shoulder examination

1. History & Physical Examination
of the Shoulder

2. Objectives
l Review pertinent anatomy of the
shoulder
l Review differential diagnosis of
shoulder complaints
l Review clinical history and physical
examination of the shoulder
l Review common shoulder injuries &
characteristic physical exam findings

3. Brief Epidemiology
l Shoulder pain: a common complaint
in primary care
– 2nd only to knee pain for specialist
referrals
– Most common causes in adults (peak
ages 40-60)
• Subacromial impingement syndrome
• Rotator cuff problems
l Athletic injuries
– Shoulder: 8-13% of all athletic injuries

4. Anatomy
l 3 Bones
– Humerus
– Scapula
– Clavicle
l 3 Joints
– Glenohumeral
– Acromioclavicular
– Sternoclavicular
l 1 “Articulation”
– Scapulothoracic

5. Anatomy
l Humerus
– Head *
– Greater tubercle*
– Lesser tubercle*
– Intertubercular (bicipital) groove
– Deltoid tuberosity
l Scapula
– Angles
• Superior
• Inferior
• Lateral (Head)

6. Anatomy
l Scapula
– Glenoid
– Acromion
– Coracoid
– Subscapular fossa
– Scapular spine
– Supraspinatus fossa
– Infraspinatus fossa

7. Anatomy
l Glenohumeral joint
– “Ball and socket” vs “Golf
ball and tee”
– Very mobile
– Price: instability
– 45% of all dislocations
– Joint stability depends on
multiple factors

8. Anatomy
l Glenohumeral joint
– Passive stability
• Joint conformity
• Glenoid labrum (50%)
• Joint capsule
• Ligaments
• Bony restraints

9. Anatomy
l Muscles
– Deltoid
– Trapezius *
– Rhomboids *
– Levator scapulae *
– Rotator cuff
– Teres major
– Biceps
– Pectoralis muscles *
– Serratus anterior *
* Scapular stabilizers

10. Anatomy
l Rotator Cuff Muscles
– S – Supraspinatus
– I – Infraspinatus
– t - Teres minor
– S- Supscapularis

11. Anatomy
l Bursae
– Subacromial
(Subdeltoid)
– Subscapular

12. Anatomy
l Neurologic
– Nerve roots
– Brachial plexus
– Peripheral nerves

13. Anatomy
l Coordinated shoulder motion
– Glenohumeral motion
– Acromioclavicular motion
– Sternoclavicular motion
– Scapulothoracic motion
Scapular-humeral rhythm

14. Differential Diagnosis
l Impingement syndrome
– Subacromial bursitis
– Rotator cuff tendinopathy
– Rotator cuff tear
– Biceps tendinopathy
l Adhesive capsulitis
l SC joint arthritis, sprain
l AC joint arthritis, sprain
l Glenohumeral joint OA
l Instablity
– GH dislocation
– GH subluxation
– Labral tear (e.g. Bankart, SLAP, etc.)
l Clavicle fracture
l Proximal humerus fracture
l Scapular fracture
l Other arthritic disease
– Rheumatoid, Gout, SLE
– Septic, Lyme, etc.
l Avascular necrosis
l Neoplastic disease
l Thoracic outlet syndrome
l CRPS
l Myofascial pain
l Referred pain
– Cervical radiculopathy
– Cardiac
– Aortic aneurysm
– Abdominal / Diaphragm
– Other GI

15. Clinical History
l Characterize pain
l Location of pain
l Night pain
l Weakness
l Deformity
l Instability
l Locking / Clicking / Clunking
l Sport / Occupation
l Previous treatments
l Alleviating / Exacerbating
l Acute vs. Chronic
l Traumatic vs. Overuse
l History of prior injury

16. Clinical History
l Mechanism of Injury

17. Physical Exam
l Observation
– Undress waist → up
l Palpation
l Active & passive ROM
l Strength testing
l Special tests

18. Physical Exam – Observation /
Inspection
l Front & Back
l Height of shoulder &
scapulae
l Asymmetry
l Obvious deformity
l Ecchymosis
l Muscle atrophy
– Supraspinatus
– Infraspinatus
– Deltoid

19. Palpation
l At rest & with movement
l Bony structures
l Joints
l Soft tissues

20. Palpation
l Surface Anatomy (Anterior)
– Clavicle
– SC Joint
– Acromion process
– AC Joint
– Deltoid
– Coracoid process
– Pectoralis major
– Trapezius
– Biceps (long head)
AC joint
SC joint
biceps

21. Palpation
l Surface Anatomy (Posterior)
– Scapular spine
– Acromion process
– Supraspinatus
– Infraspinatus
– Deltoid
– Trapezius
– Latissumus dorsi
– Scapula
• Inferior angle
• Medial border
Supraspinatus
Infraspinatus
Inferior angle
of scapula

22. Range of Motion
l Forward flexion:
– 160 – 180°
l Extension:
– 40 - 60°
l Abduction:
– 180◦
l Adduction:
– 45 °
l Internal rotation:
– 60 - 90 °
l External rotation:
– 80 - 90 °
Apley Scratch Test

23. Range of Motion
l Scapular dyskinesis (Scapulothoracic
dysfuntion)
– Compare scapular motion through
ROM on both sides
– Wall push-ups
– Symmetrical
– Smooth
– No or minimal winging

24. Strength Testing
l Test & compare both sides
l Be specific to muscle or muscle group
l Grade strength on 0 → 5 scale
– 0: no contraction
– 1: muscle flicker; no movement
– 2: motion, but not against gravity
– 3: motion against gravity, but not resistance
– 4: motion against resistance
– 5: normal strength

