Primary care visits for shoulder issues are an everyday occurrence, yet diagnosis can be challenging due to the joint’s complicated anatomy and the numerous possible causes of pain – some unrelated to the shoulder. In this video, orthopedic surgeon Justin Krogue, MD, helps PCPs efficiently assess the complaint, with tips on how patients typically describe specific injuries, valuable questions for history-taking, and simple hands-on tests to perform in the exam room.
I'm Justin Kroeger, as Michelle said, I'm a general orthopedist here at UCSF. I'm primarily based at uh Redwood Shores. We have a new location in Redwood City, as you may know. Um, and then I do surgeries in San Francisco. Um, I actually have an interesting practice where I, I, I also do halftime at Google, I'm working for, um, their, um, Health AI division doing research in medical technology, but Um, happy to talk about that as well. Today, I was gonna talk about the, the painful shoulder. This is something I'm sure you see tons of and I'm sure you're all experts in, so I apologize for what's largely gonna be, I'm sure, just, um, a review, but hopefully there's gonna be a few nuggets in here that's useful. Um, I certainly love the shoulder, so, um, if anything, I guess I'll, I'll, I'll enjoy the presentation. Um, but hopefully, there are some parts here that are, um, useful for you all as well. So, you know, I talk about the shoulder? Well, for one, I think that, um, The shoulder is interesting in that it seems to capture a right weigh heavily on kind of the imagination of people generally. I was looking through, as I was preparing for this talk, thinking about all the different ways that we use shoulder, right, in a metaphorical sense. And um I found just 5 or 6 examples here. So here's, you know, talking about shoulders as an example of like a metaphor for strength. Here is a, you know, well-known quote by Isaac Newton that kind of um refers to shoulders as almost like the, you know, the heights reached by somebody, uh, metaphorically. Um, here's, you know, leaning on a, a, a kind shoulder, right? Someone that can support you and offer emotional help for that perhaps. Um, this is referring to, you know, chip on your shoulder as, um, obviously, that you have an attitude or you're maybe a little bit more abrasive. And then this is a um classic reference to a cold shoulder where you're maybe, you know, not very kind to someone else. So, so for some reason, I feel like at least amongst MSK body parts, there aren't many other um There aren't many other places around the body that have as much, I feel like, um, use in metaphorical, uh, as much metaphorical use as the shoulders. You don't see the knee or the hip or the ankle, um, talked about in this many different ways, um, which is interesting. The other reason for talking about the shoulders, I think I've always found it, um, personally very challenging. I think it's a very common region that people have complaints, as you all know. The prevalence of shoulder pain is between 16 and 26%, so about 1 in 5 people, um, at any given time will have shoulder issues. Third most common cause of MSK consultation in primary care. Um, it's also very tough, I think, so it's very common, but unfortunately, the shoulder as opposed to some other body parts, for example, would be the knee. Um, it's actually a pretty complex region with a lot of different anatomy contained therein, and it's always, it's not always immediately clear what the patient is referring to. In addition, it's also one of the most common places where, um, there are other things, not even in that, you know, again, relatively complex anatomical area that can cause pain in that area if that makes sense. So you have the double problem of trying to, for one, disentangle a relatively complicated. Portion of anatomy and then also understanding that there's, you know, neck and heart and other issues that can cause pain that don't even originate in this complicated portion of anatomy. So, I want to break it down by um talking about the anatomy a little bit, the his uh history of physical, and then a real just basic um touch on imaging to figure out how we can perhaps approach the shoulder in a more systematic way and more reliably by the end of our examination come to a pretty useful or come to a pretty um defined differential in terms of what's causing this patient's issues. So in terms of anatomy, when a patient says they have shoulder pain, I like to think about this. For me, at least, I think when someone says they have shoulder pain, they could really mean anywhere from between essentially the sternoclavicular joint to the uh mid-humerus, uh, it's painful. And within that, right, there's a lot of different uh anatomy that is contained. And so the first step of any, you know, history obviously is actually honing in on where exactly are they actually hurting. Um, and what do we think is likely involved? And I know for me personally at least, I oftentimes even get to the exam before I realize, oh, actually I haven't even honed in on where this patient actually is having pain and therefore my exam feels, you know, unguided and, and perhaps um not focused. So it's always good with the history to kinda hone in on that. So for the bones, right, obviously you have the clavicle, you have several joints, uh, most of which are, um, synovial joints, and then you have one that's just an articulation, but you have the AC joint, you have the glenohumeral joint, um, and you have the sternoclavicular joint, although that perhaps is maybe more chest than shoulder, but still in kind of the same shoulder girdle, and then you have the scapulothoracic, um, you know, interface, not, not a true synovial joint, but the interface between the ribs. Um, the scapula. These are kind of the joints right in the bones that are involved, um, in the area of the shoulder. And then for the kind of muscular, muscular anatomy, there's a lot, right? There's the, obviously the rotator cuff we all know about, the four muscles of the rotator cuff