Primary care visits for shoulder issues are an everyday occurrence, yet diagnosis can be challenging due to the joint’s complicated anatomy and the numerous possible causes of pain – some unrelated to the shoulder. In this video, orthopedic surgeon Justin Krogue, MD, helps PCPs efficiently assess the complaint, with tips on how patients typically describe specific injuries, valuable questions for history-taking, and simple hands-on tests to perform in the exam room.
I'm just in Kroger's Michelle said I'm a general orthopedist here at UCSF, I'm primarily based at Redwood shores. We have a new location in Redwood city as you may know. Um and then I do surgeries in SAn Francisco um actually have an interesting practice where I also do halftime at google. I'm working for their health aI division, doing research and medical technology but I have to talk about that as well. Today, I was going to talk about the painful shoulder, this is something I'm sure you see tons of and I'm sure all experts in so I apologize for what is largely going to be, I'm sure just a review but hopefully there's gonna be a few nuggets in here that's useful. Um I certainly love the shoulder. So um if anything, I guess I'll enjoy the presentation but hopefully there are some parts here that are useful for you all as well. So, you know, I talk about the shoulder for one, I think that the shoulder is interesting in that it seems to capture a weigh heavily on kind of the imagination of people generally, I was looking through as I was preparing for this talk, thinking about all the different ways that we use shoulder right? In a metaphorical sense. And I found just five or six examples here. So here's, you know, talking about shoulders, an example of like a metaphor for strength here is a, you know, well known quote by Isaac Newton, that kind of refers to shoulders is almost like the, you know, the heights reached by somebody metaphorically here is you know, leaning on a kind shoulder right? Someone that can support you and offer emotional help for that perhaps. Um This is referring to you know chip on your shoulder as obviously you have an attitude or you may be a little bit more abrasive. And then this is a classic reference to a cold shoulder where you're maybe not very kind to someone else. So for some reason I feel like at least amongst M. S. K. Body parts there aren't many other there aren't many other places around the body that have as much. I feel like I use a metaphorical as much metaphorical uses the shoulder to the knee or the hip or the ankle. I've talked about this many different ways. Um which is interesting. The other reason for talking about the shoulders I think I have always found it um personally very challenging. I think it's a very common region that people have complaints. As you all know. The prevalence of shoulder pain is between 16 and 26%. So about one in five people at any given time will have shoulder issues. Third most common cause of M. S. K. Consultation and primary care. Um It's also very tough I think so it's very common but unfortunately the shoulder as opposed to some other body parts for example would be the knee. Um It's actually a pretty complex region with a lot of different anatomy contained their end and it's always it's not always immediately clear what the patient is referring to. In addition, it's also one of the most common places where there are other things, not even in that, you know, again, relatively complex anatomical area that can cause pain in that area. That makes sense. So you have the double problem of trying to, for one disentangle, a relatively complicated portion of anatomy and then also understanding that there's, you know, neck and heart and other issues that can cause pain that don't even originate in this complicated portion of anatomy. So I want to break it down by talking about the anatomy a little bit, the history, history, physical. And then really just basic touch on imaging to figure out how we can perhaps approach the shoulder in a more systematic way and more reliably by the end of our examination come to a pretty useful or come to a pretty um defined differential in terms of what's causing this patient's issues. So, in terms of anatomy, motivation says they have shoulder pain. I'd like to think about this for me, at least, I think when someone says they have shoulder pain, they could really mean anywhere from between essentially the sternal clavicle, a joint to the mid humerus is painful. And within that, right, there's a lot of different anatomy that is contained. And so the first step of any, you know, history obviously is actually honing in on where exactly are they actually hurting. Um and where do we think is likely involved? And I know for me personally, at least I oftentimes even get to the exam before I realized actually I haven't even honed in on where this patient actually is having pain and therefore my exam feels, you know, unguided and perhaps not focused. So it's always good with the history to kind of hone in on that. So for the bones, right? Obviously have the clavicle, you have several joints, uh most of which are synovial joints. And then you have one that's just an articulation, but you have the A. C. Joint, you have the humerus joint. Um and you have this particular joints that perhaps it may be more chest and shoulder, but still in kind of the same shoulder girdle. And then you have the scapula, thoracic um you know, interface not not a true synovial joint, but the interface between the ribs. Um the scapula, these are kind of the joints right in the bones that are involved in the area of the shoulder. And then for the kind of muscular muscular anatomy, there's a lot, right? There is the, obviously the rotator cuff, we all know