- December 20, 2019
Thank you very much for the introduction for having me over here. My name is Ioannis Pappou. I’m an Orthopedic surgeon out in Palm Harbor doing shoulders and hands. I’ll be talking about physical exam. Most of the times the physical exam saturated with a history, you have to elicit a thorough history. As the patient about the pain location what makes it better or worse. Nighttime pain and then also far associating your vascular symptoms such as weakness, numbness, tingling, prior surgery, if there’s been any injuries, and also you have to take into consideration from the history the patient age and activity level because it factors in to do that decision making.
Also, the history helps you focus the exam because I’m going to go over an exam that contains tests for everything but most of the times from the history you can focus your exam based on that patient history is this the ability to focus on stability. The patient is middle aged and there’s no history of trauma. You’re going to focus more on that rotator cuff and joint. So on a physical exam we have to start with the cervical spine. It’s very common to have shoulder pain with cervical spine problems and it gets missed. So you have to examine the cervical spine then the rest of the exam is very similar to other exams. Even in orthopedic inspection per patient then there will be some specialized testing for the shoulder structures. That’s what I’m going to call for a volunteer and then we’re going to need to examine thoroughly the neurovascular status of the extremity from the shoulder to the hand in the cervical spine.
Got to look for range of motion and Spurling basically how much can the patient rotate the neck up and down. And with Spurling’s What are you looking for, it’s not it’s not just how it aches. You have to have reproduction of pain from the neck down into the arm that the patient says yes this matches my pain because most human beings have some cervical problems, they mostly have some pain in the neck when they move their neck around a little bit particularly middle-aged patient. So you’ve got to have a reproduction of the patient’s symptoms not just ouch. Then on inspection it is critical to expose the patients which is very commonly missed a lot of people don’t make the patient undress and you can miss a lot of stuff.
So particularly for a first-time exam you have to expose the patient. You’ve got to look for the alignment, atrophy, scars, go into human rhythm, an active range of motion. So that he uses an example of malalignment of the shoulder. You can obviously see that the left shoulder is drooping. The clavicle stops there and then the rest of the shoulder girdle falls away from it. That’s how the extra looks it’s like coming into a very displaced clavicle fracture and that’s obvious on physical exam they may even come to you with complaints of shoulder pain and this being maligned and healed in mild union that comes that sometimes appears to be an example of deltoid atrophy from a neurologic injury. Normal deltoid the other deltoid is a trophic you can basically see the greater tuberosity and coracoid right there. Or atrophy of the supraspinatus. That can happen in super scapula nerve injuries that can happen and with partners turner, brachial plexus injuries, or chronic rotator cuff tears. There’s gonna be a side to side difference in that in the bulk of the supraspinatus and basically there’s gonna be indentations. And unless you look at the patient from the back, patients they have like a natural elevation of the arm above the head, when there’s rotator cuff tears or rotator cuff dysfunction what you see is hiking of the scapula.
So the patient will hike the scapula but then the arm will not raise much past that. So that’s why we think that’s when we talk about disrupted humeral rhythm is when this rotator cuff tears or other injuries that make your arm not abducting the glenohumeral joint. you will move the scapula but not the actual glenohumeral joint. Next patient our patient is not very useful in the shoulder it is more useful in other joints such as elbows wrists hands knees but in the shoulder join the most useful structure of the puppet is the AC joint. If there’s tenderness in the AC joint we take that into consideration. The exam we’re going to look for that on the x ray to make sure there’s no Spurs or drives or the AC joint and we want to look for that if we do order an MRI, they’re signaling the AC joint. The rest of the palpation you can pop they’re going the humeral joint. You can pop it at bicep tendon the rotator cuff but the they’re not very helpful tests what is very important is to elicit the patient’s passive range of motion so most patients will come to you with a painful shoulder. Let’s say a rotator cuff tear they’re gonna go I hurt and they don’t want to move past that what you have to do as an examiner is to physically take the arm move it all the way up to see if there’s any limitation on the passing motion. If the glenohumeral joint is intact whether there’s a rotator cuff tear or impingement or a painful rotator cuff there should be full passive motion.
