Wednesday, November 10, 2010

Shoulder Examination

The other day, I did not complete regarding the shoulder cases that I saw in the clinic with Mr Amin. Today Im eagerly would like to share the knowledge that I had. Today, after the session in the clinic had ended & I asked Mr Amin to teach us a proper way to approach shoulder pain.

In my oppinion, eventhough it wont be tested in our professional exam, but during practice, we need still need to know regarding this, right =)

Mr Amin said
"SHoulder is quite difficult for undergraduates & the examination is quite long. So things that Im going to teach today is the basic one" =)

1) Expose patient adequately. If male, ask him to take the shirt out. If female, expose the best as you can.
2) make sure the patient shoulder is at the same level as you especially if the patient is too tall or too short. You can examine in sitting position, facing the patient, but make sure the patient did not lean to the seat.
3) Make sure both ( you & the patient) are comfortable.

LOOK: ( Need to do from front, lateral & back. Make sure you compare with the normal side)

a) Contour of the shoulder - Shape & any swelling

b) Skin changes - scar, inflammation (redness)

c) Wasting of muscle - indicate prolong immobilisation
- supraclavicular region
- Trapezius, SCM, Deltoid, pectoralis

d) Deformity - any bony prominence such as prominent clavicle due to facture

e) Sulcus sign
- loss of normal shoulder contour with a visible step from the acromion process to the humeral head due to wasting & weakness of the deltoid / subluxation of the glenohumeral joint

f) attitude of both upper limbs
-shoulder internal/external rotation
-elbow flexion / extension
-wrist & fingers deformity

Lateral (go to patient side)
- Skin changes
- WAsting of deltoid muscle

Posterior (go to the back)
a)contour of shoulder

b) skin (scar/inflammation)

c) wasting of muscle
- suprascapular region
- trapezius, deltoid, supraspinatus, infraspinatus, latissimus dorsi

d) prominent medial border of scapulae
- winging of scapula
- long thoracic nerve palsy

Palpate along these structures & look for tenderness / feel for any abnormal bony prominence

( Initially stand infront of patient)
From sternal notch --> sternoclavicular joints --> along the clavicle --> acromioclavicular joint --> acromion process

(then, go to the back of patient, continue palpation from the point where you left)
palpate along the spine of the scapulae --> medial border --> tip & lateral border of the scapulae --> until back to the acromion process--> go to subacromion & palpate downwards the humeral head until mid upper arm

tenderness could indicate:-
- sternoclavicular/ acromioclavicular joint OA
- subacromial region for impingement

Ask patient to lift the arm upwards with elbow extend in few positions:-
Lateral position (normal position - 20 degree) - 0 - 180 degree
Flexion (0 - 180)
Extension ( 0 - 70 degree)
Abduction (0 - 180 degree)

then ask patient to do:-
Adduction ( 0 - 75 degree)
Internal rotation (0 - 90 degree)
Extrenal rotation ( 0 -90 degree)

Then go to the patient's back & ask patient to flex the elbow & move the shoulder like cycling. Do it simultaneously at both sides, gently & slowly ( but not too slow)
From the back, we put our hand on the scapula, observe & feel the movement.
Normal: there will be slight movement
Abnormal: if the movement is too obvious/marked
Suspect abnormality at the scapula - winging/long thoracic nerve injury

1) Instability Test (check for any instability - to suspect any dislocation)
a) Anterior drawer test
b) Posterior drawer test
c) With hand dangling downwards, pull the arm downward & observe for sulcus sign
Positive: multidirectional instability

2) Apprehension Test (anterior instability)
- abduct the shoulder & flex the elbow
- then slowly, externally rotate the shoulder
- when patient feels that the shoulder is dislocating anteriorly, he will resist the movement

3) Impingement Test ( empty can sign)
ask patient to abduct the arm
the hands do the thumbs up sign but facing downward (empty can sign)
while patient abducting the arm, we give patient downward resistance
Positive: pain felt at affected shoulder

4) Rotator cuff muscles test
a) Hawkin's test (test supraspinatus muscle)
- abduct the shoulder with elbow flex
- then slowly internal rotate the arm until patient felt pain
- do in few positions as you would like to test the whole supraspinatus muscle
arm abduct, lateral position, flexion
positive: patient felt pain

b) Napolean test (muslim's prayer) - test infraspinatus & teres minor
ask patient to put both hands on the belly like performing prayer
ask patient to push the hand outward & you give resistance to it
positive: patient felt pain at affected side

c) geber's test (test for subscapularis)
- ask patient to put both hands at the back
- try to move the hand upwards until the thumb reach the middle of the back
or you could ask the patient to push outward & you give resistance to it
positive:pain on the affected side

d) felt for biceps tendon tenderness

5) drop arm test
patient lift the arm up
alowly lower the arm
at around 105 degree patient will experience the arm is beyond his control
then arm will drop --> positive

reasons: deltoid muscle requires the intact rotator cuff to pull the humeral head towards the glenoid fossa & stabilise the humeral head to the glenoid fossa in order to allow a lever arm for further abduction by the deltoid
- with tear of the supraspinatus tendon, the leverage is not effective, therefore the deltoid is unable to hold the arm even above 90 degrees

Until here was our lesson with Mr Amin.
But I forget to ask, must we complete examination with checking the sensation
(autonomous area of axillary, radial, median & ulnar)


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