about the four muscles of the rotator cup or, you know, classic shoulder complaints, but there's also all of the kind of paris scapular musculature and also the para spinal muscular church. So things like the Deltoid biceps trapezius pec major. Um And then the things in the back of the scapula like the ram Boyd's. Um, we also have the serrated interior logistics Dorsey, the Teres major. And these are all things that can hurt, right? And these are all, perhaps some of these actually can have, you know, they're, they're well defined syndromes if you will, well defined presentations that we talked about a lot like a superior cup tear that we have all these exam findings that we think about all the time. But it's possible to have strains and pains in any of these muscles. And so sometimes things just don't fit a typical pattern because they have, you know, they have strained their systems door side, right? And that's just, you know, that can happen to any of these muscles can become strained. And so it's important that keep those kinds of things in mind as well. And then there's the masqueraders, right? So we already talked about there's all these muscles, there's all these bones um, in this area, there's a few joints, but there's also really, really solid um, masqueraders for this problem. So in the case of the neck right, there are two entities that really cause shoulder issues that come from the neck. One is ridiculous. I think as we think about first and foremost when we think about neck cause neck, um, next or originally from the next shoulder pain. And that's obviously we have a nerve that's pinched typically in a, in an area of arthritis, um causing pain radiating down the arm, But the other one that we don't think about as much, I don't think is um ketogenic pain. So you have in the post your elements of the spine with arthritis, you likely have some preset arthropod the and those percent joints are not. Um They are innovative, right? But in in similar fashion to a lot of deep structures in the body, right? They we feel that in a very vague fashion. So these are on the left showing kind of the german terms in which you feel um pain from different points. And you can see especially C. 45, C 56 and C 67 really kind of lay perfectly on the posterior aspect of the shoulder. So very very common when people come in with post your shoulder pain um that it can actually be an issue. Just not even a pinched nerve, just arthritis of the neck and something to keep in mind for sure. And then there's, you know, things that you all know much more about than I do, but for example, we all know that heart attacks can radiate to the um to the arm, to the shoulder. And then, you know, pan coast here on the X ray. Obviously we crush them shoulder pain as well. Other weird things would break complex sympathies and um other, you know, rare entities, perhaps perhaps more rare than than common, but still things to keep in mind for sure. So, when you think about the differential from the start right of a shoulder issue, I break it down into intrinsic and extrinsic and intrinsic here. I've kind of listed just the most common ones but a si joint, a very common issue or cause of pain, rotator cuff humor, all joint biceps tendon, specifically the long hand that originates in the shoulder joint infection and fracture. And the for extrinsic causes, I think about referred pain, certainly nerve as we've talked about or neck in terms of the Northrop athey, cardiovascular and then diaphragmatic. And then there's also things like, you know, Paula manager of attica or a malignancy that can cause pain in the shoulder. So, having said that, and kind of broader differential to include a lot of different things and distinct entities. It is important to remember what's most common and the four most common causes of pain in primary care, at least. According to this paper, our rotator cuff disorders, disorders, criminal vehicular joint disease, and referred neck pain. And in my practice, I think that anecdotally least is very true. I think you see rotator cup a lot. I think you see human joint arthritis rotating arthropod, the a lot you see a si joint or apathy a lot and certainly see a lot of referred pain. In fact, that's something I see amongst the most common things. I see, I think at the top of that I would throw in biceps tendon pathology is another very, very common things that you see and I, you know, I don't have exact numbers to take this down, but I would guess that 90 95% of patients for shoulder pain may belong to one of those categories of ideologies. So starting off with the history, I think actually as opposed to somebody systems or at least musculoskeletal locations, I think the shoulder is an area where you really can make a lot, a lot, a lot of progress with the history and I think it's key because the shoulder exam has so many different kind of special tests and um provocative maneuvers that you can do that if you don't go into the exam, having a pretty good idea of where this problem is and maybe even what it is, I think it can be hard to know how to kind of focus that exam, either it takes really long or it just feels very unfocused, so the history is really critical and so anytime you have an upper extremity complaint, I think hand dominance is actually really important to get that may give you a sense of ideology of pain for sure, in terms of, it's just something that's been used a lot, but certainly gives you a good sense of the impact that this problem has, write a um a problem in the dominant shoulder is much different than the problem in the non dominant shoulder additionally though, you know, the occupation is similar um and it's important just telling you both maybe the ideology, but also the