Examination of the Shoulder

Introduction

• Introduce self
• Confirm patient identity and obtain consent
• Expose patient down to waist
• Observe patient whilst undressing
  • Comment whilst patient is undressing
• Stand near examiners

Look

Clues

• Splint
• Sling

General Inspection

• General comments
  • Evidence of systemic disease
    • eg. rheumatoid, Cushingoid
  • Frailty
  • Body habitus

Anterior Aspect

Lateral Aspect

Ask the patient to turn 90º

• Muscle Wasting
  • Deltoid, Biceps, triceps
• Spinal posture
  • Cervical/Thoracic/Lumbar
    • Eg. Exaggerated kyphosis of thoracic spine

Posterior Aspect

Ask the patient to turn another 90º

Feel

• Ask patient “where is it painful ?”
• Stand to side of patient at 45°, so as to face patient & examiner
• Look at patients face whilst palpating
• “Could you please point with one finger to where it hurts the most.”
• I’m going to feel around your shoulder, please let me know when it hurts.

Anterior

Posterior Aspect

• Spine of scapulae
• supraspinous fossa
  • ganglion
  • Osteochondroma
  • Muscle mass
• infraspinous fossa
• Medial aspect of scapulae
  • Osteochondroma / bursitis

Move

From Front

• 1. Abduction
• 2. Forward Flexion
• 3. Adduction
• 4. External Rotation

From Behind

• 5. Internal Rotation
• 6. Scapulothoracic motion if Abduction abnormal

STAND IN FRONT OF PATIENT, TEST BOTH ARMS AT SAME TIME

• 1. Active
• 2. Passive
  • if Active is restricted
  • stop immediately if painful
• 3. Power (MRC grading)

Lateral Elevation | Abduction 0–160/180°

• Note glenohumeral & scapulothoracic
  • Put hand on shoulder to stabilise shoulder
• Note ROM
• Active then Passive
  • Active
    • elevate both arms in coronal plane
    • comment on
      • 1. Initiation
      • 2. scapulohumeral rhythm
        • Scapula moving too early & creating a shrugging effect (R/C path, Glenohumeral Osteoarthritis)
        • 60° Scapulothoracic, 120° GHJ
        • non-linear relationship between GHJ and scapular contribution
      • 3. painful arc syndrome (impinged or torn RC)
        • Pain in midrange of abduction suggests minor rotator cuff tear or supraspinatus tendonitis
          • Ask if any pain during this movement
          • Can’t watch face from behind!
      • 4. Pain at the end of abduction (AC arthritis)
      • 5. range (160°-180°)
  • Passive (if active not restricted due to pain)
    • if not full, passive to 180° comment on
      • active vs passive
    • Warn patient about movement
    • Hold patients shoulder & elbow
      • If passive is more than active
        • ? R/C pathology
  • Observe arm lowering comment on
    • arc of pain
    • drop arm

Forward Flexion 160-180°

• Active
  • both arms raised forward
  • comment on
    • NEER’s Impingement
    • range
    • ability (trick movements)
    • check contour of axilla
• Pathology
  • ↓ in arthritis, adhesive capsulitis, R/C tears
  • R/C impingement limits abduction more than forward flexion
  • ↑ passive over active – R/C pathology, weakness of scapular stabilizers

Adduction (Horizontal flexion)

• Adduction by cross body/cross chest adduction
  • Forward flex shoulder to 90deg
  • Try to touch opposite shoulder
  • Measure the distance from the cubital fossa to opposite acromion
  • Normal: cup hand over other shoulder at least, often more
  • ↓ in ACJ pathology
• Option
  • Adduction by swinging extended arm across body (30deg)

External Rotation 45 – 90°

• Active with shoulder adducted
  • elbows flexed to 90° & arms by side
  • start with arms forward
  • rotate arms outwards (90°)

