Principles Of The Physical Examination

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Once the examiner completes an organized history, there should be a clear idea of the differential, and this should direct which aspects of the physical examination should be emphasized. Just as in the history, there are certain expected responses (both positive and negative) for the differential-directed physical examination. During the examination, one should note whether the physical examination expectations are met (in which case the suspicion of the correct diagnosis is strengthened) or whether the expectations are not met (in which case, one must reconsider the appropriate diagnosis). Although we organize our approach based on complaint, there are certain aspects to the physical examination that should be ingrained in any competent examiner. Depending on the differential, some of these areas are emphasized more than others. Nevertheless, especially in the overhead athlete in whom multiple pathologies often exist and there is considerable overlap for many chief complaints, we repeatedly emphasize that the following tenets should be remembered:

1. Introduction to the patient and cursory assessment of general aspects. This allows the examiner to see the "big picture," to remember the whole patient, and to avoid making the mistake of focusing too narrowly on the shoulder.

2. Features of inspection such as muscle wasting, deformity, and previous surgical scars. This is especially important when the chief complaint is weakness related, which can lead to a number of other chief complaints such as pain and instability.

3. Palpation of known anatomic sites. This is crucial in the patient who complains of pain, but also can be used for other pathologies (e.g., to diagnose rotator cuff tears in patients complaining of weakness).

4. Range of motion (active and passive) with careful documentation. This is an often overlooked area of the examination but is often the key finding in overhead athletes with tight posterior capsules leading to pain and other complaints.

5. Strength testing and neurologic examination. These should be a part of every shoulder examination in the athlete.

6. Stability assessment and laxity measurements. Because laxity and "microinstability" are the "great imitators" in the athlete's shoulder, this is critical to every examination. Instability can underlie many chief complaints in the overhead athlete.

7. Special tests. These tests may be the decisive blow in ruling a diagnosis in or out; familiarity with the special tests for each diagnosis separates the beginner from the advanced diagnostician.

8. Lower extremities and trunk. Although outside the scope of this chapter, it is emphasized that the kinetic chain begins in the legs and proceeds through the trunk before it ever gets to the shoulder. The examiner is reminded that problems in the shoulder may only be a manifestation of more proximal pathology in the chain that must be corrected to allow the athlete to return to proper performance.

The patient should be prepared by removing the outer garment for a view of the bare shoulders. For women, a sports bra or designed halter top type gown will preserve modesty while allowing the examiner to pick up on often subtle aspects of the examination like atrophy or winging (Fig. 16-2). Attention to the asymptomatic side remains important to note, but the examiner must remember those physiologic adaptations that often are present in overhead athletes. With this in mind, the examiner should attempt to reproduce the conditions that bring on the chief complaint. This may involve more emphasis on range of motion when instability is suspected or palpation and special tests when pain is the chief complaint. This does not mean that we ignore range of motion in the patient with pain or palpation in the patient with instability; it is just that a dif

Figure 16-2 A and B, Direct inspection of shoulder.

Figure 16-2 A and B, Direct inspection of shoulder.

Table 16-1 Common Descriptions of Shoulder-Area Pain

Patient Description

Likely Source of Pain

Whole hand over deltoid in rubbing motion

Impingement/rotator cuff

Greater tuberosity

Impingement/rotator cuff

One finger on top of distal clavicle

Acromioclavicular joint

In the back when the arm is in the throwing position (points to posterior capsule with arm abduction/external rotation)

Internal impingement/superior labrum anterior to posterior tear

Down the neck and scapula medial border

Neck pathology

In front within deltopectoral groove

Biceps tendon, subscapularis pathology

"Deep inside"

Labral or articular cartilage pathology

Vague and diffuse down arm

Brachial neuritis/thoracic outlet syndrome (neurologic)

ferent set of red flags and expectations arise for each patient with this approach.

We now define the various chief complaints common to the athletic shoulder (and, specifically, the overhead shoulder) and discuss which initial differential corresponds to each chief complaint. Next, we describe the specific historical questions that should narrow the focus and sharpen the differential. Finally, we demonstrate the various physical examination techniques that may rule a specific diagnosis in or rule out in the athlete. We hope that this differential-directed approach provides an organized template for the correct diagnosis right from the initial history, tips off the examiner on what to expect and what not to expect throughout the physical examination, reinforces each step of the workup, and creates solid evidence for the diagnosis by the completion of the encounter.

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