Shoulder Anatomy and Shoulder Injury Assessment – Caduceus Society Grand Rounds Houston TX – Part 1
Call 281-633-8600 for an appointment. In this article, Doctor J. Michael Bennett talks about shoulder anatomy and shoulder injury assessment. This presentation was given to the Houston TX Caduceus Society. Doctor Bennett specializes in treating issues of the shoulders, elbows, and knees.
Doctor. J. Michael Bennett is a Board Certified Orthopedic Surgeon and a Fellowship Trained Sports Medicine Physician with a clinic in Sugar Land, TX, and another clinic near the Houston Galleria.
A Houston native and University of Texas graduate, Doctor Bennett completed his orthopedic residency at the Baylor College of Medicine. Dr. Bennett provided this talk to Houston’s Caduceus Society during the Grand Rounds lecture series on July 17, 2012.
Doctor Bennett’s office accepts medical health insurance from Aetna, Cigna, and United Healthcare, plus most other medical insurance providers. Call our office at 281-633-8600 to schedule an appointment or click the Book an Appointment button in the right hand column to schedule an appointment online.
This is a transcript of Doctor Bennett’s presentation. The slide titles are indicated in brackets.
[Upper Extremity Injuries in Athletes] I want to thank Ed for having me here, I used to give talks here a long time ago, about six years ago, and he called up and talked about the Caduceus Society and about getting these talks ramped up again. And I’m glad to be here and excited to see you guys again. Thanks again Ed for having me. My talk is going to be about the shoulder and how it relates to you guys. What I think, if you’re going to walk away with anything from this series of talks, it’s to at least understand the basic anatomy of the shoulder, how to do a basic exam of the shoulder, and know when to refer a patient out and when you actually need to get a little bit of help or a second opinion. I’ve had patients come over to me from other doctors for second opinions, and I’m happy to look at them and give my opinion on what’s going on and turn them back or whatever needs to be done. But I think if you can walk away with those three things, then we’ve made this a successful symposium for you guys.
[Overview] About myself, I’m with the Fondren Orthopedic Group, and I’ve been practicing sports medicine and general orthopedics here in the Houston area and Sugarland area for about seven years. I trained at Baylor and I did my sports medicine fellowship at the University of Miami and spent some time with the Hurricanes, and then I went over to spend some time with the Tampa Bay Buccaneers, so there will be some slides in here from my Miami/Buccaneers days. A lot of this will be sports-related, and some of it will be degenerative changes and arthritic, but most of it is going to be sports-related. Upper extremity injuries –like I said before, we’re going to go over the anatomy a little bit, and talk about some common injuries. I have the elbow in here as well, so if we have enough time, we’ll go into the elbow. If you guys are interested in learning anything about the elbow, I’d be happy to go through that as well just because it is part of this talk. We’ll see how we’re doing on time.
[Shoulder anatomy] Basic anatomy here, and I’m sure this is pretty basic to you guys, but I just wanted to go over it again just to point out some of the main structures you want to look at when you’re evaluating a shoulder. The sternoclavicular joint, then start at the chest plate and work laterally with the clavicle, acromioclavicular joint, glenohumeral joint, humeral head, greater and lesser tubercle, bicipital groove, and this is the deltoid tuberosity where the deltoid inserts, and then of course the scapula. These are the main structures that you want to be evaluating from a bony aspect.