are, you know, classic shoulder complaints. But there's also all of the kind of periscapular musculature and also the um paraspinal musculature. So things like the deltoid, biceps, trapezius, pec major. Um, and then the things in the, in the back of the scapula like the rhohomboids, um, we also have the serratus anterior, latissimus dorsi, the teres major. These are all things that can hurt, right? And these are all, perhaps some of these actually can have You know, there are, there are well-defined syndromes if you will, well, well-defined presentations that we talk about a lot like a superior cuff tear that we have all these exam findings that we think about all the time, but it's possible to have strains and pains in any of these muscles and so sometimes things just don't fit a typical pattern because they have, you know, they've strained their latissimus dorsi, right? And that's just a, you know, that can happen, that can any of these muscles can become strained and so it's important to keep those kinds of things in mind as well. And then there's the masqueraders, right? So we already talked about there's all these muscles, there's all these bones. Um, in this area, there's a few joints, but there's also really, really solid, um, um, masqueraders for this problem. So in case of the neck, right, there are two entities that really cause shoulder issues that come from the neck. One is radiculopathy. I think it's we think about first and foremost, when we think about neck cause, you know, neck. Um, Neck or originating from the neck shoulder pain and that's obviously we have a, a nerve that's pinched typically in a, in an area of arthritis, um, causing pain radiating down the arm. Um, but the other one that we don't think about as much, I don't think is, um, facetogenic pain. So you have in the posterior elements of the spine with arthritis, you likely have some facet arthropathy. And those facet joints are not, um, but they are innervated, right? But in, in, in similar fashion to a lot of deep structures in the body, right? They, um, we feel this in a very vague fashion. So these are on the left showing kind of the, the dermatomes or sclerotomes in which you feel, um, pain from different facet joints, and you can see, especially C4-5, C5-6, and C6-7 really kind of lay perfectly on the posterior aspect of the shoulder. So very, very common when people come in with posterior shoulder pain. Um, that it can actually be an issue just arth, you know, not even a pinched nerve, just arthritis of the neck and something to keep in mind for sure. And then there's, you know, things that you all know much more about than I do, um, but for example, uh, we all know that, you know, heart attacks can radiate to the, um, to the arm or to the shoulder, and then, you know, panos tumor showed here on the x-ray obviously would cause some shoulder pain as well. Other weird things would be like brachial plexopathies and, um, uh, other, you know, rare entities, you know, perhaps, perhaps more rare than, than common but still things to, to keep in mind for sure. So when you think about the, the differential from the start, right, of a, a shoulder issue, I break it down into intrinsic and extrinsic. And intrinsic here, I've kind of listed just the most common ones, but AC joints, a very common issue or cause of pain, rotator cuff, glunohumeral joint, um, biceps tendon, um, specifically the long head that originates in the shoulder joint. Infection and fracture. And then for extrinsic causes, I think about referred pain, um, certainly nerve as we've talked about, or neck in terms of facet arthropathy, um, cardiovascular, and then diaphragmatic, and then there's also things like, you know, polymyalgia rheumatica or malignancy that can, um, cause pain in the shoulder. So, having said that and kind of broaden our differential to include a lot of different things and distinct entities, it is important to remember what's most common and the four most common causes of pain, um, in primary care, at least according to this paper, are rotator cuff disorders, glenohumeral disorders, acromioclavicular joint disease, and referred neck pain. And in my practice, I think that anecdotally this is very true. I think you see rotator cuff a lot. I think you see glenohumeral joint, um, arthritis, rotator cuff arthropathy, um, a lot. You see AC joint arthropathy a lot and certainly you see a lot of referred neck pain. In fact, I, that's something I see amongst the most common things I see. I think on top of that, I would throw in biceps tendon pathology is another very, very common thing that you see and I, you know, I don't have exact numbers to peg this down, but I would guess that, guess that 90, 95% of patients with shoulder pain. May, um, um, belong to one of those categories, etiologies. So starting off with the history, I think actually as opposed to some body systems or at least musculoskeletal locations, I think the shoulder is an area where you really can make a lot, a lot, a lot of progress with the history and I think it's key because the shoulder exam has so many different kind of special tests and um um provocative maneuvers that you can do that if you don't go into the exam having a pretty good idea of where this problem is and maybe even what it is. I think it can be hard to know how to kind of focus that exam. Either it takes really long or it just feels very unfocused. So the history is really critical and so anytime you have an upper extremity complaint, I think hand dominance is actually really important to, to get at. It, it may give you a sense of etiology of pain for sure in terms of is this something that's been used a lot, but certainly gives you a, a good sense of the impact that this problem has, right? A Um, a problem in the dominant shoulder is much different than a problem in the non-dominant shoulder. Additionally, though, you know, the occupation is similar, um, and it's importance. It's just telling you both maybe the ideology but also the impact that this thing may have, you