impact that this thing may have. You know, a dominant um a painful lesion and the dominant shoulder of a laborer right is a much different thing than a non dominant shoulder of a software engineer in terms of its impact on life. Um location I think is actually one of the, you know, I have a lot of things listed here in history but the location here is bold and I think that's that is intentional because location is actually really critical. You can get a lot just from the location of pain. Um specifically here, I've highlighted that post ear pain is rarely intrinsic. So if they have post your shoulder pain right away, I began thinking about, you know, non shoulder organic causes of pain including as mentioned before, photogenic back pain and other causes, but rarely is that from the shoulder, you know itself in terms of the bones and anatomy of the muscles of the shoulder onset is important. Both, you know how it came on and how quickly it came on its course. Whether there's night pain, payment positions, pain with use in certain areas, whether there's weakness, loss of range of motion. Obviously the typical things like provoking alleviating factors whether or not there's any systemic symptoms or pain with other locations or you know what in terms of provoking factors, right, whether this pain is provoked by moving the shoulder or perhaps moving other things, right If they have pain in the back of the shoulder and it's provoked with certain neck positions that certainly clues you in right away, that maybe it's not from the neck. And then obviously a focused past medical history can be useful as well. So honing in on specific or some of those most common diagnoses and what the history might look like. So when you look at the A. C. Joint and this might this can happen anywhere from adolescence to middle age. Really pretty broad range of ages. You see this and you know, this is very simple but they will have pain in the A. C. Joint and that's their complaint. That's a pretty specific spot. So that's something in history that you can really hone in on. They have anti your pain and they'll point right to that kind of bump at the front of the shoulder, rotator cuff can be, you know, get an age from young in the case of the traumatic tear, perhaps to the elderly in case of degenerative tearing. And this is pretty classic classically presents with anterior lateral pain pain in the front and the side of the shoulder, difficulty, overhead activities, difficulty sleeping on that side. And then they will describe often both a weakness and also lost the range of motion so they can't move it as much and they are also weak Glenna humor arthritis, another very common cause of pain is described as kind of a deep pain. It's hard to localize as opposed to like a si joint pain which is pretty easy to localize. Um This is often felt the answer and posteriors, this is one exception to that, you know, posterior pain is rarely um shoulder and origin arthritis can certainly cause posterior joint pain. So you can have that with arthritis and then lost the range of motion and critically with arthritis as well and you have the insidious onset that this has been going on for a year more than year, no specific trauma and that came on. Um Other common things that we see adhesive capsule, itis obviously this presents with the loss of range of motion pain is more of a minor component in this scenario though, it still can be very painful as you know. Um And then for range of motion specifically they see external rotation is typically the first and most profoundly impacted direction. And one thing that's interesting is if you really dig into the history, you often will uncover in the case of adhesive capsule, itis some kind of trauma and may be incredibly minor, like even just a fall or prolonged immobilization. Um but they often can remember, so you may think, well it's minor, you're just kind of reaching in its confirmation bias. You have this diagnosis, you suspect you find some minor trauma but these are traumas, they do remember, it will be six months out and have this pain, you know, six months ago, I fell into my shoulder. Um, and obviously there was no fracture, there was no tear or anything, but it's something that is enough to remember, but not enough necessarily to prompt medical evaluation, but that is certainly a big clue in your history, that that could be what's going on. Biceps tendinitis, kind of like a si joint. You're gonna have pretty well localized pain right at the front of the shoulder and then you're gonna have things in which you're using kind of form super nation are gonna provoke pain. Things like opening cans and jars, something's working overhead, depending on the position can cause that pain and it's right in the front of the shoulder. Um, kind of specifically where the biceps tendon is and then as mentioned before post to your shoulder blade or pain radiating down the arm, you think of neck. And certainly in the case of, you know, patients are not, you know, they don't read the textbooks right, They don't know how to describe their pain perfectly. And often with rotator cuff, for example, say, you know, it hurts here to here. So it does, there is some radiation, but if it does radiate past the elbow, that is pretty um, you know, classically, we say that is not from the shoulder radiates past the elbow, that that should not happen. Obviously there are cases where that's still the diagnosis, but in general it's radiating beyond the elbow. You you should think primarily about ridiculous apathy as a cast. So for physical examination and they've got a history. Hopefully from that you you may not have exact diagnosis differential, but you hopefully now know in terms of the anatomical location, what