Shoulder Examination

Shoulder Examination

Summary

• Inspection

• Palpation

• Movement

• Special Tests

• Neurological examination

Introduction

Shoulder disorders are can be broadly classified into the following types: • Pain

• Stiffness • Instability

The common disorders arise from diseases of the following structures: • The Rotator cuff

• The Glenohumeral joint • The Acromioclavicular joint • The Clavicle

• The Neck

Naturally there are combinations of the above, but it is worth keeping the above system in mind when examining a shoulder disorder

Before Starting

• Explain what the examination entails and obtain verbal consent

• Expose the patient appropriately – expose both upper limbs but preserve dignity at all times

• Tell the patient to alert you if they experience any discomfort – always watch the patient’s face while examining

Inspection

From the Front, Side and Above

• Asymmetry

• Skin changes - bruising, sinuses • Scars

• Deltoid wasting - from disuse or axillary nerve palsy (associated with loss of sensation in ‘regimental badge’ area)

• Deformity of the clavicle - secondary to old fracture

• Swelling of the joint - infection, an inflammatory reaction or recent trauma • Asymmetry of the supraclavicular fossa

Deltoid Wasting

Left AC Joint Dislocation

Prominence of medial border of left scapula most easily seen from above (this was an Osteochondroma)

From Behind

• Rotator cuff muscle wasting

small and highly displaced in Sprengel shoulder and e root of the neck (Klippel-Feil syndrome)

cle – long • Scapula shape and situation (

Klippel-Feil syndrome) • Webbing of the skin at th

• Winging of the scapula (due to paralysis of the serratus anterior mus thoracic nerve damage)

Normal Shoulder

Klippel-Feil Syndrome Left Sprengel shoulder (undescended scapula) (also had previous unrelated spinal surgery)

Supraspinatus and Infraspinatus wasting left shoulder with large rotator cuff tear

More pronounced wasting seen with

Palpation

Does it hurt? ALWAYS ask the patient before touching them!

• Skin temperature (use dorsal surface of your hand used to compare temperatures) and tenderness

• Start from SCJ (tender due to dislocation and infection), along the clavicle (tender over tumours and radionecrosis) to ACJ (tender due to recent subluxation and osteoarthritic changes)

• Greater and lesser tuberosity, feel for rotator cuff defects and cuff tenderness • Gleno-humeral joint: anterior and lateral aspects (diffuse tenderness - infection or

calcifying supraspinatus tendonitis; local tenderness – shoulder rotator cuff tears and frozen shoulder)

• Biceps tendon / bicipital groove • Coracoid

• Spine of scapula

• Gleno-humeral joint: posterior aspect • Axilla (humeral shaft and head) – exostoses

NB - Remember to palpate with one hand only and press only on one point at a time. Palpate towards the most tender spot and watch the patient’s face

Movements

EXAMINE THE CERVICAL SPINE FIRST – quick screening movements only

• Quick screening test: "Arms above the head and behind the back "

• Move both arms at the same time. Active then passive ROM – in same movement. For example “Active abduction to 120° and further passive abduction to 170°” • Test flexion, abduction, internal rotation and external rotation

• Watch the scapulohumeral rhythm. If restricted then repeat with the scapula fixed to check for the amount of glenohumeral movement passively

• Feel for crepitation during passive motion

• Flexion (0-180°) - "Can you bring your arm forwards as high as they can go?" View patient from the side

Flexion

• Abduction (0-180°) - "Can you bring your arms away from the body, keeping them straight?" - View from front and behind. Normally patient’s arm can touch the ear with only slight tilting of the forehead. Check for painful arc and watch

scapulohumeral rhythm. Subacromial impingement - painful arc 60-120°; AC joint pathology - painful arc 170-180°. If both active and passive movements are restricted, then repeat the movements with the scapula fixed (one hand stabilises the scapular while the other tries to abduct the shoulder)

Abduction

• Internal rotation and adduction (T4) - "Can you reach the highest point up your back as high as you can? Note position e.g. T12.

Internal Rotation

• External rotation (0-70°) - "Keeping your arms tucked in tight against your body (elbows into the sides, flexed to 90°, hands facing forwards) can your move your forearms away from you? Increase in external rotation suggestive of subscapularis muscle tear. First movement to disappear in frozen shoulder

External Rotation

Special Tests

There are at least 120 different tests for the shoulder and you are not expected to know them all (or even most of them!). However, when performing a test you are expected to know how to do it properly and understand it’s relevance and shortcomings.

For more details of clinical tests for the shoulder with sensitivities, specificities, videos and original descriptions see http://www.shoulderdoc.co.uk/education/article.asp?article=497

Subacromial Impingement

• Hawkins’s test: Shoulder flexed to 90°, elbow flexed to 90° - internal rotation will cause pain1

Hawkins’s Test

AC Joint

• Scarf Test: Forced across body adduction in 90° flexion – pain at the extreme of movement over the ACJ indicates ACJ pathology

Scarf Test

Rotator Cuff Integrity

Can be divided into Lag or Resistance tests for each rotator cuff muscle – the latter follows three steps:

• "Put it there!" • "Keep it there!" • "Don’t let me push it!"

Only resistance tests have been described for the below

Supraspinatus / anterosuperior cuff:

• Jobe's test (also known as ‘empty can test’): arm abducted to 20°, in the plane of the scapula, thumb pointing down 2

Jobe’s ‘empty can’ test

Infraspinatus + teres minor / Posterior cuff

• Patte's test: 90° flexion, flexed elbow and resisted external rotation

Patte’s test

Subscapularis / Anteroinferior cuff

• Gerber's lift off test: Push examiner's hand away from 'hand behind back position' (i.e. draw hand away from contact with the back) - eliminates pectoralis major

NOTE: This test is often performed incorrectly, so some key points:

1. It is essential that the patient has a full range of passive internal rotation and active internal rotation is not limited by pain.