know, a dominant, um, A painful lesion in the dominant shoulder of a, of a, of a laborer, right, is a much different thing than a, a non-dominant shoulder of a software engineer in terms of its impact on life. Um, location I think is actually one of the, you know, I have, I have a lot of things listed here in history, but, um, location here is bolded and I think that's, that, that is intentional because location is actually really critical. You can get a lot just from the location of pain, um, specifically here I've highlighted that posterior pain is rarely intrinsic, so if they have posterior shoulder pain, um, right away I begin thinking about, you know, non-shoulder organic causes of pain, including, as mentioned before, facetogenic neck pain. And other causes, but rarely is that from the shoulder, you know, itself in terms of the bones and anatomy of the, or, uh, muscles of the shoulder. Um, onset's important, um, both, you know, how it came on and how quickly it came on, its course, whether there's night pain, pain with positions, pain with use in certain areas, whether there's weakness, loss of range of motion. Obviously, the typical things like provoking, alleviating factors. Um, whether or not there's any systemic symptoms or pain with other locations or, you know what, in terms of provoking factors, right, whether this pain is provoked by moving the shoulder or perhaps moving other things, right? If they have pain in the back of their shoulder and it's provoked with certain neck positions, that certainly clues you in right away that maybe it's not from the neck. And then, um, obviously a focused past medical history can be useful as well. So honing in on specific are some of those most common diagnosis and what the history might look like. So when you look at the AC joint, um, this might, this can happen anywhere from adolescence to middle age, um, really pretty broad range of ages, you see this? And you know, this is very simple, but they will have, um, pain in their AC joint, and if that's their complaint, that's a pretty specific spot so that's something on history that you can really hone in on. They have anterior pain and they'll point right to that kind of bump at the front of the shoulder. Um, rotator cuff can be, you know, get in age from young in the case of a traumatic tear perhaps to the elderly in case of degenerative tearing. And this is pretty classic, um, classically presents with anterior lateral pain, so pain kind of in the front and the side of the shoulder, difficulty with overhead activities, difficulty sleeping on that side, and then they will describe often both a weakness and also a loss of range of motion, so they can't move it as much and they're also weak. Glennohumeral arthritis, another very common cause of pain. is described as kind of a deep pain. It's hard to localize as opposed to like AC joint pain, which is pretty easy to localize. Um, this is often felt though, you know, anterior and posterior. This is one exception to that, you know, posterior pain is rarely, um, shoulder in origin. Arthritis can certainly cause posterior joint pain, so you can have that with arthritis and then loss of range of motion and, and critically with glenohumeral arthritis as well, you have that insidious onset that this has been going on for a year, more than a year, no specific trauma. And that came on. Um, other common things that we see, adhesive capsulitis. Obviously, this presents with a loss of range of motion. Pain is more of a minor component in this, um, scenario, though it still can be very painful, as you know. Um, and then for range of motion specifically, they see external rotation is typically the first and most, uh, profoundly impacted direction. And one thing that's interesting is if you really dig into the history, you often will uncover in the case of adhesive capsulitis, some kind of trauma and, and it may be incredibly minor like even just a fall or a prolonged immobilization, um, but they often can remember. So you may think, well, it's minor, you're just kind of reaching and it's confirmation bias. You have this diagnosis, you, you suspect, you find some minor trauma, but these are traumas I do remember. They'll be 6 months out and have this pain, like, oh yeah, you know, 6 months ago I fell on my shoulder. Um, And obviously there was no fracture, there was no tear or anything, but it's something that is enough to remember but not enough necessarily to prompt medical evaluation, but that is certainly a big clue in your history that that could be what's going on. Um, biceps tendonitis, kind of like AC joint, you're gonna have pretty well localized pain right at the front of the shoulder, and then you're gonna have things in which you're using kind of forearm supination are gonna provoke pain. Things like opening cans and jars, sometimes working overhead, depending on the positions can cause that pain, but it's right in the front of the shoulder, um, kind of specifically where that biceps tendon is. And then as mentioned before, posterior shoulder blade or pain radiating down the arm, you think of neck. And certainly in the case of, you know, patients are not, you know, they don't read the textbooks right, they don't know how to describe their pain perfectly, and they often with rotator cuff, for example, say, you know, it hurts here to here, so it does, there is some radiation, but if it does radiate past the elbow, that is pretty, um, you know, classically we say that is not from the shoulder. If it radiates past the, the elbow, that, that, that should not happen. Now obviously there are cases where that's still is a diagnosis, but in general, if it's radiating beyond the, the elbow, you, you should think, um, primarily about radiculopathy. As a cost. So for physical examination, now you've got a history, hopefully from that you, you may not have an exact diagnosis, you still have a differential, but you hopefully now know in terms of the anatomical location like what you're really thinking about, right? Is it, is it