you're really thinking about it is it is a clavicle. I see joint, joint proximal humerus, is that this particular muscle group kind of honed in and then you can focus your exam again, doing somewhat general exam, but focusing on what you think the actual problem is. So with the shoulder in particular we do start the visual inspection um and it is nice if the patient has either under garments was comfortable and get them in again and actually take a look visually at the shoulder musculature because you can actually tell a lot just from comparing the symmetry from the normal um to the affected side. Um So I would look at the inspect both sides, looking for symmetrical bulk um on both sides. Then you go into palpitation palpitation things, we'll talk more specifically about this. And then I do range of motion testing. Active first and then if activists full clearly pacifist full time to do that. But if it's not full then you would you pass a range of motion and we'll talk about why that's important. Then strength testing. Typically always including the rotator cuff potentially including other things depending on your suspicion. For example, if you have neck issues, you want to test just the groups of the shoulder, like deltoid biceps triceps for six dancers, all those. And then there's a special test which you'll include on a variable basis based on what you think potentially is going on. So for inspection, remove their shirt, I would take a look on both sides. Some things are very obvious on the top. Obviously you see the Popeye deformity of the proximal biceps tendon there. Um And on the bottom you can see a sprung clavicle right from a high grade A. C. Um separation. And then I would do you know, but it's important to be systematic and look at the bulk of the musculature. These are obviously too, you know, very obvious examples and maybe someone in common but even with more subtle things like rotator cuff tear or Glenda humor arthritis, you often will notice the difference between the infected and the uninfected shoulder just because of this. Use pain with use that leads to the patient doing less right and then leads to less musculature, muscle bulk. And then there are specific changes you might see um specifically in the back of the shoulder in terms of the bulk of the super versus interest that could clue you off in the more rare things like nerve entrapments get more rare but also the inspection can actually nail the diagnosis almost on its own at times with those. So inspection is a good place to start. Not to forget for sure with the shoulder exam for salvation will typically be behind the patient at this point and look at their shoulders and then I'll you know let them touch them and I put my finger on the clavicle, walk the clavicle to the A. C. Joint. That's a classic spot of pain. So I'll make sure and ask when I touch there if it causes pain or also ask is this where your pain is when you do feel it if my tax doesn't provoke it and then when you go just lateral to the A. C. Joint will be on the chromium. That can be a source of pain as well. And things like an autistic reality where you have an unused um a chromium ossification center um and then I'll walk right off the side of the chromium. If you do that, you can feel the edge of the chromium will be right on top of the approximate humorous and that's a common spot to have a rotator cuff tear. So pain at that kind of superior cup site is a with with palpitation is a good indicator that that could be what's going on. Additionally, you'll if you do this a lot, you'll get a good sense actually when they have a really large rotator cuff tear and you feel right at the moment in that same spot, you can get a pretty good sense of how much coverage that human head has. So they have a very large rotator cuff tear for example, and especially if one side is normal. One side not, you can feel actually um you know, the humor will have to be much more prominent with much less soft tissue coverage than on the other side, where you might feel kind of a a healthy muscle bowl surrounding the shoulder. It's obviously a just a feel thing. But if you do a lot of these, I'm sure you do. You definitely can get there where you feel, you can get a sense for how much soft tissue is surrounding the human head. The bicep tendon is a very important one to help you can basically, from behind you can do from behind your front, but behind it, I think easiest, and you just kind of roll that tendon under your finger and you can feel that essentially every single person, no matter how large you can, I guess, I shouldn't say always, but almost almost always, you can feel that bicep tendon and that is a again, a very common cause of pain and actually um, a huge help in diagnosis is that, you know, you can touch right there and they have either that provokes pain um or it reproduces exactly where the pain is. That certainly helps a lot and that always does cause some pain. So I do that always at the same time as the other shoulder to make sure that it's actually causing more pain than is normal. Um And then also the anterior posterior joint line started the class. We will go to the A. C. Joint, the chrome man off to the off to the superior cuff and approximate humorous then to the entire biceps and then kind of feeling both the interior and post your joint lines. Once you finish with inspection and palpitation you can move to range of motion. So there's kind of four, there's a lot of different ways to test the shoulder because it is so mobile. You can test different motions in different positions. But in general I think there are four kinds of main arcs to do that work well for most patients and that is for reflection all the way up. Abduction, all the way to