This is about the PS session : Examination of Shoulder for GMCA Block 4.4

1. History & Physical
Exam of the Shoulder
DR UTKARSH SHAHI
ASSISTANT PROFESSOR
DEPARTMENT OF ORTHOPEDICS

2. REVIEW OF SHOULDER ANATOMY

3. REVIEW OF SHOULDER ANATOMY
 Bones
Scapula
Clavicle
Humeral head
Posterior rib cage
 Joints
Sternoclavicular
Acromioclavicular
Glenohumeral
Scapulothoracic

4. GLENOHUMERAL JOINT
 25% humeral head surface in contact with glenoid
 Joint space thinning seen with OA

5. GLENOHUMERAL JOINT
 Humeral head coverage increased to 75% with glenoid labrum

6. MORE SHOULDER ANATOMY
 Ligaments
 Coracoclavicular
 Acromioclavicular
 Glenohumeral
 Superior GH
 Middle GH
 Inferior GH
 Coracohumeral
 Subacromial bursa
 Subdeltoid bursa

7. ROTATOR CUFF
 Supraspinatus, infraspinatus, teres
minor, subscapularis
 Form cuff around humeral head
 Keep humeral head within joint
(counter act deltoid)
 Abduction, external rotation,
internal rotation

8. MUSCLES OF THE ROTATOR CUFF
 The four major muscles of the rotator cuff rotate the humerus and properly orient the
humoral head in the glenoid fossa (socket).
 The tendons of these four muscles merge, forming a cuff around the glenohumeral joint.
 Supraspinatus: abducts the humeral head and acts as a humeral head depressor
 Infraspinatus: externally rotates and horizontally extends the humerus
 Teres minor: externally rotates and extends the humerus
 Subscapularis: internally rotates the humerus

9. SHOULDER CONDITIONS
Injury and mechanical derangement.
Congenital and developmental abnormalities.
Infection and inflammation.
Arthritis and rheumatic disorders.
Metabolic and endocrine disorders.
Tumours and lesions that mimic them.
Neurological disorders and muscle weakness.

10. HISTORY TAKING
PATIENT DETAILS CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS PAST HISTORY
FAMILY HISTORY PERSONAL HISTORY
TREATMENT HISTORY NEGATIVE HISTORY

11. COMPLAINTS
PAIN STIFFNESS
SWELLING DEFORMITY
WEAKNESS INSTABILITY
PARASTHESIA LOSS OF FUNCTION

12. PAIN
Site Time and mode of onset
Severity or Intensity Character or Nature
Progression Referred pain
Aggravating factors Relieving factors
Any diurnal variation Any seasonal variation

13. SHOULDER PAIN KEY POINTS
 Shoulder pain is a common complaint in primary care
 2nd only to knee pain for referral to Ortho or primary care sports medicine
 Most common causes in adults (peak ages 40-60)
 Subacromial impingement syndrome
 Rotator cuff problems
 Athletic injuries
 Shoulder accounts for 8-13% of athletic injuries
 History and examination are keys to diagnosis

14. PAIN
 The extent of reference is governed by a number of factors.
 The depth of the structure beneath the skin.
 The position of the structure within the dermatome.
 The severity of the lesion

15. PAINFUL ARC
 This is not a diagnosis but a localising sign.
 There are 4 common causes of a painful arc at the shoulder joint.
 All involve soft tissues being pinched between the humerus and the underside of
the acromion.
 These are:
 Supraspinatus (pain on resisted abduction)
 Infraspinatus (pain on resisted lateral rotation).
 Subscapularis (pain on resisted medial rotation).
 Subacromial bursa (pain at extremes of all passive ranges

16. PAINFUL ARC
 The patient’s arm is passively and actively abducted from the rest
position alongside the trunk. Pain in the acromioclavicular joint
occurs between 140°and 180° of abduction. Increasing abduction
leads to increasing compression and contortion in the joint. (In an
impingement syndrome or a rotator cuff tear, by comparison, pain
symptoms will occur between 70° and 120°.

