The Stanford 25

An Initiative to Revive the Culture of Bedside Medicine

Shoulder Exam

In addition to teaching and attending, Doctor Mark Genovese is involved in research including clinical trials and interventions in rheumatic diseases such as rheumatoid arthritis, psoriatic arthritis, & osteoarthritis. In the video below, he demonstrates examination of the shoulder in the notes, he provides several clinical pearls.

 

 

Introduction: Careful examination of the shoulder can provide valuable information and help the physician determine when imagine studies may or may not be helpful.

Technique:

  • Unique aspects of the history include: +/- past trauma, occupational hazards, repetitive shoulder use, inflammatory disease, fibromyalgia, infection, and previous cervical disease.
  • Inspection: Observe both shoulders together. Note any atrophy or asymmetry.
    • With patient sitting up, put both shoulders through full range of motion actively and passively.
    • With patient sitting up, palpate shoulder:
      • Exert pressure on the subacromial bursa, which lies lateral to and beneath the acromion. Subacromial bursitis is a common cause of shoulder pain.
      • Palpate the bicipital tendon in the biciptial groove as the patient rotates the humerus internally and externally. Tenderness on this maneuver is consistent with bicipital tendinitis.
      • Palpate the acromioclavicular joint. Note tenderness, bony hypertrophy, or (rarely) synovial swelling.
        • OA & RA often affect the acromioclavicular joint; however, OA rarely involves the glenohumeral joint (exceptions include traumatic or occupational causes of shoulder pain).
      • Palpate the glenohumeral joint by placing the thumb over the humeral head (medial and inferior to the coracoid process) while the patient rotates the humerus internally and externally.
        • Tenderness is indicative of glenohumeral pathology.
      • Very rarely a synovial effusion can be palpated. If appreciated, it may indicate RA, infection, or acute rotator cuff tear.
  • Suspect fibromyalgia when glenohumeral pain accompanies diffuse periarticular pain and point tenderness.
  • Rotator cuff pathology is a common cause of shoulder pain.
    • Suspect rotator cuff pathology if 1) pain is elicited by active abduction but not passive abduction, 2) pain is located over the lateral deltoid. 3) presence of night pain, 4) a positive ‘impingement sign,” 5) a positive ‘drop arm test.”
      • Impingement sign: Physician raises patient arm into forced flexion while stabilizing the scapula and so preventing its rotation.  Pain developing before 180° of forward flexion is considered positive.
      • Drop Arm Test: Ask patient raise arm to 90° of abduction and lower it slowly. A suddenly dropped arm is considered positive.
    • Tendinitis or tear of the rotator cuff can be confirmed by MRI or ultrasound.

Further Reading:

Luime J.J., Verhagen A.P., “Does This Patient Have an Instability of the Shoulder or Labrum Lesion?” JAMA. 2004;292:1989-1999.

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Written by stanford25admin

June 7, 2010 at 3:55 pm

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