Assessment of shoulder injuries in primary care

1. SHOULDER INJURIESMonis Khan PGY-1

2. TABLE OF CONTENTS
1. Shoulder Anatomy
2. Review of Shoulder Exam
3. Special Tests
4. Common Shoulder Injuries Seen in Family Practice

3. ANATOMY: ROTATOR CUFF MUSCLES
● Rotator Cuff Muscles maintain shoulder
joint stability.
● They ensure the humeral head is held in
the glenoid fossa of the scapula.
● All rotator cuff muscles originate at the
scapula and insert onto the humeral
head.
○ Since Teres Major inserts into the bicipital
groove of the humerus (not the humeral
head), it is not a rotator cuff muscle
“SITS”:
1. Supraspinatus
2. Infraspinatus
3. Teres Minor
4. Subscapularis

4. ANATOMY: MUSCLES OF SHOULDER
Remember: muscles move
from their point of insertion
towards their point of origin

5. ANATOMY: POP QUIZ
1. Which muscle of the rotator cuff internally rotates the shoulder.
a. Subscapularis
- Although teres major internally rotates the shoulder, it is NOT a muscle of the rotator cuff
1. Which muscles of the rotator cuff externally rotate the shoulder.
a. Infraspinatus
b. Teres minor
1. Which muscle of the rotator cuff abducts the shoulder?
a. Supraspinatus (0-15 deg),
- Although deltoid abducts the shoulder, it is NOT a muscle of the rotator cuff

6. SHOULDER EXAM
Look, Feel, Move

7. Shoulder Exam: Look
Scars – previous surgery / trauma
Erythema - inflammatory joint disease
Atrophy - nerve injury (traumatic/iatrogenic)
Deformity- asymmetry of the shoulder girdle
Swelling- shoulder dislocation
Anterior Posterior
● clavicular fracture
● humeral fracture
● anterior dislocation of the
humeral head
winged scapula (long thoracic nerve injury)
scoliosis
atrophy of trapezius, deltoids – wasting may indicate accessory,
axillary nerve injury
Muscle wasting of supra and infraspinatus fossa – nerve injury /
chronic rotator cuff tear

8. Shoulder Exam: Feel
Assess temperature of shoulder joints – warmth may suggest inflammatory arthropathy/infection
Palpate the various components of the shoulder girdle (note any swelling / tenderness)
1. Sterno-clavicular joint
2. Clavicle
3. Acromio-clavicular joint
4. Coracoid process – 2cm inferior and medial to the clavicular tip
5. Head of humerus
6. Greater tuberosity of humerus
7. Spine of scapula

9. Shoulder Exam: Feel

10. Shoulder Exam: Active ROM
If the glenohumeral joints movement is reduced due to injury or inflammation, increased scapular movement will be noted in
abduction

11. Shoulder Exam: Passive ROM
1. Ask the patient to fully relax and allow you to move their arm for them
1. Warn them that should they experience any pain they should let you know immediately
1. Repeat the above movements passively – feel for any crepitus during movement of the joint

12. Shoulder Exam: Video
https://www.youtube.com/watch?v=vu1vuugtvIo

13. SPECIAL TESTS
1. Supraspinatus
2. Infraspinatus
3. Teres Minor
4. Subscapularis

14. Special Tests: Jobes/“Empty Can” Test
This clinical test assesses the function of supraspinatus.
1. Abduct the arm to 90° and angle the arm forward by ~30 ° (so that the shoulder is in the scapular plane).
2. Internally rotate the arm so that the thumb points down toward floor.
3. Push down on the arm whilst the patient resists the pressure.
This test assesses for weakness in the supraspinatus and/or impingement. Weakness may represent a tear in the supraspinatus
or pain due to impingement.

15. SPECIAL TESTS: PAINFUL ARC
This clinical test assesses for impingement of supraspinatus.
1. Passively abduct the patient’s arm to its maximum point of abduction.
2. Ask the patient to lower their arm slowly back to a neutral position.
Impingement/supraspinatus tendonitis typically causes pain between 60-120° of abduction, however this test is not specific as
many other conditions can cause pain in this arc of motion and therefore it should not be used in isolation for diagnosis.

