11/5/2013

1

Physical Exam of thePhysical Exam of the Shoulder and Hip

and Diagnoses of Common Problems

Pierre Rouzier, MDUniversity of Massachusetts

New England College Health AssociationNovember 8, 2013

Goals and Objectives

• Review shoulder and hipReview shoulder and hip anatomy

• Discuss shoulder and hip exam

• Present cases common in primary care and sports medicinemedicine

• Discuss management of injuries (if time permits –wish me luck!!)

11/5/2013

2

Case histories• 22 yo tennis player with

“pain serving”• 18 yo hockey player

“crashed shoulder into the boards”

• 21 yo mt. biker “fell on shoulder – came out of place”

Anatomy

11/5/2013

3

Shoulder Anatomy

• Shoulder Complexp– Glenohumeral– Acromio-clavicular– Scapulo-thoracic– Sterno-clavicular

• Bones– Scapula

• Glenoid• Glenoid• Acromion• Coracoid Process

– Humerus– Clavicle

Static Stabilizers of the Shoulder

• Ligaments– Acomio-clavicularAcomio clavicular– Coracro-clavicular– Coracromial– Sterno-clavicular

• Shoulder Capsule– Gleno-humeral ligaments

• CartilageCartilage– Glenoid Labrum (50%)

• Sub-Acromial Bursa

11/5/2013

4

Dynamic Stabilizers: Rotator Cuff

• Supraspinatus– Abduction

• Infraspinatus– External Rotation

• Teres MinorExternal Rotation– External Rotation

• Subscapularis– Internal Rotation

Shoulder anatomy

11/5/2013

5

Physical Exam

• InspectionP l ti• Palpation

• ROM• Strength• Laxity• Special Testsp

Standard Exam

• Inspection: deformity/atrophy/wingingl k l b l• Palpation: neck, para-scapular, sub-acromial

space, AC joint, biceps tendon• ROM: abduction, flexion, internal/external

rotation• Strength: abduction, internal & external g

rotation• Laxity: anterior/posterior/inferior;

apprehension and relocation

11/5/2013

6

Standard Special Tests• Rotator Cuff Strength

– Scaption/Empty Can/Jobe’s: SupraspinatusE l R i I f i– External Rotation: Infraspinatus

– Internal Rotation: Sub-Scapularis• Impingement

– Neer and Hawkin’s Test• Laxity

– Apprehension, Relocation, Sulcus Sign, Load and Shift• Biceps Tendon

– Speed’s testSpeed s test• Labrum

– Speed’s Test, O’Brien’s test• AC Joint

– Arm Crossover Test

Inspection

11/5/2013

7

Rotator Cuff Strength Testing

Supraspinatus

Subscapularis

Infraspinatus/teres minor Internal/external rotation

Impingement Tests

• Hawkin’s • Neer

11/5/2013

8

Impingement

Laxity Exam

11/5/2013

9

Tests for laxity

Speed’s Test: Biceps Tendon

11/5/2013

10

O’Brien’s test – SLAPLabral tear (Superior Labrum Anterior to Posterior)

AC Joint Exam: Arm Crossover Test

11/5/2013

11

Rotator cuff tendonitis - history

• 22 yo female presents ith h ld iwith shoulder pain

after playing tennis on several occasions after long lay off. Lots of overhead smashes and serves.

• Pain with lifting arm, combing hair, sleeping

• Hurts to play tennis!

18 yo hockey player with direct trauma to ac joint, pain and tenderness

11/5/2013

12

21 yo mountain biker fell onto shoulder, anterior deformity, loss of shoulder “roundness”,

inability to int/ext rotate

Shoulder DislocationSelf-reduction technique

11/5/2013

13

Case examples - hip• 26 yo female runner with R lateral hip pain after

increasing mileage• 19 yo female runner with deep L hip/groin

pain, hurts with every step• 20 yo male soccer player has anterior R hip pain

after hard kicks• 19 yo male BB player left groin pain for “months”• 55 yo male cyclist has hip pain and trouble

getting on and off his bike

11/5/2013

14

Hip Anatomy

Hip and pelvis - normal anatomy

11/5/2013

15

Physical Exam of the Hip

• Inspection• Palpation• Leg length• Range of motion• Strength• Pain against resistancePain against resistance• Impingement signs

Trochanteric Bursitis26 yo female runner with R lateral hip pain after increasing mileage

• Tender directly over greater trochantergreater trochanter

• Tight ITB• Positive Ober sign

11/5/2013

16

Trochanteric bursitis

• Home rehabPT• PT

• Ice, ice massage• NSAIDs• Corticosteroid injection

Femoral Neck Stress Fracture19 yo female runner with deep L hip/groin pain, hurts with every step

• Increasing mileage, slow progression of painprogression of pain

• Difficulty with weight bearing, limp

• Pain with int/ext rotation• No palpable tenderness• X-Ray• Bone scan, MRI• REST, REST, REST

11/5/2013

17

Hip Flexor Strain20 yo male soccer player has anterior R hip pain after hard kicks

• Common, can be long-lasting, nuisance

• Rest, ice, rehab

Hip Labral Tear19 yo male basketball player with persistent groin pain

• FrustratingFrustrating• Hip impingement sign

– FADIR (Flexion, Adduction, Internal Rotation)• MRI arthrogram• Arthroscopic surgery

11/5/2013

18

FAI(femoroacetabular impingement)

Hip Arthritis55 yo male cyclist has hip pain and trouble getting on and off his bike

• DJDNSAID l i• NSAIDs, glucosamine

• Weight loss• Maintain ROM• Appropriate activity• Hip replacement??p p

11/5/2013

19

Questions??