Physical Exam of the Shoulder, Dr. Christopher Baker

So the physical exam of the shoulder for me I think is a little bit of a black box. And once you get into that black box you can really get into the weeds and get lost and cannot forget what your goals are of why you’re there and so you know we can go through kind of the point by point approach to that. Or we can go for a more goal-oriented approach is how I call it and we’ll go through this as a disclosure I do have some speaking fees that I that I collect from Zimmer Biomet unrelated to this no content regarding this talk. The setup is the most important part of the physical exam in my opinion. OK. If you can’t see the patient you can’t do a good physical exam. OK. And I’m sure that all of you that see patients on a regular basis have to go back and forth.
Yeah. Be great with your staff. No they need to take their pants off when we’re looking at their knee. When you look at the physical exam and you and you have this patient if she has her clothes on and she’s covered up it’s a very difficult thing to get a good exam on. I I’ve seen all of the different type of robes where you can put it on from the back or the front where it’s like a it’s like a pink paper vest you guys are everything you guys have those. It’s the most useless gown ever. It doesn’t actually cover anything. You can’t access anything and I don’t know whether it goes on front to back or back to front. So what I do is I actually take our shorts and I rip the crotch out of the shorts and I tell the women to put it on like a halter top and it’s the best it’s the best robe that you could ever put on a patient unless they’re really big then it’s a little bit tougher.
But that is the best way to make the patient comfortable you comfortable and you’re not negotiating that gown. That’s my Dr. Baker tip number one when you’re examining the shoulder You need to examine both sides so get the patient to the edge of the bed. OK you want to be able to get on the right side you want to be able to get on the left side and you will have access to that patient on both sides. If it’s a guy they need to take their shirt off. This is tough for young guys that are you know worried about their body or guys are overweight but they’re gonna get over that they’re there to see you for a reason take off the shirt take a look at them when you go through the physical exam like I alluded to earlier you could do this step by step you know fifty point exam you can do all kinds of different special tests or you can go for the money you know in general we’re looking at inspection, palpation, range of motion, strength, instability neuro vascular test, special tests this could take you a really long time.
Most of the time takes me less than five minutes to get a good exam on a shoulder. Sometimes patients don’t fully understand that I got a good exam on them because it’s so quick. But the reality is is you don’t need to do every special test under the sun because you’re just going to get lost in the weeds. This guy’s Richard Hawkins he was my mentor and he’s kind of really taught me my exam techniques in the shoulder and his answer was always go for the money. OK. Take a careful history and go for the money and the reason for that is when you examine these patients the things that this patient has are not going to be the same things that this patient has. OK. When you see this patient, you’re not looking for a slap tear OK. When you see this patient, you’re not looking for degenerative arthritis in general.
OK so focus your exam based on the type of patient you’re seeing based on their age based on their history and then make sure you know your anatomy if you know your anatomy and you have a good history of the patient. You’re going to have an idea. Most of the time what you’re dealing with this lady is likely coming in with some form of arthritis or some form of a rotator cuff complaint. That’s pretty much it. Biceps tendonitis. No not really slapped tea, No not really. So then you’re going for the money every exam starts with inspection and we said at that first part is taking off their clothes you want to look it from the back. You want to look at it from the front. If you have this patient come in and they have been complaining of pain along the back aspect of their lateral shoulder and you don’t take off their shirt you’re going to miss their diagnosis who has a diagnosis here.
Boom shingles OK. Orthopedic surgeons can diagnose shingles because we take their shirts off. It’s pretty straightforward. Muscle atrophy is another thing that you can examine straight off about without ever touching the patient. You look at it from the back. You see the trapeze. You’ll see tissue. You see the deltoid muscles you turn around you look at the front. You got trapezial tissue again. Deltoid Peck all of those musculatures provide silhouettes and have symmetry. So when you’re looking at both sides I would say orthopedics is very easy because you don’t have to know anything. You just have to know what’s different. OK. You get an x ray get both shoulders. What’s different. Both knees. What’s different it’s very straightforward for the most part then you can tailor that exam based on the patient. So if this patient is a seventy five year old person what is the most likely diagnosis.