clavicle, AC joint, glen humeral joint, proximal humerus? Is it this particular muscle group? You're kinda honed in and then you can focus your exam again, doing somewhat general exam but focusing on what you think the actual problem is. So with the shoulder in particular, we do start with the visual, visual inspection. Um, and it is, um, nice if the patient has, uh, either undergarments or is comfortable and get him in a gown and actually take a look, um, visually at the, the shoulder musculature cause you can actually tell a lot, um, just from comparing the symmetry from the normal, um, to the affected side. Um, so I would look at the, I inspect both sides looking for symmetrical bulk, um, on both sides. Then you go into palpation, palpating the things, we'll talk a bit more specifically about this. Um, then I do range of motion testing, active first and then if active is full, clearly passive is full, don't have to do that, but if if active is not full, then you would do passive range of motion and we'll talk about why that's important. Then strength testing typically always including the rotator cuff, potentially including other things depending on your suspicion. For example, if you had a neck issue, you would want to test just the myoomal groups of the shoulder like the deltoid, biceps, triceps, wrist extensors, all those. And then there's a special test which you'll include on a variable basis based on what you think um potentially is going on. So for inspection, I remove their shirt, um, I would take a look on both sides. Some things are very obvious, so on the top, obviously you see the Popeye deformity of a proximal biceps tendon tear. Um, and on the bottom you can see, um, a sprung clavicle right from a, a high-grade AC, um, separation. And then I would do, you know, but it's important to be systematic and look at the bulk of the musculature. These are obviously two, you know, very obvious examples and maybe somewhat uncommon, but even with more subtle things like rotator cuff tear or um glenic humor arthritis, you often will notice a difference between the affected and the unaffected shoulder just because of disuse, um, pain with use that leads to the patient doing less, right, and then leads to less musculature muscle bulk. And then there are specific changes you might see, um, Specifically in the back of the shoulder in terms of bulk of the um supraspinatus versus infraspinatus that could pull you off of the more rare things like nerve entrapments. Um, get more rare but also the inspection can actually nail the diagnosis almost on its own at times with those. So inspection is a good place to start and not to forget for sure with the shoulder exam. For palpation, I'll typically be behind the patient at this point. I've looked at their shoulders and then I'll, you know, let them know I'm gonna touch them and I'll put my finger on the clavicle and walk the clavicle to the AC joint. Um, that's a classic spot of pain, so I'll make sure and ask when I touch there if it causes pain or I'll also ask, is this where your pain is when you do feel it if my touch doesn't provoke it. Um, then when you go just lateral to the AC joint, it'll be on the acromion. That can be a source of pain as well and things like an osteoacromiale where you have an unused, um, Acromial ossification center, um, and then I'll walk right off the side of the acromion. If you do that, you can feel the edge of the acromion and it'll be right on top of the proximal humerus, and that's a common spot, um, to have a rotator cuff tear. So pain at that kind of superior cuff site is a, um, with, with palpation is a good indicator that that could be what's going on. Additionally, you'll, if, if you do this a lot, you'll get a good sense actually when they have a really large rotator cuff tear. And you feel right after the acromion in that same spot, you can get a pretty good sense um of how much coverage that humeral head has. So if they have a very large rotator cuff tear, for example, and especially if one side is normal, one side is not, you can feel actually, um, you know, the humeral head would be much more prominent with much less soft tissue coverage than on the other side where you might feel kind of a, a, a healthy muscle bulk surrounding the shoulder. It's obviously a, a just a feel thing, but um, If you do a lot of these, I'm sure you do, you definitely can get there where you feel, you can get a sense for how much soft tissue is surrounding the humeral head. The biceps tendon is a very important one to, to palpate. You can basically from behind, you can do it from behind or front, but behind is I think easiest and you just kind of roll that tendon under your finger and you can feel that essentially in every single person, um, no matter how large you can, uh, I guess I shouldn't say always, but almost, almost always you can feel that biceps tendon, and that is a, again a very common cause of pain and actually, um, a huge help in diagnosis is that, you know, you can touch right there and they have either that provokes pain. Um, or it, uh, reproduces exactly where their pain is. That certainly helps a lot. And that always does cause some pain, so I do that always at the same time as the other shoulder to make sure that it's actually causing more pain than is normal. Um, and then also the anterior and posterior joint lines. So start at the clavicle, go to the AC joint, the acromion, off to the, um, off to the superior cuff and the proximate humerus, then to the anterior biceps. And then kind of feeling both the anterior and posterior joint lines. Once you finished with inspection and palpation, you can move to range of motion. So there's kind of 4, you know, there's a lot of different ways to test the shoulder, um, because it is so mobile you can test different motions in different positions. But in general, I think there are 4 kind of main arcs to do that work well for most patients, and that is for flexion all the way up, um, abduction all the way to the side all the way up, you know, external