Passive

• if not full, passive

Option

• Active with shoulder abducted 90°
  • do not do this if patient had pain on abduction!
  • arms abducted to 90° & elbows flexed 90°
  • external rotation (90°)
  • internal rotation (90°)
    • usually 20° greater in dominant arm
    • Watch for compensatory arching of back
    • In this position, it may be falsely limited in patients at risk of involuntary subluxation, dislocation
    • ↓ ER – massive R/C tear
      • in massive R/C tears, passive motion with ↑ ROM but patients arm will drift back on letting go

FROM BEHIND PATIENT

Internal Rotation

• Apley Scratch Test (T7 for women, T9 for men)
  • Reach behind your back & run your thumbs over the middle of your spine
• Mark with your index finger & compare to contralateral side
  • superior angle of scapula (T2)
  • blade of scapula (T4)
  • inferior angle of scapula (T7)
  • Iliac crests – L4-5 interspace
  • Abdomen, greater trochanter, PSIS, sacrum
  • This movement also requires extension but is a very functional measurement
  • 2 levels higher in non-dominant hand
  • IR is the first motion lost in adhesive capsulitis (last to come back)
• Options
  • IR in 90° abduction (30-45deg)
  • You can also test by asking patient to
    • Hands behind head: ER in abduction
    • Hands up back IR in adduction

Scapulothoracic Motion

• Perform if abduction abnormal
• Stabilize shoulder & move passively

Special Tests

• order of special tests depends on your clinical suspicion
• For example
  • If elderly
    • Impingement
      • I noted on movement he had a positive / negative Neer’s Impingement Sign & Drop arm sign
      • Hawkins Test
        • Is also positive
    • Rotator cuff
      • Supraspinatus: Jobe
        • (feel muscle, +ve , 5/5)
      • Infraspinatus / teres minor: resisted ER test
      • Subscapularis: Belly press & Lift off test
    • AC joint
      • Cross Chest compression
    • Biceps
      • Speeds
      • Yergasons
  • If young
    • do stability testing first
      • Quantitative
        • Sitting
          • Sulcus
          • Anterior & posterior draw
      • Provocative
        • Sitting
          • Posterior
            • Jerk
          • Anterior
            • Apprehension
            • Relocation
            • Release
      • Generalised Ligamentus Laxity
    • Slap
      • O’ Brien’s Test

Impingement / Rotator Cuff

• Findings
  • Tenderness of subacromial bursa
  • Painful arc of abduction
    • Pain on abduction between 60-100°, maximal at 90°
    • Pain ↑ with resistance at 90°
    • Patients sometimes ER to clear GT under acromion (diminishing pain & allowing greater elevation in the coronal plane)
  • Abnormal scapulohumeral rhythm during abduction
  • Weak suprspinatus muscle-tendon unit
  • Weak infraspinatus muscle-tendon unit
• Already performed
  • Neer’s
  • Drop arm
• To Perform
  • Hawkin’s
  • Impingement

Hawkins Impingement Reinforcement Test

Neer’s Impingement Sign

Neer’s impingement test

• Inject LA (10 cc of 1% xylocaine)

Drop-arm Test

Rotator Cuff

• Test pain & grade power
• Feel muscle belly & comment on
• Presence of contraction
• Stength 1-5

• 1. Supraspinatus: Jobe
• 2. Infraspinatus & Teres Minor: Resisted ER
• 3. Subscapularis: Belly press test & lift off test

Supraspinatus (Suprascapula nerve)

• Supraspinatus isolation test (Jobe test)
  • Abducted 90°
  • 30° anterior to coronal plane
  • elbows fully extended
  • thumb pointing downwards
    • patient pushes up towards ceiling against resistance
  • Differential Diagnosis
    • 50% of power at this position is from supraspinatus
    • Deltoid dysfunction
    • OA

Infraspinatus (Suprascapula nerve) / Teres Minor (axillary nerve)