This patient has enforcement just wasting their most likely to have a rotator cuff tear a chronic long-term rotator cuff tear. What is the most likely diagnosis this 20 year old pitcher? It’s a liberal injury. It’s a cyst it’s an injury to a nerve it’s a super scapula nerve injury. So these are different diagnoses that are gonna come based on the patient. And we already have a really good idea of what their diagnosis is just by taking off their shirt. When we look at this patient a very different injury. So this patient has complete deltoid wasting and we’ll just assume that that’s the only muscle that’s injured it’s going to be likely to be an or nerve injury. So this patient presents to you after a shoulder dislocation it gets put back in or an 80 year old person that can move with this atrophy of the deltoid.
And those are the types of things that you can see this kid’s a very different scenario again. Now what we see here rather than just enforcement just wasting we see deltoid wasting we see trapeze you’re wasting the whole shoulder girl is gone basically. And so people will be sent to me again. No one takes off their shirt. It’s a 15 or 18-year-old kid and they get sent to me for a rotator cuff tear because they can’t lift their arm. They don’t have a rotator cuff here. They have a nerve injury right. So they have either a brachial plexopathy or they have parsonage turner syndrome which is just an inflammatory brachial plexopathy. OK. So just taking off the shirt we’ve already got diagnoses in half of our patients. Then you can look at deformity. It doesn’t take an orthopedic surgeon to know that there’s a difference here.
Right. The question is it a dislocation or is it a fracture. This patient obviously has an injury to the AC joint. When you see this this kid comes in he’s got a nice rounded shoulder on his left side on his right side. He has this squared off shoulder and an a basically a lump in the front of the shoulder. He’s got a shoulder dislocation. Again, these things are very easy to do but you have to take their shirt off to know that this guy’s an 80-year-old guy comes in and says oh I had a pop and my arm is swollen down here. He has no pain he’s got great function. He’s got a biceps tendon rupture. You don’t need an MRI to tell you that he’s got a popeye deformity. You know the type of injury that we’re dealing with this is something that is it’s I wonder I almost wonder if it’s an infectious disease in Tampa because when I train in Pittsburgh and in Greenville, South Carolina I never once saw a peck rupture.
I moved to Tampa and I see a peck rupture like every other week. Dr. Gaston probably the busiest peck rupture guy in the whole state because guys use accessory, we’ll say accessory. Was what it was. Pharmaceuticals what I will say accessory pharmaceuticals to assist in their mainly physique. OK so their steroid users and these guys don’t stop. They keep going as they get older at some point the muscles out strengthen the tendons and they rupture the tendon. So again all these things are very easy to diagnose if you take off the shirt medial border scapular winging this is kind of probably on everybody’s board exam right long thoracic nerve injury you know common after attraction type injury so inspection alone can really get you a lot of diagnoses take it off. Look at their exam and look at their skin and go from there.
Palpation is important. It’s not the end all be all. I don’t necessarily palpate all these spots but I do think if you’re examining the shoulder. You need to look at the spine at least briefly you at least need to touch the center of the spine make sure there’s no major step off or craziness. Make sure they have a reasonable range of motion and that they don’t have any glaring impingement type symptoms. Before you move on the AC joint is something I always palpate. Now anything more medial on the sternoclavicular joint it’s all patient directed. So if they say I’m hurting right here then yes I’ll give more involved there but I don’t sit around and spend much time on the scapula thoracic joint in that in that state and the average patient. When you follow down the clavicle you can basically fine if you step off at the middle after the clavicle you’re going to know that there’s something you need to evaluate there but for the most part we’re palpitating the AC joint the biceps groove the lateral cuff to just get a sense of where these patients are hurting a lot of patients don’t have any pain.
