The shoulder is complex, with many possible sources of pain or weakness. Board-certified orthopedic surgeon Sara Edwards, MD, draws on years of experience to break down conditions by age group, location of symptoms, and physical exam observations. She illustrates tests for detecting specific injuries and explains when to order imaging, what images may show, and when referral to a specialist makes sense.
I've got a brief talk here talking about shoulder anatomy and the exam and we'll go over, you know, patients that um kind of how I think about shoulders as far as the differential is included. And um when I order an MRI when I think it's a problem to an orthopedic surgeon and we'll try to touch on all those today. If you have any concerns or questions, obviously put them in the chat box and we'll answer them at the end as we go. So um hang on, let me forward. Uh so I'm just gonna give you a brief introduction about me. Um Again, my name's Sara Edwards and I am actually a midwesterner. I'm not from the Bay Area, although I feel like I'm adopted it. I love it. Um I did medical school in my orthopedic residency at Northwestern University in Chicago and I did my fellowship and shoulder and sports medicine at Columbia in new york. And then um I then moved here briefly where I was in private practice in the East Bay back in 2006. I'm telling you how old I am. So 2006 and then I worked with a group called Oakland bone and joint specialists. And I was there for about three years and I got very homesick and I moved back home to Illinois and went and joined the faculty at Northwestern. I also missed academics And so I was on faculty northwestern um until 2013. And then my husband's job brought us back to the area in 13. And um I was in private practice a teaching private practice on the peninsula called Sore orthopedics. But I also became cal doctor at that point. So I started working with I was I was the head team physician at Northwestern. And then when I moved back here they put me on football cal and so that was really fun and I did that from 2013 to 18. And and I still work at U. C. Berkeley so I'm there a half day week and I take care of the general students. Um I joined the full time faculty UCSF in 2020 so literally right at the beginning of the pandemic I'd signed a contract in January to come over and um anyway so that was kind of fortuitous timing. It was good to be employed in a big organization and not struggling with private practice when everybody locked down. Um So anyway yeah right now and I work for U. C. S. F. I work at the Berkeley outpatient center two days a week and then I'm also in marin, I'm in our marine office right now giving this lecture and I'm there one day a week and then I go to UC Berkeley a half day week and see the students. Um I live in Orinda. I'm a citizen of the East Bay. So I know the East Bay well I know um I think she said she's out in Dublin, I love all these, that's kind of like my towns out there and I feel like I'm always in walnut creek. It's funny when you move through the tunnel and on the weekends you never come back through the tunnel you stay on that side which is I love it out there. Um And then I'm currently also a team doctor. I take care of um numerous professional leagues. I help take care of the L um the ladies professional golf association was here you know a week ago we were the team doctors for the US Open which was really fun. We did the PGA tournament um and I take care of city College in san Francisco, that's my big team I take care of now. So I'm gonna start I've been talking all day in clinic so forgive my voice but I'm going to start by talking about just basic anatomy the shoulder just to give everyone a refresher. So we're on the same page. So there are the bones and Osti ology which will go over the capsule of the shoulder, ligaments, nerves and muscles and all of those can be affected and and caught me a source of pain or problems. So the bony anatomy, the main Osti ology, you know you have the clavicle which is right up here on top and you can feel that usually in most patients and the clavicle articulates with the shoulder blade at the chromium process and that forms one of the joints to the shoulder which is the A. C. Joint, the chromium Navicular joint. And then again the scapula is such an interesting bone to me because it's it's large and it's got all these attachments for the muscles and the rotator cuff to come off as well as the bicep tendon. So the core coid processes here, that's where your bicep short head of your bicep originates in your core code. Breaking Alice. You have your hue mural head obviously that's fractured frequently and elderly patients who might fall. Um And you have the greater to ferocity, the lesser to ferocity. And then the bicep it'll group for the long head is right here in the middle. So that's your basic bony anatomy. So we're all on the same page. Um I'm sorry one more thing I would have mentioned on the three main joints of the shoulder. So you have the scapula, thoracic joint where the scapula actually articulates with the rib cage. And we get about 30% of our motion through the scapula. And