17. PAINFUL ARC
 In the evaluation of the active and passive ranges of motion, the
patient can often avoid the painful arc by externally rotating the
arm while abducting it. This increases the clearance between the
acromion and the diseased tendinous portion of the rotator cuff,
avoiding impingement in the range between 70° and 120°.

18. PAINFUL ARC

19. FOCUSED HISTORY

20. FOCUSED HISTORY QUESTIONS
 Mechanism of Injury
 Helps predict injured structure
 Example: Fall directly onto anterior/superior shoulder  AC joint injury
(shoulder separation)
 Example: Arm forcefully abducted and externally rotated  subluxation
or anterior dislocation
 Example: If chronic pain, note activity that triggers pain, such as the
cocking phase of throwing or the pull-through phase of swimming

21. Characteristics of pain
FOCUSED HISTORY QUESTIONS
Night pain when lying on affected side,
muscle atrophy
Rotator cuff tear
< 30 yo Biomechanical, inflammatory
> 45 yo, Hx of trauma Rotator cuff tear - 35% of pts
Painful arc (60-120°abduction) Subacromial impingement
Pain > 120° abduction Acromioclavicular joint
Catching, popping, clicking GH or AC joint arthritis, labral tear

22. REFERRED PAIN

23. REFERRED PAIN
 The shoulder is derived from the fifth cervical segment and therefore refers
pain into the C5 dermatome.
 The acromioclavicular joint is a C4 structure and refers pain into the C4
dermatome.
 The shoulder is deep and proximal in the C5 dermatome, hence it can
potentially refer pain a great distance.
 Conversely the acromio-clavicular joint is a superficial structure at the
distal end of the dermatome causing it to give rise to accurate, local pain

24. REFERRED PAIN
 Typically pain of glenohumeral origin is felt in the upper arm, often at
the insertion of the deltoid.
 Severe shoulder problems can cause pain to radiate as far as the
radial side of the wrist.
 Rotator cuff problems often include pain radiating to upper arm
 If pain starts in neck and radiates to shoulder, consider cervical spine
disease

25. 25
 Consider OTHER sources of referred pain
 Cervical spine – spondylolysis, arthritis, disc disease
 Cardiac - myocardial ischemia
 Diaphragmatic irritation
 Thoracic outlet syndrome
 Gallbladder disease
 Complex regional pain syndrome (a.k.a, reflex sympathetic dystrophy)
REFERRED PAIN

26. INSTABILITY
Time of Onset
•Congenital
•Developmental
•Acquired
Frequency
•Single episode
•Recurrent Aggravating factors
Associated
symptoms
•Pain
•Disability
•Neurovascular
Reducibility
•Reducible
•Irreducible Associated Illness

27. INSTABILITY
 History of instability
 Glenohumeral subluxation or dislocation
 Aggravating factors
 Overhead work, repetitive movements, sports
 Relieving factors/treatments tried
 Rest, immobility, medications, other treatments
 History of Prior Shoulder Problems or Surgeries

28. PARASTHESIA
Aetiology
Mode of
onset
Duration
Site and
Pattern
Progression
Aggravating
and Relieving
Factors

29. LOSS OF FUNCTION
Mode of onset
• Sudden
• Gradual
Duration
• Congenital
• Chronic
• Acute
Involved region
and function(s)
Progression
Associated
features

30. STIFFNESS
Generalised Localised
Locking Ankylosis

31. SWELLING
Site Shape Size
First notice
Associated Symptoms
•Pain
•Pressure
•Neurological
•Vascular
•Articular
Progression
Any other swelling Reducibility
Any discharge
•If present
•Duration
•Regular or intermittent
•Character of discharge

32. DEFORMITY
Site
Associated Symptoms
• Neurological
• Vascular
• Articular
Amount of
disability
Time of Onset
• Congenital
• Developmental
• Acquired
Correctability
• Completely correctable
• Partially correctable
• Incorrectable