the side, all the way up, external rotation at the side. You can also do this at 90°. It doesn't add a lot of value. So doing it at the side is totally fine. And then internal rotation is that you know the one that's a little more complicated just because it's hard to test at the side because your belly gets in the way. So the way most people do this is just seeing how far up their back they can go. Um and that gives you a sense of how much they can internally rotate. Um and these are some of the normal values. So most people, you know normal quote unquote should be able to get almost 180° both in for reflection. An abduction, you can see I have slash 90 there in abduction. That's because really you're getting 90° of Glenna human abduction and the other 90° or so comes from the scapula, thoracic um Um interface. So if you actually stabilize the scapula, have them raise their arm up, they'll get a little above 90 potentially with humor joint. But then the rest of that motion actually comes from the scapula coming up. Um And then for internal rotation we kind of measures mentioned with the the amount the number or where they reach in terms of the thoracic vertebra and here is just a best estimate based on, you know, the landmarks that that you know, in terms of where things are located. So if they're active range of motion is okay, then, you know, their past will be fine tune, you can move on. But if the active is not okay, then check the passive motion in the same planes with the same maneuvers just with you yourself doing it. Um If passive active is bad, but passive is okay, you can think about a rotator cup there, that's a a probably the most calm or most likely ideology of issues if that's the case. If they're both bad, right? When you think about frozen shoulder for sure or arthritis and now they have not just, you know, an active limitation how far they can move because of some weakness, but the shoulder joint itself is contracted. And that could be from as mentioned frozen shoulder arthritis. It can also be from a longstanding rotator cuff tear. Right? If they haven't had therapy or haven't moved that shoulder in a long time, they can certainly also develop a contractor. But even in that case, typically still the active loss will be worse than the passive loss. Whereas in frozen Children arthritis, you expect those both to be about the same. Um other range of motion testing as you're doing this, especially with kind of that forward flexion motion. Um as they're coming down, you can assess either for a painful art and for for a drop arm so painful arc is that as they kind of lower their shoulder, raise it or lower in between 60 and 120 degrees, they have some pain and then drop arm obviously as they're actively lowering their arm in that same range, they actually have a painful drop, They're unable to keep it up themselves. But both of these are actually relatively um um sensitive, you know, these are all moderate in their performance but these are relatively sensitive tests for rotator cuff pathology. So when I'm doing my examination as they come to the top and I'll make sure and tell them to go down slowly from the top and kind of this in the scapula plane and watch for painful arc and drop arm sign. Once you're finished with the range of motion. Obviously moved to strength. As mentioned that almost always do a rotator cuff exam because it is so common and then you can do other strength as you feel indicated to do. Um So the tested four different muscles of the rotator cup for the super the super spin. It is, there's a number of different ways to do this in the literature shows that you know the classic things we talked about in terms of thumbs down thumbs up. Not necessarily all that important. But what is important If you abduct their arms in the plane of the scapula which is about 30° anterior to the coronal plane. And then you resist you know further abduction with the arm and you're looking for obviously weakness but also pain. Um and they are painful week with that you're thinking perhaps superior cuff right? Might be impacted for infra for this one. You can test it just at the side of external rotation. And this is typically the way that I'll do my um that's all the external rotation testing that I'm doing that I'm doing. But if they do have a slide on it, I actually don't if they do have specific external rotation complaints you can also do um Extra rotation at 90° up here and that's more specific to the Terry's minor. You think about that anatomically as that's beneath the interest that inserts lower on the humerus and as you abduct that that brings a kind of more in plain with that motion. So theoretically at 90° of abduction. With external rotation. You are testing more specifically the Terry's minor versus the interest is but obviously you're doing both in both cases. But those can be used if you have a suspicion that one or the other is more problematic than than the other. Um The infrastructure. This is much more commonly torn than the terry's minor. And that is because you know tears are most common complication of rotator cuff tear is a superior cup and then it kind of moves backwards and forwards and so as it starts in the super spin it as it moves backwards it will get into this into this. But it would have to go through the entire interest before it got to the terry's minor. So that's the reason it's less common. It is also of course possible to have isolated tears of the interest or the terry's minor. But those are just less common. So for that reason you know I think you know extra rotation decide is a good default test to do and then you can obviously add in the additional Extra rotation of 90° if you are suspicious for that sub scapular testing just like the