Same thing for all motion planes that should be full external rotation internal rotation if you don’t have full passive motion there’s really only three things are going to cause that there’s gonna be a dislocated shoulder there’s going to be arthritis of the glenohumeral joint. Are you gonna pick up on x rays or it will be a frozen shoulder and that’s really the only thing that gives away frozen shoulder you don’t pick it up on physical on an x rays you don’t pick it up on MRIs. It’s a physical exam assessment there is limitation of passive motion that means you when you go to move the patient’s shoulder it doesn’t move past that whereas the other shoulder moves freely all the way up. Same thing with the rotation if you move them in abduction, one shoulder is gonna move full to 90, the other is just not gonna go past it. So you have to test for passive range of motion. Then I need a volunteer to come up please to show you how we do that specialized testing whoever comes up when you get the benefit that you get to feel how to do that. Anybody.
So we’ll start by examining usually their rotator cuff first. First this is nears and that’s forced Hyperreflexia. You move the arm up and you kind of stabilize the shoulder blade and you tried to bring the rotator cuff into contact with the acromium. And if they have pain what for what is from impingement or rotator cuff tearing. They will report pain with that. This next Hawkin’s and that’s with shoulder forward flex in here would do forced interpretation. And again that makes it tuberosity and the pathologic rotator cuff impinged on the grated on their acromium. Third test is Jobe’s. And that’s the so-called empty can test. You have the patient hold both arm as if they’re holding and emptying a can and then you ask them to resist you. If that elicits pain that’s a positive test. If it’s a torn rotator cuff when you will actually see that the patient not only has pain but they actually give there’s a there’s weakness. For test Yocum You have them put the hand on the counter a lot of shoulder and ask them to resist you if it’s impingement. There’s gonna be pain if it’s a torn rotator cuff that actually give and the arm will fall down then hold them. Far. Far from that.
So for rotator cuff tears that involved the subscript realize there’s three tests. One is called the bear hug. Again, with this in this position before reflection and internal rotation you ask them to push it down and that should be excellent strength if they have weakness in that and you can break it up. That’s usually a subject realized here. There’s also another test for the subscapularis I should call the belly press. If you ask the patient to put the hand on the belly and then use it to bring the elbow forward and the elbow should move to the level of the belly and that should give you good resistance if the elbow gives and moves back or they’re honorable to bring it to the level of the belly. That’s usually a subject last.
Final test for such gap is called the lift off. You have them put the arm behind the back and raise it away from the back and then you ask them to resist you push me away from the body. So there should be resistance if they don’t have resistance in that that means that there’s usually an injury subscap. In bigger subscapularis tear not only is that no resistance just relax your arm what you will do on the lift off is you will move away from the set from the surface from the spine.
And as soon as you let go the arm falls back on their back as usually an interim rotation like that means that there is a subscap tear. For the most frequent rotator cuff tear is being Supraspinatus and infraspinatus. First being out is the most sensitive this is weakness in external rotation. So you have the arm there you have some to resist you and they just don’t have strength it just give and you they also have lag so you passively external rotate slowly and when you let go the arm falls back just a little bit. Sometimes it’s subtle it’s only a few degrees depending on the size of the tear but bigger tears like it will rotate the arm over here and the arm will almost like fall right back into the joint due to the added bottom. Like you should be able to put it here as the patient hold it there the arm should stay there if it doesn’t stay and it lags, that means it’s a torn rotator cuff. And that’s the majority of the test you will be doing for most patients will come in the office with shoulder pain because they involve middle aged people with rotator cuff pain whether it’s impingement or tears the AC joint is a lot simpler and dumber or you’ve got to just put your finger on the AC joint you kind of see the clavicle and you follow the clavicle you puppet the AC joint there’s also a divot in most human beings where the clavicle ends and the between the spine of the scapula that you can feel like a soft spot the.
Joining us right in front of that, join us right there so you just put your fingers on it and tried to see if there’s pain in that days joint and then you can load that that joint with cross arm deduction and they have to report pain directly in the AC joint because a lot of this has to come be positive in other conditions like this cross I mean deduction tests may be positive in rotator cuff tears are impingement they have to report that it’s painful directly in there for that to mean something and know just painful in general. Finally for that bicep and labrum we’ll have a few tests the first is called Speed’s test you put the arm in there playing on the scapula you ask them to hold it up with the arm with the arm should be needed and they resist you if very poor pain that’s a positive test.