[X-ray correlation] When you’re getting x-rays – and this is key – when I see patients, sometimes they’ll come in from other doctors or other facilities and they’ll have one view here, which is an AP view of the shoulder, and then they have an internal or external view of the shoulder, internally rotated or externally rotated. That’s great if you’re looking for a tuberosity fracture, but it’s not going to tell you if that shoulder is located or where that shoulder is in space and time. This could actually be anterior or it could be posterior, so you have to get at least one of these two views. A lot of patients won’t be able to lift their arm up to get an axial lateral if they’re really in a lot of pain, so a scapular y is a good option here. That’s just having them sitting and tilting their body. So this shows you that the shoulder is located and not dislocated because you see the circle here, the humeral head, and you see another circle in the middle, and that’s a glenoid, so you know they’re in alignment there. This tells you that you’re not dislocated because there’s the humeral head, here’s the glenoid. Like I mentioned before, this is your golf ball and this is your golf tee. This is how you think about it, especially when you think about bony defects in the glenoid. Like I mentioned before, the golf ball rolling off of the golf tee. So those are just some things to think about when you’re getting x-rays. You want at least two of these three views.
[Soft tissue anatomy] Like I said, I apologize if this is redundant, but this is kind of key. Ligaments are attachment to bone, but these are things you want to look at when you’re actually evaluating and looking at a patient, and what you want to be thinking about with what might be injured. The coracoclavicular ligaments link the coracoid to the clavicle. Up here, these are the ligaments that are injured usually in AC joint dislocations. And usually, if you have a high-riding clavicle, these are more likely stretched or injured. There are the trapezoid and conoid ligaments, these are the two over here. The glenohumeral ligaments, which go from the glenoid to the humerus here, account for your stability in the shoulder joint. In patients that have Marfan syndrome, those ligaments are all going to be loose, so that’s why the shoulder is going to be popping in and out of the joint because of the laxity within these ligaments. If you have a patient with adhesive capsulitis or frozen shoulder, these ligaments thicken up and get inflamed and irritated and causes and internal rotation or external rotation or lack of internal or external rotation. Biceps tendon, it’s in the front of the shoulder and dives in deep and surfaces at the top of the glenoid here. The glenoid labrum is the little bumper around the glenoid. Just some basic anatomy and things to be thinking about.
[Soft tissue anatomy 2] These are just some dissections that we did. This is the glenoid here, just a straight-on shot. This is the biceps inserta here at 12 o’clock and the glenoid. This is what was shown earlier; this is a SLAP tear. I’d probably describe this as a type two SLAP tear which actually ripped off from the glenoid. Bone is here, and the labrum is here. The patient or the thrower rotates their arm backwards. With the cocking motion of throwing, this peels back. It’s called a peel-back sign. We do this arthroscopically when we’re looking at a patient to evaluate them and see if they do have a SLAP tear. They put their arm back, like they’re in a throwing position, and if this peels back and pops over that rim of bone there, then that’s a positive sign. Those we’ll fix, and we’ll actually fix those with a couple of anchors and some sutures, and that pulls it down to actually hold it to the bone and let it heal. Now you can have type 1 tears with this little flap off here. The type one type of SLAP tears can cause some pain and some popping sensation as well. When you get into type three, four, five, six, and seven (there are actually that many types of SLAP tears out there), then it depends on where the tears are. It could be the front of the labrum, it could be up and on the biceps, it could be the back of the labrum, but either way, those all contribute to mechanical symptoms in the shoulders. When a patient comes in and they’re popping and clicking, a lot of times it’s due to these flaps or tears along this area. When you have a dislocation, obviously this is the front of the shoulder, and this is the corocoid right here, and this is the labrum that actually ripped off, and this is where the anterior-inferior dislocation occurs. This is basically looking at the biceps. This is the CA ligament that I mentioned before, and I’m looking at this arthroscopically. This is the arc here, so this is the rotator cuff all around here, and this is supraspinatus right here. When this arm comes out, the abduction and external rotation and this can actually pinch over here, and that’s what’s called an impingement. Sometimes you can get some bony spur formations in this CA ligament that actually causes impingement on that tendon. Sometimes this ligament looks pristine, clean, and intact and there’s no evidence of degeneration or anything like that, and if that’s the case, you leave it alone. If it is damaged or partially torn, we’ll actually remove that portion of the ligament and smooth down the bone spur underneath it. This is where you’re going to see the bone spurs, right in that little space right there.