1. Resisted external rotation

• elbows flexed to 90°
• arm by the side
• Feel for muscle
  • Teres minor is tested with infraspinatus
    • Teres minor is only involved in massive rotator cuff tears
• If weak, perform
  • Dropping sign
    • Irreparable degeneration of infraspinatus
  • Hornblower’s sign
    • irreparable tear of infraspinatus & teres minor

2. Dropping sign

• 0° of abduction, forearm is placed in 45 deg of external rotation
• Pt asked to externally rotate against examiner’s hand
• If the patients arm falls back to 0° of ER, than +ve test
• 100% sensitivity & 100% specificity for irreparable degeneration of the infraspinatus

3. Hornblower’s sign

• Power of external rotation in 90° of abduction in the scapular plane
• Examiner places the patients elbow at 90 deg flexion with maximal ER
• Examiner’s other hand is used to judge external rotation force
• When the examiner’s hand is released a positive test is recorded if the patient is unable to externally rotate
• 100% sensitivity & 93% specificity for irreparable tear of infraspinatus & teres minor
• “dropping” & “hornblower’s” signs in evaluation of rotator cuff tears.

Subscapularis (Upper & Lower subscapular nerves)

1. Belly Press Test

• Described in Gerber’s 1996 article
• Patients with R/C pathology usually cannot do lift off test because of ROM
• Resisted Internal Rotation with hand on belly
• Must keep elbow forward

I’m going to hold onto your elbow

Could you now try to “Press your wrist into your belly”

• Negative
  • Elbow forward
  • Pt uses subscap to internally rotate arm to press belly
• Positive
  • Pt compensates for lack of subscapularis
    • Extending shoulder

2. Gerber subscapularis lift off test

• Christian Gerber in JBJS(B) 1991
• “Pathological lift off test – patient is unable to lift the dorsum of his hand off his back”
  • Put dorsum of patients hand on buttock then lift it off buttock & let go
  • Gerber’s test is normal if patient can hold hand off buttock
  • Pt must have full IR & not be limited by pain to use this test
• other feature that Gerber described was ↑ passive ER with indistinct endpoint

AC Joint

• 1. Localized crepitus over AC joint
• 2. Passive Cross-chest adduction
• 3. AC injection with LA
• 4. O’Brien test

1. Crossed chest adduction test

• Passive FF to 90 & adduction
• Pt places hand behind back & examiner extends shoulder further, lifting forearm off back
  • Places rotational stress at AC joint

2. O’Brien Test

• Stephen O’Brien Am J Sports Medicine 1998
• Step 1
  • Elbow straight
  • FF shoulder to 90°
  • 15° towards midline
  • IR arm until thumb points downward
  • Apply downward force whilst patient resists it
  • Note presence & location of pain
• Step 2
  • Palm now faces forward
  • Apply downward force whilst patient resists it
• Positive if
  • Pain only during step 1
  • Pain at top of shoulder is AC joint
  • Pain deep in shoulder is injury to glenoid labrum

Biceps Tendon

Tendinitis

• Localised tenderness
• Speed Test
• Yergason’s test

Speed Test

• FF 90 deg, elbow extended, palms pointing towards the ceiling
• Push down on wrists & patient resists
• Positive if patient complains of pain
• Assess pain or popping at bicipital groove (long head of biceps)

Yergason’s Test

• Arm by the side, elbow flexed 90 deg, pronate forearm
• Shake patient’s hand
• Ask patient to try to flex & supinate forearm
• Positive if patient complains of pain in anterior aspect of shoulder

Stability

Biceps Instability Test

• Instability of long head of biceps in intertubercular groove
• Associated with R/C tear
• Stop sign position: abduction 90°, elbow flexed, ER shoulder
• Feel for bicipital groove
• IR shoulder
  • palpable or audible click & pain as biceps tendon reduces & then subluxates passing over the lesser tuberosity

Stability Testing

• Anterior Instability
  • Sitting (on edge of couch)
    • Quantitative laxity tests
      • Sulcus
      • AP drawer
      • Load & shift
    • Provocative
      • Jerk
  • Lying
    • Provocative tests
      • Apprehension
      • Relocation
      • Release

