Physical Examination of the Shoulder: An Evidence-Based Approach PDF
Preview Physical Examination of the Shoulder: An Evidence-Based Approach
Ryan J. Warth Physical Peter J. Millett Examination of the Shoulder An Evidence-Based Approach 123 Physical Examination of the Shoulder Ryan J. Warth (cid:129) Peter J. Millett Physical Examination of the Shoulder An Evidence-Based Approach Ryan J. Warth, M.D. Peter J. Millett, M.D., M.Sc. Steadman Philippon Research Institute The Steadman Clinic Vail , CO , USA Steadman Philippon Research Institute Vail , CO , USA ISBN 978-1-4939-2592-6 ISBN 978-1-4939-2593-3 (eBook) DOI 10.1007/978-1-4939-2593-3 Library of Congress Control Number: 2015934007 Springer New York Heidelberg Dordrecht London © Springer Science+Business Media New York 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. T he use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. T he publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper S pringer Science+Business Media LLC New York is part of Springer Science+Business Media (www.springer.com) Pref ace P roper diagnosis and treatment of the various physical ailments with which patients present to health care providers depends on accurate and effi cient history and physical examination. This is arguably never more important than in the evaluation of symptoms relating to the shoulder, one of the most com- plicated of all the bioengineering marvels of the human body, and one of the most common sources of patient complaints. The differential diagnosis of shoulder pain requires consideration of a very long list of potential etiologies that can range anywhere from bursitis and rotator cuff disease to cervical spine pathology in addition to any number of coexisting conditions. Appropriate performance and interpretation of the shoulder examination are essential skills that can answer many questions regarding etiologies, potential diagnoses and treatment options including sur- gical planning and postoperative management. This book provides an inte- grated approach to the diagnosis of numerous shoulder pathologies by combining discussions of pathoanatomy and the interpretation of physical examination techniques and was written for any health care professional or student who may be required to evaluate patients who present with shoulder pain. This information will allow the clinician to make informed decisions regarding further testing procedures, imaging and potential therapeutic options. The primary goal of this book is to provide readers with the knowl- edge and confi dence required to perform an appropriate examination and to generate a succinct list of differential diagnoses using an evidence-based approach. Vail, CO, USA Ryan J. Warth, M.D. Peter J. Millett, M.D., M.Sc. v Contents 1 About This Book ........................................................................... 1 2 Range of Motion ............................................................................ 5 3 Strength Testing ............................................................................ 39 4 Rotator Cuff Disorders ................................................................. 77 5 Disorders of the Long Head of the Biceps Tendon ..................... 109 6 Glenohumeral Instability ............................................................. 139 7 The Acromioclavicular Joint ........................................................ 183 8 The Sternoclavicular Joint ........................................................... 209 9 Scapular Dyskinesis ...................................................................... 219 10 Neurovascular Disorders .............................................................. 241 Index ....................................................................................................... 271 vii About This Book 1 The primary purpose of this book is to provide a E xamination of the shoulder has historically comprehensive guide for anyone who is required been stigmatized as being overly diffi cult or to examine the shoulder. An online version of this intimidating, especially for the inexperienced book is provided for easy accessibility. investigator who has yet to develop the necessary While many books serve as an exhaustive list fund of knowledge to adequately evaluate shoul- of all the available shoulder examination maneu- der function. As a result, imaging studies have vers, few have undertaken the task of developing been relied upon to make diagnoses that should a text that both simplifi es and illustrates the most have been made during the initial physical exam- important pathoanatomy, procedural elements, ination. There are numerous factors that may be and clinical data involved with physical exami- involved with the perceived diffi culty of the nation of the shoulder. The goal of this book was shoulder exam: to present the most relevant clinical data and 1. Factors in the patient’s history are often examination maneuvers in a digestible, predict- nonspecifi c . able manner such that the application and inte- The nonspecifi c nature of many historical gration of the presented techniques can occur fi ndings is particularly frustrating for the inex- quickly and seamlessly. perienced clinician. This is especially true for A lthough there have been numerous indi- physicians who are forced to care for patients vidual studies evaluating the usefulness of the with musculoskeletal