33. WEAKNESS
Site
Generalised
Localised
Type
Pure Motor
Sensorimotor
Muscular
Mixed
Duration
Acute
Chronic
Onset
Sudden
Gradual
Progression
Progressive
Static
Regressive

34. DIFFERENTIAL DIAGNOSIS
1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

35. DIFFERENTIALS IN SHOULDER
 Trauma
 Impingement & Rotator Cuff
 Subcoracoid Impingement
 Outlet (subacromial) Impingement
 Calcific Tendonitis
 Rotator Cuff Tears
 Rotator Cuff Arthropathy
 Proximal Biceps Tendonitis
 Biceps Subluxation
 AC Pathology
 Acromio-Clavicular Injuries (AC Separation)
 Distal Clavicle Osteolysis
 AC Arthritis
 Instability
 Traumatic Anterior Shoulder Instability (TUBS)
 Posterior Instability & Posterior Dislocation
 Multidirectional Shoulder Instability (MDI)
 Luxatio Erecta

36. DIFFERENTIALS IN SHOULDER
 Injuries in throwing athlete
 SLAP lesion
 Internal Impingement
 Glenohumeral Internal Rotation Deficit
(GIRD)
 Little Leaguer's Shoulder
 Posterior Labral Tear
 Degenerative Conditions
 Glenohumeral Arthritis
 Adhesive Capsulitis (Frozen Shoulder)
 Avascular Necrosis of the Shoulder
 Scapulothoracic Crepitus
 Neurovascular Disorders
 Scapular Winging
 Suprascapular Neuropathy
 Thoracic Outlet Syndrome
 Brachial Neuritis (Parsonage-Turner Syndrome)
 Quadrilateral Space Syndrome
 Scapulothoracic Dyskinesis
 Muscle Ruptures
 Pectoralis Major Rupture
 Deltoid Rupture
 Triceps Rupture
 Latissimus Dorsi Rupture

37. Physical
Examination
General
Examination
Systemic
Examination
Regional
Examination

38. GENERAL EXAMINATION
Vitals
•Pulse
•Blood Pressure
•Respiratory Rate
•Temperature
Consciousness Orientation Comfort level Position of Patient
Height and Weight
General
Appearance
Pallor Icterus Clubbing
Cyanosis Pupillary Reaction Lymphadenopathy Dexterity Anything specific

39. Systemic
Examination
Respiratory
System
Cardiovascular
System
Gastrointestinal
System
Central Nervous
System

40. REGIONAL EXAMINATION
• InspectionLOOK
• PalpationFEEL
• Strength TestingMOVE
• Shortening or Lengthening
• Range of Motion
• Regional measurements
MEASURE
• Depends upon specific region in considerationSPECIAL TESTS

41. PHYSICAL EXAM - GENERAL
 Develop a standard routine
 Alleviate the patient's fears
 Adequate exposure - bilateral
 Males – shirtless
 Females – tank top or sports bra
 Compare shoulders

42. EXAMINATION OF THE SHOULDER
1. Observe the patient, front and back.
2. Observe the shoulder.
3. Observe the axilla.
View from rear with patient standing
straight and look for lateral symmetry,
swelling, position of scapula and signs
of muscle wasting.

43. INSPECTION
 Swelling, asymmetry, muscle atrophy, scars, ecchymosis
and any venous distention
 Note posture (e.g., shoulder protraction)
 Deformities
 Squaring of shoulder - anterior dislocation
 Scapular "winging" - shoulder instability and serratus anterior or
trapezius dysfunction
 Atrophy - supraspinatus or infraspinatus - consider rotator cuff
tear, suprascapular nerve entrapment or neuropathy

44. PALPATION
Sternoclavicular
joint
Clavicle
Acromioclavicular
joint
Subacromial
bursa
Coracoid processBicipital groove
Greater tuberosity Lesser tuberosity
Scapula (spinatus
muscles)
TIP: Start medially at
the SC joint, proceed
laterally, end posteriorly

45. ANTERIOR SHOULDER POSTERIOR SHOULDER

46. 46
Palpation of AC Joint
 Patient's arm at his/her side
 Note swelling, pain, and gapping.