16. SPECIAL TEST: RESISTED EXTERNAL ROTATION
This clinical test assesses the function of infraspinatus and teres minor
1. Position the patient’s arm with the elbow flexed at 90°and in slight abduction (the abduction tests whether the patient can keep
the arm externally rotated against gravity).
2. Passively externally rotate the arm to its maximum.
Pain on resisted external rotation may suggest infraspinatus/teres minor tendonitis.
If the arm falls back to internal rotation or there is a loss of power it may suggest a tear in the infraspinatus tendon or muscle
wasting.

17. SPECIAL TEST: ABDUCTED EXTERNAL ROTATION
This clinical test assesses the function of teres minor.
1. Position the arm in 90° of abduction and bend the elbow to 90°.
2. Passively externally rotate the shoulder to its maximum degree.
If the patient is unable to keep the arm in this position (i.e the arm falls back to internal rotation) this may represent a positive
“hornblower’s” sign (pathology in the teres minor).

18. SPECIAL TEST: “LIFT-OFF TEST”
Internal rotation against resistance
This clinical test assesses the function of the subscapularis muscle.
1. Ask the patient to place the dorsum of their hand on their lower back.
2. Apply light resistance to the hand (pressing it towards their back).
3. Ask the patient to move their hand off their back.
4. An inability to do this (loss of power) indicates pathology of the subscapularis (e.g. tendonitis/tear).

19. Common Shoulder Injuries in the
Family Practice:
1. Acromioclavicular injury
2. Clavicular fracture
3. Glenohumeral dislocations
4. Humeral fractures

21. AC SEPARATION
● Common injury, making up 9% of shoulder girdle injuries
● Mechanism
○ direct blow to the shoulder sustained while falling
● Physical Exam
○ Abnormal contour of the shoulder compared to contralateral side
○ Pain usually over AC joint. can be referred to the trapezius
○ lateral clavicle or AC joint tenderness
● Check brachial plexus/ axillary n.

22. AC SEPARATION
Grade I
Mild tenderness over
AC joint, mild swelling,
full ROM
Grade II
Mod/severe pain,
clavicle slightly
displaced up
Grade III
Arm kept in
adduction,
obvious deformity

23. AC
SEPARATION:
MANAGEMENT
Grade I
Mild tenderness over
AC joint, mild swelling,
full ROM
Grade II
Mod/severe pain,
clavicle slightly
displaced up
Grade III
Arm kept in
adduction,
obvious deformity
Tx:
• Conservative (sling,
ice, analgesia, physio)
• 6 weeks before lifting
Tx:
• Conservative with
late distal clavicle
excision
• Refer to Ortho <72h

24. CLAVICULAR FRACTURES
● 75-80% of all clavicle fractures will occur in the middle third segment
○ most often seen in young, active patients
● FOOSH or direct trauma to lateral aspect of shoulder
○ medial fragment: sternocleidomastoid muscle pulls the medial fragment posterosuperiorly
○ lateral fragment: pectoralis and weight of arm pull the lateral fragment inferomedially
● Physical exam will reveal a “tent” deformity
● Associated injuries are rare, but may include:
○ ipsilateral scapular fracture
○ rib fracture
○ pneumothorax
○ neurovascular injury
Open fractures usually the result of the
medial fragment "buttonhole" through
platysma

25. MANAGEMENT OF CLAVICULAR FRACTURES
Imaging
● sitting/standing upright, standard AP view of bilateral shoulders
Treatment
● If clavicle minimally displaced (<2cm), treat nonoperatively:
○ sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks
● If clavicle is >2 cm displaced, open fracture, floating shoulder or associated with subclavian
artery/vein injury, must refer to ortho for ORIF

