So now we're going to move
on to the shoulder examination.
The shoulder is one of the most complex
joints in the body, if not the most complex,
because unlike the knee
joint and finger joints, etcetera,
it has three degrees of freedom, which means
that rather than just having flexion and extension
and maybe a little bit of torsion
that you can have with your knee,
this has flexion, extension, abduction, adduction,
external rotation and internal rotation.
So it's an extremely flexible
joint, which, of course, gives us
a lot of room to do a lot of
different things with our shoulder,
but it also provides a lot
of opportunities for injury.
In addition, it's the only place in the body
where a muscle is passing between two bones,
two bony structures, which,
of course aren't very forgiving.
If there's any inflammation
within that compartment.
In this case between the scapula, the acromion
part of the scapula and the humeral head.
So with that in mind, Shayla has graciously allowed me
to draw a tattoo of the shoulder anatomy on her arm,
and so we'll take a look at some important structures.
Whenever I'm doing inspection, I first am
just looking at both shoulders simultaneously.
I'm looking for any obvious asymmetry which
may indicate atrophy of the muscle groups.
I'm also looking to see if there's any step
off where the acromioclavicular joints are
to see if there's a recent
injury to the AC joints.
Atrophy may show up on the supraspinatus
areas if there's loss of musculature there
or you'll see some flattening
in the infraspinatus areas.
I'll also always add, if somebody has any
shoulder pains, particularly back shoulder pain,
that's a common place for shingles,
Zoster, you don't want to miss Zoster.
Make sure you have the patient
take off their shirt and put a gown on
so you can take a look
at the skin in the area.
With that, we'll move on to palpation.
So I like to do a full circle to get all
the structures without missing any.
So I'll typically start with the cervical spine.
Now, patients who have neck
pain, oftentimes it's radiating axial
axial pain can radiate from the
neck to the posterior shoulder.
And anytime somebody
complains a posterior shoulder pain,
I'm usually thinking about neck
disease, not shoulder disease.
So that's why I start over here on the
cervical spine to look for tenderness there,
the paraspinal musculature.
Then I'm moving over here to the supraspinatus.
Then I can feel the spine of her
scapula, which I'll show here in my model.
Here's the spine.
So I'm going above it for supraspinatus
and below it for the infraspinatus.
looking for any tenderness or
again, loss of muscle bulk in that area.
Then I'm going to move
along here to find the AC joint,
which is that nice, palpable groove that ends
the clavicle and where it attaches to the acromion.
It's typically around 4 centimeters proximal
or medial from the end of the acromion,
which I've shown here.
In my model here, the acromion is a
nice squared off section of bone there,
which is a part of your
scapula, your shoulder blade,
and you should be able to
very clearly feel this sulcus
between the end of the acromion
and the top of the humeral head.
And so I'm pushing on right
here to identify that location.
This is an important location for when
ultimately you may be doing a acromio-
forgive me, a subacromial injection of steroids or
lidocaine for the purposes of diagnosis or treatment.
I can also actually palpate this is representing
the head of the humerus, the supraspinatus,
the subscapularisis, the
infraspinatus and the teres minor.
I can actually palpate the supraspinatus
tendon if I bring her elbow backwards.
I'm actually bringing this
humeral head forward.
I can actually now palpate approximately
where her supraspinatus muscle is.
And so if there's soreness in that area, I'd be
more concerned about a supraspinatus injury.
I'll bring her her humeral head back.
You can sort of see what happens
there when I bring her elbow back.
You see that bony
prominence that pops forward.
That's the top of her humeral head and
this is where her supraspinatus is located.
Now, I'll move that back to where it was.
I've already done the AC joint,
so continuing to wrap around.
I'm moving along the clavicle here, ending
at the sternoclavicular notch right here.
One last structure that's worthy of mention
because it's in this area is the biceps tendon,
the long head of the biceps tendon.
I love my model here because
it really shows this quite well.
This is the bicipital
groove on the humerus.
And this little string here represents
the long head of the biceps tendon,
which runs along that groove,
goes deep through this groove
and ultimately is going to insert on the
glenoid labrum deep inside this joint.
And so while we think of this muscular
tenderness areas inserting perhaps out here,
it's actually really quite
deep inside the groove there.
But if I rotate the humerus internally and
externally, I'll actually be able to palpate
that cable, that tendon
underneath my fingers.
So I'm going to put my fingers right about
here and just rotating her arm in and out,
I can feel this tendinous structure
passing right underneath my fingertips.
And since the biceps tendon
can be ruptured or injured,
it's good to be able to identify
that on the physical exam.
So having done inspection and palpation,
we'll go ahead and do range of motion.
There's a quick way and a longer
way, we'll do the quick way first.
Shayla, if you wouldn't mind,
just touching the back of your head
and now touch the small of your back.
That essentially runs through
the entirety of range of motion,
and if a patient can do that painlessly,
I'm almost done with the shoulder exam
because whatever is causing them
pain, it's probably not the shoulder
if they can do those maneuvers painlessly.
Again, I mentioned that if somebody
says they have posterior shoulder pain,
it's probably not the shoulder.
It's probably a neck problem.
So putting that aside, I said there's a long way to
do range of motion, so we should do that as well.
So we're going to
demonstrate shoulder flexion,
which is bringing your
arms straight from your body,
Great, then putting your arms
like this will have you reach,
I'm sorry, just lifting your shoulders up.
That's a ABduction, abduction and
then bring your arms across your body.
That's ADduction, adduction
and now putting your arms out again.
We'll have you rotate up for external
rotation and then down for internal rotation.
So this is a good place
to pause and just highlight
that patients who have adhesive
capsulitis, also known as frozen shoulder,
they're going to have a lot of trouble with range
of motion and may not be able to get more than
30 or 40 degrees off from the ribcage.
So that's an easy, quick way to see if
adhesive capsulitis is at play, particularly if
that was active range of motion where
she was doing the work, but if I passively
can't get very far with range of motion, then that would
be a good a good indication for adhesive capsulitis.
Active range of motion ensures that
her muscles are doing the work.
And so you're stressing the
rotator cuff and all the muscles.
But passive range of motion, she shouldn't
be using any muscles or ligaments at all
or any muscles or tendons at all.
This is just me doing the work, so when I
have significant limitations in that regard.
I'm thinking about adhesive capsulitis.