internal rotation testing is a bit more complicated just because again your belly's in the way of of doing kind of a good internal rotation strength test. So there's a few different ways to do this. I've shown to hear one that I think most of us UCSF because it's just really easy and has been shown to be as reliable as anything else, is the bear hug test. So you have them grab their contra lateral shoulder with whatever arm you're testing asked them to keep that shoulder down on their body and then you apply kind of you know, an extra extra on the rotating force to the shoulder trying to raise it up and ask them to keep their fingers on their shoulder. And if they're normal they can actually mean effectively, you can raise them up, you can pick them up with that arm and they'll stay firmly planted on the shoulder is very very strong. So if you if you get even a little bit of the hand raising up, certainly if it comes off that's weak, but even if the hand is raising up and they'll be indication of weakness with the caveat it may be painful which can cause some weakness right without actually being weak. So that's the one thing with all the strength testing figure out. Is is it actually week or is this motion for whatever reason painful and therefore they're weak but certainly normal is being able to really maintain your hand solidly on there. You can also do the liftoff test which is which is um you put their hand behind their back, right? And you ask them to push um push against your hand as you put their hand behind their back. Or alternatively you can also just pull their hand off their back and ask them to keep it there. And if they're not able to keep it there, that's kind of effectively not even anti gravity strength in terms of strength testing if that makes sense. So a you're not necessarily able to dynamically grade their strength with just kind of that that version of the liftoff test but can give you a sense that there is weakness or not if they're not able to maintain their arm off of their back. Another way to test internal rotation which is um not hard to do is you have them put their hands on their belly and put their elbows out towards the front and you can actually push on the shoulder as the resistance. And that does test internal rotation as well. That's another easy one to do just from the front is called the belly. Press, push on their belly with their elbows out and then you're pushing back on there. I'm there. So on to the special test at this point you've done, you know your inspection, you palpate it, we've done a good history inspect and palpate a range of motion and strength. So at this point you probably have a pretty darn good idea um what the issue is. Um And you can focus those special tests based on what you think those are. So we're I mean there's literally dozens and dozens of these can't cover them all today. We'll just mention a few that most of which you probably know. Um But these again are just included in a variable basis depending on what you are suspicious is going on. So here's the you know the most classic test for impingement. Um Nears and hawkins test always remember these by you know, hawkins is like a hawk flapping in the breeze. Um And then nears like I always say near here like when they ask if your present right here. Um But these are just testing your passive range of motion right in the case of both, these tests are stabilizing the scapula with one arm to try to prevent the scapula moving too much with the other arm removing the shoulder. In the case of the nearest test, you're bringing it basically in the full for reflection. In the case of the hawkins test, you're taking them kind of from 90 degrees of abduction with the arm externally rotated to internally rotated. And what you're looking for in both of these cases is as you're kind of driving that greater to ferocity towards the under surface of the acro me in in the case of you know uh silver chromium and Benjamin. Um we're super stubborn, Crow me, a little pain syndrome as it's been called perhaps more commonly now, um that is painful. Right? So this is something that is, you know, reasonably sensitive but as you can tell it's really poorly specific. These tests are I think it speaks to the fact that for one these are maneuvers that generally with organic problems of the shoulder, just painful. So with these these raised my suspicion for perhaps rotator cuff pathology but certainly are not, you know, blocking any diagnoses on their own. This test is pretty useful. This illustration is awful. I don't know where I found this actually, but um in the case of O'Brien's tests are bringing their hand straight up the Ford flex 90° horizontally ab abducted across the body a little bit and then you rotate the forearm and in turn the shoulders so that the thumb is down. And then you ask them to maintain you know, elevation of the shoulder as you're pushing down on it. And then you do the same thing with the thumb up. And if the if it is painful, the thumb down, the question is whether it is better or worse with the thumbs up and if it is worse with the thumb down than up, that is a positive O'brian's test, but it's important to go the next step because this can be positive in two conditions. Um classically one would be a slap tear. So and I would say slap tear slash long head biceps pathology. So biceps tendinitis because the biceps tendon does insert onto or does originate from the superior labrum. So either slap issues, superior labor issues or the biceps tendon that comes from there. That's one kind of classic finding or one classic ideology of a positive O'briant's. The other though is a C. Or three apathy. And so in this case you're gonna have pain Yes, still on the front of the