When you were last enraptured by my physical exam series, I was explaining the different directions doctors use to confuse themselves and everyone else. I am happy to leave that land of relativity and now re-embark on the actual human body. I am sure this relativistic view of direction was invented by some liberal anatomist intent on socializing the human body. It is a stop on the road to death panels, in my opinion. It’s good to get that posterior to me.
My distraction (I get distracted, you know) happened as I was trying to explain how the shoulder works. Since the shoulder moves in so many directions and with such huge angles, I felt it was necessary to totally confuse you and so hide any chance you would pick up my ignorance. It’s always good to keep your readers snowed. So, after spending a whole post making poems about the shoulder (that will no doubt go down in the anals annals of poetry about joints) and another post about the confusing directions we doctors use to confuse other doctors, I will now talk about the actual exam of the shoulder.
As you probably have been taught, the shoulder is the joint that attaches your arms to your body. Some people refer to the top of their torso as their shoulders (as in “shoulder straps”), but this is not what I am talking about. The shoulder is supposed to be the joint between three bones:
- The humerus - which is the long bone in the upper arm, and got its name because of its habit of playing practical jokes on the ulna. The other bones are always inviting the humerus to parties.
- The clavicle – also known as the collarbone. This bone actually looks nothing like a collar, and it resents the implication.
- The scapula – called the shoulder blade. The collarbone is jealous because the scapula has a much cooler nickname. This causes the scapula to snicker often at the clavicle’s wimpy nickname.
Examining the shoulder
The examination of the shoulder involves inspection (looking at it), palpation (touching it), and assessing the range of motion. This means that the doctor has all sorts of ways to inflict pain on the person during this exam - which is a secondary goal for many doctors, as hurting the patient allows us to charge more.
The normal shoulder:
- Looks just like a shoulder should.
- Doesn't hurt when you push on it (although a karate chop may elicit some pain)
- Moves all over the place.
But you seldom see doctors documenting a shoulder exam in a person not complaining of pain. If they did, the exam would look like this:
Shoulder: Appears shoulder-ish, nontender (aside from karate chop maneuver) and moves all over the place.
It is when the shoulder is messed up that the exam is undertaken. So let's look at the three parts of the exam and how they relate to things that go wrong.
When examining the shoulder, the first thing to do is to look at it. This is made much harder as people without fail wear thick sweaters or dress suits when coming in for shoulder pain. So the first step of the exam is to say: “Can you please undress so I can look at your shoulder?”
The patient generally responds by saying: “It hurts my shoulder when I take it off.”
Which invariably results in me and several of my staff helping the patient to get the top off, usually involving the use of utensils such as shoehorns, putty knives, and plungers. This makes me wonder how they got the clothes on in the first place. It also makes it necessary to overlook the trauma caused by the utensils.
One of the nice things about examining the joints is that you have a built-in comparison. I make it a habit to stand back and look at both shoulders at once, noting any visible difference between the two. The first notable asymmetry seen is the separated shoulder. This problem is not the same as a dislocated shoulder. Shoulder separation is a condition where the clavicle and scapula disconnect at a joint called the AC joint (acromioclavicular). The acromion is a knobby process coming off of the top of the scapula. Note: my spell-check wants me to change the word "acromion" to "accordion," but I know no condition where the clavicle separates from an accordion. If it did separate, people would probably be thankful.
In the absence of accordions, the AC joint separation can be seen on inspection:
The first clue to this is the blinking red arrow that appears over the separated shoulder. A more sophisticated clinician, however, will note the bump over the AC joint region is bigger on the one side than the other. Personally, I think that the red arrow method is more accurate, but the blinking does get annoying after a while. A shoulder separation is usually treated by simply putting the arm in a sling and then torturing the patient using physical therapy. Alternatively, it can be fixed by putting a screw between the two bones. The latter procedure was perfected by Dr.'s Black and Decker.
The dislocated shoulder, on the other hand, is a condition where the humerus comes out of the socket formed by the scapula and clavicle.
There are no flashing arrows present, but the big bulge on the front of the shoulder and the pained facial expressions of the patient, make this diagnosis relatively easy.
Which reminds me of a (true) story.
I was vacationing with my family in Puerto Rico a few years ago. We had toured the island and had come to the west coast town of Rincon to spend the night. The waves on that side of the island are relatively large, and so Rincon is a popular gathering place for surfer dudes (and babes).
Our hotel was right on the beach, with a bar situated about 20 feet up from the shore. I was out frolicking in the waves with my kids and decided to show them about body surfing. Perhaps I felt that they were thinking of me as some doctor dork and wanted to show myself more as the surfer dude type; I am not certain. But something possessed me to pretend I knew what needed to be done to body surf.
I wasn't too good at it, though, and was starting to give my kids the impression that body surfing involved going into a big wave and getting salt water in your nose. I didn't succeed in moving much but I did bob up and down, so I thought I was ready to show my surfing savvy. As a particularly large wave came in, I started swimming forward and moved rapidly toward the shore. Success. I imagined the kids bragging to their friends about their cool surfer dad and my wife deciding to wear bikinis around the house to keep the image up.
But there was one problem I hadn't considered: the waves were breaking right on the shore. I noticed this fact as I was raised about 5 feet above the beach and then flung down head-first into the sand. I instinctively put my arm in front of me to protect my neck from the imminent collision. My face was rammed into the sand, but my neck was spared injury. My shoulder, however, was explaining to my cerebral cortex that there was something very wrong. The pain was severe.
I stood up, with arm hanging at my side, and walked toward the hotel. Some folks at the bar noted that I had blood on my face and that my arm was dangling. They also noticed that I said, "I hurt my shoulder! Ow! I hurt my shoulder!" Some very nice bar patrons ran to my aid and walked me to their table. One of my rescuers explained to me that I probably dislocated my shoulder, and that he was very experienced in putting it back in place. He suggested I lay on the table so he could fix it immediately.
Dazed, and desirous of stopping the pain, I complied with this shoulder expert. I laid face-down on the table with my panful arm dangling over the edge. Another bar patron (who had apparently studied anesthesiology) offered me some beer to help me deal with the pain. I was not aware of the analgesic properties of beer, so I went without the wonder-drug.
My kids ran to get their mother and someone called an ambulance while the world shoulder authority went to work, pulling my arm downward and then forward. Instead of the desired "thunk" of the shoulder going back into joint, my cerebral cortex was sent the message: "Who is this bozo pulling on my arm?? It hurts when he does that!" I explained to my would-be shoulder repair man that it actually increased the pain, and he offered to try other maneuvers he knew. The anesthesiologist offered some vodka. I thanked them for the kind offers, but decided to wait for the ambulance to take me to the hospital.
I ended up being diagnosed with a fracture of the humerus - right through the "surgical neck" (little black arrow). I got to see the workings of a public Puerto Rican hospital (Two rules: bring your own bed-linens, and avoid radiology techs who don't interpret screams of "mucho dolor" as reasons to stop twisting), and I got to experience the wonders of Percocet.
I recovered at home without surgery, although it was several months before I could lie flat in bed.
The morals of the story:
- Being a surfer dude is over-rated
- Don't go to a bar to get your medical evaluation and treatment
- All shoulder pain is not dislocation.
Gosh, I have written this much and haven't even gotten to the other parts of the exam. I guess this means my shoulder exam posts will continue. Sorry.
Have a beer; it'll make you feel much better.