OrthoFracs Logo

Examination of the Shoulder

Summary

  • Expose patient down to waist
  • Observe patient whilst undressing
    • Comment whilst patient is undressing
  • Stand near examiners

Look

Clues

  • Splint
  • Sling

Anterior Aspect

Make statement regarding patient overall health

  • e.g.
    • rheumatoid habitus
    • cushingoid
  • no obvious signs of systemic disease
  • Skin
    • scars, sinuses, swelling
    • Pigmentation, Ecchymosis, Erythema
  • Symmetry
    • Bone
      • Clavicle, Sternoclavicular Joint, ACJ, Acromion, Coracoid Process
    • Muscle Wasting
      • Trapezius, Deltoid, Pectoral contour, deltoid, Popeye deformity(more easily seen with elbow flexed)
  • Posture
    • Arm internally rotated
      • Posterior dislocation
  • This patient has no obvious signs of systemic disease
  • There is no obvious skeletal deformiy, muscle atrophy or asymmetry.
  • There are no scars , swellings or skin changes.

Please straighten your elbow

  • There is no popeye deformity

Lateral Aspect

Please turn around sir

  • Muscle Wasting
    • Deltoid, Biceps, triceps

There are no further scars or abnormalities

Posterior Aspect

Please turn around & face the back wall

  • Skin
  • Symmetry
    • Bone
      • Scapula
        • Height
        • Winging of scapula
        • Sprengel’s deformity
          • congenital malformation
          • scapula is smaller & carried higher than on the uninvolved side
        • Lateral scapular slide
          • Soft tissue contracture draws the dominant arm scapular away from midline, common in throwing athletes
          • ↑ 1.5cm correlates with posterior shoulder pain & anterior impingement syndrome
      • Spine
    • Muscle Wasting
      • Trapezius
      • Atrophy of supra / infraspinatus fossae
        • supraspinatus
        • infraspinatus
      • Triceps

There are no obvious skin changes,

there is normal symmetrical scapular contours

no wasting in the supraspinatus or infraspinatus fossae

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

  • Skin
    • Warmth
      • inflammation rarely influences skin temperature, as the joint is well covered
  • Bony prominences
    • SC joint
    • Clavicle
    • AC joint
      • chronically enlarged AC joint
        • painless osteophytes
        • painful ACJ arthritis
      • if you can’t find ACJ
        • pushing down on clavicle & look for motion
    • Acromion
  • Tenderness
    • os acominale is painful in overuse or trauma
      • usually non tender
    • cuff defect
  • Subacromial bursa
    • tenderness just anterior to acromion
      • Subacromial bursitis, R/C impingement or tear
      • passively extend patient’s shoulder brings the subacromial bursa anterior to acromion & ↑ ease of palpation
      • passively forward flex shoulder & see if it ↑ pain
  • Anterior capsule
  • Long head biceps tendon / bicipital groove
    • IR shoulder 10 deg
    • groove then faces anteriorly
    • Palpate 1 to 4cm distal to anterior acromion
    • Painful
      • Biceps tendonitis

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 stabilize 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
        • 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

  • 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 good with your index finger & compare to bad side
      • tip of scapula (T2)
      • blade of scapula (T4)
      • 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 suspician
  • 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

  • FF shoulder to 90°
  • Elbow at 90° (thus pt’s forearm is in front of body)
  • Passively IR shoulder
    • Drives GT & R/C into acromion & CA ligament

Neer’s Impingement Sign

  • FF flex shoulder whilst examiner’s hand on pt’s shoulder (scapula stabilized)
  • Look for reproduction of pt’s symptoms at maximum FF
    • It brings the AL acromion into contact with the affected R/C & GT

Neer’s impingement test

  • Inject LA (10 cc of 1% xylocaine)

Drop-arm Test

  • If pt’s passive ROM is much greater than active ROM – perform this test
  • Passively abduct arm to maximum amount
  • Warn the patient that you are about the let go
  • Ask patient to slowly lower arm
    • Positive Sign if
      • At 100°, the patient is unable to control arm & arm drops to side
        • Caused by pain of R/C tear & axillary nerve palsy
      • Inject with LA
        • If it improves, more likely due to pain
  • Cause
    1. Massive cuff tear
    2. Axillary nerve palsy
    3. Neuromuscular impairment

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
    1. Localised tenderness
    2. Speed Test
    3. 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
Acromiohumeral Distance
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.
Load & Shift Test
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
Webpage Last Modified: 28 January, 2010