O’Brien tests for labral tears you have to put the arm from this position across the chest and ask them to hold it there. They resist you. They will report to whether there’s pain or not. And then the important thing is that you have them. In You rotate the arm. And you see if the pain is worse or it has even a with internal rotation. If the pain is worse with a thumbs down or it is there’s weakness with internal rotation that usually implies that there is a labral tear then we’re going to do it. There are multiple tests for labrum. One how the one that I like a lot does that show the so-called Kim to from my Korean surgeon and Kim you you put the arm in hybrid external rotation until they report pain and usually with labrum because this creates a peel back phenomenon they will report some pain and then you ask them to flex a bicep make a bicep there. And if the pain is worse when they flex the bicep that usually means that there’s a significant injury in the labrum because it puts further stress on the damaged structure. A test looking specifically at the posterior labrum is a so-called jerk test. You’re putting the arm is this position you’re trying to simulate a bench press. You pushing the humerus backward while you’re resisting there and the shoulder blade and you’re trying to trying to grind the human head on the posterior power with the labrum if there’s pain with that you actually have some clicking,
If you feel that. You may have a finger right here actually. Hurting you do. Some cleaning for sure there but that’s how you do that you want to put that in the position and elicit pain.
Then for some patients will come in with a history of dislocation what you’re looking for is apprehension. So for anterior dislocations the shoulder typically pops out until anteriorly and inferiorly when the arm is in this position. To the so-called arthritic or labrul abduction external rotation position you’ll bring the arm in that position and if the patient has apprehension or lack a sense of impending doom or that the shoulders are going to dislocate we’ll call that a positive apprehension test., If you put your arm on the ball the humerus and you push it back in the socket and the report that the apprehension gets better that usually implies that there is the diagnosis of instability is true they report relief in the apprehension. For posterior dislocations the provocative position is that same as the jerk this. Is in forward flexion we push the arm backward and again if they report that they have instability or apprehension, you can relieve the apprehension by putting your hand, put your thumb on the ball of this humerus and pushing it back into socket. And that will relieve their apprehension.
Finally, for patients will come in with instability I like to look for whether they have problems with their quality and in general and the body. And the way to do that is the so-called Beighton’s criteria for generalized ligament laxity. So you’re going to have a patient hyperextend their finger joints and if they extend past 90 that’s considered a positive test. The hyperextend their elbow sleeve extend past neutral. That’s a positive. If they can touch their thumbs through the forearms that’s a positive test. If you have those three positives then that means that they have some sort of generalized ligaments laxity Ehlers-Danlos variance and something of that sort.
We take into decision making whenever we plan for future surgery because they tend to be less successful in humans who have this kind of condition. Thank you very much. And finally, you need to be examining all muscle groups in the upper extremity you’re going to test for shoulder abduction exultation interpretation elbow flexion extension position should the nation reflect an extension and then for the finger’s flexion extension intrinsic sensation.
Just a thought in your muscle exam this are this is a little table that I’m giving you with the most frequent diagnoses that people come into the office that contain shoulder pain and how you really don’t need much past that good physical examination imaging to hour after the correct diagnosis and just a basic physical exam and a good X ray is really all you need. So impingement usually the patient will report a painful range of motion that will have a painful arc particularly in abduction. However, their passive motion will be full. Their strength will be normal. They’re not gonna have an external rotation or interpretation lag and they will have positive impeachment signs, the tests that I told you about. Patients who have a rotator cuff tear similar to an impeachment exam they will have a painful active range of motion.
They’ll typically have full passing motion by they will have weakness in manual muscle testing. They will definitely demonstrate a lag. If you’re a seasoned Examiner You can pick that up and that will have positive impingement signs. A frozen shoulder can be very confusing because unless you specifically test for passive range of motion because they have a painful and limited motion but the key is that they’re passing motion is not for the patient will not have full passive elevation or rotation. Their strength will be normal. They will not have any to be an external rotation lag and typically the impingement signs are positive just because they stretch the inflamed joint now. Notice how this and this are very similar Rotator cuff injuries and cervical radiculopathy of the C5 C6 or the supra scapular but they’re very similar exams have a painful motion but they have a full passive range of motion. There’s weakness they do get they can demonstrate an external rotation like the keys that typically if you have a cervical radiculopathy the patient will report reproduction of the symbols would Sperling’s whereas with our rotator cuff tear there simply will be exacerbated with the impingement signs in ready globally that the impingement signs are not really very painful. They report in pain.
In general, it doesn’t get any worse when you’re doing the impingement signs. So in summary you need to be thorough. Start with a good history including cervical spine doing your vascular exam and then focus your exam on the history to do a good example. The rotator cough AC joined the bicep labor more instability and typically MRI is only useful for surgical planning. You don’t need to start with an MRI. Thank you.