Dr. Ioannis Pappou, Physical Exam of the Shoulder - Florida Orthopaedic Institute

Thank you very much for the introduction for having me over here. My name is Ioannis Pappou. I'm an Orthopedic surgeon out in Palm Harbor doing shoulders and hands. I'll be talking about physical exam. Most of the time the physical exam saturated with a history, you have to elicit a thorough history. As the patient about the pain location what makes it better or worse. Nighttime pain and then also far associating your vascular symptoms such as weakness, numbness, tingling, prior surgery, if there's been any injuries, and also you have to take into consideration from the history the patient age and activity level because it factors in to do that decision making.

Also, the history helps you focus the exam because I'm going to go over an exam that contains tests for everything but most of the times from the history you can focus your exam based on that patient history is this the ability to focus on stability. The patient is middle-aged and there's no history of trauma. You're going to focus more on that rotator cuff and joint. So on a physical exam we have to start with the cervical spine. It's very common to have shoulder pain with cervical spine problems and it gets missed. So you have to examine the cervical spine then the rest of the exam is very similar to other exams. Even in orthopedic inspection per patient then there will be some specialized testing for the shoulder structures. That's what I'm going to call for a volunteer and then we're going to need to examine thoroughly the neurovascular status of the extremity from the shoulder to the hand in the cervical spine.

Got to look for range of motion and Spurling basically how much can the patient rotate the neck up and down. And with Spurling's What are you looking for, it's not it's not just how it aches. You have to have reproduction of pain from the neck down into the arm that the patient says yes this matches my pain because most human beings have some cervical problems, they mostly have some pain in the neck when they move their neck around a little bit particularly middle-aged patient. So you've got to have a reproduction of the patient's symptoms not just ouch. Then on inspection it is critical to expose the patients which is very commonly missed a lot of people don't make the patient undress and you can miss a lot of stuff.

So particularly for a first-time exam you have to expose the patient. You've got to look for the alignment, atrophy, scars, go into human rhythm, an active range of motion. So that he uses an example of malalignment of the shoulder. You can obviously see that the left shoulder is drooping. The clavicle stops there and then the rest of the shoulder girdle falls away from it. That's how the extra looks it's like coming into a very displaced clavicle fracture and that's obvious on physical exam they may even come to you with complaints of shoulder pain and this being maligned and healed in mild union that comes that sometimes appears to be an example of deltoid atrophy from a neurologic injury. Normal deltoid the other deltoid is a trophic you can basically see the greater tuberosity and coracoid right there. Or atrophy of the supraspinatus. That can happen in super scapula nerve injuries that can happen and with partners turner, brachial plexus injuries, or chronic rotator cuff tears. There's gonna be a side to side difference in that in the bulk of the supraspinatus and basically there's gonna be indentations. And unless you look at the patient from the back, patients they have like a natural elevation of the arm above the head, when there's rotator cuff tears or rotator cuff dysfunction what you see is hiking of the scapula.

So the patient will hike the scapula but then the arm will not raise much past that. So that's why we think that's when we talk about disrupted humeral rhythm is when this rotator cuff tears or other injuries that make your arm not abducting the glenohumeral joint. you will move the scapula but not the actual glenohumeral joint. Next patient our patient is not very useful in the shoulder it is more useful in other joints such as elbows wrists hands knees but in the shoulder join the most useful structure of the puppet is the AC joint. If there's tenderness in the AC joint we take that into consideration. The exam we're going to look for that on the x ray to make sure there's no Spurs or drives or the AC joint and we want to look for that if we do order an MRI, they're signaling the AC joint. The rest of the palpation you can pop they're going the humeral joint. You can pop it at bicep tendon the rotator cuff but they're not very helpful tests what is very important is to elicit the patient's passive range of motion so most patients will come to you with a painful shoulder.

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