rotation at the side. You can also do this, um, at 90 degrees. It doesn't add a lot of value, so doing it at the side is totally fine. And then internal rotation is the, you know, the one that's a little more complicated just because it's hard to test at the side cause your belly gets in the way. So the way most people do this is just see how far up their back they can go, um, and that gives you a sense of how much they can internally rotate. Um, and these are some of the normal values. So most people, you know, normal quote unquote should be able to get almost 180 degrees both in forward flexion. An abduction, you can see I have slash 90 there in abduction. That's because really you're getting 90 degrees of glenohumeral abduction, and the other 90 degrees or so comes from the scapulothoracic, um. Um, interface. So if you actually stabilize the scapula, have them raise their arm up, they'll get a little above 90, um, potentially with glenohumeral joint, but then the rest of that motion actually comes from the scapula coming up. Um, and then for internal rotation we kind of measure as mentioned with the, the amount, the number, uh, or where they reach in terms of the thoracic vertebrae and here it's just a, you know, best estimate based on, you know, the landmarks that, that you know in terms of, um, where things are located. So if their active range of motion is OK, then you know their passive will be fine tuned, you can move on, but if the active is not OK, then check the passive motion in the same planes. With the same maneuvers just if you yourself doing it. Um, if passive, if active is bad, but passive is OK, you can think about a rotator cuff tear, that's a, um, a Probably the most common or most likely etiology of issues if that's the case. If they're both bad, right, then you think about frozen shoulder for sure or arthritis, and now they have not just a, you know, an active limitation how far they can move because of some weakness, but the shoulder joint itself is contracted and that could be from, as mentioned, frozen shoulder, arthritis. It could also be from a long-standing rotator cuff tear, right, if they haven't had therapy or haven't moved that shoulder in a long time, they could certainly also develop A contracture. But even in that case, typically still, the active loss will be worse than the passive loss. Whereas in frozen shoulder and arthritis, you expect those both to be about the same. Um, other range of motion testing as you're doing this, especially with kind of that forward flexion motion, um, as they're coming down, you can assess either for a painful arc and or for a drop arm. So painful arc is that as they kind of lower their shoulder, raise it or lower it in between 60 and 120 degrees, they have some pain, and then drop arm obviously as a, as they're actively lowering their arm in that same range, they actually have a painful drop. They're unable to keep it up themselves. But both of these are actually relatively um um. Sensitive, you know, these are all moderate in, in their performance, but these are relatively sensitive tests for rotator cuff pathology. So when I'm doing my um examination as they come to the top right, I'll, I'll make sure and tell them to go down slowly from the top and kind of this, in, in the scapular plane and watch for a a painful arc and drop arm sign. Once you finished with the range of motion, um, obviously move to strength as mentioned, I would almost always do a rotator cuff exam because it is so common and then you can do other strength as you feel indicated to do. Um, so to test the 4 different muscles of the rotator cuff for the sup the supraspinatus, there's a number of different ways to do this and the, the literature shows that, you know, the classic things we talked about in terms of thumbs down, thumbs up, not necessarily all that important, but what is important. If you abduct their arms in the plane of the scapula which is about 30 degrees anterior to um the coronal plane, and then you resist, you know, further abduction with the arm and you're looking for, um, obviously weakness but also pain. Um, and if they are painful or weak with that, you're thinking perhaps superior cuff, right, might be impacted. For infraspinatus, for this one, you can test it um just at the side with external rotation. And this is typically the way that I'll do my, um, That's typically all the external rotation testing that I'm that I'm doing, but if they do have, I put a slide on it. Actually don't. If they do have specific external rotation complaints, you can also do um External rotation at 90 degrees up here, and that's more specific to the teres minor. You can think about that anatomically as that's beneath the infraspinatus, it inserts lower on the humerus and as you abduct that, that brings it kind of more inflamed with that motion. So theoretically at 90 degrees of abduction with external rotation, you are testing more specifically the teres minor versus the um infraspinatus, but obviously you're doing both in both cases. Um, but those can be used if you have a suspicion that one or the other is, is more problematic than, than the other. Um, the infraspinitus is much more commonly torn than the teres minor, and that is because, you know, tears are most common, most common location of rotator cuff tear is the superior cuff, and then it kind of moves backwards and forwards. And so as it starts in the supraspinatus, it moves backwards, it will get into the infraspinatus. But it would have to go through the entire infraspinatus before it got to the teres minor, so that's the reason it's less common. It is also, of course, possible to have isolated tears of the infraspinatus or the teres minor, but those are just less common. So for that reason, you know, I think it, you know, external rotation at the side is a good default test to do, and then you can obviously add in the additional. External rotation at 90 degrees if you are suspicious for that. Subscapularis testing, just like the internal rotation testing is a