then you have the Glenna human joint which is what most people think is the classic shoulder joint. But that's our rotational motion as we spin around is from the global human joint. And then again the A. C. Joint access of suspension device to kind of keep our shoulder in place relative to the rest of our body and then the ligament anatomy. So again all these processes have these ligaments that can be injured with trauma or just over time with overuse. So you have you know the C. C. Ligaments and I love they described them so anatomically that's pretty easy. But the cork oak articular ligaments, the C. C. The C. A ligament which is the core co chromium ligament which comes across the shoulder like that. And then you have the three main ligaments in the global human joint Are the superior blend of humor ligament, the middle Glennon humor ligament and the inferior blend of humor ligament. And these are important for overall shoulder stability. So when patients dislocate their shoulder, you know, they're likely to tear or to stretch out these inferior ligaments here. Um So they give us stability for anti or post here when people have dislocations and there's there's a group of the three are in the front and the back. So there's the anterior ones and the poster ones. Um The tendon anatomy. Again this is probably the most common thing you see in your office are the rotator cuff issues. So so these are frequently um you know worn out or damaged. You see the ages 10 and there's 44 rotator couples. You've got your super your interest. Panetta's, you're terry's minor down here and then in the front of the shoulder is the subs cap, which is the broad flat one that runs down the front of the shoulder and then the large muscles that surround and envelope the shoulder. You've got the pec major in the front, the deltoid and the lotus imus in the back. And those are all vital for our shoulder function. The history when you, when you meet a patient with shoulder problems, you know, usually just like probably most of you do with most primary care problems. You know the history really guide you on the diagnosis and and after they've told you what's wrong. Usually I can tell exactly what's going on in their shoulder. But you know, the main questions that I'm asking is do they have pain? Do they have weakness or both? Um You also always want to check their neck because there is an association. Sometimes patients will have neck pain or some type of neck pathology that will radiate to the shoulder. So they frequently go together in every patient I'm seeing on differentiating. Is this coming from their neck or their shoulder? Because there is so much overlap and then you also want to know there's a history of trauma? All right. So have they dislocated if they fall and they crashed the bicycle? That again might be my second most common chief complaint barriers. So when someone crashing their bike, I think I saw five patients today who crashed bikes. So extremely common. The other thing that really is my it's really a go to when you're evaluating a shoulder is their age. So less than 40. Immediately put your differential to certain pathologies. So under the age of 40, they're more likely to have rotator cuff impingement. You rarely rarely see a full thickness tear of the rotator cuff and someone under the age of 40. And I don't think I really learned that until I was probably 1/4 or fifth year Ortho resident. I didn't understand that. You know, you just didn't see all these rotator cuff tears and 30 year olds, but if you start paying attention Under the age of 40, unless there's some type of trauma. And I have seen it twice in my career, one was a defensive end who dislocated his shoulder playing football and he had a full thickness rotator cuff tear and another was a girl who fell, she was, she was a spectator at a football game who fell and she injured her shoulder and had a full thickness tear. So again, Twice in 16 years of practice, it's not very common. Um Labral pathology is much more common in the younger patients and so again when someone is unstable when they've dislocated their shoulder, they're going to, you know this is an X ray down here, what that looks like when the shoulders out the front. But they almost all will get tears of their labrum. So the labrum which is the the lining of the glen oid will tear upon that force. Um We often will see bicep tendinitis as well, so patients then tend to be a little more athletic, maybe lifting heavier weight and you'll get inflammation of the bicep tendon which runs right in front. And that's a common source of pathology. So it's easy like if you feel it right there in the front of their shoulder and they'll isolate, will say it hurts right here. You're thinking bicep, if they're pointing more to the side or to the back, that's more rotator cuff. Okay? Um And again they can't get rotator cuff impingement or tendon Asus. And this MRI and it shows that so here's a rotator cuff that is you know this thick gray muscle is the cuff muscle. And you can see it follows the insertion down here. And what you can sell is it inserts onto the greater tubarao City should be a