Examination of shoulder

Shoulder symptoms may be due intrinsic causes or referred causes due to spine, thorax or abdomen pathology. Hence it is important to rule out referred causes for shoulder pain.

History

Should include age, handedness, occupational and recreational activities and the shoulder symptoms. In patients with pain; ask for the exact site, duration, onset, progress, character, radiation, associated symptoms, aggravating factors and relieving factors. In case of left sided shoulder pain ask for cardiac symptoms. Patient should be asked to point out the site of pain with a single finger. If site is over the lateral arm especially during overhead activity, the cause is likely to be rotator cuff pathology or impingement. Superior pain especially on adduction is suggestive of acromioclavicular pathology. Anterior shoulder pain may be due to long head of biceps pathology. Deep shoulder pain is likely to be due to glenohumeral pathology or labral lesions.
In patients with instability; ask for the duration, onset, frequency, precipitating posture or activity, position of shoulder after the dislocation, and how it gets corrected after an episode. Also ask for history of epilepsy as posterior instability is more likely in such patients. Also look for history suggestive of voluntary dislocation.

Glenohumeral instability has been classified according to the cause and direction. Cause can be classified into traumatic and atraumatic. Atraumatic instability develops either due to laxity or overuse. Direction of instability can be classified into anterior, posterior, inferior and multidirectional. If history of trauma is not present then careful history of occupational and recreational activities must be made to identify overuse. Position of arm at the moment of instability is very helpful in the identification of the direction of instability. In anterior instability, the shoulder will be abducted, externally rotated and extended. In posterior instability, the shoulder is adducted, internally rotated and flexed. In inferior instability, the arm is abducted and the hand is supported over the head.
Anterior instability causes pain during late cocking phase of throwing due to anteroinferior capsule laxity. Posterior instability causes pain during follow through phase. Patients with anterior instability may present with dead arm syndrome; paralysing pain in the maximally externally rotated, abducted and extended position.

Different age groups have different causes for their presentation. Patients <25 years present due to traumatic dislocations, recurrent instability or acromioclavicular pathology. Adults below 40 years present due to impingement, frozen shoulder or ACJ arthritis; and those over 40 years present due to rotator cuff impingement or tear and osteoarthritis of glenohumeral or acromioclavicular joint. The steps of physical examination of shoulder is determined by patient’s presenting complaints and history. The entire region from the cervical spine to the hand should be examined.

Inspection

Patient should be dressed in such a manner that shoulder can be assessed fully. Observe the posture and the bony and soft tissue contour of both shoulders and look for any asymmetry. Observe whether the pelvis is level and the spine is straight as their malalignment may cause secondary shoulder abnormality.

Drooping of shoulder may be caused by trapezius palsy. Winging of scapula is abnormal prominence of vertebral border of scapula. Winging can be produced by injury, dysfunction of muscles and nerve palsy. It may be dynamic or static. Dynamic winging may be due to trapezius palsy or serratus anterior palsy. True winging is due to serratus anterior palsy. Serratus anterior supplied by long thoracic nerve, and it’s action is protraction of the scapula. It’s function is tested by asking the patient to stand at an arm length from wall and push against it. Pseudowinging is produced by trapezius palsy, acromioclavicular dislocation and scapular dysrrhythmia. In trapezius palsy, winging is more during abduction of shoulder, the inferior angle of shoulder is rotated laterally and it is more obvious when the patient stoops forward so that the body so parallel to the floor and then tries to abduct the shoulder. In serratus anterior palsy, winging is more pronounced during forward flexion of the shoulder and the inferior angle of scapula is rotated medially. Winging may also occur due to scapular muscle dysrrhythmia due to shoulder instability or rotator cuff tear. It may also occur acromioclavicular joint dislocation with ruptured coracoclavicular ligaments or fracture of outer third of clavicle.

A step deformity may be seen at the ACJ in dislocations of the ACJ. Contour of clavicle may be altered in case of clavicle malunion or nonunion. Popeye sign of abnormal prominence of biceps is seen in patients with long head of biceps rupture. Abnormal contour of anterior auxiliary fold and pectoralis major is seen patients with pectoralis major tendon rupture and Poland syndrome. Wasting of supraspinatus and infraspinatus may be seen.

Palpation

Feel for local rise of temperature. Stand on the back of the patient and palpate the structures of the shoulder using the Kochers method of palpation starting at the sternoclavicular joint and moving laterally over the clavicle, ACJ, coracoid, spine of scapula and down the humerus. Look for tenderness, irregularity, thickening, defect, abnormal mobility etc. Biceps tendon should be palpated in its groove anteriorly.

