Duke Orthopaedics
Wheeless' Textbook of Orthopaedics

Shoulder: Physical Exam

- See:
        - Diff Dx of Shoulder Pain
        - Shoulder Examination Tests (from shoulderdoc.co.uk)

- History: (questions for modified Simple Shoulder Test);

- C-Spine:
    - r/o radiculopathy as well as axillary nerve hypaesthesia;
    - Spurling's manuever:
           - mechanical stress, such as excessive vertebral motion, may exacerbate symptoms;
           - gentle neck hyperextension w/ head tilted toward affected side will narrow size of neuroforamen and may exacerbate symptoms or produce radiculopathy;

- Shoulder Tenderness:
    - anterior capsule / biceps tendon;
    - AC joint;
    - posterior sulcus;

- ROM:
    - active and passive abduction of shoulder/scapular thoracic complex; 
          - see abductors of the shoulder
          - view from behind to note symmetry and possible winging of scapula;
          - combines glenohumeral and scapulothoracic motion;
          - be sure to have patient abduct the arm in the scapular plane (30-40 deg anterior to the coronal plane);
          - abduction should be measured with simultaneous maximal abduction of both arms, as the angle formed
                  by the humeral shaft and the midthoracic line;
          - functional evaluation:
                  - bring hand actively behind the neck with the elbow above the acromion;
                  - bring the elbow straight forward from that position, actively positioning the hand on top of the head with the elbow over the acromion;
                  - bring the elbow straight forward from that position, and fully elevate the arm from that position;
                  - the hand is not allowed to touch the head or neck during these functional movements;
          - references:
                  - The movements of shoulder joint.  A plea for use of 'plane of scapula' as plane of reference for movements occuring as humero-scapular joint. Johnson TB. Br J Surg. 1937;25:252-260.
    - IGHE: isolated glenohumeral elevation:
    - IR: internal rotation: (ability to touch thoracic spine);
          - loss of internal rotation may be especially common in throwing shoulders;
          - contracture of the posterior capsule will prevent the normal posterior translation/rotation when the arm is elevated;
                  - the result is superior elevation of the humeral head with elevation and accentuation of impingement; 
          - references:
                  - Reliability, Precision, Accuracy, and Validity of Posterior Shoulder Tightness Assessment in Overhead Athletes
                  - Posterior Capsular Contracture of the Shoulder 
                  - Quantification of Posterior Capsule Tightness and Motion Loss in Patients with Shoulder Impingement 
    - ER: external rotation: (both in adduction and abduction)
          - particular attention should be paid to external rotation a 0 and 90 deg of abduction;
          - loss of a small amount of external rotation can result in subacromial impingement, and this impingement prevents the greater tuberosity from rotating clear of the
                  acromion during arm elevation;
          - when there is more external rotation in the injured shoulder than the non injured shoulder, consider the diagnosis of subscapularis rupture; 
          - excessive ER with the arm at the side (rotation of >90 deg), may be an indicator of shoulder hyperlaxity and a risk factor for postoperative instability  
          - ref: Elbow Valgus Laxity May Result in an Overestimation of Apparent Shoulder External Rotation During Physical Examination

- Motor Exam:

    - trapezius
    - rhomboids
    - supraspinatus:
          - supraspinatus muscle is tested with the shoulder abducted 90 degrees, flexed 30 deg and then maximally internally rotated;
          - downward pressure is resisted primarily by the supraspinatus;
    - infraspinatus:
         - dropping sign:
                - tests power of external rotation at 0 deg of abduction;
                - patients forearm is placed in 45 deg of external rotation, and patient is asked to externally rotate against examiner's hand;
                - if the patient's arm falls back to 0 deg of external rotation then a positive test is recorded;
                - 100% sensitivity and 100% specificity for irreparable degeneration of the infraspinatus;
    - teres minor:
         - responsible for 45% of power of external rotation;
         - hornblower's sign:
                - power of external rotation in 90 deg of abduction in the scapular plane;
                - the examiner places the patient's forearm in 90 deg flexion w/ maximal external rotation;
                - the 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 and 93% specificity for irreparable degeneration of teres minor;
    - subscapularis
         - positive lift-off test:
                - indicates a tear of the subscapularis   
                - patient is unable to lift the hand away from his back while maximally internally rotated
                - ref: Diagnostic value of four clinical tests for the evaluation of subscapularis integrity
    - deltoid:
    - biceps:
    - reference:
         - The 'dropping' and 'hornblower's' signs in evaluation of rotator cuff tears.

- Impingement and Rotator Cuff Test:
    - impingement sign and test
    - drop arm test: for rotator cuff tears;
           - have the patient abduct his arm to 90 degrees and then ask him to lower his arm to his side slowly while the examiner applies gentle pressure;
           - at approximately 30 deg of abduction, the patient will no longer be able to gradually lower his arm and it will fall to his side;
    - AC joint:
           - arm is placed into forced adduction while surgeon palpates AC joint and notes any possible instability and or tenderness;
           - note that posterior tenderness from hyper-adduction of the shoulder may result from posterior capsular tenderness;

- Tests for Instability:
    - sulcus sign: (for multidirectional instability)
           - a gap between the humeral head and undersurface of the acromion;
           - appears when the longitudinal traction is placed on the humeral shaft w/ arm at side while in a seated position;
           - the sulcus sign is felt to be pathognomonic of multidirectional instability;
           - upto 1 cm of displacement may be normal, where as displacement of 3 cm is severe;

    - exam for anterior instability:
           - rotatory stress test:
                  - for determining presence of Bankart Lesion
    - posterior instability:
           - jerk test: pt's arm is abducted to 90 deg and internally rotated;
                  - the examiner axilly loads the humerus while the arm is moved horizontally across the body
                          - the left hand stabilizes the scapula;
                  - look for a sudden jerk as the humeral head slides off the back of glenoid; 
                  - refs:
                          - Painful jerk test: a predictor of success in nonoperative treatment of posteroinferior instability of the shoulder.
                          - Capsulolabral augmentation for the the management of posteroinferior instability of the shoulder.
    - SLAP tear:
         - speed's test:
              - used to examine the proximal tendon of the long head of the biceps
              - forward flex the shoulder (60 deg) against resistance while maintaining the elbow in extension and the forearm in supination
              - tenderness in the bicipital groove in dicates bicipital tendinitis
         - obrien's test
              - shoulder is held in 90 degrees of forward flexion, 30 to 45 degrees of horizontal adduction and maximal internal rotation;
              - grab the patient's wrist and resists the patient's attempt to horizontally adduct and forward flex the shoulder
              - refs:
                    - An evaluation of the anatomic basis of the O'Brien active compression test for superior labral anterior and posterior (SLAP) lesions. 
                    - The crank test, the O'Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears.

- Vascular Exam:
    - need to rule out thoracic outlet syndrome

Classification and physical diagnosis of instability of the shoulder.

Translation of the glenohumeral joint in patients with anterior instability: awake examination versus examination with the patient under anesthesia..

An Evaluation of the Apprehension, Relocation, and Surprise Tests for Anterior Shoulder Instability.

In vivo anatomy of the Neer and Hawkins sign positions for shoulder impingement.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, March 4, 2013 8:43 am

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