[Muscles] This is the rotator cuff. Start with the deltoid, which is the large muscle on the outside of the shoulder, then you go on to the rotator cuff, and it’s S.I.T.S: Supraspinatus, Infraspinatus, Teres minor, and subscapularis. Adam went over that as well with you guys. It’s just basic anatomy regarding the shoulder.
[Muscles 2] This is just looking at it anatomically. Cadaver dissection here, this is a nice picture here of the coracoid. This is what we actually, when I talked about that Laterjet procedure where we have a shoulder that’s dislocated anteriorly because of the bone defect in the glenoid down here, we cut this bone here, the coracoid, move it down here, and actually screw it down here to the inferior aspect of the glenoid to give them a bone block so the shoulder doesn’t dislocate. This is the subscapularis tendon up front coming down and over. The biceps tendon over here, so the subscap is actually covering that area. So that’s why (Adam mentioned before) you usually see a snapping, dislocating biceps when your subscapularis is detached, because the subscapularis is also kind of on one side of the biceps so it kind of keeps that biceps from snapping over, and when it’s detached, that biceps will slide over into this region where the subscapularis is. This is the superspinatus up top and in behind. You’ve got infraspinatus and teres minor right over here. Once again, the clavicle and the acromion back here. These are the ligaments, the CA ligaments, coracoacromial ligaments over here, and the coracoclavicular ligaments over here. They both stabilize this whole structure here. So basically, if you have a detachment of the ligament here between the acromioclavicular joint and the ligaments here between the coracoclavicular joint, you essentially almost have a floating shoulder because that scapula now is kind of floating on its own. There’s not really a lot holding that scapula to the thoracic body other than the musculature here. So if you do have a patient that has these chronic AC joint dislocations where their clavicle is popping up like that, they’re going to get a lot of fatigue in these muscles down here because these muscles are overworking trying to keep that shoulder in place. It’s important that these guys are really working on strengthening that arm and doing their rotator cuff muscular exercises to help balance out that shoulder. Otherwise, sometimes this can lead to pain, and if it does lead to pain, then depending on how unstable they are, we’ll actually go in there and reconstruct these ligaments to actually stabilize their shoulder.
[MRI correlation] You guys have gone through this already.
[Shoulder Assessment] When you first see the patient walk into your office, what are the things you want to be looking at? What is the cause of the pain? Did they just wake up one morning and have pain all of a sudden, or were they in a car wreck? Did they fall down on an outstretched extremity? What’s the mechanism of injury? Have they had a previous history of problems with the shoulder? Location, duration and intensity of pain? Having any creptitus, numbness, distortion in temperature? Weakness or fatigue in the shoulder? What gives them relief? Do they feel pain worse at night when they’re sleeping? Does it feel better when they hold their arm up against their body? Do they have any numbness or tingling involved? Those are all things that you want to be running through your differentials, or at least your diagnostic processes to run through a number of differentials to see what’s going on.
[Shoulder Assessment 2] So then we just look at the patient and have them walk in and expose their shoulder so that you can look at their shoulders. Look for symmetry across the shoulders. Are they kind of protecting one side or raising one side over the other? With he position and shape of the clavicle, like I mentioned before, do they have a dislocation of the clavicle? The acromion process: is it painful over the acromion? Do you feel any crepitus? Crepitus would indicate some soft tissue swelling, sometimes indicating a fracture in this area. Biceps and deltoid symmetry: sometimes you might think that this guy has a rotator cuff problem with complete asymmetry and atrophy on one side, but then it’s a neck issue. It’s a disk or a spur. Postural assessment: kyphosis, lordosis, and look at the shoulders. Position of the head and the arms: are they tilting their head to one side or have spasms on this side? Maybe it’s not the shoulder, and maybe it’s something else going on within the sternocleidomastoids in the neck. Scapular elevation and symmetry: this is something that often doesn’t get looked at by a lot of docs. Scapular protraction and winging: when you’re giving a physical exam like Adam showed you earlier, raising the arms up and down and out to the side, look at their backs too. Look at their scapulas. Is their scapula winging out? Is it protruding? Because that means, once again, that there’s an imbalance in the musculature and you’re going to have to focus on the muscles between the scapula and the thoracic ribs as well as the rotator cuff. So you can’t hone in and focus on just one thing; you‘ve got to be thinking holistically here.