Some of the patients have pain everywhere. Does that help your diagnosis? Not really. I mean I just thought I saw a patient today before I came. She hurt everywhere I touched including her skin. How patient wasn’t that valuable to me in her exam. Range of motion is this is where people start to get lost in the weeds. OK. So to me range of motion has two kinds either full and symmetric or not. OK that’s kind of how I determinant up all ballpark. Okay I’ll say this is 90 degrees. You may see it’s ninety-five. Some may say it’s 80. Who knows right? So if the patient does this and both arms go up all the way and they’re symmetric I say full symmetric range motion you can dial in whatever kind of number you want. If they don’t have full symmetric range motion this one goes up at this one doesn’t.
I want to know why. OK. Do they have full passive motion? So first is active and then passive. Right. So if I ask them to lift their arm up and they do it both we’re done we move on from physical exam with range of motion. If they do this and then they stop then I say OK. Now I’ve got to figure out is this patient stopping because they can’t get it there or do I need to help them and can I get it there if I can’t get them there. That’s that’s a limited passive and limited active range of motion right. So again, as we look at the shoulder what does that matter. So if it’s limited if it’s not limited we move on. OK. If it’s limited only actively and then I can move them the rest of the way I want to know why is it limited passive actively but not passively.
So things that cause limited passive range of motion or generally pain. So that’s going to be bursitis right. Pinching of the rotator cuff underneath the sub a criminal spur a rotator cuff tear can cause you to have limited range of motion actively but not with full passive but range of motion and then calcific tendonitis is a little bit of a tough one. If they have early calcific tendonitis or not that inflammatory then they can usually get full motion. But some of them come in in this acute phase where they can’t move the arm at all then it’s a little bit harder to diagnose but an x ray will get you there. So if the patient has limited range of motion and you see a big calcified lesion that may explain why they’re not able to get full motion. So if they have full motion move on to the next step.
If they have full passive motion you know that it’s gonna be one of those three things generally a tendinitis a tear or some other calcific tendonitis or something like that. Now what if they have limited passive range of motion as well. So we’ve got them we come up and they can’t move in on their own and then we go to move it as well. There are only a couple things that cause stiffness that is stiff passively. OK. The most common one that I see. And if you walk away from here the one thing that I think could help your physical exam and help your patients and my patients is that is frozen shoulder. OK so adhesive capsulitis generally has limited passive and limited active range of motion. So when I go to help them move that arm it’s stiff and it’s painful and usually it’s in two planes.
So let’s say they get to 90 degrees or maybe one hundred and ten degrees and then when you your arms at your side the right wing goes all the way up to the left wing just doesn’t go OK. If that is the case only two things can cause that are frozen shoulder or arthritis. OK there’s only two things that are you’re gonna see on any regular basis they’re going to cause those problems that is easily determined based on an x ray. OK. So with your x ray they either have arthritis and you can see bone spurs and no no cartilage or they have a normal x ray and this is just a pictorial version of this and they have inflammatory thickening of the capsule that’s going to limit their active and passive range of motion. Okay. So do they have full motion if it’s limited does it limited both actively impassively and why.
All right. Now some folks are gonna have full motion passively but not actively now. A large tear can cause that as well. And that is going to be a weakness limiting the range of motion and we’ll get into this more when it comes to strength. So when you look at strength again I’m very simple. Is that weaker is it not. OK. So if I push on them and they feel about the same five out of five strength be equal on both sides. Symmetric and equal is a good word to use because it shows that you’ve looked at both sides and it gives you an idea because some people don’t have four hundred and eighty two hundred eighty degrees the range of motion some people stop at a hundred fifty and when they get a hundred fifty on both sides and you examine both sides you know it’s normal for them.
OK so in strength. Are they weak or are they not? So if I push on their arms and they’re both strong I move on. OK if I push on their arms and one easily comes down that shoulder is weaker now; I want to know again why is that weaker. If you want a great four out of five three out of five whatever numbers you want to use that’s fine but why are they weaker. Are they weaker due to pain or are they weaker due to true weakness? One way to figure that out if you’re comfortable doing shots hopefully you will be after this discussion is you can give him an impingement injection test. You do a sober criminal injection you could just use lidocaine if you want to. You can mix it with Kenalog you can mix it with Marcaine. Whatever you want to do to decrease the inflammation in the shoulder or sorry.