bit more complicated and just because again, your belly's in the way of, uh, of doing kind of a good internal rotation strength test. So there's a few different ways to do this. I've shown two here. One that, um, I think most of us at UCSF use cause it's just really easy and has been shown to be as reliable as anything else is the bear hug test. So you have them grab their contralateral shoulder with whatever arm you're testing, ask them to keep that shoulder down on their body. And then you apply kind of, you know, an external, externally rotating force. To the shoulder, trying to raise it up and ask them to keep their fingers on their shoulder. And if they're um normal, they can actually, I mean, effectively, you can raise them up, you can pick them up with that um arm, and they'll stay firmly planted on the shoulder. It's very, very strong. So if you, if you get even a little bit of the hand raising up, certainly if it comes off, that's weak, but even if the hand is raising up, and that'll be indication of weakness. With the caveat, it may be painful. Which can cause some weakness, right? Um, without actually being weak. Um, so that's the one thing you have to, with all of the strength testing figure out is, is it actually weak or is this motion for whatever reason painful and therefore they're weak. But certainly normal is being able to really maintain your hand solidly on there. You can also do the lift-off test which is very, which is, um, you put their hand behind their back, right, and you ask them to push, um, push against your hand as you put their hand behind their back. Uh, or alternatively, you can also just pull their hand off their back and ask them to keep it there, and if they're not able to keep it there, that's kind of effectively not even anti-gravity strength in terms of strength testing if that makes sense. So, a, um, you're not necessarily able to dynamically grade their strength with just kind of that, um. That version of the lift-off test but can give you a sense if there is weakness or not, if they're not able to maintain their arm off of their back. Another way to test internal rotation, which is, um, not hard to do, is you have them put their hands on their belly and put their elbows out towards the front, and you can actually push on the, um, the shoulder as a resistance, and that does test internal rotation as well. So that's another easy one to do just from the front is called the belly press. Push on their belly with their elbows out and then you're pushing back on there. On their um Ls. So onto the special test, at this point, you've done, you know, your inspection, you palpated, you, we've got a good history, inspected palpated range of motion and strength. So at this point, you probably have a pretty darn good idea um what the issue is, um, and you can focus those special tests based on what you think those are. So we, we're, I mean there's literally dozens and dozens of these, can't cover them all today, we'll just mention a few that most of which you probably know. Um, but, um, these again are just included in a variable basis depending on what you are suspicious is going on. So here's the, you know, the most classic test for impingement, um, nears and Hawkins test. I always remember these by, you know, Hawkins is like a hawk, it's, you know, flapping in the breeze, um, and then near is like, I, I would always say near here like when they ask if you're present, right, you say here. Um, but these are just tests, these are passive range of motion, right? In the case of both these tests, you're stabilizing the scapula with one arm to try to prevent the scapula moving too much. With the other arm removing the shoulder, in the case of the nearest test, you're bringing it basically in the full forward flexion. In the case of the Hawkins test, you're taking them kind of from 90 degrees of abduction with the arm externally rotated to internally rotated. And what you're looking for in both of these cases is that you're kind of driving that greater tuberosity towards the undersurface of the acromion. In the case of, you know, uh, subacromial impingement. Um, or subacromial, subacromial, um, pain syndrome as it's been called perhaps more commonly now, um, that is painful, right? So this is something that is You know, reasonably sensitive, but as you can tell, it's really poorly specific. These tests are. I think that speaks to the fact that, um, for one, these are maneuvers that generally with organic problems of the shoulder are just painful. So with these, these raise my suspicion for perhaps rotator cuff pathology but certainly they're not, you know, blocking in any diagnosis, um, on their own. This test is actually is pretty useful. This illustration is awful. I don't know where I found this actually, but, um, you know, in the case of O'Brien's test, you're bringing their hand straight up, um, the, in the forward flex 90 degrees, you then horizontally or abducted across the body a little bit, and then you, um, pronate the forearm and internally rotate the shoulder so that the thumb is down, and then you ask them to maintain, you know, elevation of the shoulder as you're pushing down on it. And then you do the same thing with the thumb up, and if the, if it is painful with the thumb down, the question is whether it is better or worse with the thumb up. And if it is worse with the thumb down than up, that is a positive O'Brien's test, but it's important to go to the next step because this can be positive in two conditions. Um, classically, one would be, um, a slap tear, so, and I would say slap tear slash, um, long head biceps pathology, so biceps tendonitis because the biceps tendon does insert onto or just originate from the superior labrum. So either slap issues, superior labrum issues, or the biceps tendon that comes from there, that's one kind of classic finding or one classic etiology of a positive O'Brien's. The other though is the AC arthropathy. And so in this case, you're gonna have pain, yes, still in the front of the shoulder