History Shoulder & Neck Exam Tiffany Bohon MD Assistant Professor of Family Medicine & Orthopedics/Sports Medicine

• • • • • • • • • •

Duration Location Radicular Injury/trauma Aggravating/alleviating factors Night pain Numbness/tingling/weakness Occupation/activities Dominant hand Hx of shoulder issues

Physical Exam

Shoulder

• • • • • • •

Inspection Palpation ROM Strength Special tests Neurovascular exam **Always examine c-spine w/ shoulder**

http://snoworthopaedics.com/portfolio/biceps-tendon-rupture/

Inspection • • • • • •

Atrophy Shoulder asymmetry Swelling Ecchymosis Erythema Posture http://hotchsibgrp.wordpress.com/2014/09/14/anatomy-of-theshoulder-joint-human-atlas-of-anatomy-netter-download/

http://www.foundrysportsmedicine.com/our-blog/bid/109741/Anterior-Shoulder-Instability

Palpation Bony: • SC joint • Clavicle • AC joint • Acromion • Greater tuberosity • Coracoid process • Spine of scapula • Humerus • C-spine

Soft tissue: • Short/long head of biceps • Subacromial bursa • Muscles of shoulder • Periscapular muscles • Anterior/posterior capsule

Rotator Cuff

Range of Motion Passive= 0% effort by patient Active= 100% effort by patient • • • • • •

Forward flexion: 160-180° Lateral abduction: 160-180° External rotation arm at side: ~90° External rotation w/ arm abducted 90°: ~90° Internal rotation w/ arm abducted 90°: ~70° Internal rotation: ~T7

RC Strength • Teres minor/infraspinatus: External rotation w/ 90 ° elbow flexion • Subscapularis : Internal rotation w/ 90 ° elbow flexion • Subscapularis: lift off or belly press • Supraspinatus: empty can; 90° abduction, 30° forward flexion w/ thumb down

http://orthoinfo.aaos.org/topic.cfm?topic=a00064

Teres minor/infraspinatus: External rotation w/ 90 ° elbow flexion

http://classconnection.s3.amazonaws.com/522/flashcards/1066522/p ng/shoulder_test1330050731990.png

Subscapularis: Internal rotation w/ 90 ° elbow flexion

http://classconnection.s3.amazonaws.com/522/flashcards/1066522/p ng/shoulder_test1330050731990.png

Subscapularis: lift off or belly press

http://classconnection.s3.amazonaws.com/443/flashcards/1607443/jpg/1s20-s1058274608001730-gr91359771717358.jpg

Signs/Special Tests: Impingement Neer: abduction of pronated arm w/ GH joint in plane of scapula

http://www.aafp.org/afp/2005/0901/afp20050901p811-f5.jpg

Hawkins: shoulder in 90 ° of forward flexion w/ elbow in 90 ° flexion & forcibly internally rotating the shoulder

– Cross over test – O’Brien’s

http://www.aafp.org/afp/2000/0515/afp20000515p3079-f3.jpg

Signs/Special Tests • Joint stability

– Load & shift: pt supine, 90 ° abduction/90 ° external rotation position, apply anterior & posterior force to humeral head; for anterior/posterior laxity – Sulcus sign: seated w/ downward traction on elbow; += >2cm displacement; inferior laxity – Apprehension test: seated, 90/90 position w/ anterior pressure on humerus; += ‘apprehension’ that it’s going to dislocate – Relocation test: supine, 90/90, have pt ‘throw’ against your hand; += less pain/apprehension when examiner is applying posterior force to humeral head

http://www.aafp.org/afp/2005/0901/afp20050901p811-f4.jpg

Signs/Special Tests • Labral pathology

Supraspinatus: empty can; 90° abduction, 30° forward flexion w/ thumbs down

http://painmuse.org/wp-content/uploads/obrienac.jpg

Biceps pathology Speed’s: resisted forward flexion of shoulder with elbow extended and forearm supinated; += pain at bicipital groove

Yergasons: elbow flexed to 90° w/ forearm pronated; += pain in bicipital groove w/ resisted supination

http://www.aafp.org/afp/2000/0515/afp20000515p3079-f4.jpg

http://www.mhhe.com/hper/physed/athletictraining/illustrations/ch22/2217b.jpg

Physical Exam • • • • • • •

Neck

Inspection Palpation ROM Strength Special tests Neurovascular exam **Always examine c-spine w/ shoulder**

Inspection • • • • • •

Atrophy Shoulder asymmetry Swelling Ecchymosis Erythema Posture

Palpation • Spinous processes: – C2 is 1st palpable process – C7 is larger than those above them

• Muscles: – Sternocleidomastoid – Trapezius

• Lymph nodes

ROM • • • •

Flexion: 60 ° Extension: 70° Lateral flexion: 20-45° Rotation: 90°

Strength & Neuro Exam

https://www.google.com/search?q=neck+rom&rls=com.microsoft:enUS:IEAddress&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiuy63vmKbaAhV FzoMKHaE9CB4Q_AUICigB&biw=1920&bih=963#imgrc=pAmLOaE3oX8u eM:&spf=1523036443110

UpToDate

Special Tests • Spurling’s maneuver – Extend & rotate the neck to side of the pain and apply axial load on head – + test= limb pain or parathesias produced – Specific, not sensitive

Special Tests

Special Tests

• Adson’s

• Roo’s

– Loss of the radial pulse when the arm is abducted, extended backward, the head is turned ipsilaterally, and the patient inspires (UpToDate) – + test = loss of radial pulse – Common in Thoracic Outlet Syndrome

– repetitive and vigorous hand grip while the arms are abducted overhead for 3 min (UpToDate) – += paresthesias, inability to complete – Common in Thoracic Outlet Syndrome

https://www.google.com/search?rls=com.microsoft%3AenUS%3AIEAddress&biw=1024&bih=651&tbm=isch&sa=1&ei=h63HWp_ iOoXljwThwLOQCw&q=adsons+test&oq=adsons+test&gs_l= psyab.3..0j0i10i24k1.1735.2659.0.2773.5.5.0.0.0.0.134.585.0j5.5. 0....0...1c.1.64.psy-ab..0.5.578...0i67k1j0i10k1.0.GYvRUllBDI#imgrc=YWasBHPKyLp3EM:&spf=1523035531107

https://www.google.com/search?q=roos+sign&rls=com.microsoft:en-US:IEAddress&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjEie_Tk6baAhXMqYMKHVmAycQ_AUICigB&biw=1024&bih=651

References • Griffin, L.Y. (2005). Essentials of Musculoskeletal Care 3rd Ed. Rosemont, IL: American Academy of Orthopaedic Surgeons. • Hoppenfeld, S (1976). Physical Examination of the Spine & Extremeties. Upper Saddle River, NJ: Prentice Hall. • Puffer, J.C. (2002). Twenty Common Problems in Sports Medicine. McGraw-Hill. • Woodward, T.W. (2000). The Painful Shoulder: Part I. Clinical Evaluation. American Family Physician 2000 May 15;61(10):3079-3088. • UpToDate