47. 47
Palpation of Bicipital Groove
 Patient sitting, beginning with
the arm straight
 Patient actively flexes biceps
muscle while examiner
provides supination and ER
 Examiner palpates the
bicipital groove for pain

48. RANGE OF MOTION (ROM)
 Evaluate active ROM
 If movement limited by pain, weakness, or tightness, assist
passively
 Lack of full ROM with active and passive exam is found in
adhesive capsulitis and arthropathy
 Evaluate bilaterally for comparison

49. 49
RANGE OF MOTION
Movement
Forward flexion
Extension (behind back)
Abduction
Adduction
External rotation*
Internal rotation*
Normal range
0-180°
0-40°
0-180° (with palms up)
0-40°
0-45° (arm at side, elbow flexed)
0-55° (arm at side, elbow flexed)

50. 50FORWARD FLEXION
 Arm straight and brought upward
through frontal plane, and move as
far as patient can go above his head.
 0° is defined as straight down at
patient's side, & 180° is straight up.

51. 51ABDUCTION
 Arm straight
 Hand – palm up (arm supinated)
 ROM measured in degrees as for
forward flexion

52. 52
EXTERNAL AND INTERNAL ROTATION
 Arm at side, elbow flexed to 90° and held at waist
 Examiner externally or internally rotates arm

53. APLEY SCRATCH TEST FOR ER/IR
Internal rotation and adduction
Reach for lower scapula
Compare bilaterally – note level reached
External rotation and abduction
Reach for upper scapula
Compare bilaterally – note level reached

54. OTHER MOVEMENTS
 Extension-with arm by the patient’s side, lift the arm back wards
as far as possible.
 Adduction-draw the arm across the anterior chest wall as far as
possible.
 Circumduction
 Shrugging of shoulders

55. PAINFUL ARC
 In the evaluation of the active and passive ranges of motion, the
patient can often avoid the painful arc by externally rotating the
arm while abducting it. This increases the clearance between the
acromion and the diseased tendinous portion of the rotator cuff,
avoiding impingement in the range between 70° and 120°.

56. 56STRENGTH TESTS
Flexion
Extension

57. STRENGTH TESTS
External rotation
Infraspinatus
Teres minor
Internal rotation
Subscapularis

58. SPECIAL TESTS
•Empty can test
•Lift off test
•Drop arm test
Rotator cuff
•Neer’s sign
•Hawkin’s test
Impingement tests
•Speed’s testBiceps tendon
•O’Brien’s test
•Crank test
Labral tear
•Apprehension Test
•Relocation test
•Anterior release test
Instability tests

59. 59
ROTATOR CUFF
 Empty can test
Supraspinatus
 Lift off test
Subscapularis

60. 60DROP ARM TEST
 Purpose: tears in the rotator cuff, primarily
supraspinatus muscle
 Method: patient abducts (or examiner passively
abducts) arm and then slowly lowers it
 May be able to lower arm slowly to 90° (deltoid function)
 Arm will then drop to side if rotator cuff tear
 Positive test: patient unable to lower arm further
with control
 If able to hold at 90º, pressure on wrist will cause arm to fall

61. GLENOHUMERAL JOINT STABILITY
Anterior Glenohumeral Instability
Apprehension test
Relocation test
Anterior release test

62. APPREHENSION TEST - SITTING
 90° of abduction
 Examiner applies slight anterior
pressure to humerus and
externally rotates arm
 Positive test = patient expresses
apprehension

63. APPREHENSION TEST - SUPINE
 Patient in supine position with
affected shoulder at edge of
table, arm abducted 90°
 Examiner externally rotates by
pushing forearm posteriorly.
 Positive test = patient
expresses apprehension