The tenderness over the glenohumeral joint is elicited anteriorly over a point 1cm inferior and lateral to the coracoid process and posteriorly over the point 2cm medial and inferior to the angle of acromion. Diffuse tenderness over the trapezius and interscapular area may be seen in patients with shoulder instability and scapular dysrrhythmia due to abnormal shoulder biomechanics.

Movements

Assess range of motion using the recommendations of the American Shoulder and Elbow Surgeons Research Committee 1. Abduction is tested in the scapular plane (30 degree- anteriorly)and not in the coronal axis of the body. Ideally patient should be stripped to the waist and examiner should stand behind the patient and both shoulders are abducted simultaneously. In the resting position the vertebral border of both scapula should be equidistant from the vertebral column. Both scapula should move symmetrically when the arm is abducted, asymmetrical movement is noted as scapular dyskinesis. Normally the ratio of glenohumeral to scapulothoracic movement on abduction is 2:1.

Shrug sign is seen in patients with supraspinatus dysfunction, the patient shrugs at the beginning of abduction to substitute glenohumeral abduction by supraspinatus with scapulothoracic motion. If there is abnormal prominence of vertebral border then there is dynamic scapular winging. Maximum achievable angle between the humerus and thorax is recorded as shoulder elevation. Internal and external rotation are measured in 90 flexion of elbow and with arm by the side of body and in 90 abduction of shoulder. Rotations are better tested in the supine position after applying pressure over the anterior shoulder to fix the scapula.

Strength testing

Strength of rotator cuff muscles are measured. Supraspinatus is assessed in the empty can position; 90 abduction of shoulder with elbow straight and shoulder in the fully internally rotated position with the thumb pointing downwards and the patient is asked to abduct further against resistance. Strength of infraspinatus is measured with the arm in 90º abduction, elbow at 90º flexion and the patient is asked to externally rotate against resistance.

Special tests

May be classified into
Tests for impingement
Tests for laxity
Tests for instability
Tests for rotator cuff disease
Tests for SLAP
Tests for biceps tendon
Tests for ACJ
Tests for cervical disc disease

1. Tests for impingement


A. Neer impingement sign- (Forced forward elevation test)

Examiner position- Stand next to the patient with one hand over the top of shoulder and other hand holding the patient’s arm.
Patient position- Standing.
Joint position- Arm by the side of body
Procedure- Stabilise the scapula with one hand, passively flex the shoulder fully and then push further.
Interpretation- Pain is due to rotator cuff impingement. Test is 79% sensitive and 53% specific.

B. Hawkins-Kennedy test (Forced internal rotation test)

Examiner position- Stand in front of the patient.
Patient position- Standing.
Procedure- Flex the arm and elbow to 90 degrees and then internally rotate the shoulder using the flexed forearm as a lever.
Interpretation- Test is positive if pain is reported. Test is 79% sensitive and 59% specific.

C. Neer impingement test

Inject 10 ml of 1% lidocaine into the subacromial space using a sterile technique. Then ask the patient to actively abduct. Relief of pain for the duration of the anesthetic effect is confirmatory of impingement.

2. Tests for laxity


A. Anterior drawer test

Described by Gerber and Ganz.
Examiner position- Stand on the affected side
Patient position- Supine. Patient’s hand is stabilised in the axilla of examiner.
Joint position- Shoulder in 80-120 abduction, 0-20 forward flexion, 0-30 external rotation.
Procedure- Stabilise the shoulder with one hand, grasp the proximal humerus with the other hand. Apply anterior translation force.
Interpretation – Click and abnormal laxity indicate anterior instability. Grade the degree of translation.
0- None or minimal when compared to contralateral shoulder.
1+ – Up to glenoid rim.
2+- Beyond glenoid rim and spontaneously relocates.
3+- Dislocates and doesn’t reduce spontaneously.

B. Posterior drawer test

Described by Gerber and Ganz.
Patient position- Supine.
Joint position- Shoulder in 80-120 abduction, 20 forward flexion, 60-80 internal rotation.
Procedure- Stabilise the shoulder, grasp the proximal humerus. Apply posterior translation force.
Interpretation- Click and abnormal laxity indicate posterior instability. Grade the degree of translation.