problems without the various shoulder examination techniques, it is necessary training. As an example, a patient nearly impossible to understand which maneu- with an anteroinferior labral tear (i.e., Bankart vers are the most relevant without a complete lesion) may present with a sudden onset of systematic review of each technique. This book sharp pain with movement, a gradually inten- provides a literature review that iterates the sifying dull pain or even the absence of pain in relative utility and effi cacy of the various phys- some cases. This highlights the necessity to ical examination maneuvers and provides guid- perform a complete examination in each ance as to which techniques are most important patient with a shoulder condition such that for each individual diagnosis or series of diag- notable and potentially problematic condi- noses. In addition, we provide an evaluation of tions can be identifi ed and properly treated. current research surrounding the different 2. Physical examination fi ndings commonly examination techniques thereby identifying overlap across multiple pathologies. knowledge gaps upon which improvements can There are many shoulder pathologies that be sought. present in similar ways. For example, the R.J. Warth and P.J. Millett, Physical Examination of the Shoulder: An Evidence-Based Approach, 1 DOI 10.1007/978-1-4939-2593-3_1, © Springer Science+Business Media New York 2015 2 1 About This Book active compression test, initially developed tis, rotator cuff tears, labral lesions, acromio- for the identifi cation of labral pathology, is clavicular pathology, and/or various fractures also sensitive for acromioclavicular joint among a long list of other potential pathology in certain patients. The identifi ca- pathologies. tion of biceps tendon pathology and SLAP 5. There may be multiple coexisting conditions tears can also be diffi cult since there does not that present similarly. exist an examination maneuver with adequate O ne of the most diffi cult aspects of the sensitivity and/or specifi city values. Although shoulder examination is discerning the fi nd- a positive test can be useful in many cases, it ings of different pathologies that may be pres- is important to recognize the ability of each ent in the same patient. These fi ndings may test to detect various other pathologies. This overlap on many occasions, forcing the inex- book will identify these discrepancies and perienced clinician to guess at the correct provide strategies for the avoidance of diagnosis. This book will provide the reader confusion. with the tools required to make these impor- 3. The utility of palpation is limited due to over- tant distinctions thus allowing for an accurate lying muscle and fat. diagnosis and the development of a focused, The deltoid is a large, thick muscle that structured treatment plan. often precludes the ability to palpate normal 6. Signifi cant pathologies may be asymptomatic. or abnormal structures around the shoulder Sometimes the most important historical complex. Even though palpation is diffi cult, fi ndings are those that do not exist. This is it is still a necessary portion of the physical especially important for shoulder conditions examination process as there are certain that tend to progress over time—the devel- clues that can be obtained with superfi cial or opment of symptoms often go unnoticed to deep palpation. Another diffi culty is that the patient for a signifi cant period of time. deep palpation may engender pain as a result However, it is still important to recognize of the pressure from the examiner’s fi ngers how these pathologies affect the patient’s rather than from the pathologic process. This shoulder function. Thus, it is always impor- is especially important when evaluating tant to complete a full, structured examina- anterior shoulder pain as a result of coracoid tion even if the patient denies symptoms. impingement—deep palpation of the cora- One important example is that of rotator cuff coid will generate pain in most patients who disease. While it is well recognized that the are not extremely thin; however, this may or prevalence of rotator cuff disease increases may not be the result of subscapularis with age [ 1 –3 ], the development of symp- impingement underneath the coracoid toms does not always follow this pattern of process. progression [4 ]. However, studies have 4. Specifi c pain patterns are variable and have found that patients with asymptomatic rota- not been fully defi ned for the shoulder. tor cuff tears develop changes in glenohu- In most cases, the precise location, inten- meral range of motion, changes in shoulder sity, onset, timing, and quality of shoulder strength [ 5 , 6 ], and changes in radiographic pain have not been fi rmly attached to any spe- parameters [7 ] . As the tear biology changes cifi c diagnosis. Although certain pain patterns and progresses, symptoms may eventually are helpful and may lead the clinician to per- become noticeable and potentially disabling. form certain maneuvers, this information A study by Yamaguchi et al [4 ]. found that should not be considered a reliable indicator patients with asymptomatic rotator cuff tears for any one condition. As an example, anterior developed symptoms at an average of 2.8 shoulder pain can be the result of osteoarthri- years independent of whether an increase in
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