solid black structure and you can see that it's filled with kind of whitish gray fluid within the tendon itself even though it's intact, which is what tendon oh sis looks like. And then you also see this white stripe of fluid above it and that's the bursa that lies right above the rotator cuff and that's what you're going to see when they get versatile inflammation Other. Um so then when the patient's age is over the age of 40, then I'm thinking, you know, I have a whole different differential in my mind. So I often will tailor the physical exam to their age. So if it's an under 40 patient, I'm thinking, Okay, does this patient have instability? Have they had dislocations? If it's an over the age of 40 patient, you're much more likely to have rotator cuff problems, they still get cuff impingement. Um, but this is where you're most likely to see rotator cuff tears in the over the 40-age group and it increases by decade. So, um, you know, a 50 year old, you know, is 20 likely to have a terror once they hit 60 year, almost 50% likely to have a terror Over the age of 70. You know, the number ranges from 50 to 70%. Even asymptomatic patients will have rotator cuff tears. So that is something to look for. The other thing you start to see over the age of 40 is a frozen shoulder or adhesive capsule. Itis and that's a classic, you know, people will come in, they feel this insidious onset of pain. Um particular, it's more common in women between 40 and 60. Although we do see it in men, there's an Associated Association with diabetes and with hypothyroidism and or any thyroid problem really, they can get it with hyperthyroidism to Haifa is more common. Um and that will they usually have exquisite pain and lack of motion. And so that's something something that we'll see with frozen shoulder. Um once they hit 50, then you're more likely again to see that full thickness rotator cuff tear shoulder osteoarthritis, a frozen shoulder a rotator cuff are throw apathy. And again, this X ray here shows shoulder arthritis. You can see narrowing between the bones. Um You've got the human head here, the girl annoyed here and again, there's no space left in between. So that's what shoulder arthritis looks like. Um So I'm gonna briefly touch on these different diagnoses and what the classic findings are and we'll talk about that. So again sub microbial impingement or rotator cuff tendon. Oh sis is probably the most common thing that I see. They have a classic description of pain with overhead activities. A night pain along the side of the arm and they will not have weakness. Alright so that's what differentiates them usually from a full rotator cuff tear. They have full strength but they get this classic night pain which rotator cuff tear as well as well. But they say it's not my shoulder doc is actually down here. And so they'll there's the bursa will radiate down to the axillary nerve distribution and they will feel this pain kind of down the side of their arm in that zone and that again is classic for a rotator cuff tendon, oh sis or a tear. Um And they will wake up at night. I never really understood that. They will frequently say it's waking me up at night and wake me up. And the reason, so if you were to sprain your ankle or have an ankle injury, you know, you we would tell someone just to keep it up to keep it elevated so it wouldn't swell for rotator cuff when they're upright during the day, they're effectively elevating their shoulder above their heart and they don't get swelling and as soon as they lie down at night the fluid will will go to the shoulder and settle in that spot and they will wake up in pain. So that's why they classically do that. Um So that's one thing, you know again suburb chromium impingement, extremely common, full thickness rotator cuff tears have the exact same description usually. So pain overhead with overhead activity putting things up here pain at night. All right. But they often will have weakness. So that's when I test them. Um If they present with gross weakness in their arm it's usually a pretty large tear. Um They often they can have an insidious onset of pain where it's very gradual. They don't remember any trauma or it can be traumatic. So don't get confused. You're like well nothing really happened to cause that terror. Well most of them actually there's no event most of the time. It's an insidious beginning to that um frozen shoulder also usually does not have a traumatic history but sometimes they'll remember something very subtle. Like they'll say oh I was walking my dog and she was pulling my arm and then my arm really starting to hurt after that point. Or I was you know I've heard like I was putting the luggage in the overhead compartment in the airplane and then it started to hurt. So so that again is really classic with a frozen shoulder. Their pain is out of proportion to their examine. You'll say well nothing happened and these people are miserable. It's a bad diagnosis out because it's very very painful and they don't understand why it happens. We don't we don't fully understand what happens yet. So I'm doing some research on it but we don't really have a grasp of