C. Load and shift test

Described by Silliman and Hawkins
Patient position- Sitting
Joint position- Arm by the side and hand resting in the lap of patient
Procedure- Stabilise the shoulder with one hand, grasp the proximal humerus with the other hand. Load the humeral head against the glenoid and then slide the head anteriorly and posteriorly
Interpretation- Look for abnormal anterior translation, which suggest anterior instability. Grade the translation.

D. Sulcus sign

Described by Neer and Foster.
Patient position- Sitting
Joint position- Arm by the side and hand resting in the lap of patient
Procedure- Hold the elbow of the patient with one hand and then stabilise the shoulder with other hand and then apply longitudinal traction.
Interpretation- Appearance of a gap more than the other side below the acromion suggest inferior capsular laxity. It is indicative of multidirectional instability. Grading – 1+ -0-1cm, 2+- 1-2cm, 3+- >2cm.
Recent modification- Now externally rotate the shoulder, if the gap persists then rotator interval is likely to be defective.

E. Gagey hyperabduction test

Principle – Tests inferior glenohumeral ligament complex.
Patient position – Sitting
Examiner position – Behind seated patient
Joint position – Arm by the side of body.
Procedure – Place the forearm of examiner on the top of shoulder to stabilise the scapula. Abduct the shoulder of patient maximally and note the range of abduction till the scapula start moving.
Interpretation – Normal range of passive abduction is 105 degrees. If it is more then there is IGL laxity.

3. Tests for Instability


Glenohumeral laxity is the ability to translate the humeral head to glenoid rim. Glenohumeral instability is the pathological translation of humeral head on the glenoid that compromises patient comfort and shoulder function. Multidirectional instability is instability in two or more directions. The hallmark of inferior instability is positive sulcus sign.

A. Apprehension test

Patient position- Supine,
Joint position- Shoulder in 90 abduction, elbow in 90 flexion.
Procedure- Maximally externally rotate shoulder while applying anteriorly directed pressure.
Interpretation- Look for apprehension.

B. Jobe apprehension relocation test

If apprehension is present with previous test, repeat the test with posteriorly directed pressure. Absence of apprehension is confirmatory of anterior instability. This test is the gold standard for the diagnosis of anterior instability. With apprehension as the criteria for diagnosis; it shows 85% accuracy, 68% specificity, 100% sensitivity, 100% positive predictive value and 78% negative predictive value.

C. Jerk test

Patient position- Supine
Joint position- Shoulder abducted to 90, elbow flexed to 90.
Procedure- Grasp elbow. Axially load the shoulder. Adduct the shoulder horizontally across the body
Interpretation- Clunk and pain in presence of posterior instability. Return to abducted position may produce another jerk due to relocation of joint.
Reliability – 90% sensitivity, 85% specificity, 72% positive predictive value and 94% negative predictive value. 10

4. Tests for rotator cuff disease


A. Supraspinatus

Jobe empty can test

Ask the patient to actively abduct the shoulder in the scapular plane with the elbow in extension with the shoulder in full internal rotation and the thumb pointing down. 

Reinard identified by electrical studies that more fibres of supraspinatus are active if the test is done with the thumb pointing up (Full can test) and may be more useful. Jobe test has 75% accuracy in detection of supraspinatus tear. 
B. Subscapularis

Integrity of upper and lower fibers of subscapularis are tested separately.

i. Lift off test

Lower fibres are tested by the lift-off test; ask the patient to place the dorsum of the hand against the small of back and then lift the hand posteriorly away from the body against resistance. Inability to lift the hand indicate subscapularis tear.

ii. Belly press test

Upper fibres are tested by the belly press test; patient is asked to place his palm against the umbilicus and push against the abdomen. Inability to do this indicate subscapularis tear.

C. Infraspinatus

Drop sign

Done to detect infraspinatus tear. Patient is asked to lie in the lateral decubitus position with the affected side up. Flex the shoulder and elbow to 90 degrees. Hold the wrist and externally rotate to the maximum. Now release the wrist and ask the patient to hold the limb in external rotation. In presence of infraspinatus tear, he will not be able to do this.

5. Tests for Superior labrum Anterior Posterior (SLAP) lesion


Numerous tests are available, but they are of 2 types; active tests which try to recreate the torsional traction force that caused the injury or passive tests that exert compressive stress on the labrum. O’Brien test is an active test and crank test is a passive test.