[Shoulder Assessment 3] Then you go into actually touching the patient and evaluating the patient. Bony palpation is key; these are the areas that you want to focus on. Start here at the sternoclavicular joint and work your way laterally. Start at the sternoclavicular joint of the chest plate, then clavicle, acromioclavicular joint, the coracoid in the front of the shoulder, acromion, humeral head, the greater and lesser tuberosity, the bicipital groove. Adam described that great test, the Crash test, that I’ve actually been doing for a while, I just didn’t know it was called the Crash test. I do that when I’m doing an ultrasound evaluation and that’s a great way to expose that superspinatus because it really raises it in front of you and you can actually palpate it directly. When I was in Miami, the doctor I trained with, Dr. Uribe, is the doctor for the Dolphins and the Hurricanes, and he’d have patients come in and do that exact same test, but we’d actually palpate. If you have a thin enough patient, you can actually palpate a rotator cuff tear, especially if it’s a big tear. Onece again, I mentioned scapular vertebral border. It’s important; really look at the scapula. More and more studies are talking about when it comes to shoulder pain, you’ve got to look at the scapula and the scapula-thoracic movement across the shoulder joint because if that’s imbalanced, it’s going to throw the kinetics completely off for the shoulder and they’re going to be predisposing themselves to injury.
[Shoulder Assessment 4] Once again, going down to the soft tissues like the rotator cuff, the bursa, – these are things you want to be thinking about – biceps, CA ligament, just kind of everything we’ve already talked about. Once again, look for atrophy, look for asymmetry, look at strength. Like I mentioned before, you could be dealing with what you think is a rotator cuff but may be a Parsonage-Turner or brachial plexopathy, which is an inflammation of the nerves. This may be something that’s not going to get any better with just trying to work out and do the exercises. Maybe this is something that needs further work-up. Just things to think about here.
[Shoulder assessment 5] You guys should all be really good at cervical spine evaluations. This is the first thing to do with every single one of my patients. I want to make sure I’m dealing with a shoulder issue. Start with the neck and work your way out to the shoulder as well. Look at range of motion. Look at lateral bend; do they have any numbness or tingling down the arm when they tilt their head to one side or the other? Spurling signs: put direct pressure down on the head and neck. Do they have symptoms of paresthesia or numbness in their arms? Palpate the neck. Do they have paraspinal spasms? Are they tender along the facets? Are they tender along the spinous processes. Once I’ve ruled this out and I know its not anything cervical, then I move on to the shoulder. Range of motion and manual motor testing: range of motion is key. Like Adam mentioned, look at symmetry. Some patients may not have full range of motion in both arms, but you just want to make sure that they’re symmetrical. Instability: you want to make sure they’re not popping out of the joint. That being said, you don’t want to have them show up at your clinic and pop them out of joint. You want to make sure that you can recognize it before it happens. So if a patient comes in to you and says “Hey doc, my shoulder pops out three or four times a month, I’m in pain,” and you evaluate them and you put them at an abduction-external rotation, it may very well just pop out on you at the clinic and you’re going to find yourself having to reduce it at the clinic, which is not going to be fun. So you just want to make sure that you say, “Does it hurt when you go in this position just a little bit?” Don’t push them all the way. If they’re apprehensive, that’s an apprehensive sign right there, so just stop. Don’t push them any further. That’s a provocative test; that means you’re provoking the symptoms. Good neurovascular exam: make sure they’ve got good blood flow and good sensation. One thing you’ll see occasionally is thoracic outlet syndrome. Patients come in saying “My hand goes numb in this position here. What’s going on?” You do what’s called an Adson’s test and lift their arm up, turn their head, and if the fingers turn blanche, and their pulse diminishes, that actually means the thoracic outlet is closing up and squeezing the nerves and vessels up in this area. That can actually be addressed with just stretching and therapy. But you’ve got to be able to recognize these things and call them as they are.