why people develop frozen shoulder. It's one of those mystery is still in orthopedics that's considered idiopathic. I'm trying to solve it. I'm working on it. Um They also again, will describe a night pain, but instead of being down the side of their arm it's usually deep inside and they feel this throbbing kind of taking deep inside. The classic finding on their exam is that they're active motion will equal their passive motion. Um So and we'll talk a little bit about that in a second. But one of the physical exam things that I do is to assess their motion and everybody and a frozen shoulder will physically be blocked. Like you'll try to lift their arm and they'll say I can't lift anymore and if you try to help them, same thing, it will physically feel blocked and you can't move it. So that's the hallmark of a frozen shoulder. Is that the active and passive motion are both blocked. Um Osteoarthritis of the shoulder. Again, they'll describe the kind of a deep gnawing toothache E like pain in their shoulder. Um they will also get a lack of emotion and they're active and passive will be limited. So they usually lose rotation first. So when you check them I'm gonna show you on the screen. But you know you'll see their good side goes out here. They're bad side might go you know this can go 60°,, this one will go 10 or 20 so they will lose their rotation. You won't be able to see it. They'll often describe a grinding sensation in their shoulder that's uncomfortable for them. Um Okay so when I exam so I'm gonna move on to example I want to touch on those very common diagnoses just so we're all on the same page and then talk to you about how I examine the patients. So you know the first thing I do is inspect the patient. I think it's important to have them in a gown. I have usually men will remove their shirt and not put anything on. Um I'll have a woman in a gown but so I can get a good view of of what is happening in their shoulder. And you can see, you know, gross muscle atrophy and that's what I'm looking for. I'm looking at their skin to see if there's any skin changes. I'm looking for muscle tone here. You can see this patient has significant atrophy. You know, this is their interests. Pineda's fossa completely atrophied. Super spontaneous fossa completely atrophied. So, so that tells me a story. When I look at that, I'm like okay, those nerves aren't working, there's either nerve damage or the muscles not attached but something isn't functioning there. You can also describe if there's winging in the shoulder in a traumatic case, you'll see bruising echo moses, um You see abrasions from them crashing their bikes and then I will focus on palpitating different landmarks about the shoulder. So the main ones I look, I always palpate a lot. I started the stern of particular joint right here um where the collarbone meets the sternum and palpate for any pain. And then I'll palpate along the top of the clavicle all the way to the A. C. Joint. You can feel a little bump where they me and I will palpate and see if there's any problem there. And you can see if they just have pain. That's a sign of the A. C. Joint problems. They could have an a si joint separation where you'll feel a little step off of the joint. But the most common thing is just pain from arthritis there and there's another diagnosis called Osteo ISIS, in the distal clavicle where young, athletic people, men or women can get some resort option of the bone from extensive heavy lifting so that if you look at them on X ray, you'll actually, it looks like the bone is disappearing and it's from overloading. So you'll see it people that bench very very heavy weight. Um And it will often be painful at the A. C. Joint. It's kind of an unusual process to that it starts to just resort of the bone in reaction to chronic stress so that those are the main points I palpate. I also will feel the bicep tendon again, I showed you that earlier, but where the tendon runs right in front of the joint, palpate, you can actually feel the groove and most people. Um And if that is, the bicep tendon is a source of pain, they will, they'll tell you, they'll let you know that it hurts when you, when you press there. Um, and then also the greater to ferocity. So again, with people with impingement, you know, I can feel right off the board of the Ukrainian, you can feel and just push right there on the side of the arm and that's your greater to ferocity. And that can be a source of pain as well for rotator cuff. And then again, range of motion. And I think people kind of blow off range of motion, but I think it's one of the most important parts of the exam because again, it's telling me a story of where their shoulder is. So I will check their forward flexion. So I check four different ranges of motion on them. So I'm going to try to show you on my screen, but it's, we'll see how we do. But you want to go forward flexion so straight up in front of your body, palms down and then you want to do a deduction. So abduction going up to the side And the night record them as a degree. So if they stop here, that's 90° from from the bottom. Normal should be about 165, Some people