- Hello, my name is Dr. J. Michael Bennett. I'm an Orthopedic Sports Medicine
Physician with the Fondren Orthopedic Group, and today I wanted to put together
some basic videos just explaining exactly what happens in the doctor's office
regarding the physical exam. A lot of times patients will come into our office
and we'll run through a series of different tests. You'll hear us using
specific names for those tests, or you'll see us typing in on a computer, or writing
them down. A lot of times patients don't really know exactly what's going on or
what we're looking for. I wanted to go ahead and clear away a little bit of the
mystery behind that and go through exactly each test, and what we are looking for
with each test, and why we do those tests. So today we're going to specifically focus
on the shoulder exam. The initial shoulder exam begins just by inspection. You want
to look at the shoulder and see exactly how the patient's standing while relaxed.
Sometimes the patients can be hunched upward, sometimes they can posture a
little bit, raising they're shoulder. Sometimes you can even see a little muscle
atrophy where the muscles seem to be a little bit smaller on one side compared to
the other side. You can even see sometimes deformity if you have a fracture or broken
clavicle, bruising or swelling. You may even see a little bit of a discrepancy in
regards to the scapula in the back where the scapulas tends to stick out a little
bit more. All these are very important in regards to the physical exam. So first off
when we evaluate a patient, we just look at their shoulder generally speaking. The
next thing we want to do is look at their range of motion and see what they actively
can do on their own. So we have them start by going for forward flexion, all the way
up as high as they can, and usually we'll use a little tool called the goniometer to
evaluate exactly what that measurement is, and it will tell us exactly how many
degrees of motion that they have. If they have full range of motion they
come on back down, they come on out to the side all the way up, all the way up, come
on back down, we usually have them put their arms at their side, rotate outward,
and then they rotate behind. Okay, that gives us all plains of motion, forward
flexion, abduction, external and internal rotation. If we see any discrepancies,
that again is another sign that something is pathologically wrong with the shoulder.
It could be a stiff shoulder, it could be a rotator cuff tear. The next thing that
we like to do is evaluate their muscle strength, okay. Have them put their arms
at their side, have them gently push out, have them gently push in, have them hold
their arms up with their thumbs down, and hold up and resist, okay. That actually
looks at the strength regarding the external rotators of the shoulder, the
internal rotators of the shoulder, as well as the deltoid, and the supraspinatus
tendon. When they're actually turning their thumbs downward that actually
isolates the supraspinatus tendon so it actually will show us the strength. So if
you have a patient that has a acute rotator cuff tear, they'll try to resist
you and that arms going to fall at their side, or they may just have a rotator cuff
bruise or an inflammation. The next thing you in the physical exam is palpate. And
it usually starts with looking at the shoulder and you palpate the bony
prominences across the shoulder. You start with the clavicle, you push across the
clavicle over to the acromioclavicular joint here. If you have a patient that say
was a football injury or skiing injury where they're land directly on the
shoulder, sometimes you can get a discrepancy right at the AC joint here,
where you'll see the clavicle higher than the acromion, and you'll see a lump there.
Sometimes you can get just a sprain there. This is also where you're going to see a
clavicle fracture. If you see a little bit of a bump right where the clavicle is
or some swelling or bruising, that is indicative of an injury at the clavicle.
Next thing we do is we palpate the biceps tendon which is right around here. This is
the long head of the biceps tendon and it actually extends from the top of the
shoulder all the way down to the biceps muscle, and then you have another tendon
down here to the elbow. Sometimes you can have a biceps rupture
where as a patient will be lifting something heavy, they'll feel a pop and
then they'll have some swelling here, and then they'll have some fullness of this
biceps, we call that a Popeye deformity. So that's actually something we look for
in the physical exam as well. Then, we just kind of push out here to the
tuberosity region to see if there's any injury to the tuberosity of the shoulder.
That may indicate a fracture or a rotator cuff injury as well. The next thing that
we do is a series of specific tests that we use to isolate certain areas of the
shoulder. The first test we'll do is we abduct the shoulder and have the patient
relax, and we just torque the shoulder just a little bit in different angles or
across the body. This is called a Hawkins test and what that does is it kind of
rotates the humeral head underneath the acromion, and if you have any inflammation
or rotator cuff injury that'll be painful to the patient. The next thing we do, is
we have the patient bring their arm up to their side with their thumb down again,
reach all the way across their body like this, and then have them resist us, okay.
And if you push directly down, and they drop their arm, that's a positive Obrien's
Test and that can isolate the rotator cuff again and tell us if they have a rotator
cuff problem. The next thing we want them to do is rotate their hand upward, hold
their arm forward flexed like this and resist, okay. This is a Speeds Test, this
isolates the long head of the biceps, so if you have an injury to the long head of
the biceps they'll have pain and they'll drop their hand, okay. The next thing we
have them do, is reach across their shoulder and scratch their other arm. If
they can do that without pain then that means that their AC joint is okay. If it
hurts them when they do that usually that means that they either have a clavicle
injury or an AC joint injury, sometimes a biceps injury as well. The next thing we
do, we have them push in on their belly, stick their elbow out, and hold their arm
out as strong as they can. If they can resist you without pain then
you know the subscap tendon is okay, which is the tendon in the front of the
shoulder. Sometimes if you have a patient that has a subscap tendon tear, they will
not be able to bring their elbow out to their side, and will not be able to push
down onto the belly, okay. The next test we do is, if you have a patient with a
history of dislocations or instability of the shoulder, if they bring their arm out
to the side abducted, and you put a little bit of stress or pressure out here in
different angles here, it creates a what we call an apprehension sign. That means
that it feels like the shoulders going to pop out of joint and they become very
uncomfortable when you do that position. If you do have a patient that's had a
history of dislocations I do not recommend that you do that with a lot of stress,
because you could very well create a dislocation in the clinic. So if they're
at all apprehensive in that position, that's a positive apprehension sign. The
next thing you can do is have the patient lay down on the table and you can evaluate
their shoulder stability. You have the patient gently abduct their arm to their
side, and you gently put some stress on the posterior aspect of the elbow, and see
if the elbow slides in and out of the glenohumeral joint. You can do that with
abduction external rotation, you can do it also with inferior translation, okay.
There's another way of doing this as well, is having them sit at their side and
seeing if you can stress it downward. Sometimes if you have patients that have
multidirectional instability or a very loose shoulder, you'll see what's called a
sulcus sign, where you pull down on the arm and you'll see an indention in here at
the acromion here as the humeral head subluxates inferiorly. Like I said before,
if you have a patient that has multidirectional instability or a lot of
laxity in the shoulder, be careful with this exam because you could very well
create a dislocation if they're very loose, or if they have any incompetency
regarding the glenohumeral joint. So these are just a few of the basic exams
regarding the shoulder and what we're looking for when we're doing the shoulder
exam. So hopefully that'll help and if you have any questions or comments please feel
free to go to our website or call our office at 281-633-8600. Thank you.