shoulder, but right pinpoint over the A. C. Joint. So that's one important thing. I think when you're doing this exam to make sure you ask where that pain is because depending on where it is, it totally changes kind of the interpretation of the test bicep tendon. And I would actually love, this is one of the the exam maneuvers the examiners actually do really like especially the jorgensen's test and I'll tell you why. So speed test you do with the arm and for reflection, a little bit of horizontal abduction. So you're kind of, the arm is a little bit more outward than midline and then you have their forearm and super nation and you're asking them to maintain that. So that's, you know, that causes the biceps to you're using the biceps, right? Because you're trying both to flex essentially the elbow and then also to super Nate the forum. And then the other test here that you can do is your business tests and that's where you have their arm at their side. Their elbow flex and then you essentially you can do it this way you have you can give them a handshake and then you ask them to super Nate the forum against resistance and you're checking for pain at the shoulder. And I love these tests. As you all know. I feel like at least I feel my practice that patients are very suggestible. And so when you're doing exam maneuvers and there's a clear kind of link between what you're doing what you're looking for. I feel like they'll give you maybe not purposeful right there, my malingering but they're just giving you kind of what maybe they think should be the case in the case of especially the your distance test, it's so distant right there you're holding their wrist and what you're really looking for is pain right here in the front of the shoulder. So I think this is a I find this to be very useful in differentiating vices pathology from others. So I kind of won't tell them exactly what I expect first. But I will do the test, I'll ask if it's painful if they say yes, I'll ask them where they should be right here that I'm feeling pretty good that you know that bicep tendon is really the issue. Um And same thing with speed test to a degree. But I feel like this is just even more removed. You know they're sitting there, they're focused on their wrist. So they tell you their shoulder hurts. That to me is a really good indicator that that really is what's going on a si joint special test. Similar to the O'briens test. Um If you bring just the body just across or bring the arm just across their body right passively. So you're doing a form and you're pushing against essentially fully horizontally abducting the arm. If they have pain in the front of the right of the A. C. Joint that's a positive um cross body detection test. But also similar to the O'brien test. It's important to ask when they when you say it's painful or not whatever it is because this can also be painful and a variety of conditions things arthritis will cause pain here plenty of arthritis. This can be painful even with like a pair of scapular stuff because it's a stretch in the back of the shoulder. So with this one it's a it's a great test. Easy to do. But just make sure you ask where that pain is being reproduced. Um Here's you know if you're if you're suspicious of instability as being um the complaint, there's a few other special tests to do this is the soca sign. So if you have a patient right who maybe has dislocated in multiple ways and multiple times over the years. It doesn't give you a great history for kind of the same mechanism by which it happens perhaps their female. Maybe they're an overhead athlete of some kind um The smoke aside is a good thing to check for. We have the other side. You just pull down on the arm and you look for essentially a kind of indentation between their chrome Ian and their approximate humorous that develops and that's just a sign that things are pretty lax in that shoulder. Um, let's keep that for a second. If you're looking for anterior instability, which is the most common type of traumatic instability of the shoulder, a great test is to kind of put them in a position where they would come out and in that position they feel pretty uncomfortable. And then you put a force that opposes that force, right? And then that will make them feel more comfortable. So in the case of anti instability, the position of apprehension is with the arm 90 degrees abducted and externally rotated and that's gonna make them feel pretty uncomfortable and they're like they're gonna come out the front and then to oppose that forced the relocation test as you push on that right over the kind of humor joint, just backwards. And if they have, you know, that sense of apprehension when they're up and it goes away when you push away, push back, that's a good sign that perhaps they have entire instability. This is a test to that you can kind of work into this. This is another one where it's, I think it's open to the power of suggestion quite a bit you say, oh, it's just bothering you and just better. So I like to do this one too just by surprising them and you're just talking to them moving the shoulder around and you move them into a position like this and just see if it seems to bother them. And then you can also do the opposite of the relocation test right? So you can kind of be having them there, you're pushing on the shoulder then you're releasing and you see if that seems to bother them and I think it can be pretty reliable if you do it in that way. And then the other way to test um instability is actually to do it alone and shipped test and this is actually where you just put them supine, you have their arm a little bit abducted. You have therefore um kind of up as you can see and then you just grab their proximal or grab