just write 180 of a simplicity to follow the arc of the motion. So your shoulders will make you do a little math, not too hard. And then I check the external rotation at the side. That's what I showed you before. So have their arms, make sure their upper arm is touching their body and this is this is zero where you're right in front of your body and then you have a rotate out. When you measure that degree and normals, anywhere between 50-70 is typical. Um And again, lots of pathologies such as arthritis instability can cause some limitation in the range of motion. And then internal rotation can be measured a few ways you can have them reach behind their backs. So you just say reach up as high as you can go and you can see and then you and then we often record it as opposed to an angle, will record it. You know, internal rotation goes to um you know, we'll say two thoracic level 66 44. Sometimes, you know if they're arthritic they'll just be able to go to their their bottoms will say to the sacrum lumbar spine, thoracic spine. So um that's how we measure internal rotation. And um anyway, so and those are those are really effective. It's really important again, so I usually do that with him standing but if they are limited, so let's assume you're doing the exam and they can't lift their arms so they'll say okay this one goes all the way this one stops here, I think it's very important to have them lie supine on a table and then I go through the range of motion with them supine because I'm locking their scapula down. The scapula will allow them to cheat on their true shoulder motion on the global human joint so they can compensate by by using their accessory trapezius muscles here. They'll kind of be able to lift their shoulder a little bit further and then they're scapula will take and absorb a lot of the motion. But if you have them lie flat on their back there, scapula is locked down on the table and they can't cheat. So that's a nice way to check with their true motion is and again, I don't do that on everyone. But if I notice they're limited, then I want to get that true number. I'll have a life flat. Um There are three main diagnoses that can cause an active and passive blog to motion. The three ones are a shoulder dislocation. So typically that patient has had a history of trauma. They've been to an er they'll tell you I dislocated my shoulder. All right. But occasionally you'll get an elderly patient from a nursing home has come in and all of a sudden she's not moving her arm and they've had a traumatic fall. Maybe witness. Maybe not in that patient could potentially have a dislocation. So I actually see that at least once a month someone, some elderly patients had a dislocated shoulder for, you know, they usually have dementia so they can't really communicate very well what's going on and you'll see that patient. It's um but yes, you'll find a dislocation occasionally in the office from someone who's taken a fall um Who's not as verbal as you know, as a as a younger athletic person. Um The other just the other diagnoses that can cause that. So they're shoulder instability and dislocation, shoulder osteoarthritis. They will have usually some type of block and then the frozen shoulder which I talked about earlier. So again without even checking an X ray and MRI based on their history and physical exam. I usually can say all right, you've got one of these three things. Let's go get an X ray and we can tell. So that's that's the nice thing about the shoulder exam. That's why I like it. Um There's specific tests for rotator cuff. So I'll touch on those. Um There's the near Hawkins and joke tests are the big three. There's three that we primarily check. The near sign or test is when they have painful range of motion within an arc of 20 to 120 degrees. I'm trying to move for the camera And then that tends to disappear the higher they go. So between 20 and 120 though they will have this pain throughout an arc of motion. Um The Hawkins test is um well I'll do the job test. The joke test is also sometimes called the upside down beer sign. But you have a put their arms out just a little bit and turn their thumbs upside down. And then you apply a downward force like this. So like they're holding a can upside down and if that reproduces pain then that's a sign of rotator cuff impingement or a tear. Often this isolates the super spontaneous muscle. So if they go into this position and you try to put the pressure in their arm drops. That's a sign that there's a full tear of the superstar status. So it's helpful for two reasons. One if it pain is just a positive test but if it's weak that also shows that the cuff is most likely torn all the way through. So that's the joke test or the upside down. Beer test. It's funny. I've lately I've been getting a lot of peer to peer review requests for mris and they're like you didn't document the upside down can sign and I'm like I did it's called the joke side as well but it's interesting I think different people called different things but they are they are one and the same. The Hawkins test is when the arm is forward flexed in front of your body and then you