Pain in the shoulder to allow them to resist you to see if they truly have weakness. That’s a good way to find out whether they’re weak due to an injury or weak due to pain. OK so the things that cause you to be weak due to pain impingement generally sometimes calcific tendonitis other things that cause you to be weak due to weakness is gonna be a tear or some type of a nerve injury. OK so again this can also help you with your motion if you give them a shot and that active motion goes from partial to full. Then you’ve just kind of eliminated pain as the cause of their limited range of motion. So make sense questions on range of motion strength. Straight forward. All right. When we look at instability there’s my instability test. If a patient comes to me for shoulder pain and they can do this I’m pretty good.
We move on to the next thing. I’m not going to sit there and go through 10 different exams and lay them down and do shuck and jive and all these different things. Now if the patient comes to me for an instability problem that’s a different issue. So, the patient says hey I’ve dislocated my shoulder 10 times and they can do this. I’m still not that worried. I’ll go to their X-rays will move further. I don’t think you need to be worried but if they’re not willing to put their arm in that position they probably should come see us. OK. If it’s their first time they’ve ever dislocated and they have this kind of motion therapy. They’re probably fine and leave me alone. If they’ve dislocated many times haven’t come see us. If they dislocated one time and they can’t do this have them come see us.
OK. When you look at other types of exams you can go into load and shift type test. Most common patient but I think where you can get lost in the weeds is the 14 to 20-year-old woman thing plays volleyball or swims and or her shoulder pops out. She says she’s never gone to the E.R. for it she’s never had a reduction for if she does it on her own and these are where those exams start to be helpful. But you get lost in the weeds a little bit here. The load shift tests what you’re doing is you’re basically holding your chromium you’re placing that humeral head into the Glenoid and you’re forcing it into the center to center it into that shoulder then you’re going to shift it to the front and you gonna shift it to the back and always start on the patients not affected side.
So start on their good side so it doesn’t hurt they trust you and you get their baseline. So if you take their good side and you can take that shoulder and slide it way out the back and you can feel it slide out the back of the shoulder when you go to the affected side it does that. You won’t be surprised because they’re symmetric. That’s that patient they have loose joints that tends to be how they are. If you start on that injured side and it comes out and they’re like dramatic about it you start to get a little bit nervous and then you don’t want to continue with your exam so that the leadership test is a good one. It’s relatively safe to do and you’re not going have any problems. So this test is another good test for that same type of patient.
You basically place your fingers underneath the edge of the chromium and you pull down on the humerus and see if your fingers can kind of sink underneath the chromium between the humerus head and again you start on the good side and they go way down on that side you’re going to expect that they’re going to do that on the other side. Usually they’re guarding the injured side so usually won’t be quite as unstable but it’s another good test to just give you an idea of how problematic the shoulder is. The next is the apprehension test. So so the first range of motion that I said I have my patients do this. That’s basically what we’re recreating here. But now you’re doing it under your control because that patient you’re concerned because they can’t get there. Maybe you want to determine how far they can get before they become apprehensive.
I don’t push that personally I don’t know how aggressive you guys when it. When a person comes in with a first time shoulder dislocation. How aggressive are you to see if you can pop them out. Not very because you’ll pop them out. OK so the last thing you want to do is if a patient comes to you for shoulder dislocation is put him in this position and say let me know when it when to stop and then boom, they pop out in your office. Now you’re in trouble. So apprehension test is something that you can do but again I would be careful with that. The relocation test is another one where all you’re doing is basically placing your hand on the front of that shoulder and you’re preventing it from popping out. OK so if you have the young lady that has really loose joints and you’re just trying to see whether she truly comes out or not this is a good thing to do and if you can put her in this position and she has no apprehension you can pretty much move on but if she has apprehension here you can move on to this position and push them back and see if it makes her feel better and if you have an idea that she maybe she is truly having some instability maybe she should come see us and we’ll work on that.
