The Exam for Shoulder Pain - Stanford Medicine 25
Summary
TLDRDr. Brenda Christopher offers an insightful overview of the clinical examination process for shoulder pain, emphasizing the importance of assessing range of motion and identifying common pathologies such as rotator cuff injuries, impingement, and adhesive capsulitis. She demonstrates various diagnostic tests, including the Speed's, Neer's, and Hawkins-Kennedy tests, and discusses the signs of chronic shoulder instability and labral tears. This comprehensive guide is essential for medical professionals looking to enhance their examination skills.
Takeaways
- 👕 Start by having the patient undress to assess for range of movement limitations or functional abnormalities.
- 🔍 Initial inspection involves looking at the front, side, and back for muscle bulk and asymmetrical bony abnormalities.
- 🌟 Before examining the shoulder, check the cervical spine to ensure the pain is not originating from there.
- 📏 Assess range of movement through various positions like forward flexion, abduction, crossbody adduction, and internal/external rotation.
- 🆚 Compare the range of motion on both sides to identify any discrepancies.
- 👀 Observe the scapula for any asymmetries or abnormal motion during the range of motion tests.
- 💪 Targeted clinical examinations for common shoulder pathologies include tests for the rotator cuff tendons and other structures.
- 🤲 Test the rotator cuff by assessing the power and pain in supraspinatus, infraspinatus, teres minor, and subscapularis.
- 📉 Impingement tests include the Neer's, Empty Can, and Hawkins-Kennedy tests to replicate symptoms of supraspinatus pinching.
- 🤕 Palpation over the anterior joint line can reveal tenderness and subacromial-subdeltoid space issues.
- 🚑 Adhesive capsulitis is indicated by a reduction in both active and passive range of movement, often with scapula motion asymmetry.
- 🤹♂️ Specialized tests for biceps tendon pathology include Speed's and Yergason's tests, assessing for pain and abnormal movement.
- 🛑 Acromioclavicular pathology is diagnosed by localized pain over the AC joint and night pain when rolling over.
- 🔄 The Scarf test and painful arc in abduction are indicative of AC joint issues.
- 👐 Sulcus sign and apprehension relocation test are used to assess for shoulder instability and labral tears or SLAP lesions.
- 🏥 Acute lesions present with anterior joint line fullness and loss of power on resisted movements.
Q & A
What is the first step in the clinical examination of a patient with shoulder pain according to Dr. Brenda Christopher?
-The first step is for the patient to take off their shirt to assess for any limitation of range of movement or functional abnormalities.
Why is it important to examine the cervical spine before conducting a shoulder examination?
-It is important to ensure that no pathology is originating from the cervical spine, confirming that the issue is purely with the shoulder.
What are the different types of movements assessed during the range of movement examination of the shoulder?
-The movements assessed include forward flexion, abduction, crossbody adduction, external rotation, extension, and internal rotation.
What is the purpose of comparing the range of motion of the right and left shoulders during the examination?
-Comparing both sides helps identify any asymmetries that may indicate a problem or pathology in the shoulder.
What is the significance of observing the scapula during the range of motion examination?
-Observing the scapula helps identify any asymmetries or abnormalities in scapular motion, which can indicate a pathology in the front of the shoulder.
Which structures are tested in the rotator cuff examination?
-The rotator cuff examination tests the supraspinatus, infraspinatus, teres minor, and subscapularis tendons.
How is the power of the supraspinatus muscle tested during the clinical examination?
-The power is tested with the patient's arm in 90 degrees of abduction and 30 degrees of forward flexion, pushing down against resistance.
What is the purpose of the 'empty can test' in the rotator cuff examination?
-The 'empty can test' assesses the power of the supraspinatus and infraspinatus muscles by having the patient simulate the action of emptying a can by bringing their thumb to the floor.
What is the 'Gerber's lift-off' test used to assess?
-Gerber's lift-off test is used to assess the integrity of the subscapularis muscle, checking for internal rotation lag sign.
How can the strength of the serratus anterior muscle be assessed?
-The strength of the serratus anterior is assessed by having the patient perform a standing pushup and observing for any winging of the scapula.
