yo male with progressive pain/stiffness
shoulder
Pain is constant and unable to do ADLS
Feels like it’s popping with motion
NSAIDS – Some relief
Case #5
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Physical Exam:
FE: 100
ER: Neutral
IR: Back Pocket
“Ratcheting” motion
Cuff Strength
Normal
Case #5
Radiographs
Case #5
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Diagnosis?
Endstage Shoulder Osteoarthritis
Treatment?
Physical Therapy and/or refer to Ortho
Cortisone Injection
Shoulder Replacement
Case #5
Case #6
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History:
14 yo female with
longstanding history of both
shoulders going “in and
out”
No traumatic event
Has never had them
reduced in the ER
Sometimes “grosses friends
out” by dislocating her
shoulder at parties
Case #6
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Physical Exam:
Full Range of Motion
Normal Cuff
Strength
Sulcus - Grade 3
Hypermobile Signs +
Case #6
Hypermobile Tests
Case #6
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Radiographs – Normal

Diagnosis?
Atraumatic, bilateral shoulder instability
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Treatment?
PT, PT, PT
More PT
MRI – Normal or Enlarged joint capsule
If absolutely fails everything – Capsular shift
Case #6
Capsular Shift
Case #7
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History:
80 yo female with occasional ache in
shoulder
Swims everyday
No Injury
Pain is minimal, but just wants to get it
checked out
Takes no pain meds
Case #7
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Physical Exam:
Full ROM
Mild pain with reaching overhead
+ Impingement Sign
+ Hawkins Test
Profound weakness of supra/infraspinatus
Case #7
Radiographs
Case #7
MRI
Case #7
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Diagnosis?
Massive Rotator Cuff Tear
Treatment?
No role for surgical repair
Leave it alone
Physical Therapy
Occasional cortisone injection
Summary

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A focused, thorough H&P is critical to correctly
diagnosing a shoulder problem.
Expose the shoulder for the exam and compare to
the other side.
Age, alone, is an important predictor of a
patients’ diagnosis.
Always order an x-ray series prior to ordering a
shoulder MRI. Everyone deserves a normal set of
x-rays!
X-ray series should always, at a minimum, include
a true AP (grashey) and an axillary view.
Summary

Not all rotator cuff tears can, or should be, fixed.

Traumatic, unidirectional, recurrent dislocaters
should be surgically repaired.

Atraumatic, multidirectional, and/or voluntary
shoulder dislocaters should almost never be
surgically repaired.

Physical therapy is a tremendous adjunct to
treatment for the majority of shoulder injuries.

If you have questions, please call or refer your
patients. We are always happy to help!
Thanks!!
www.reboundmd.com