O’Brien’s test (Active compression test)

Patient position- Standing.
Examiner position – By the side with one hand on shoulder and other hand on the distal forearm.
Joint position- Forward flexion of shoulder to 90, adduction of 10-15, fully internally rotated. Elbow straight. Thumb pointing down.
Procedure- Elevate against resistance. Repeat with shoulder in external rotation.
Interpretation – Pain in internal rotated position and absence of pain in external rotation suggestive of SLAP lesion. Ask about the location of pain, if it is over the acromioclavicular joint then the test is negative.
Sensitivity- 90%
Specificity- 98%

Crank test (Compression rotation test)

Patient position – Supine
Joint position- Shoulder in 160 abduction, 30 forward flexion. Elbow flexed
Procedure- Stabilise scapula with one hand, grasp the elbow with the other hand. Axially load and rotate externally and internally.
Interpretation- Pain and reproduction of patient’s symptoms indicate labral pathology
Reliability – 91% sensitive, 93% specific, 94% positive predictive value, 90% negative predictive value.

Resisted supination external rotation test

Patient position- Supine.
Joint position- Shoulder 90 abducted, elbow 70 flexed, forearm semipronated.
Procedure- Externally rotate the shoulder and ask the patient to supinate the forearm against resistance.
Interpretation- Pain indicative of SLAP lesion.

Anterior slide test

Patient position – Standing.
Joint position – Hand on hips with thumb pointing posteriorly.
Procedure – Apply forward and axial pressure over the elbow and ask the patient to resist.
Interpretation – Pain indicate superior labral pathology.
Reliability – 78% sensitive and 90% sensitive for type II SLAP lesion.

6. Test for Biceps long head


Pathology may be tendinitis, tear, instability of the long head of biceps or synovitis of its sheath.

Speed test

Patient position- Standing.
Examiner position- By the side of patient with one hand over shoulder and other hand over the anterior aspect of distal forearm.
Joint position – Shoulder forward flexed by 60. Elbow extended. Forearm supinated.
Procedure- Flex the shoulder against resistance with elbow kept straight.
Interpretation – Anterior shoulder pain indicate long head of biceps pathology.
Sensitivity- 90%
Specificity – 14%
Reference – Bennet WF. Arthroscopy. 1998 Nov‐Dec;14(8):789‐96

Yergason test

7. Tests for acromioclavicular joint


Horizontal adduction test- The shoulder is passively elevated to horizontal and the arm is adducted across the body beyond the full range. Ask the patient if there is pain and the site of pain. If pain is located over the ACJ then the test is positive for ACJ pathology. Test is 77% sensitive and 79% specific with an accuracy of 79%

8. Test for cervical spine


Spurling test
Patient position – Sitting
Joint position – Neck flexed forward and tilted laterally.
Procedure – Apply axial load over the head.
Interpretation- Reproduction of patient’s symptom of radiating pain indicate cervical root pathology.

Further Reading

Richards RR, An KN, Bigiliani LU et al: A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994; 3:347-52

Chronopoulos E, Kim TK, Park HB, et al. Diagnostic value of physical tests for isolated chronic acromioclavicular lesions. Am J Sports Med . 2004;32(3):655-661

Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med . 2008;42(2):80-92

Jobe FW, Jobe CM. Painful athletic injuries of the shoulder. Clin Orthop Relat Res . 1983;(173): 117-124.

Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train . 2007;42(4):464-469.

Itoi E, Kido T, Sano A, et al. Which is more useful, the “full can test” or the “empty can test,” in detecting the torn supraspinatus tendon? Am J Sports Med . 1999;27(1):65-68.

Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle: clinical features in 16 cases. J Bone Joint Surg Br . 1991;73(3):389-394.

Harryman DT 2nd, Sidles JA, Harris SL, Matsen FA 3rd. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am . 1992;74(1):53-66

Speer KP, Hannafi n JA, Altchek DW, Warren RF. An evaluation of the shoulder relocation test. Am J Sports Med . 1994;22(2):177-183

Kim SH, Park JC, Park JS, Oh I. Painful jerk test: a predictor of success in nonoperative treatment of posteroinferior instability of the shoulder. Am J Sports Med . 2004;32(8):1849-1855

O’Brien SJ, Pagnani MJ, Fealy S, et al: The active compression test: A new and effective test for diagnosing labral tears and acromio-clavicular joint abnormality. Am J Sports Med 26: 610–613, 1998

Parentis MA, Mohr KJ, ElAttrache NS: Disorders of the superior labrum: Review andtreatment guidelines. Clin Orthop 400: 77–87, 2002

Posted by Dr Rajesh Purushothaman, Associate Professor, Government Medical College, Kozhikode, Kerala, India

Copyright @Dr Rajesh Purushothaman, Associate Professor, Government Medical College, Kozhikode, Kerala, India

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