2. The hand should be at the level of the mid-lumbar spine and not the buttock. 3. Avoid shoulder extension and isolate rotation by stabilising the scapula or elbow

• Napoleon / LaFosse Belly-Press test: if patient cannot fully internally rotate and push on their belly, elbow will drop backwards if positive. The examiner pushes against the patient’s elbows.

Note: the ‘Belly-Off’ test is a variation of this where the examiner tries to pull the hand away from the abdomen. (Described by Scheibel et al. 2005)

Gerber’s Lift Off test Belly-Press test (LaFosse)

Biceps Tendon

• Check for rupture of long head of biceps tendon (Popeye sign)

Rupture of right long head of biceps tendon – Popeye sign

• Speed's test: Supinated arm, with elbow fully extended, flexed forwards against resistance

Speed’s test

Deltoid

• Resisted abduction at 90°, neutral rotation

Serratus anterior

• Winging scapula: Ask the patient to push against a wall, with their palms flat and their fingers pointing downwards. Best performed with arms at waist level.

Instability Testing

Laxity tests

• These tests examine the amount of translation allowed by the shoulder starting from positions where the ligaments are normally loose

• The amount of translation on laxity testing is determined by the length of the capsule and ligaments as well as by the starting position (i.e. more anterior laxity will be noted if the arm is examined in internal rotation - which relaxes the anterior structures, than if it is examined in external rotation - which tightens the anterior structures)

• Use the contralateral shoulder as an example of what is 'normal' for the patient

Drawer Tests

• The patient is seated with the forearm resting on the lap and the shoulder relaxed • Examiner stands behind the patient

• One of the examiner's hands stabilizes the shoulder girdle (scapula and clavicle) while the other grasps the proximal humerus

• These tests are performed with (1) a minimal compressive load (just enough to centre the head in the glenoid) and (2) with a substantial compressive load (to gain a feeling for the effectiveness of the glenoid concavity)

• Starting from the centered position with a minimal compressive load, the humerus is first pushed forward to determine the amount of anterior displacement relative to the scapula

• The anterior translation of a normal shoulder reaches a firm end-point with no clunking, no pain and no apprehension

• A clunk or snap on anterior subluxation or reduction may suggest a labral tear or Bankart lesion

• The test is then repeated with a substantial compressive load applied before translation is attempted to gain an appreciation of the competency of the anterior glenoid lip

• The humerus is returned to the neutral position and the posterior drawer test is performed, with light and again with substantial compressive loads to judge the amount of translation and the effectiveness of the posterior glenoid lip, respectively

Anterior Drawer Test

Anterior Drawer Test Posterior Drawer test

Stability Tests

Anterior Apprehension test

• Assess anterior stability of the shoulder

• The patient sits with the back toward the examiner • Shoulder is abducted to 90° with the elbow flexed to 90°

• The examiner pulls back on the patient's wrist with one hand while stabilizing the back of the shoulder with the other

• Slowly push the head of the humerus forwards while externally rotating the shoulder • A positive test is indicated if the patient becomes apprehensive or fearful with this

manoeuvre

Anterior Apprehension

Jobe's Relocation

Posterior Apprehension Test / Jerk Test

• Assess posterior stability of the shoulder

• The patient sits with the arm internally rotated and flexed forward to 90°

• The examiner grasps the elbow and axially loads the humerus in a proximal direction • While axial loading of the humerus is maintained, the arm is moved horizontally

across the body

• A positive test is indicated by apprehension

Neurological Examination

• Check distal pulses and perform neurological examination

Advanced Knowledge

Special Tests

Subacromial Impingement

• Neer’s sign: Pain at mid-arc of passive abduction in the scapula plane

• Neer's test: Pain eliminated by local anaesthetic injection into the subacromial bursa • Copeland Impingement Test: Passive abduction in internal rotation painful (in the

scapula plane); pain eliminated with passive abduction in external rotation.

Hawkin’s Test

Neer’s sign (when the pain is eliminated with abduction in external rotation this is known as the Copeland Impingement Test)

Rotator Cuff Tests

Infraspinatus + teres minor/posterior cuff

• Resisted external rotation (ER) with the arms by side (Resistance test for

Infraspinatus)

• ER Lag: Hold arm fully ER by side and release. If arm drops forward = massive infraspinatus tear(Lag test for Infraspinatus)

• Hornblower's sign (Emery): Similar to Patte's test. Inability to ER & Abduct from hand in front of mouth (against gravity) (Lag test for Infraspinatus & Teres Minor) • Hornblower's sign (JBJS, 1998) / Drop test: With arm in 90º abduction & ER,

elbow 90º (Positive = massive tear of both infraspinatus and teres minor and operative repair will result in 50% failure)

ER Lag Sign Patte’s test Hornblower’s Sign

Biceps Tendon

• Yergason's test: Feel for subluxation of the biceps tendon out of the bicipital groove when the arm is gently internally and externally rotated in adduction

• AERS test: Abduction External Rotation Supination test. Pt feels pain on resisted Supination in this position. Test with elbow abducted & ER to 90o

AERS test (LaFosse)

References

1. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med.1980; 8:151 -8)

2. Jobe FW, Moynes DR. Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries.Am J Sports Med. 1982;10:336 -9