Omuz problemleri konusunda hazırlanmış basit bir kılavuz.

1. Examining the
Shoulder
Adam Meakins
Clinical Lead Physiotherapist

2. Shoulder Pain
Is common…
• 3rd most common MSK complaint
• Prevalence rates between 6-30%
• ‘Impingement’ most common
Luime JJ (2004) Prevalence and incidence of shoulder pain in the general population;
a systematic review. Scand J Rheumatol. ;33(2):73-81

3. “The shoulder complex often
renders the clinician with
frustrating uncertainty”
Jørgen Jevne
http://blogs.bmj.com/bjsm/2015/01/06/the-sexy-scalpel-unnecessary-shoulder-surgery-on-the-rise/

4. Why…?
Shoulders can be complicated
• Many pathologies cause shoulder pain
• Many clinical tests are not specific or sensitive
• Pain is a complex phenomenon
Dean BJ (2013). Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain.
Br J Sports Med. Nov;47(17):1095-104.
Hegedus EJ (2012). Which physical examination tests provide clinicians with the most value when examining the shoulder?
Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. Nov;46(14):964-78.
Melzack R, and Katz J (2013). Pain. Cognitive Science. Vol 4, Issue 1, 1–15, DOI: 10.1002/wcs.1201

5. But shoulders don’t
have to be complicated

6. Painful Shoulders
Are either…
1. Stiff and painful
2. Weak and painful
3. Unstable and painful

7. Three criteria…
Can help plan best Mx…
1. Hx of trauma
2. Age
3. Shoulder External Rotation Test

8. But First…
Is it even the shoulder…?
• RED FLAGS
• Pain on neck movement
• Pain below the elbow
• Neural symptoms
• +ve Spurling Test

9. The Stiff
and
Painful Shoulder

10. Stiff and painful…?
1. Trauma = No
2. Age = >50
3. Ext Rot = Reduced both
ACTIVE and PASSIVE
Dx = OA or Frozen Shoulder
Mx = X-ray (not US) / Physio

11. Stiff and painful…?
1. Trauma = Yes
2. Age = Any
3. Ext Rot = Reduced both
ACTIVE and PASSIVE
Dx = Missed Frac / Disloc
Mx = X-ray (not US) / Ortho

12. The Weak
and
Painful Shoulder

13. Weak and painful…?
1. Trauma = No
2. Age = 30+
3. Ext Rot = Weak/painful
on RESISTED testing
Dx = Rotator Cuff Tendinopathy
Mx = Refer to Physio

14. Rotator Cuff Tendinopathy: Other Signs
• +ve Painful arc sign
• +ve Hawkins Kennedy test
• +ve Neers test
• Pain/Weak full/empty can
• Pain/Weak resisted ER
>3 +ve tests = +LR2.93
(95% CI 1.6-5.3)
Michener LA (2009) Reliability and diagnostic accuracy of 5 physical examination tests and
combination of tests for subacromial impingement. Arch Phys Med Rehabil. Nov;90(11):1898-903.
Weak and painful…?

15. Weak and painful…?
1. Trauma = Yes
2. Age = <50
3. Ext Rot = Weak/painful
on RESISTED testing
Dx = Rotator cuff tear
Mx = Refer to Ortho

16. Weak and painful…?
Rotator Cuff Tears: Other Signs
SP 77% +ve test can NOT rule in a tear
SN 73% -ve test FAIR to rule out a tear
SP 94% +ve test CAN rule in a tear
SN 46% -ve test can NOT rule out a tear
SP 84% +ve test FAIR to rule in a tear
SN 100% -ve test CAN rule out a tear
• Drop Arm Test
• ER Lag Test
• IR Lag Test
Miller CA (2008) The validity of the lag signs in diagnosing full-thickness tears of the
rotator cuff: a preliminary investigation. Arch Phys Med Rehabil. Jun;89(6):1162-8.

17. The Unstable
and
Painful Shoulder

18. Unstable and Painful…?
1. Trauma = No
2. Age = 20+
3. Ext Rot in Abd = Painful
and/or APPREHENSIVE
Dx = Congenital Instability
Mx = Refer to Physio

19. Unstable and Painful…?
1. Trauma = Yes (>6/52+)
2. Age = Any
3. Ext Rot in Abd = Painful
and/or APPREHENSIVE
Dx = Structural defect
Mx = Refer to Ortho if had physio

20. Unstable and Painful…?
Posterior Apprehension Test
• Rare < 10%
• Usually fits/electrocution
• Can be traumatic

21. Unstable and Painful…?
Inferior Hyperabduction Test
• Even rarer < 5%
• Usually hypermobile

22. Summary
Is the painful shoulder…
– Stiff think OA / Frozen / missed dislocation
– Weak think Rotator Cuff Tendinopathy / Tear
– Unstable think congenital / structural defect
Use three simple criteria to decide Mx…
– Trauma
– Age
– Shoulder External Rotation

23. Thank You
Questions