[Instabilitity: Anterior and posterior drawer tests] These are just some basic exams. As far as stability is concerned, if you’re worried about dislocating somebody in this position, particular the abduction external position, sometimes you can assess stability just by having them sit upright or lay down and shucking the shoulder back and forth. This is where you abduct and externally rotate, you’ve just got to be careful because sometimes they’ll actually pop out on you if they are unstable. This is a Sulcus test where you just pull longitudinal traction down the arm, and if you feel a divot here between the acromion and the tuberosity, that means that they’re pretty lax. That’s a positive Sulcus test. A clunk test is when they actually clunk or pop out a joint. I wouldn’t recommend that necessarily.
[Tests continued] Apprehension test, like I mentioned before, this is the position that they are apprehensive in. That means that they are prone to an instability, or they may have some anterior labrel symptoms. Posterior apprehension test is where the arm comes across the shoulder and basically shucking posteriorly and feeling for any instability. A relocation test is basically where you use external rotation and anterior pressure to see if they have a decrease in their symptoms. You put them in this position, but you’re putting pressure on the front of their shoulder while they’re lying down and seeing if they feel better. If you use pressure and they feel like their symptoms come back, that is a positive relocation test. That means they have instability of the front of the shoulder.
[Shoulder Impingement] Once again, this is like what Adam mentioned before. These are just the basic tests that we do. Neer’s test and Hawkin’s test are used to determine impingement and assess impingement for soft tissue structures. Raising their arm above their head and having them lean to the side actually brings the rotator cuff near the acromion. Sometimes you can have them reach across their body and they’ll feel pain either anteriorly or posteriorly in the shoulder. That’s also sometimes indicative of some biceps pathology as well.
[Supraspinatus weakness] With the drop arm test, as Adam mentioned before, have the arm out to the side, then help them lift the arm to 90 degrees, then have them lower the arm. If they are unable to hold the arm up and it just drops, that’s a positive drop arm sign. If they are able to slowly lower the arm, that means that the tendon is intact and they at least don’t have a massive tear.
[Empty can test] This is for supraspinatus pathology. Basically, 90 degrees and drop your thumbs down to the floor. That’s why it’s called an “empty can”; because you’re emptying a can. Downward pressure is applied and weakness and pain are assessed bilaterally, and that will actually indicate if you have any pain in the supraspinatus region, indicating a rotator cuff pathology.
[Other tests] Once again, here’s the scapula winging I was talking about. I have patients, after I’ve evaluated them completely in the front as far as range of motion and strength is concerned, have them do a push up on the wall and lean up against the wall. Sometimes, these are pretty obvious and the scapula just wings out at you. That creates an instability in the scapular-thoracic junction here, leading to a bursitis underneath the scapula and the muscles at the front are trying to compensate, so everything just becomes completely off-balance and you end up with more problems. You want to make sure you know that this is what’s going on as well. Plus, this could also indicate an injury to the long thoracic nerve, so it could be a nerve issue as well. With bicep irritation, like Adam mentioned before, use Speed’s test. Bring your arm out, supinate the arm, and basically resist downward pressure if you have some anterior pain. Yergason’s test is where you actually try to rotate or supinate the arm with elbow extension and if you have biceps pain, that indicates a biceps pathology as well.
If you have any questions about the information presented in this lecture or if you need to visit with a doctor specializing in the shoulder, elbows, knees and hand, please call our office at 281-633-8600 for an appointment with Dr. Bennett.