but right pinpoint over the AC joint. So that's one important thing I think when you're doing this exam to make sure you ask where that pain is because depending on where it is, it totally changes kind of the interpretation of the test. Biceps tendon, like, I would actually love, this is one of the, the exam maneuvers, and these exam maneuvers I actually do really like, especially the Jorgeson's test, um, and I'll tell you why. So speeds test you do with the arm and uh uh for flexion, a little bit of uh horizontal abduction, so you're kind of, the arm is a little bit more outward than midline, and then you have their forearm and supination, and you're asking them to maintain that. So that's, you know, that causes the biceps to You're using the biceps right because you're trying both to flex essentially the elbow and also to supinate um the forearm. And then the other test here that you can do is Jorgeson's test, and that's where um you have their arm at their side, their elbow flexed, and then you essentially, you can do it this way, you can have, you can give them a handshake, and then you ask them to supinate the forearm against resistance. And you're checking for pain at the shoulder. And I love these tests because as you all know, I feel like, at least I feel in my practice that patients are very suggestible. And so when you're doing exam maneuvers and there's a clear kind of Link between what you're doing, what you're looking for, I feel like they'll give you, maybe they're not purposeful, right? They're not malingering, but they're just giving you kind of what maybe they think should be the case. In the case of, especially the Jorgeson's test, it's so distant, right? You're, you're holding their wrist and what you're really looking for is pain right here in the front of the shoulder. So I think this is a, um, I find this test to be very useful in differentiating, um, vices pathology from others. So I'll, I kind of won't tell them exactly what I expect first. But I will do the Jorgeson's test. I'll ask if it's painful. If they say yes, I'll ask them where. And if they're able to, if they show me right here, then I'm feeling pretty darn good that, you know, that biceps tendon is really the, the issue. Um, and same thing with speeds test to a degree, but I feel like the Jorgeson's is just even more removed, you know, they're sitting there, they're focused on their wrist, so if they tell you their shoulder hurts, that to me is a really good indicator that, um, Um, that really is what's going on. AC joint special test, similar to the O'Brien's test, um, if you bring just the body just acro or bring the arm just across their body, right? Passively, so you're doing a forearm and you're pushing against, uh, essentially fully horizontally abducting the arm. If they have pain in the front of the, uh, right of the AC joint, that's a positive, um. Cross-body abduction test, but also similar to the O'Brien test, it's important to ask when they, when you say it's painful or not, where it is, cause this can also be painful in a variety of conditions. Things that like arthritis will cause pain here, um, clinic arthritis. This can be painful even with like perisscapular stuff cause it's a stretch in the back of the shoulder. So with this one, it's a, it's a great test, easy to do, um, but just make sure you ask where that pain is being reproduced. Um, here's a, you know, if you're, if you're suspicious of instability as being, um, the complaint, there's a few other special tests to do. This is the, the sulcus sign, so if you have a patient, right, who maybe has dislocated in multiple ways and multiple times over the years, doesn't give you a great history for kind of the same mechanism by which it happens. Perhaps they're female, maybe they're an overhead athlete of some kind. Um, the sulcocyte is a good thing to check for where you have them at their side, you just pull down in the arm and you look for essentially a kind of indentation between their acromion and their proximate humerus that develops, and that's just a sign that things are pretty lax in that shoulder. Um, we'll skip that for a second. If you're looking for anterior, um, instability, which is the most common type of traumatic instability of the shoulder, a great test is to kind of put them in a position where they would come out, and in that position, they'll feel pretty uncomfortable, and then you put a force that um opposes that force, right? And then that will make them feel more comfortable. So in the case of anterior instability, The um position of apprehension is with the arm 90 degrees abducted and externally rotated, and that's gonna make them feel pretty uncomfortable and they're gonna, like they're gonna come out the front and then to um oppose that force, the relocation test is you push on that, um, right over the kind of the glennohumeral joint just backwards. And if they have, you know, that sense of, um, apprehension when they're up and it goes away when you push away, uh, push back, that's a good sign that perhaps they have anterior instability. This is a test too that you can kind of work into. This, this is another one right where you, it, it's, I think it's open to the power of suggestion, um, quite a bit. You say, oh, is this bothering you, is this better? So I like to do this one too just by surprising them if you're just talking to them, moving their shoulder around and you move them into a position, um, like this and just see if it seems to bother them. And then you can also do the opposite of the relocation test, right? So you can kind of be having them there, you're pushing on the shoulder and then you're releasing and you see if that seems to bother them and I think uh it can be pretty reliable if you do it in that way. And then the other way to test um instability is actually to do like a load and shift test, and this is actually where you just put them supine, you have their arm a little bit abducted, you have their forearm kind of up as you can see, and then you just grab their