Physical Examinationof the Shoulder
James A. Tom, MDSports Medicine and Shoulder Dept. of Orthopaedic Surgery
Drexel University College of MedicinePhiladelphia, PA
Evaluation of the Shoulder
• Thorough history of presenting complaint• Information regarding surrounding anatomy
• Neck• Elbow• Chest• Diaphragm
• Imaging studies based on clinical suspicion• Not simply ordered “to make the diagnosis”
Anatomy
Rotator Cuff• 4 muscles that enable shoulder
flexion, abduction, ER, and IR• SPN = most commonly injured
History
• Subsequent questions directed to specific patient population
• Young Acute injuries, instability, AC joint injury• Middle-aged Inflammatory conditions, impingement,
adhesive capsulitis• Older Arthritis, impingement, RTC pathology
History
• History of injury• Acute• Chronic
• Mechanism of injury (MOI)• Secondary gain
• Litigation• Worker’s Compensation• Psychiatric illness
History
• Pain• Character• Location• Intensity• Duration• Radiation• Factors associated with exacerbation / relief• Interference with work /
daily activities (ADLs)
• Objective measuresVASValidated scoring
systems
Physical Exam
Inspection / Palpation• General appearance• Gross anatomy• Observation of simple tasks
(e.g., disrobing)• General muscle tone /
symmetry• Bony prominences• Skin coloration
(e.g., Raynaud’s, CRPS)
• Systemic laxity (e.g., Th-forearm flexibility, knee-elbow recurvatum)
Physical Exam
ROM• Normal shoulder motion from
both GH joint & scapulothoracic articulation in 2:1 ration
• Comparison with contralateral shoulder
Physical Exam
• Active / Passive ROM• Discrepancy indicative of
specific disease
• Abduction 180° Adduction 45°
Flexion 180° Extension 45° IR 55° ER 45°
Physical ExamStrength• Graded system of manual muscle testing• Objective description of strength
• 5/5 FROM vs. gravity & full resistance4/5 FROM vs. gravity & some resistance3/5 FROM vs. gravity but no resistance2/5 FROM at gravity neutral1/5 Muscle contracts but no motion0/5 Muscle unable to contract
• Neurologic problem or muscle injury
Impingement
Neer’s impingement sign• Subacromial impingement• Passive FE of arm
impingement of SPN tendon under CA arch
• (+) test = reproduction of pain
Impingement
Not Neer’s impingement test• Subacromial injection with local
anesthestic• Most sensitive / specific test for
impingement
• (+) = pain relief after injection
Impingement
Hawkin’s impingement sign• Subacromial impingement• Adducted shoulder flexed
forward to 90° with IR
• (+) test = reproduction of pain
Rotator Cuff Tear
SPN stress test• ~ “empty (beer / soda) can sign”• Supraspinatus tear• Resisted abduction of internally
rotated and forward flexed arm (in scapular plane)
• Performed in supination to eliminate sx of impingement
• (+) = pain and weakness
Rotator Cuff Tear
Drop arm test• RTC tear – larger• Passively abducting shoulder
90° and asking pt to hold it in that position and then slowly lower it to the side
• (+) = inability to hold arm up or lower it slowly and smoothly
Rotator Cuff Tear
Lift off test• Subscapularis tear• Eliminates pectoralis major as
internal rotator• ~ “belly press test” with hand
pressed against abdomen while attempting to maintain elbow position anterior to midaxillary line
• (+) = unable to lift arm off back
InstabilityApprehension test• Shoulder instability• Best performed supine to stabilize
scapula• Shoulder placed in unstable
position of abduction / ER• May produce posterior shoulder
pain with “internal impingement”
• (+) = resistance & apprehension as humeral head subluxates anteriorly
Instability
Relocation test• Extension of apprehension
test for instability• Shoulder placed in
apprehensive position and then applying posteriorly directed force to proximal humerus
• (+) = relief of apprehension and greater degree of ER
InstabilityLoad and shift test• Shoulder instability• Seated position with arm adducted
while examiner holds proximal humerus and attempts to translate it ant / post
• Supine position with arm abducted to position in scapular plane with axial load applied to elbow to concentrically reduce humeral head. Followed by attempt to translate ant / post
• Graded on degree of translation
Instability
Sulcus sign• Inferior shoulder laxity• Downward traction of arm as it
hangs at side (neutral rotation and neutral flex-ext)
• (+) = gap between humerus and acromion
Instability
Jerk test• Posterior instability• Posteriorly directed force on
forward flexed and adducted arm produces post sublux
• Then placement of arm in coronal plane may relocate subluxated humeral head with audible / palpable “clunk”
Biceps Tendon Disease
O’Briens’s test• “Active compression test”• Superior labral – biceps pathology
(SLAP lesions)• Shoulder forward flexed 90° and
slightly adducted across body while elbow kept straight and arm internally rotated. Resists downward force on arm.
• (+) = reproduction of pain and relative relief with supination
Biceps Tendon Disease
Yergason’s test• Bicipital tendonitis• Resisted forearm supination
with slightly flexed elbow
• (+) = reproduction of pain
Biceps Tendon Disease
Speed’s test• Bicipital tendonitis• Elbow extended as patient
forward flexes shoulder against resistance
• (+) = reproduction of pain
AC Joint Degeneration
Cross-body adduction test• AC joint degeneration• Passively adducting arm across
chest while palpating AC joint
• (+) = pain in area of AC joint
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