their arm with your arm and you kind of push it into the scapula, push it into the annoyed and then you just kind of pushing it forward if you're doing anti instability or pushing them backwards. If you're doing post your instability and the grading here is depending on how far you can push this glen. Oy or sorry, humorous relative to the glen oid. So if you get it just to the rim that's the one you actually give it over the rim but it goes right back. That's a two And then if you actually get it to dislocate and stay there, it's a three And in the relaxed position you'd be surprised. I mean most people greeting one is normal. So you can actually get people up to the rim. We've had no instability events at all in the past. So the shoulders pretty mobile in general. And that this test shows that and then there's the this is this could be a whole talk on its own but there's a whole, then there's all the tests right that you would do for things that are not the shoulders. So if you're suspicious that it's not the shoulder, um This is where you would do all of those different tests. So certainly the cervical range of motion is important thing to check. You're looking here just to see if they're limited, which would be an indication perhaps that they have arthritis in their neck and that could be a reason. Certainly if they're moving their neck as well. And they find that that reproduces shoulder pain. That's even more specific, right? Um as a sign that perhaps their pain is actually neck in origin, The sperling test is assigned for ridiculous empathy right? Where you're pushing you load the head. Um Actually while you're also playing a lateral flexion and rotation. And if that reproduces the ridiculous, you know the pain or ridiculous empathy that would be positive sign for cervical, ridiculous apathy. And then as mentioned before, you can do the bottom of the Miitomo neurologic exams as indicated rights, checking the sensation from the shoulder all the way through the arm to the owner side of the forearm and upper arm for C. Five to T. One. And then the maya tones as well from the deltoid biceps triceps, extensions finger flexors and then and muscles. So those are things I certainly don't do it every single patient. But if I'm suspicious that it's second origin I would add in. That's really the meat of the talk will leave time for Q. And A. But just a quick mention of imaging with the shoulder it's always as as most joints it's always um appropriate to start with the X rays first line and actually can see a lot. So even though we don't see obviously we see bones and joints on an X ray and we don't see you know soft tissue like labrum and tens and things like that. However I do think if you have a keen eye you can see a lot actually an X ray even if it is soft tissue in origin. So on this X ray here obviously you see right to highlight a high riding human head um you see the under surface of the chromium has undergone what we would call an acetate realization. So it started to kind of wear away and form a kind of a nice hemisphere and similarly on the on the humorous side right. You notice that that greater ferocity which is typically pretty prominent has been kind of shaved down and looks pretty smooth um Which is called the federalization of the human head. So this is all kind of classic for rotator cup are tropical, right? They've got a really large rotator cuff tear over time because they have this large rotator cuff tear that causes the human head to be able to move approximately when you use the delta and other muscles. But that happens eventually the human head hits the a chromium that causes this kind of reshaping right of the chromium and also the human head. So this is obviously a relatively market example um of soft tissue pathology that you can see through its correlates on the bony morphology. But in general the X ray is quite useful and can tell you a lot. But certainly there are still cases where you don't know right? So I can be the next step and generally you know the decision to get an M. R. I. Or not is based on if you have a patient for whom you're pretty sure they have shoulder pathology. The X ray has been negative. Um And you're pretty sure and you're and you're not sure of the next step in treatment and I think an M. R. I. Is the next step what I mean by that is. Um If you if you have a 65 year old patient right who has potentially a degenerative rotator cup. So they got to you know they got paid their shoulder maybe a little bit of weakness. It's been there for a long time, no specific trauma and that's specific situation. Um Regardless with the M. R. I. Shows the treatments going to physical therapy. So that situation obviously would be fine to just give them physical therapy and see how things go and then if it doesn't get better you can do an M. R. I. Um But in general right if you've got a suspicion for shoulder pathology you have negative X ray and the treatment would depend on the findings of the M. R. I. Then certainly MRI's indicated, having said that of course we can memorize a lot. It's um you know it's totally fine to get M. R. I. For just not sure as well. Those are the two main states. I would say ultrasound is also super useful and diagnosis of the shoulder. And as orthopedic surgeons were really bad at that still, we're trying to get better I think and using that more. But it's been shown to be very effective and accurate in diagnosing certain conditions, especially things like rotator cuff, your biceps tendon issues. So if that's in your wheelhouse as well um that's certainly a useful adjunct to imaging is ultrasound. Um So here's my references and I appreciate your attention and I'll stop talking at you now and answer any questions that you may have.