Shoulder joint examination and special tests

1. Examination of the
Shoulder Joint

2. Objectives
• Anatomy of the shoulder
• Clinical history and physical
examination of the shoulder
• Review common shoulder injuries
& characteristic physical exam
findings.

3. Brief Epidemiology
• 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
• Athletic injuries
– Shoulder: 8-13% of all athletic injuries

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

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

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

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

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

10. ANATOMY

11. Anatomy
• Rotator Cuff Muscles
– S – Supraspinatus
– I – Infraspinatus
– t - Teres minor
– S- Supscapularis

12. Anatomy
• Bursae
– Subacromial
(Subdeltoid)
– Subscapular

13. Anatomy
• Neurologic
– Nerve roots
– Brachial
plexus
– Peripheral
nerves

14. Anatomy
• Coordinated shoulder motion
– Glenohumeral motion
– Acromioclavicular motion
– Sternoclavicular motion
– Scapulothoracic motion
Scapular-humeral rhythm

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

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

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

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

19. INSPECT..............

20. INSPECT

21. INSPECT

22. SPRENGEL DEFORMITY

23. INSPECT

24. Palpation
• At rest & with movement
• Bony structures
• Joints
• Soft tissues
 TENDERNESS
 SWELLLING
 PALPABLE GAP IN MUSCLES
 ROM

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

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

27. Range of Motion
• Forward flexion:
– 160 – 180°
• Extension:
– 40 - 60°
• Abduction:
– 180◦
• Adduction:
– 45 °
• Internal rotation:
– 60 - 90 °
• External rotation:
– 80 - 90 °

28. PALPATION
Apley Scratch Test

29. PALPATION

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

31. Strength Testing
• Test & compare both sides
• Be specific to muscle or muscle group
• 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

32. Strength Testing
• 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

33. Strength Testing
• 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

34. Strength Testing
• 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

35. Strength Testing

38. Special Tests
1. INSTABILTY
2. IMPINGEMENT
SYNDROME
3. ROTATOR CUFF TEAR
4. BICEPS TENDON
PROBLEM
5. AC JOINT PROBLEMS
6. STIFF SHOULDER

39. INSTABILTY

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

51. IMPINGEMENT

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

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

56. Impingement Signs
• 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

57. •ROTATOR CUFF
TEARS

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

60. Rotator Cuff Tear: Drop-Arm Test
• 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
• Positive test
– patient unable to lower arm
further with control
– If able to hold at 90º, pressure
on wrist will cause arm to fall

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

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

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

70. • AC JOINT PROBLEMS

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

72. AC Arthritis / DJD

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

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

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

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

77. history
• pain in the
• shoulder joint may be
referred from the neck,
chest or the abdomen
(from irritation of the
• diaphragm which is
supplied by the same
segments i.e. C3, 4 & 5

78. INSPECTION
• flattened due to wasting of the deltoid muscles
• from tuberculous arthritis, rheumatoid arthritis, osteoarthritis, rotator cuff*
lesions etc. It may
• be prominent with rotmded fullness seen in subdeltoid bursitis or effusion
of the joint. ln effusion
• of the shoulder joint, which is not very common, the swelling extends
beyond the anterior and
• posterior margins of the deltoid and along the long tendon of the biceps
due to existence of
• synovial sac. But in subdeltoid bursitis fullness is only seen just beneath
the deltoid muscle and
• does not go beyond the margins of this muscle

79. PALPATION
• .- The shoulder joint is best palpated by keeping the arm by
• the chest wall with one hand and with the other hand lo palpate the shoulder joint from all
• aspects. In supraspinatus tendinitis pressure just below the acromion process will elicit tenderness.
• In painful arc syndrome pressure just below the acromion will elicit tenderness if the arm is
• adducted, but not if the arm is abducted as the tender spot will disappear under the acromion
• process. Similarly in front just below the coracoid process one can feel the anterior aspect of the
• joint and note if there is any tenderness. Posteriorly also the joint is palpated similarly. In
• osteoarthritis if the arm is made to sway a little the palpating hand al the shoulder joint will
• feel the crepilus. Three bony joints are important to palpate in the shoulder joint - (a) Tip of
• coracoid, below which is the anterior aspect of the shoulder, (b) Tip of the acromion, below
• * 'Rotator cuff' is a cuff comprised of tendons of the four muscles which fuse with the
• capsule of the shoulder joint to give additional strength to it. These four muscles are - anteriorly
• subscapularis, superiorly supraspinatus and posteriorly infraspinatus and teres minor.
• 224 A MANUAL ON CLINICAL SURGERY
• which lies the superior aspect of shoulder and (c) Grea ter
• tuberosity, its prominence.
• It is a good practice to feel the acromioclavicular as well as
• the stemoclavicular joints to exclude any organic disease there.

