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

Bony anatomy• Glenohumeral joint• Acromioclavicular (AC) joint

Anatomy

Glenoid labrum• Rim of fibrocartilage• “Deepens socket”

Anatomy

Joint capsule

Anatomy

Rotator Cuff• 4 muscles that enable shoulder

flexion, abduction, ER, and IR• SPN = most commonly injured

History

History• Age• Occupation• Hand dominance• Chief complaint

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

History

• Associated symptoms• N / T / P• Weakness

• Level of disability• Work• Athletics

History

• Previous treatment• NSAIDs• Injection• PT• Surgery

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

Thank You