A thorough clinical evaluation of the entire shoulder girdle coupled with a knowledge of relevant anatomy, medical history, clinical tests, and a complete problem focused physical examination can enable a physician to work through the algorithm for diagnosis and treatment of shoulder injury and pain.
Since cervical spine pathology can refer pain to the shoulder and even result in weakness of the shoulder, an examination of the cervical spine, including a motor, sensory and reflex assessment may be necessary. In obtaining a history, the examiner should be aware of other pertinent facts such as general health status, previous injuries and conditions and prior treatments.
Inspection should be from all views and should note muscle mass and tone, deformities, scars, masses, bruising, discoloration and swelling. Inspection of the shoulder requires adequate visualization of the entire upper extremity, shoulder girdle, chest, and back. Instability patterns of the shoulder include anterior, posterior, inferior, and a combination of the 3 referred to as multidirectional. The examiner should then focus on active shoulder motion in forward flexion, abduction, external-internal rotation, and composite motions where the patient places an arm behind the back and then lifts the arm up and externally rotates it as if to throw a ball or to serve. Finally, the examiner should perform a passive cross-arm adduction test, which pinches the subacromion space and is positive with impingement syndromes and also tests the acromioclavicular joint and is positive with acromioclavicular joint pain. Tears should be assessed whether they are partial or complete and can be evaluated by MRI or arthroscopy. The table below demonstrates a stepwise approach for evaluating shoulder pain that begins at the neck, proceeds to the sternoclavicular, acromioclavicular, and scapulothoracic components of the shoulder joint, then focuses on particular anatomic sites, rotator cuff strength, and impingement signs, followed by glenohumeral tests. Patients sent for evaluation with AP and lateral views of the affected shoulder may require additional properly performed views depending on their diagnosis. For example, multiple diagnoses may be made after an athlete has a contact injury to the shoulder. The evaluation is designed to test for the most common causes of shoulder pain in both athletes and nonathletes.
The key to management of the injured or painful shoulder in the athlete is correct diagnosis. When a patient presents with a shoulder injury or pain, it is critical to any treatment that an accurate diagnosis be made. Knowledge of the shoulder anatomy and the patient's pertinent history together with using a stepwise approach to examine shoulder pain, as in the algorithm presented, provides a basis for a complete evaluation of shoulder injury.
The examiner should use a stepwise approach to physical examination of the athlete or patient presenting a complaint of shoulder injury, pain, weakness, or restriction of motion. The examiner then internally rotates the arm, which brings the greater tuberosity, rotator cuff, and biceps tendon under the acromioclavicular arch.
To evaluate anterior apprehension of the left shoulder, the examiner stands behind the patient placing the left hand on the patient's elbow. The first part of the examination is to duplicate active neck motion, which includes flexion-extension (chin on chest, chin all the way up), lateral rotation (chin on left shoulder, chin on right shoulder), and lateral bending (ear on left shoulder, ear on right shoulder). If the passive range of motion is abnormal, results could be indicative of pain (the patient will not adequately relax), a frozen shoulder (adhesive capsulitis) or degenerative changes that would be observed on x-ray.
Begin with the sternoclavicular joint followed by the acromioclavicular joint and then the biceps tendon. The physician should list all positive findings because multiple diagnoses are quite possible. Ability to detect labral signs indicative of a tear is probably the least accurate test for the shoulder. The examiner should look for training errors in the athlete's program or chronic overuse injury.
These structures work together to provide the shoulder complex with multiple degrees of freedom, which allow the upper extremity to be abducted, adducted, rotated, flexed, and extended.
The examiner should inspect muscle tone, symmetry, and deformity, especially at the acromioclavicular and sternoclavicular joints, shoulder, scapula, and clavicle.
The patient’s activity level should be factored into the decision for further diagnostic workup.
The patterns of instability that should be examined include anterior (with apprehension test), posterior (with a posterior drawer), and inferior (by applying a downward pressure on the arm). Alternatively, pain may be a normal adaptation to increasing loads placed on the shoulder as it accommodates new demands.
The biceps tendon is anchored to the superior glenoid via the superior labrum and is commonly referred to as the biceps labral complex. Scapular thoracic rhythm should be assessed from a posterior vantage point with the arms fully abducted. The position of instability by history as well as a physical examination and the component of multidirectional instability should be documented. If a patient has signs of a labral tear with clicking or popping or a positive O'Brien's test, the clinician should try to determine whether the findings are associated with instability, which would have profound implications on type of treatment and recovery time. It should be stressed that repeated physical examinations over time, particularly with highly competitive athletes, are needed to evaluate changing pain patterns, which may highlight the real diagnostic culprit. The physician should understand the role of selective lidocaine and corticosteroid injections to determine and treat subacromial pain syndromes and acromioclavicular joint pain. With increasing external rotation and forward pressure on the humeral head, the patient may express an apprehensive look, try to resist with muscular contractions, or simply state that the shoulder is beginning to dislocate.
The examiner must record the positive findings, using the algorithm, and review the clinical picture of problems with the shoulder, addressing each of them individually.
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