What are the three specialist tests for shoulder impingement mentioned in the script?
-The three specialist tests for impingement are the Neer's test, the Empty can test, and the Hawkins-Kennedy test.
What is the purpose of palpation over the anterior joint line in patients with impingement?
-Palpation over the anterior joint line is useful to check for tenderness and to reveal the subacromial and subdeltoid space, which can be affected in patients with impingement.
What are the Jurgis and Speed's tests used to assess?
-Jurgis test assesses the biceps tendon with resisted supination, while Speed's test evaluates it with resisted forward flexion, both checking for pain or abnormalities.
How is adhesive capsulitis typically presented in terms of range of movement?
-Adhesive capsulitis usually presents with a reduction in both active and passive range of movement, with external rotation being the first to be affected.
What is the purpose of the sulcus sign test for assessing shoulder instability?
-The sulcus sign test assesses for shoulder instability by applying a downward force on the humerus and looking for a sulcus or gap that appears over the lateral deltoid region.
What is the apprehension and relocation test used to assess?
-The apprehension and relocation test is used to assess shoulder instability by applying downward pressure and observing if it causes pain or discomfort, which then decreases with relocation.
What are the common tests for labral tears or SLAP lesions?
-The common tests for labral tears or SLAP lesions are the Speed's test, O'Brien's test, and the Crank test.
How can acute lesions in the shoulder be identified during clinical examination?
-Acute lesions can be identified by the presence of anterior joint line fullness and a loss of power on resisted movements.
Outlines
👩⚕️ Clinical Examination of Shoulder Pain
Dr. Brenda Christopher, a sports and exercise medicine physician, introduces a clinical examination process for patients with shoulder pain. The examination begins with a visual assessment of the patient's range of movement and functional abnormalities, including muscle bulk and bony asymmetries. It's recommended to check the cervical spine to rule out non-shoulder related pathologies. The physician demonstrates how to assess the range of motion through various movements and compares both shoulders for any discrepancies. The importance of observing scapular motion for potential front shoulder pathologies is emphasized. The video then proceeds to targeted clinical examinations for common shoulder pathologies, starting with the rotator cuff, which includes testing the supraspinatus, infraspinatus, teres minor, and subscapularis muscles. The anatomy of the scapula is briefly explained to understand the tests better. Specific tests for the rotator cuff are detailed, such as the empty can test and Gerber's lift-off test, as well as the assessment of the serratus anterior muscle.
🏥 Advanced Shoulder Pathology Tests and Diagnosis
This section delves into specialized tests for shoulder impingement, which involves the pinching of the supraspinatus tendon. Three tests are highlighted: Neer's test, the empty can test (already discussed in the previous paragraph), and the Hawkins-Kennedy test, each aiming to replicate symptoms by reducing space and pinching the supraspinatus. The script also mentions palpation over the anterior joint line to detect tenderness and assess the subacromial-subdeltoid space. Tests for biceps tendon pathology, such as Speed's and Yergason's tests, are described, along with adhesive capsulitis, characterized by reduced range of movement and scapular motion asymmetry. Acromioclavicular pathology is discussed, with the scarf test and painful arc in abduction as diagnostic tools. The script touches on chronic shoulder instability, with the sulcus sign and apprehension and relocation tests as assessment methods. Labral tears or SLAP lesions are identified through the Speed's test, O'Brien's test, and the crank test. Finally, acute lesions are characterized by joint line fullness and loss of power on resisted movements.
🎵 Closing and Copyright Notice
The video concludes with a thank you to the patient and viewers for their patience, followed by an invitation to visit the website for further videos on shoulder joint examination. A copyright notice is provided, indicating that the program is copyrighted by the Board of Trustees of Leland Stanford Junior University, with a prompt to visit the university's medical department website for more information.
Mindmap
Keywords
💡Clinical Examination
💡Range of Movement
💡Cervical Spine
💡Rotator Cuff
💡Supraspinatus
💡Impingement
💡Adhesive Capsulitis
💡Acromioclavicular Pathology
💡Shoulder Instability
💡Labral Tears
💡Scapular Motion
Highlights
Introduction to clinical examination for shoulder pain by Dr. Brenda Christopher.