80. I This is another method of pa lpating
Fig.15.1.- Note that the plane
of the scapula is not in the
coronal plane of the body but is
slightly inclined forwards (about
30°). Abduction and adduction
take place in the plane of the
body of the scapula (A-A)
whereas flexion and extension
occur at right angles to that plane.
CODMANS METHOD
The left hand is used to palpate the right
shouJder of the patient. The thumb lies along the depression
below the spine of the scapula to palpate the posterior aspect
of the shoulder joint. The tip of the index finger is placed just
anterior to the acromion to feel the superior aspect (at the
insertion of the supraspinatus) and slJghtly anterior aspect of
the joint and other three fingers a re )Placed on the clavicle to
hold it. Examiner's right hand grasps the patient's flexed elbow
and the patient's am1 is moved gently backwards (extension)
and forwards (flexion) and the sho ulder joint is carefully
palpated. The examiner's right hand is used to palpate patient's
left shoulder.

81. • , ~~t:llinp Effusion in the joint is difficult
to palpate
• through the deltoid. fullness, however,.
can be discovered in the
• ax ill a. Subdeltoid bursitis ma y give
rise to swelling and
• tenderness just beneath the acromion
process.
• The corresponding axilla should be
always palpated
• while exami.ning the affected shoulder.
This palpation
• should be deep high in the axilla to
detect any fullness
• there to indicate joint effusion. As the
inferior aspect of
• the joint is lax and redundant
accumulation of fluid
• starts here in case of joint effusion

82. • MOVEMENTS.- The shoulder joint is a very mobile
• joint and the bony configuration is such as to sacrifice
• the stability of the joint to certain extent to compromise
• with greater ranges of movement.
• While examining for the ranges of different
• movements of shoulder joint, firstly the patient must
• be stripped upto the waist and these movements should
• be examined not only from in front but also from
• behind (particularly during abducton to see the scapular
• movement). This is because of the fact that an
• ankylosed gleno-humeraJ joint will show some range
• of movement due to the movement of the scapula as
• also the acromioclavicular and sternoclavicuJar joints.
• Secondly the different movements must be compared
• with those of the normal side to exactly assess the
• differences. Thirdly the clinician must have a clear idea
• about the plane of the body of the scapula along which
• the abduction and adduction movements occur. This is
• not in the coronal plane of the body but is slightly

83. • inclined forwards about 30° with this plane (fig.15.1).
• Flg. 15 .2 .-- Codman' s method of
• palpation of the shoulder joint. Note the
• placement olf the clinician's fingers on the
• shoulder joint. See the text.
• EXAMINATION OF INDIVIDUAL JOIN'I PATHOLOGIES 225
• So during abduction the arm is carried forwards and outwards while during adduction the
• arm is carried backwards and inwards. Flexion and extension take place at right angle to this
• plane i.e. in flexion the arm is carried forwards and medially and in extension backwards and
• laterally. Fourthly in the movement of abduction the shoulder joint itself moves for 100°- 120°,
• the additional 60°-80° is obtained by the forward rotation of the scapula and some movement
• of the clavicle. But these movements occur a lmost simultaneously except in the initial 25°-30°
• when the whole of the movement takes place at the shoulder joint. For every subsequent 15°
• of elevation of the arm, the gleno-humeral joint contributes 10° and the scapular movemen t
• 5°. To note exactly how much movement is contributed by the gleno-humeral joint, the scapula
• is fixed by the clinician from behind and the patient is asked to abduct the shoulder.
• The range permitted in each movement is as follows : h
• Abduction - 180°; flexion - 90°; extension - 45°; •. :.;
• rotations - both medial and la teral - one quarter of a circle
• about a vertical axis; circumduclion - results from succession
• of the foregoing movements.

84. THANK YOU