proximal or you grab their arm with your arm and you kind of push it into the um scapula, or sorry, push it into the glenoid, and then you're just kind of pushing it forward if you're doing anterior stability you're pushing it backwards if you're doing posterior instability. And the grading here is depending on how far you can push this glenoid, or sorry, humerus relative to the glenoid. So if you get it just to the rim, that's a 1. If you actually give it over the rim but it goes right back, that's a 2, and then if you actually get it to dislocate and stay there, it's a 3. And in the relaxed position, you'd be surprised. I mean, most people, grading one is normal, so you can actually get people up to the rim, um, we've had no instability events at all in the past. So the shoulder is pretty mobile in general and that this test shows that. Uh, and then there's the, you know, this is a, this could be a whole talk on its own, but there's a whole, then there's all the tests, right, that you would do for things that are not the shoulder. So if you're suspicious that it's not the shoulder, um, this is where you would do all of those different tests. So certainly the cervical range of motion is an important thing to check. You're looking here just to see if they're limited, which would be an indication perhaps that they have arthritis in their neck, and that could be a reason. Certainly if they're moving their neck as well and they find that that reproduces shoulder pain, that's even more um specific, right? Um, as a sign that perhaps their pain is actually, um, neck in origin. The Spurling test is a sign for radiculopathy, right, where you're pushing, you, you load the, the head, um, axialally while you're also applying a lateral flexion and a rotation, and if that reproduces the radicular, you know, the pain or radiculopathy, that would be a positive sign for cervical radiculopathy. And then as mentioned before, you can do the dermatomal and myoomal neurologic exams as indicated, right? So checking the sensation from the shoulder all the way through the arm to the ulnar side of the forearm and upper arm for C5 to T1 and then the myotomes as well from the deltoid, um, biceps, triceps, wrist extensors, finger flexors, and then, um. Interosseous muscles. So those are things I, I cer certainly don't do in every single patient, but if I'm suspicious that it's neck in origin, I would add in. And that's really the meat of the talk. Um, it won't leave time for Q&A, but just a quick mention of imaging, um, with the shoulder, it's always, as, as most joints, it's always, um, Appropriate to start with the X-rays first line and actually you can see a lot. So even though we don't see, obviously we see bones and joints on, on X-ray and we don't see, you know, um, soft tissue like labrum and um tendon, things like that. However, I do think if you have a keen eye you can see a lot actually on X-ray, even if it is soft tissue in origin. So on this X-ray here, um, obviously you see right a highlight, a high riding humeral head. Um, you see the undersurface of the acromion has undergone what we would call an acetabulization, so it started to kind of wear away and form a kind of a nice hemisphere. And similarly on the, um, on the humeral side, right, you notice that that greater tuberosity, which is typically pretty prominent, has been kind of shaved down and looks pretty smooth, um, which is called like ephemeralization of the humeral head. So this is all kind of classic for rotator cuff arthropathy, right? They've got a really large rotator cuff tear over time because they have this large rotator cuff tear that causes the um humeral head to be able to move proximally, um, when you use the deltoid and other muscles, when that happens, eventually the humeral head hits the acromion that causes this kind of reshaping, right, of the acromion and then also the humeral head. So This is obviously a, a relatively marked example um of soft tissue pathology that you can see through its correlates on the bony um morphology but um in general the X-ray is quite useful and could tell you a lot, but certainly there are still cases um where you don't know, right? So MRI can be the next step and generally, you know, the decision to get an MRI or not is based on if you have a patient for whom you're pretty sure they have shoulder pathology, the X-ray has been negative. Um, and you're pretty sure, and, and you're, and you're not sure of the next step in treatment, then I think an MRI is the next step. What I mean by that is, um, if you If you have a 65 year old patient, right, um, who has potentially a degenerative rotator cuff tear, so they got a, you know, they got pain in their shoulder, maybe a little bit of weakness. It's been there for a long time, no specific trauma. Well, in that specific situation, um, regardless of what the MRI shows, the treatment's gonna be physical therapy. So in that situation, obviously it would be fine to just give them physical therapy and, um, see how things go and then if it doesn't get better, we can do an MRI. Um, but in general, right, if you've got a suspicion for shoulder pathology, you have a negative X-ray, and the treatment would depend on the findings of the MRI, then, um, certain MRI is indicated. But having said that, of course, we get MRI's a lot and it's, um, you know, it's, it's totally fine to get an MRI if we're, if you're just not sure as well. Those are the two main things. I would say ultrasound is also super useful. And diagnosis of the shoulder and um as orthopedic surgeons we're really bad at that still. We're trying to get better I think and using that more but it's been shown to be very effective um and accurate in diagnosing certain conditions, especially things like rotator cuff tear, biceps, tendon issues. So if that's in your wheelhouse as well, um, that's certainly a useful adjunct to imaging is, is ultrasound. Um, so here's my references and I appreciate your attention and I'll stop talking at you now and answer any questions that you may have.