25. Strength Testing
l External rotation
– Tests RTC muscles that ER the
shoulder
• Infraspinatus
• Teres minor
– Arms at the sides
– Elbows flexed to 90 degrees
– Externally rotates arms
against resistance

26. Strength Testing
l Internal rotation
– Tests RTC muscle that IR the
shoulder
• Subscapularis
– Arms at the sides
– Elbows flexed to 90 degrees
– Internally rotates arms
against resistance
– Subscapularis Lift-Off Test
– Other techniques

27. Strength Testing
l Supraspinatus
– “Empty can" test
– Jobe’s Test
– Tests Supraspinatus
– Attempt to isolate from
deltoid
– Positioned sitting
– Arms straight out
– Elbows locked straight
– Thumbs down
– Arm at 30 degrees
(in scapular plane)
– Attempts to elevate arms
against resistance

28. Special Provocative Tests
l Impingement Signs
l Drop-Arm Test
l Speed’s Test
l Yergason Test
l Cross-Arm Adduction
l Sulcus Sign
l Apprehension test
l Relocation test
l O’Brien’s Test
l Crank test

29. Subacromial Impingement Syndrome
l Impingement of:
– Subacromial bursa
– Rotator cuff muscles and
tendons
– Biceps tendon
l Between
– Acromion
– Coracoacromial ligament
– AC joint
– Coracoid process
– Humeral head
l Rotator cuff tendonosis

30. Impingement Signs
l Neer’s Sign
– Arm fully pronated and
placed in forced flexion
– Trying to impinge
subacromial structures
with humeral head
– Pain is positive test

31. Impingement Signs
l Hawkin’s Sign
– Arm is forward elevated
to 90 degrees, then
forcibly internally
rotated
– Trying to impinge
subacromial structures
with humeral head
– Pain is positive test

32. Rotator Cuff Tear
l Partial thickness tear
l Full (Complete) thickness
tear
l May be due to:
– Impingement
– Degeneration
– Overuse
– Trauma
l Partial tears
– Conservative
l Complete tears
– Surgery

33. Rotator Cuff Tear: Drop-Arm Test
l Abducted arm slowly lowered
– May be able to lower arm slowly
to 90° (deltoid function)
– Arm will then drop to side if
rotator cuff tear
l Positive test
– patient unable to lower arm
further with control
– If able to hold at 90º, pressure on
wrist will cause arm to fall

34. Biceps Tendonosis
l Injury to long head of
biceps tendon
l Typically an overuse
injury
– Repetitive (overhead)
lifting
– Impingement

35. Biceps Tendonosis: Speed’s Test
l Forward flex shoulder to
about 90°
l Abduct shoulder to about
10°
l Arm in full supination
l Apply downward force to
distal arm
l Pain is positive test
l Weakness without pain:
muscle weakness or rupture

36. Biceps Tendonosis: Yergason’s Test
l Elbow flexed to 90°
l Start in pronated position
l Active supination & flexion
against resistance
l Palpate biceps tendon
l Pain or painful pop is
positive test
– Tendonosis
– Subluxation

37. AC Separation
AC Sprain /
Separation
– Typically due to
fall onto tip of
shoulder
(acromion)
– Arm tucked into
side
– Treatment
depends on type

38. AC Separation
l AC Sprain / Separation
– Typically due to fall
onto tip of shoulder
(acromion)
– Arm tucked into side
– Treatment depends on
type

39. AC Arthritis / DJD

40. AC Joint: Cross-Arm Adduction Test
l Arm flexed to 90°
l Arm adducted to > 45°
l Hyperadduct shoulder
(down on elbow)
l Positive test is pain in AC
joint
l Watch out for false-
positives
– Where is the pain?

41. Shoulder Instability
l Failure to keep humeral
head centered in glenoid
l Dislocation
– Complete disruption of joint
congruity or alignment
l Subluxation
– Partial or incomplete
dislocation
l Laxity
– Slackness or looseness in joint
– May be normal or abnormal

42. Instability: Sulcus Sign
l Inferior instability
l Arm relaxed in neutral
position
l Arm pulled downward
at wrist
l Positive test is a visible
sulcus at infra-acromial
area
– Compare to
contralateral side

43. Instability: Apprehension Test
l Anterior instability
l Shoulder abducted to 90°
l Slight stress to humeral
head directed in anterior
direction
l While externally rotating
shoulder
l Positive test is
apprehension due to feeling
of instability or impending
dislocation
– Beware if false positives

44. Instability: Relocation Test
l Anterior instability
l After a positive
apprehension
l Apply posteriorly directed
force over externally
rotated humeral head
l Positive test is relief of
apprehension
l Anterior release test

45. Glenoid Labral Tear
l Tear in glenoid labrum
l Usually due to instability
l SLAP Tear (Superior Labrum
Anterior to Posterior)
– Superior labral tear
– Fall on outstretched hand or
shoulder
– Rotator cuff tendonosis or
tears
l Bankart Lesion
– Anterior-inferior labral tear
– Anterior shoulder dislocation
/ subluxation

46. O’Brien’s Active Compression Test
l Labral, AC, or biceps pathology
l Arm flexed to 90°
l Arm cross-arm adducted 10-
15°
l Elbow extended
l Max pronation
l Resist downward force
l Positive test if painful
l Beware location of pain
– AC
– Biceps
– Internal +/- click

47. O’Brien’s Active Compression Test
l For labral pathology
– Repeat testing with
– Max supination
– Should be pain free

48. Labral Tear: Crank Test
l Abduct arm to 90-120°
l Stabilize shoulder
l Elbow secured with one
hand
l Axially load with ER / IR at
shoulder
l Positive test: audible or
painful click / catch /
grind

49. Diagnostic Injection
l AC joint
l Subacromial space
l Glenohumeral joint
l Biceps tendon (long head)