27. 1. Anterior 95%
● subcoracoid (most common)
● subglenoid (1/3 associated with fracture of the greater tuberosity or glenoid rim)
● subclavicular
2. Posterior
3. Inferior and Superior
GLENOHUMERAL DISLOCATIONS

28. ANTERIOR SHOULDER DISLOCATION
Symptoms
● traumatic event causing dislocation
● feeling of instability
● shoulder pain complaints
○ caused by subluxation and excessive translation of the humeral head on the glenoid
Physical Exam
● Slight abduction, ext rotation
● Squared off, loss of coracoid process
● Check brachial plexus, axillary N
● apprehension sign
● patient supine with arm in 90/90 position
● positive sign in mid-ranges of abduction is highly suggestive of concomitant glenoid bone loss

29. Radiographs
● see imaging of shoulder
● a complete trauma series needed for evaluation
○ true AP
○ scapular Y
○ axillary
ANTERIOR DISLOCATION: MANAGEMENT

31. ● Represents 2-4% of shoulder dislocations
● Caused by 3 “E”s:
○ Epilepsy
○ EtOH
○ Electricity
● Diagnose early to prevent long term complications
Physical Exam
● Arm held across chest, adducted, and internally rotated
● Flat and squared off
Imaging
● AP may appear normal
● “light bulb” sign on x-ray
POSTERIOR SHOULDER DISLOCATION

33. 1. Relaxation of patient with sedation or intraarticular lidocaine is essential
2. Reduction
○ simple traction-countertraction is most commonly used
3. Immobilization
4. Physical therapy
○ strengthening of dynamic stabilizers (rotator cuff and periscapular musculature
SHOULDER DISLOCATION: MANAGEMENT
Remember to repeat x-ray and check neurovascular status
post reduction
If NV injury, rotator cuff tear, etc. f/u with Ortho

34. ● Primarily older population after a low energy fall
Mechanism
● FOOSH, arm pronated limits abduction
Physical Exam
● Arm held close to body, mov’t limited by pain
● Tender, hematoma, bruising
PROXIMAL HUMERAL FRACTURES

35. 85% minimally displaced
● Most of these fractures can be managed nonoperatively, using a sling for immobilization, early ROM
exercises, and strength training.
● Early ROM crucial for avoiding adhesive capsulitis (frozen shoulder)
Consider referring to Ortho:
● If displacement > 1cm away, or > 45 degrees angulation
● If comminuted fracture (>3 bony fragments)
PROXIMAL HUMERAL FRACTURES

36. SUMMARY OF SHOULDER INJURIES
Mechanism Physical exam Diagnostic imaging Management Complications
AC Separation Downward blow to
shoulder
- Abnormal contour
- Pain usually over AC
joint
sitting/standing AP
shoulder
G1-2: Conservative (sling,
ice, analgesia, physio)
6 weeks before lifting
G3: refer to Ortho
Check for brachial plexus/
axillary n.
Clavicular # FOOSH/ direct trauma to
lateral aspect of shoulder
Tent deformity sitting/standing
upright, AP view of
bilateral shoulders
< 2cm displacement: sling
immobilization with gentle
ROM exercises at 2-4
weeks and strengthening at
6-10 weeks
>2cm displacement:
Refer to Ortho for ORIF
Pneumothorax
Rib #
Also check for brachial
plexus, axillary n.,
subclavian a./v, injury
Anterior
Shoulder dislocation
Direct trauma Slight abduction, ext
rotation
Apprehension Sign
true AP
scapular Y
axillary
Sedation, traction-
countertraction,
immobilization and
physiotherapy
Check brachial plexus,
axillary n.
Increased risk of recurrent
dislocation
Check for Bankart/ Hill-
Sachs lesions
Posterior
Shoulder dislocation
3 “E”s:
1. Epilepsy
2. EtOH
3. Electrocution
Slight adduction, internal
rotation
“Lightbulb” sign
Proximal Humeral # FOOSH arm pronated limited
abduction
sitting/standing AP
shoulder
Immobilization with sling,
early ROM + strength
training
Adhesive capsulitis