The Exam for Shoulder Pain - Stanford Medicine 25

Summary

Dr. 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

00:00

👩‍⚕️ 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.

05:01

🏥 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.

10:02

🎵 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.

Keywords

💡Clinical Examination

Clinical examination is a systematic approach used by healthcare professionals to assess a patient's health condition through observation, palpation, and specific tests. In the video, Dr. Brenda Christopher conducts a clinical examination focusing on shoulder pain, which includes assessing range of motion, muscle bulk, and functional abnormalities to diagnose potential issues.

💡Range of Movement

Range of movement refers to the extent to which a joint can move through its normal arc without pain or limitation. The video script describes assessing range of movement through various shoulder movements like forward flexion, abduction, and internal and external rotation to identify any abnormalities or restrictions that may indicate shoulder pathology.

💡Cervical Spine

The cervical spine is the upper part of the spine that supports the neck and allows for its movement. In the context of the video, it's important to examine the cervical spine to rule out any pathology that might be causing referred pain to the shoulder, ensuring that the shoulder pain is not originating from the neck.

💡Rotator Cuff

The rotator cuff is a group of muscles and tendons that surround the shoulder joint and are crucial for its stability and movement. The script mentions testing the rotator cuff tendons such as supraspinatus, infraspinatus, teres minor, and subscapularis to diagnose common shoulder pathologies like tears or impingements.

💡Supraspinatus

Supraspinatus is one of the rotator cuff muscles that helps in lifting the arm and stabilizing the shoulder joint. In the video, Dr. Christopher tests the power of the supraspinatus muscle by having the patient resist downward pressure in a specific position to check for weakness or pain.

💡Impingement

Impingement refers to a condition where the rotator cuff tendons get pinched or compressed as they pass through the shoulder's narrow subacromial space. The video describes several tests for impingement, such as the Neer's test, Empty Can test, and Hawkins-Kennedy test, which aim to reproduce symptoms by decreasing the space and impinging the supraspinatus.

💡Adhesive Capsulitis

Adhesive capsulitis, also known as frozen shoulder, is a condition characterized by stiffness and pain in the shoulder joint, with a significant reduction in both active and passive range of movement. The script mentions this condition and its characteristic limitation in external rotation and the presence of muscle spasms or trigger points.

💡Acromioclavicular Pathology

Acromioclavicular pathology involves injuries or conditions affecting the acromioclavicular joint, where the shoulder blade meets the collarbone. The video script describes localized pain over the AC joint, night pain, and the use of specific tests to diagnose this condition.

💡Shoulder Instability

Shoulder instability refers to the looseness or hypermobility of the shoulder joint, which can lead to subluxation or dislocation. The script discusses tests like the sulcus sign and apprehension and relocation test to assess for signs of shoulder instability.

💡Labral Tears

A labral tear is an injury to the labrum, the cartilage ring that deepens the shoulder socket and provides stability. The video mentions tests like the Speed's test and O'Brien's test to diagnose labral tears, which can occur due to dislocations or overhead activities.

💡Scapular Motion

Scapular motion refers to the movement of the shoulder blade during shoulder joint motion. The script emphasizes the importance of observing scapular motion for any asymmetries or abnormalities, which can indicate pathology in the shoulder, such as rotator cuff issues or adhesive capsulitis.

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]

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