Importance of assessing range of movement and functional abnormalities in shoulder examination.
General inspection for muscle bulk and bony abnormalities to identify asymmetries.
Cervical spine examination to rule out pathology originating from the spine.
Assessment of shoulder range of movement including forward flexion, abduction, and crossbody adduction.
Observation of scapula and scapular motion for asymmetries indicating potential pathology.
Targeted clinical examinations for common shoulder pathologies.
Anatomy of the scapula and its relevance to rotator cuff tendon testing.
Testing of supraspinatus power and pain assessment in a specific shoulder position.
Empty can test for rotator cuff pathology and its method.
Testing infraspinatus and teres minor integrity through resisted accident orientation.
Subscapularis test for internal rotation lag sign and power assessment with Gerber's liftoff.
Assessment of serratus anterior strength through a standing pushup test.
Difference in presentation of rotator cuff pathologies between younger and older patients.
Specialist tests for shoulder impingement syndrome and their methodology.
Palpation techniques for identifying tenderness and revealing subacromial space.
Tests for biceps tendon appa including Speed's and Yergason's tests.
Adhesive capsulitis diagnosis through range of movement assessment and muscle spasms.
Acromioclavicular pathology diagnosis through localized pain and night pain assessment.
Scarf test and painful arc in abduction for AC joint assessment.
Chronic shoulder instability assessment with the sulcus sign and apprehension relocation test.
Labral tears or SLAP lesions assessment through Speed's, O'Brien's, and Cranks tests.
Acute lesions diagnosis through anterior joint line fullness and resisted movement power loss.
Conclusion and invitation to visit the website for further educational videos.
Transcripts
[Music]
hello my name is dr. Brenda Christopher
I'm a sports and exercise medicine
physician today I'll be talking to you
about the clinical examination of a
patient who presents with shoulder pain
the clinical examination starts with the
patient taking their shirt off because
here I can assess for a limitation of
range of movement or any functional
abnormalities I start with a general
inspection of the front the side and the
back and here I'm looking at muscle bulk
any bony abnormalities which are
asymmetrical before I conduct a shoulder
examination it's best practice to do an
examination of the cervical spine to
ensure that no pathology is originating
from there and it's purely shoulder so
we assess range of movement by forward
flexion abduction all the way up to the
top
crossbody adduction external rotation
and then if I can position your side on
for extension and then turn around to
the back for internal rotation and I
compare right to left it's good practice
to get the patient to repeat the full
range of motion whilst you observe the
scapula and you look for any asymmetries
and scapular motion so an abnormality or
an asymmetry in scapular rhythm can
often mean that there's a pathology in
the front of the shoulder so next I'm
going to show you targeted clinical
examinations of the shoulder joint for
the most common pathologies I will start
with the rotator cuff as it is the most
common diagnosis we will test the for
rotator cuff tendons supraspinatus
infraspinatus teres minor and
subscapularis so it's useful to know the
anatomy of the scapula with the spine
dividing the supraspinatus fossa and the
infraspinatus fossa the supraspinatus
tendon and muscle bellies originated in
the fossa here and then worked their way
around to the anterior aspect of the
shoulder and the inferior infraspinatus
muscle belly lies here to test
supraspinatus i get them in ninety
degrees of abduction and thirty degrees
of forward flexion and this is in the
scapular plane here I test for power of
supraspinatus by pushing down and I make
sure the right side is equal to the left
and I'm also asking the patient for any
pain then I get the patient to simulate
emptying a can by bringing their thumb
to the floor and I can assess power
again
and Oscar payn and can you play trans
like this and then externally rotate so
next I test the integrity of
infraspinatus and teres minor by
resisting accident orientation and I ask
for pain or a noted loss of power or any
asymmetry this is a test for
subscapularis where you place the hand
in this position and if the patient can
maintain this position that's normal if
there's a internal rotation lag sign the
patient's hand will drop towards the
back I can also assess for power with
Gerber's liftoff where I ask the patient
to resist my downward motion even though
serratus anterior is not strictly a
rotator cuff tendon I assess the