64. 64RELOCATION TEST
 Performed after positive result on
anterior apprehension test
 Patient supine
 Examiner applies posterior force on
proximal humerus while externally
rotating patient’s arm
 Positive test = patient expresses relief

65. ANTERIOR RELEASE TEST
 Patient in supine position, arm
abducted 90°
 Examiner performs Relocation Test,
then releases downward pressure
 Positive test = patient expresses pain
or instability when the humeral head
is released

66. IMPINGEMENT - NEER’S SIGN
 Patient seated with arm at
side, palm down (pronated)
 Examiner standing
 Examiner stabilizes scapula
and raises the arm (between
flexion and abduction)
 Positive test = pain

67. IMPINGEMENT - HAWKIN'S TEST
 Patient standing
 Examiner forward flexes
shoulder to 90°, then forcibly
internally rotates the arm
 Positive test = pain in area of
superior GH joint or AC joint

68. BICEPS TENDON – SPEED’S TEST
 Forward flex shoulder against
resistance while maintaining
elbow in extension and
forearm in supination
 Positive test = tender in
bicipital groove (bicipital tendinitis)

69. LABRAL TEAR (SLAP) - O'BRIEN'S
ACTIVE COMPRESSION TEST
 Patient standing
 Arm forward flexed 90°, adducted 15° to 20° with elbow straight
 Full internal rotation so thumb pointing down
 Examiner applies downward force on arm - patient resists
 Patient externally rotates arm so thumb pointing up
 Examiner applies downward force on arm - patient resists
 Positive test = Pain or painful clicking elicited with thumb down
and decreased or eliminated with thumb up

70. 70LABRAL TEAR - CRANK TEST
 Shoulder elevated to 160° in the
scapular plane
 A gentle axial load is applied
through glenohumeral joint with
one hand, while other hand does
IR and ER
 Positive test = pain, catching, or
clicking in the shoulder

71. DUGA’S TEST
The patient is seated or standing and touches
the contralateral shoulder with the hand of
the 90°-flexed arm of the affected side then
attempt to lower the elbow to the chest is
made.
Acromioclavicular joint pain suggests joint
disease (osteoarthritis,
instability, disk injury, or infection).
A differential diagnosis must exclude anterior
subacromial impingement and shoulder
dislocation

72. PROVISIONAL DIAGNOSIS
1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

73. INVESTIGATIONS
DIAGNOSTIC
IMAGING
LABORATORY
TESTS
OTHER
SPECIALIZED
TESTS

74. DIAGNOSTIC
IMAGING
PLAIN
RADIOGRAPHS
CONTRAST
RADIOGRAPHS
SPECIALIZED
IMAGING
MODALITIES
ULTRASONOGRAPHY

75. LABORATORY
TESTS
HAEMATOLOGY
SEROLOGY
IMMUNOLOGY
ENZYME
ANALYSIS
SYNOVIAL
FLUID ANALYSIS

76. OTHER
SPECIALIZED
TESTS
BONE BIPOSY
BONE MINERAL
DENSITOMETRY
DIAGNOSTIC
ARTHROSCOPY

77. RADIOLOGY OF SHOULDER

78. RADIOLOGY OF SHOULDER

79. RADIOLOGY OF SHOULDER
ANTERIOR SHOULDER DISLOCATION SUBCAPITAL HUMERUS FRACTURE

80. DEFINITIVE DIAGNOSIS
1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

81. CASTS AND SPLINTS FOR SHOULDER
SHOULDER BRACE SHOULDER SPLINT

82. CASTS AND SPLINTS FOR SHOULDER
SHOULDER IMMOBILIZER SHOULDER SPICA

83. U SLAB AND HANGING CAST

84. SHOULDER ARTHROPLASTY PROSTHESIS

85. REVERSE SHOULDER PROSTHESIS

86. THE END
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