internally rotate it and then the examiner which would be you. The doctor internally rotates it further and applies a force. And if that causes pain then that is a positive test. So near Hawkinson job or the big big three I think. Yeah, here's a picture of the Hawkins test again that internal rotation reproduces pain in the job test or the upside down. Beer can sign. Okay, so those are your rotator cuff tests. Um This is also for rotator cuff. This is so again this test, the upside down can sign. It's weak, specific for the super spa NATO's. The external rotation lag sign is when the arm is out like this. And in this test infra spitting this. This is very specific and then you apply a pressure and if they're weak they'll go like that, it'll just fall right in and that's how you tell that the interest Benitez is damaged. So I might have had, I thought I had a video there is going to show you that. No, it's not connected in any way. That's that's testing that. The other, another rotator cuff test is the hornblowers side. So this is this position and this isolates the terrys minor so you can get very specific, you know. So essentially superstar status here in first minutes here and then terry's minor is up here like you're pulling a horn and a semi truck, you know when you're a kid used to tell the, I used to, we used to do that for fun where we would like tell the semi truck drivers to pull their horn and so that's why they call it the hornblowers test. So it's up here and if that is weak they can't hold their arm in that position. That's a sign of a massive rotator cuff tear, including the terrys minor. And then for the sub scapular eras, the specific test is called the liftoff test. So if you look here and you lift the arm off, if they can't do that, that's a sign of the subs cap being torn. So again, very specific for the subs cap. The other one for the subs cap is a belly press test. You can put their hands on your belly and they should be able to bring their elbows forward like this. And if they can't do that, that's a sign that the subs cap is torn as well. So there's two good ones for the subs gap. Okay, so then I'm going to move on and talk a little bit about labral testing in the shoulder. And um I think my favorite test is for a slapped. This is for slap tear. It's called O'brien's active compression test. So when you're trying to differentiate what is the slab terror or where they are, you can feel pain with pal patient biceps and bicep pain is very specific for first lap lesions, superior labral tears. And then um the also the speed test which is another bicep sign but also good for labour. Superior labrum where you have the arm completely. Super native. Any forward flex it above. And if that causes pain that's part of it. And then there's also the O'briens active compression test. So this is similar to the to the empty can sign. But the empty can sign. If you notice the arm is abducted a little bit for the O'briens test, you actually a deduct the arm about 10 degrees so it's in and then your thumb is upside down and you test it. And if that causes pain then you have a flips of the thumb is up, comes up same position. And if the pain is relieved when you do that, that's a positive test for a slap tear. So start with the thumb down, finished with the thumb up. I think I have one, I can feel it popping it. And uh anyway that's that's a sign. There's something wrong in the labrum. If the patient is complaining of pain that I would order an M. R. I tried to look um that is a classic finding. Um and those typically slap terrorists are super liberal tears are caused by generally falling in a compression load on the arm or by traction. Or sometimes overhead throwers get them from from chronic, you know, throwing and having chronic contraction to the arm speeds test. As I went over earlier. Again, you palpate the front. Full super nation lived the arm up and that's indicative of a super liberal terror or a bicep tendon terror. And this is for gross instability such as anterior posterior. Um and it's for anti r apprehension. So if you want to check someone to see if there are dislocating out the front, usually we do it with them lying down on the table so that patients lying down arms in this position and you try to actually bring the arm forward. You can feel it sub lux in the joint and then if that just going to this position causes discomfort, you'll see their face. That's called apprehension. To alleviate that. You apply a post your force onto their human head, which you can see in the second picture here, he's loading that shoulder back and that will alleviate their pain. They'll say, oh that feels better because they don't feel like their shoulders going to pop out, you're giving it some traction for us. So that's the test for instability. And then you can do the same thing post eerily so for post your instability. So this is this is the position the arm comes out when they when they dislocate at the front, and 95% of them are into your dislocations, 5% of them are posterior dislocations. And it comes out in this position with the arm in front. So you put the arm when you're testing