Quantitative Tests of Laxity

• Test for amount of laxity

1. Sulcus Sign

• Pt sitting
• This is testing for inferior instability
• needs to be compared to the opposite side
  • in front of patient
  • hands in lap
  • pull down on elbow, other hand gripping acromion to stabilize it
  • one at a time
• look for sulcus between lateral edge of acromion & humeral head

Grade	Distance
1	1 cm
2	1-2 cm
3	> 2 cm

• Suggestive of multidirectional instability
• Performing this test with arm adducted stresses the superior glenohumeral ligament & rotator interval
• Performing this test with the arm abducted 90° stresses the IGHL.
• If there is inferior translation without symptoms the patient has inferior laxity; if there are symptoms the patient has inferior instability

2. Drawer Test – anterior & posterior

• Always examine other shoulder first
• Stabilise scapula with other hand (grip Acromion)
• Grasp proximal humerus with thumb & index finger
• Push anteriorly & posteriorly
• Normal
  • 25% anteriorly
  • 50% posteriorly
• But compare with other side

3. Cofield’s Stability Tests (glenohumeral ligament)

• Glenohumeral ligament is tightened with progressive ER
• Anterior & posterior draw performed with varying degrees ER
• Supine

4. Load & Shift Test

• Similar to Drawer test but shoulder is mildly abducted
  • Pt is at edge of table so that shoulder hangs off it & the table then acts to counteract applied forces
  • Tuck the pt’s hand into your arm pit, thus freeing both hands to manipulate the shoulder
  • Vary the amounts of abduction to find the most laxity
    • A compressive force is delivered to the humeral head to reduce it into the glenoid. The arm is positioned in 20° of abduction, 20° of forward flexion & neutral rotation. Anterior & posterior forces are then placed on the proximal humerus & direction & degree of translation are determined.

Grade	Description
1	head translation up to the glenoid rim that is greater than the other side
2	head translates over the glenoid rim but spontaneously reduces when the force is removed
3	humeral head translation over the glenoid rim which remains locked when the force is removed

Provocative Tests

Posterior Instability – Patient Sitting

1. Jerk Test / Posterior stress test

• Arm is at 90° forward flexion & flexed at the elbow to 90°
• A pressure is applied posteriorly to translate the shoulder back, then the arm is brought around to abduction & the shoulder relocated
• scapula is stabilized with the other hand during this manouver.
• Positive if apprehension or Jerk felt
  • patient experiences pain +/- apprehension
  • unlike anterior test patient has +ve test if pain only
  • should reproduce the patients symptoms

2. Passive Circumduction Adduction Manoeuvre

• Standing position
• Stand behind patient
• Hand to stabilize shoulder & feel for subluxation
• Elbow extended, move arm to extended & slightly abducted postion
• Then passively move patient’s arm in circle movement moving backwards & upwards
• At the top of circle, move arm to front of patient into flexed & adducted position
• Posterior dislocation occurs when shoulder is forward flexed & adducted

Posterior Instability – Patient Sitting

1. Apprehension Test

• Ask patient to relax
• Take it slow & ask patient to say when it hurts etc
• Abduct shoulder to 90°
• Elbow flexed to 90°
• Examiner then ER arm
• Positive if
  • Pt reacts by expressing concern or anxiety
  • look for apprehension (pain not reliable indicator)

2. Relocation (Jobe Relocation Test)

• Push posteriorly on the anterior aspect of proximal humerus
  • This should relieve the patients symptoms

3. Release

• By releasing or easing the posteriorly directed pressure the patient’s apprehension should return

Other options

4. Crank Test

• Similar to apprehension test, but in upright position
• Examiner’s thumb pushes on posterior shoulder to apply anterior leverage
• index & middle fingers are positioned on anterior shoulder to prevent against sudden dislocation

LIGAMENTOUS LAXITY (Wynne-Davies Criteria)

1. Thumb touching forearm on flexing wrist
2. Fingers parallel to forearm with wrist extension
3. Elbows extend past 180°
4. Knees extend past 180°
5. Foot dorsiflex past 45°

“If 3 of the 5 pairs of joints examined in any one individual showed this degree of laxity it is taken as positive.”

