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“Pinches & Pops and Tears”: The
diagnosis of common shoulder
problems
By Don Coerver PhD, PA
PA--C, DFAAPA
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http://jimmysmithtraining.com/
Types of Shoulder Problems
• Traumatic
• Fractures
• Dislocations e.g. A
A--C & Glenohumeral joints,
labrial tear
• Rotator cuff tears
• Mechanical
• Degenerative arthritis
• Adhesive capsulitis
• Inflammatory
http://thesebonesofmine.wordpress.com/category/shoulder-girdle/
• Bursitis/tendonitis
• Inflammatory arthritis e.g. RA
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Mechanisms of Injury
• Falling onto the “point” of the
shoulder--AC separation
shoulder
• Forced abduction/external rotation of
the shoulder
shoulder--anterior dislocation or
rotator cuff tear
• Forced adduction/internal rotation of
the shoulder
shoulder--posterior dislocation
• Direct blow to the shoulder or clavicle
clavicle-fracture
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Shoulder Exam Sequence
• Inspect
• Palpate
• Range of Motion
• Neuro
• Sensory
• Motor
• DTRs (if appropriate)
• Special Tests
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Inspection: Anterior Shoulder
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Inspection: Posterior shoulder
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http://meded.ucsd.edu/clinicalmed/joints2.htm
http://meded.ucsd.edu/clinicalmed/joints2.htm
Inspection
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http://meded.ucsd.edu/clinicalmed/joints2.htm
http://meded.ucsd.edu/clinicalmed/joints2.htm
Shoulder Range of Motion
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Sensory: Sharp/Dull
bilaterally
Deep Tendon Reflexes
(DTRs)
• Deltoid region axillary nerve (C5)
• Biceps C5
• Middle finger, palmer
aspect (C7)
• Little finger, palmer
aspect (C8)
• Brachioradialis C6
• Triceps C7
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Spurling test
AC joint tenderness test
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http://www.aafp.org/afp/1999/1101/p2035.html
Special Testing: AC Stress Test
• Indications
• Trauma to the AC
joint
• AC arthritis
Br J Sports Med 2010;44:370–375. 374 doi:10.1136/bjsm.2010.071928
Rotator Cuff Pathology
• Impingement
tendonitis
• Rotator cuff tears
http://www.shouldersurgery.org.uk/shoulder/the-painful-shoulder
http://houghsportmedicine.cmswiki.wikispaces.net
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Neer’s Impingement Sign
Hawkin’s Impingement Sign
• Indications
• Impingement
tendonitis
p
• Small or incomplete
Rotator Cuff Tear
•Indications
•Impingement tendonitis
•Small or incomplete tear of the Rotator Cuff
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Br J Sports Med 2010;44:370–375. 374 doi:10.1136/bjsm.2010.071928
Br J Sports Med 2010;44:370–375. 374 doi:10.1136/bjsm.2010.071928
Special Testing: Rotator Cuff
Tear
Empty Can Test (Jobe’s
(Jobe’s test)
• Drop Arm Test
• Abducts the arm to 900
• Actively lowers the arm
slowly
Complete tear -- arm drops
quickly to side
Incomplete tear -- unable to
lower arm smoothly and
slowly
• Isolates the supraspinatus muscle
• Pain may indicate impingement or
rotator cuff tear
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Br J Sports Med 2010;44:370–375. 374 doi:10.1136/bjsm.2010.071928
Br J Sports Med 2010;44:370–375. 374 doi:10.1136/bjsm.2010.071928
Lift Off TestTest- subscapularis
tear
• Internally rotate the
arm and lift the arm
posteriorly off the
back
• The test is positive if
the patient cannot
do so.
Knee Surg Sports Traumatol Arthrosc (2010) 18:1712–1717
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Shoulder instability testing
• The patient is
supine with the arm
abducted to 900 and
the elbow flexed to
900
• Maximal external
rotation is applies
while pressure is
applied to the
posterior aspect of
the humeral head
• Looking for sudden
apprehension
feeling
• The test can aid in
predicting a second
occurrence of an
anterior dislocation
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Br J Sports Med 2010;44:370–375. 374 doi:10.1136/bjsm.2010.071928
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Labrum tears: SLAP Lesions
• The patient is supine with
the examiner at the patient’s
side
• The arm is abducted to 1200
with the elbow flexed to 900
and forearm supinated
supinated..
• The shoulder is moved into
full external rotation
• The patient is asked to flex
his elbow against resistance
• A positive finding is the
reproduction of the pain
Yeargson’ Test: Biceps
Tendonitis
• Elbow flexed to 900, arm
at side, patient
supinates forearm
against resistance
Note pain in bicipital
groove.
Biceps Load II Test
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J Shoulder Elbow Surg (2012) 21, 13-22
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Speed’s Test: Biceps
Tendonitis
• Speeds Test: forearm supinated, elbows
extended, patient flexes arm forward against
resistance
Note pain
in biceps
tendon.
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Br J Sports Med 2008;42:628–635. doi:10.1136/bjsm.2008.048074
Patient with
shoulder pain
Consider
Likelihood of a complete
rotator cuff tear 15%
History of trauma,
night pain, or pain
with overhead
activities
Consider partial
thickness tear or
t d iti with
tendonitis
ith or
without bursitis
Referred sources of
shoulder pain: Cervical
spine, cardiac disease,
diaphragmatic irritation,
thoracic outlet syndrome,
and gallbladder disease
All Negative
If all yes, likelihood of
complete rotator cuff tear 35%
If negative, likelihood
of complete tear 5%
Empty Can Test
If positive likelihood,
of complete tear 50%
Drop Arm Test
Positive
Likelihood of
complete
rotator tear >
95%
Negative
Likelihood of a
complete rotator cuff
tear 45%
MRI negative for
full thickness tear
Likelihood of full
rotator cuff tears 10%
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MRI positive
For full thickness tear
Likelihood of full
rotator cuff tear
75%
Likelihood of
complete rotator cuff
tear is < 5%
Consider AC joint
disease, shoulder
instability, or a
labrum tear in
patients younger
than 45 years
Consider AC joint
disease,
glenohumeral
arthritis, or biceps
tendonitis in patients
older than 45 years
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http://www.ncpainmanagement.com/AssessmentPainfulShoulder.htm
Management of Shoulder
problems
• Rotator cuff
impingement or tear
• AC joint
osteoarthritis
• NSAIDs
• Strengthening
exercises
• Subacromial
injection (judiciously
in tears)
• Refer 33--4 months if
not progressing
• NSAIDs
• AC joint injection
• Refer
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Anterior Shoulder
Anatomy
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http://www.aaos.org/news/aaosnow/jan11/cover1_t1.pdf
Demonstration
& Practice
Time!
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