for it, you put the arm forward and you apply downward pressure. And if that reproduces their pain, that's a sign that they're having poster instability or a poster labral tear. This is most common in young people and athletes. So you see this in football players that are blocking. So you see, you know, the lineman are lined up and putting their arms out to and that that's where we typically see that diagnosis. The other issue, you know, you see multidirectional instability, where a patient has some underlying hypermobility or Ehlers Danlos syndrome and they will have the way we test for that. I look for a patient who has hyper extensible elbows, I'll check their elbow extension. I look at their wrist flexion. So this is normal. If I'm trying to flex my wrist down, I'm trying to touch my thumb to my forum and I cannot, most people cannot touch that. But if you can go all the way down and touch, that's a sign of hyper mobility. Um The sulcus sign is where you pull a downward pressure with the arm like this and pull it straight down and you'll see a gapping between the Ukrainian and the whole shoulder joint will subluxation fairly. So sometimes that's normal in a neutral position but it's not normal. If they externally rotate to 30° you should not see that subluxation. So so that's how we check for multidirectional instability as far as X rays go. Um When I evaluate a patient, usually we have 33 views of the shoulder. Um I want to true ap of the shoulder or gracie view and again can identify the different anatomy here. Um I like an outlet view which shows me that a chromium morphology and you can see here, you know we look at that outlet to see what the shape of the crimean is. This person has a curve to chromium which makes them a little more likely to get rotator cuff issues. And then this is an axillary lateral view down here. So when I'm ordering shoulder x rays again you have to write on the requisition ap outlet maxillary lateral or they'll just shoot three a piece um with different rotation of the arm. You don't want that. The axillary is probably the most important to make sure the patient doesn't have instability. So we really, even though that looks like it's reduced you can't actually prove it without this view. So absolutely lateral is extremely important when you're ordering the shoulder film. Uh Well you C. T. Scans a lot to help us make decisions um for fractures. So if you have a patient with a proximal humerus fracture comes in. Um I think it's very appropriate to order a CT scan. We use that to make decisions whether the patient needs to go to surgery. We're looking at the actual displacement of the bone fragments and that's how you might wonder why sometimes. Oh why didn't they operate on that one versus the other? And what we do is we look at each of these fragments and how far they are spread apart from each other. And um whether it needs surgery or not, which is almost like every fracture. I guess. We look at the amount of displacement, the shoulder can actually tolerate a lot of displacement. So Um this bone a little less. This one can demonstrate maybe five but these other fragments can demonstrate a centimeter or so this fracture here, you know that it's impacted in a various position, which commonly happens. So the head normally sits here and then it's impacted down. But that patient will do okay if you live alone, they might lose a little motion. So it kind of depends on their age. If they're if they're an elderly patient, I would leave that one alone for sure. Um, M r imaging is very important. So how do we determine who needs an MRI? Um So if anyone's had a dislocation, I ordered an MRI on them uh at their visit. Alright, so that patients going to MRI, so I can see what's going on. This is a patient who had a large had a dislocation. They get these large impact in injuries in the back of the human head, from the dislocation that's called a hill Sachs lesion and then they get labral tearing up front. So this labor was completely torn off. And I'm really looking to see if there's a fracture, a fracture of this bone. This is very common, but I want to see if something is fractured off that bone and that's an indication for an urgent operation and as far as a more chronic history, which most of them are, most of them have not had a dislocation. Most patients you guys see they're going to come in, they've had shoulder pain for a long period of time. So if it's chronic, if it's their first time being seen and they have no weakness, I will send them to therapy and then give them some anti inflammatories, whatever payments they can tolerate and have them come back in 6-8 weeks. And if they are not better, then I'll get an MRI. Alright. If it's chronic and they present to me and they're already weak in the shoulder, then I'll get the MRI right away. So that's how I determine who needs the MRI right away. So weakness is the main thing and the main main two forms weakness in this this motion testing, that sucre and testing the infra out here. So that's obviously the subs caps Week two, you're going to check it. But those are the main reasons I order an MRI and when I do it okay.