SLAP Lesions

• Sitting

O’Brien Test

Step 1

• Elbow straight
• FF shoulder to 90 deg
• 15 deg towards midline
• IR arm until thumb points downward
• Apply downward force whilst patient resists it
• Note presence & location of pain

Step 2

• Palm now faces forward
• Apply downward force whilst patient resists it

Positive if:

• Pain only during step 1
• Pain at top of shoulder is AC joint
• Pain deep in shoulder is injury to glenoid labrum
• Supine

Compression-Rotation test (McMurray’s Shoulder test)

• Shoulder ABD 90°
• Elbow Flexed 90°
• Compression force to humerus
• Humerus rotated
• Attempt to trap torn labrum
• +ve if pain & click

Other Muscles

Looking from Back

Scapula Stabilizers

• Serratus Anterior Long thoracic nerve
  • 1. Winging
  • 2. “Wall push off test
    • modified pushup against the wall
    • if subtle, get patient to perform pushup with the arms at various heights above & below shoulder level
  • 3. Shoulder protraction against examiners hand
• Rhomboids Dorsal scapula nerve
  • “pull the shoulders back”
  • palpate muscles
  • rare injury to nerve produces milder winging
• Trapezius Cranial nerve X1- spinal accessory nerve
  • Weakness of trapezius causes a more lateral scapula & winging
  • “shrug shoulders”
  • palpate muscle
  • Nerve injured in surgical procedures like dissection of posterior cervical lymph nodes

• Deltoid (axillary nerve)
  • Test anterior, middle & posterior fibers independently
  • arm by side
  • resisted elevation
  • Looking from Side
    • Anterior fibres: Forward flexion against resistance
    • Posterior fibres: Extension against resistance
• Latissimus Dorsi (thoracodorsal nerve)
  • Climbing a ladder action – patient starts with arm 90° flexion & elbow flexed, then tries to extend the shoulder against resistance

Looking from Front

• Pectoral Major (medial & lateral pectoral nerves)
  • Press hands together in front of body
  • To test strength, one hand at a time against examiners hand

Sensation Testing

• Axillary Nerve
  • Shoulder patch
• Musculocutaneous Nerve
  • Becomes lateral antebrachial cutaneous nerve
    • Lateral side of forearm

Thoracic Outlet Syndrome

Compression of neurovascular structures above the first rib

1. Adson’s Test

• Shoulder abducted 30° & maximally extended, neck facing away
• Feel for quality of radial pulse
• Pt inhales deeply
• Positive if less than when shoulder is in neutral position

2. Wright’s Test

• Similar to Adson’s Test
• But arm is abducted 90° & fully ER

3. Roos Test

• Shoulder abducted 90 deg, elbow flexed 90 deg
• Pt open & closes hand 15times
• Positive if numbness, cramping, weakness or inability to complete procedure

4. Halstead’s Test

• Patient is standing
• Arm by the side, feel the pulse
• Patient then turns head away & extends neck
• Examiner then pulls on arm
• Positive if pulse is obliterated

5. Hyperabduction Test

• Feel both radial pulses
• Pt then abducts both armsfully
• Positive if pulse is reduce

Snapping Scapular Syndrome

• retract & protract scapular
• produces a palpable & often audible grating
• feel at supramedial corner of scapula

OTHER

CEPHALAD JOINT – NECK

• 1. ROM
• 2. Tenderness
• 3. Compression Test
  • Slight extension
  • Compression
• 4. Spurling’s test
  • Neck in lateral flexion, rotation
  • Stressed with compression
  • Positive if pain in ipsilateral extremity