strength of this by asking the patient
to do a standing pushup
and if you can visualize any winging of
the scapula serratus anterior weakness
is present younger patients will
complain of an Associated trauma with
their rotator cuff pathologies and this
is in contrast to the older patient
where there'll be a gradual onset of
shoulder pain and no associated trauma
the next pathology is impingement and
this represents a pinching of
supraspinatus there are three specialist
tests for impingement the first one is
nares where I ask the patient to fully
internally rotate the arm and passively
flex the shoulder joint this should
decrease the space and impinge on the
supraspinatus and it should replicate
any symptoms such as pain the second
test is a test that we've already
carried out for rotator cuff pathology
it's empty cams test and that is again
reducing the space here and if this
elicits pain it's consistent with signs
of impingement so the final test is the
hawkins kennedy test where there's an
element of internal rotation and cross
body adduction and it's here that I'm
trying to pinch the supraspinatus
and calls pain palpation over the
anterior joint line is useful if it's
tender and then also to reveal the
subacromial sub deltoid space you can
ask the patient to bring their hand in
this position and then feel over the
anterior joint line again so patients
who have impingement can also have
scapula movement asymmetries there are
two specialist tests jurgis ins and
speeds for biceps tendon appa 'they
speeds is resisted forward flexion and
note that i'm bauer painting the biceps
tendon as I do this I'm asking for any
pain jurgis ins is resisted supination I
ask the patient to hold my hand or shake
my hand and again I palpate over the
origin and the insertion the biceps
tendon adhesive capsulitis usually is
shown by a reduction in range of
movement both actively and passively
external rotation is usually the first
range of movement to be effected with
adhesive capsulitis you often notice an
asymmetry of scapula motion secondary to
the limitation of the range of movement
in the glenohumeral joint it's useful to
note that many patients might have
muscle spasms or trigger points within
the trapezius in adhesive capsulitis in
the initial stages of adhesive
capsulitis there's a painful range of
movement later on in the disease there's
a restricted range of movement
acromioclavicular pathology is probably
the easiest diagnosis to make when
examining the shoulder joint those often
localized pain over the AC joint and the
patient will point directly to this the
patient can complain of night pain when
they roll over to the affected shoulder
because this loads the acj locate the AC
joint and feel for a step-off deformity
also assess for any crepitus or pain the
scarf test is a specialist test which
compresses the space where I force
crossbody adduction whilst palpating the
joint a positive test is pain or
crepitus there will also be a painful
arc in a duction in the 150 to 180
degrees of abduction so the last 30
degrees of motion signs of chronic
shoulder instability which represents
subluxation or hyper laxity of the
shoulder joint can be assessed with the
sulcus sign and here I'm applying a
downward force of the humerus and I'm
looking for a sulcus that will appear
over the lateral deltoid region another
way to assess shoulder instability is by
the apprehension and relocation test
assimilating a dislocation
I applied downward pressure with a
fulcrum with my fist under the posterior
aspect of the shoulder if this causes
any pain or discomfort I then apply a
downward pressure which should hopefully
reach all the patients and the pain goes
away labral tears or slap lesions are
commonly seen in athletes may be a
consequence of dislocations or are often
seen in motor vehicle accidents when the
arm is in the overhead position so the
first test of the slap lesion is the
speeds test which is the same test that
we did for the biceps tendon appa the--
this is because the biceps inserts at
the superior edge of the labrum
O'Brien's test is resistance to me when
I press down
and if that's positive it should cause
pain and the final test is cranks test
where I'm internally and externally
rotating the shoulder trying to cause
pain whilst also palpating four clunks
acute lesions usually present with an
anterior joint line fullness and you can
also see a loss of power on resisted
movements Thank You chair for being
patient today thank you for watching
this done for 25 examination of the
shoulder joint please visit our website
and subscribe to further videos the
preceding program is copyrighted by the
Board of Trustees of the Leland Stanford
junior University please visit us at
med.stanford.edu
[Music]
[Music]
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