What I would advise you not to do is do that rotate them in and let go of that arm because then it will really pop out OK. The Beighton score is something that also goes along with these types of patients that when you have these multi directional instability or loose jointed people it basically is just an examination looking at how extensible their joints are and how flexible they are and it’s a score of one to 10 one to ten two for each side and then the 5 1 9 1 9 sorry because 5 you can only bend over one time they don’t do each leg there obviously. So basically if they can hyper extend their 5th digit they could touch their thumb to their forearm hyper extend their elbows and their knees and put their palms flat on the floor without any difficulty then that’s a really loose jointed person they’re gonna have shoulder complaints and that’s something that needs lots of rehab.
Ok so I wouldn’t recommend you go through all this I would recommend you have an idea of do they have normal range of motion and then move on for that very rare patient that has multi directional instability learn a couple of these tests you feel a bit more comfortable with it and then go from there. Neuro vascular honestly might neuro vascular is radial pulses if they have symmetric radial pulses. I move on. OK now if you have these patients that have these really weird outlandish kind of complaints and numbness and tingling all these things you can start to get into thoracic outlet. I get all kinds patients that come to me with thoracic outlet weirdness and they’ve looked on the Internet and they find it. I think I diagnose thoracic all at once in my career and I see shoulders all day long. It’s just not that common of a problem.
I think the surgeries happen more times and people who are just seeking some type of remedy for whatever it may be that don’t necessarily have thoracic outlet. They’re just trying to see if that’s the cure to their problem. But you can do the Roos tests you can do the ad since test. We won’t go into all this but basically what you’re trying to do as you’re trying to pinch the nerve vascular bundle vascular neural you can either do arterial or venous and you’re trying to basically cut that off and reproduce the numbness and odd symptoms in their distal extremities. There are a thousand special tests in the shoulder. OK. We don’t agree on any of them. OK. When you look at different Juergens and speeds and O’Briens and O’Driscoll the list goes on and on every other every guy that’s ever done an exam in the shoulder has one named after him and none of them have very good inner observer reliability.
The positive predictive value is very low generally all of them. When the patient has pain, they almost all go out the window. So it’s very tough to do that so I wouldn’t recommend that you go through and learn all these special tests if you see a lot of sports medicine you see a lot of pitchers you might need to start getting into it a little bit to have an idea but I guarantee you that my exam and my kind of diagnosis based on O’Brien and O’Driscoll can be different than Dr. gas or different and doctor. And this is all we do and we still can’t agree on it. So don’t spend too much time doing that spend your time worrying about your thorough history know your anatomy examine your patient with their shirt off OK get a range of motion find out if it’s limited or not get their strength is it limit or not and try to determine why you think it’s limited.
The most common diagnosis is still that I see every day in my office as a frozen shoulder. So if they have limited range of motion passively and actively in their X-ray is normal. My standing diagnosis is a frozen shoulder. There’s almost nothing that can do that other than a frozen shoulder if they have a normal X-ray with limited passive and active range of motion. Special Tests how many guys have been on a Disney cruise. All right. So last year when a Disney cruise. This is how we looked when we got on the boat and that was after four days at sea things were going so well at that point. Maybe for my kids they had too much rum. You’re right. All right. So questions on physical exam I don’t want to go through that typical way. This is just kind of how I approach it going through.
I would say I do. So I so first of all I probably see one to two frozen shoulders every day I would guess if I was going to guess and so on three days a week. That’s six patients maybe a week that I see that’s probably 30 a month. That’s hundreds of patients I see every year with frozen shoulder. I might operate on one every two years. Probably one every two years and it’s that recalcitrant diabetic who you give him a shot they get a little bit of motion back but it keeps coming back keeps coming back.
But it’s super rare degree. Yeah.
Yeah. They almost all need a cortisone shot in my opinion. I have had physical therapists I have had occupational therapists I have had orthopedic surgeons come see me that all I had a frozen shoulder that I had normal MRI eyes normal surgeries all from frozen shoulder and just undiagnosed. So open up your mind don’t diagnose yourself. See if she has seen a shoulder specialist. Or. So intraarticular for frozen shoulders. How you do it can go from the back from the front from the top. I’ll go through that on my next talk. Intraarticular. It’s got to be in the joint if you put it in the sub criminal space they might get some effect but it’s not going to be very big.