Shoulder and upper arm diagnoses

Background

Shoulder anatomy

Shoulder anatomy, anterior.

Shoulder anatomy, posterior.

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

• Shoulder Dislocation
  • Anterior shoulder dislocation
  • Posterior shoulder dislocation
  • Inferior shoulder dislocation
• Clavicle fracture
• Humerus fracture
• Scapula fracture
• Acromioclavicular joint injury
• Glenohumeral instability
• Rotator cuff tear
• Biceps tendon rupture
• Triceps tendon rupture
• Septic joint

Nontraumatic/Chronic:

• Rotator cuff tear
• Impingement syndrome
• Calcific tendinitis
• Adhesive capsulitis
• Biceps tendinitis
• Subacromial bursitis
• Cervical radiculopathy

Refered pain & non-orthopedic causes:

• Referred pain from
  • Neck
  • Diaphragm (e.g. gallbladder disease)
• Brachial plexus injury
  • Rucksack paralysis
• Axillary artery thrombosis
• Thoracic outlet syndrome
• Subclavian steal syndrome
• Pancoast tumor
• Myocardial infarction
• Pneumonia
• Pulmonary embolism

Evaluation

Rotator Cuff Tests

• Supraspinatus Test (+ LR 3.2)
  • Abduct arm to 90', forward flex it 30' with thumb down ("empty beer can position")
  • Test for pain/weakness against resistance to continued abduction
• Infraspinatus and Teres Minor Test
  • Stabilize the elbow against the patient's waist and bend the elbow to 90'
  • Test for pain/weakness against resistance to external rotation
• External rotation lag sign - more specific to teres minor, given overlap between infraspinatus and teres minor
  • Support the arm to 20-30 degrees in scapular plane, externally rotated, elbow flexed to 90 degrees
  • Positive test is pain or difficulty in keeping the arm from internally rotating when clinician lets go
• Subscapularis (+ LR 1.9)
  • Place hand behind lower back
  • Test for pain/weakness as patient attempts to push examiner's hand away by moving dorsum of hand away from back
• Drop arm test
  • Patient is unable to hold or smoothly lower an extended arm at 90' of shoulder abduction with out dropping it

Impingement Tests

• Maneuver of Neer
  • Prevent scapular rotation with one hand while raising patient's straightened arm in full forward flexion to overhead
  • Positive sign is pain in the arc between 70-120'
• Hawkins Impingement Test
  • Position the shoulder at 90' of abduction and elbow at 90' of flexion
  • Then rotate shoulder internally bringing the arm across the front of the pt
  • Positive sign is pain during this maneuver

See Also

• Diagnoses by Body Part (Main)
• Shoulder x-ray interpretation