Shoulder Exam

Introduction

In order to make sense of the joint examination, you must have an understanding of functional anatomy. Without this, the provocative maneuvers used to define the precise nature of the joint problem will make no sense. By gaining an appreciation for the basic structures and functioning of the joint, you’ll be able to “logic” your way thru the exam, even if you can’t remember the eponym attached to each specific test! The complete examination of the knee or shoulder is usually performed in the setting of pain, decline in function or other focal complaint.

Shoulder Exam

I think that the most daunting aspect of the shoulder exam is appreciating
the functional anatomy of this incredibly mobile joint. The primary benefit
of the ball and socket arrangement is that it allows the hand to be positioned
precisely in space, maximizing our ability to function.

Observation

The shoulder joint is created by the confluence of 3 bony structures: the scapula,
humerus and clavicle. These are held together by ligaments and an intricate
web of muscles. Critical external landmarks include the following:

1. Acromion
2. Clavicle
3. Scapula
4. Deltoid muscle
5. Supraspinatus
6. Infraspinatus
7. Teres Minor

Anterior View On Left, Posterior On Right.

Location Of The Muscle Groups Is Approximated In The Pictures Above.

Start by looking at the normal (or more normal) side. Note any scars,
obvious asymmetry, discoloration, swelling, or muscle asymmetry.

Palpation

Gently palpate around the shoulder, touching each of the
landmarks noted above. Make note of pain.

Range of Motion (ROM)

If there are no symptoms, test both sides simultaneously. Otherwise, start
with the normal side.

Active ROM:

1. Abduction: Determine the extent to which the patient can abduct
   their arm. The patient should be able to lift their arm in a smooth, painless
   arc to a position with hand above their head. Normal range is from 0 to 180
   degrees.

• Adduction and Internal rotation (Appley Scratch Test): Ask the patient
  to place their hand behind their back, and instruct them to reach as high
  up their spine as possible. Note the extent of their reach in relation to
  the scapula or thoracic spine. They should be able to reach the lower border
  of the scapula (~ T 7 level).

• Abduction and External rotation: Ask the patient to place their
  hand behind their head and instruct them to reach as far down their spine
  as possible. Note the extent of their reach in relation to the cervical spine,
  with most being able to reach ~C 7 level.

  

• Forward flexion: Ask the patient to trace out an arc while reaching
  forward (elbow straight). They should be able to move their hand to a position
  over their head. Normal range is 0 to 180 degrees.

• Extension: Ask the patient to reverse direction and trace an arc
  backwards (elbow straight). They should be able to position their hand behind
  their back.

Passive ROM

If there is pain with active ROM, assess the same movements with passive ROM.
Have the patient relax and place one of your hands on their shoulder. Gently
grasp the humerus in your other hand and move the shoulder through the range
of motions described above. Note if there is pain, and if so which movement(s)
precipitates it. Also note if you feel crepitus with the hand resting on the
shoulder.

Pain/limitation on active ROM but not present with passive suggests
a structural problem with the muscles/tendons, as they are firing with active
ROM but not passive. Crepitus suggests DJD. Limitations in movement in any of
the directions should be noted. Where exactly in the arc does this occur? Is
it due to pain or weakness? How does it compare with the other side? Determining
the precise etiology can be defined using the tests below, though realize that
there is often a significant amount of overlap between several conditions.

Impingement, Rotator Cuff Tendonitis and Sub-Acromial Bursitis

Anatomy and Function: I have placed these processes under one heading
as they are all linked. Impingement is a dynamic condition that can lead to
tendonitis and bursitis. Shoulder pain in general is very common, with impingement
as the root cause in a large number of cases. The 4 tendons of the rotator cuff
all pass underneath the acromion en route to their insertions on the humerus.
The space between the acromion/coracoacromial and the tendons can become relatively
narrowed for any number of reasons (e.g. the growth of an oteophyte on the under
surface of the bone). This causes the tendons to become “impinged upon.” The
resulting friction inflames the tendons as well as the subacromial bursa, which
lies between the tendons and the acromion. The net result is shoulder pain,
particularly when raising the arm over head (e.g. swimming, reaching for something
on a top shelf, arm positioning during sleep). Over time, chronic irritation
to the tendons can lead to fraying, tears, and even complete disruption.

Right Shoulder Anatomy (anterior view)

Several tests can be done to localize the problem:

Sub-acromial Palpation: Gently palpate in the region of the sub-acromial
space (see picture below). Palpation may cause pain if the tendons/bursa are
inflamed.

The following two tests passively maneuver the tendons so that they are most
likely to rub against the acromion, generating symptoms related to impingement
if it is in fact present.

Neers Test:

1. Place one of your hands on the patient’s scapula, and grasp their forearm
   with your other. The arm should be internally rotated such that the thumb
   is pointing downward.
2. Gently foreard flex the arm, positioning the hand over the head.
3. Pain suggests impingement.

Neer’s Test For Impingement

Hawkin’s (for more subtle impingement)

1. Raise the patient’s arm to 90 degrees forward flexion. Then rotate it internally
   (i.e. thumb pointed down). This places the greater tubercle of the humerus
   in a position to further compromise the space beneath the acromion.
2. Pain with this maneuver suggests impingement.

Hawkins Test For Impingement

It’s worth noting that defining the precise location of the problem (ie. bursitis,
tendonitis or even partial rotator cuff tears) can be difficult to make on clinical
grounds. One helpful adjunct is the diagnostic subacromial bursa injection. Local
anesthetic and steroids are injected into the bursa. If the symptoms are due to
bursitis, this provides significant relief. However, if the symptoms are predominantly
caused by tendonitis or a partial rotator cuff tear, this will have little effect.
MRI can also be extremely helpful in defining the precise nature of the pathology.

Evaluation of the Muscles of the Rotator Cuff

Anterior View On Left, Posterior On Right.

Anatomy and Function: There are 4 major muscles that allow shoulder
movement. As mentioned above, symptoms caused by rotator cuff tears or tendonitis
are often related to impingement. Acute shoulder trauma can also result in injury.
Each of the 4 muscles can be tested individually as follows:

Supraspinatus: Connects the top of the scapula to the humerus. Contraction
allows the shoulder to abduct. This is the most commonly damaged of the rotator
cuff muscles. Testing (aka “empty can test):

1. Have the patient abduct their
   shoulder to 90 degrees, with 30 degrees forward flexion and full internal rotation
   (i.e. turned so that the thumb is pointing downward).
2. Direct them to forward flex the shoulder, without resistance.
3. Repeat while you offer resistance.

Supraspinatus (Empty Can)Test

Interpretation: If there is a partial tear of the muscle or tendon, the patient
will experience pain and perhaps some element of weakness with the above maneuver.
Complete disruption of the muscle will prevent the patient from achieving any
forward flexion. These patients will also be unable to abduct their arm, and
instead try to “shrug” it up using their deltoids to compensate.

Infraspinatus: Connects the scapula to the humerus. Contraction allows
the arm to rotate externally. Specifics of testing:

1. Have the patient slightly abduct (20-30 degrees) their shoulders, keeping
   both elbows bent at 90 degrees.
2. Place your hands on the outside of their forearms.
3. Direct them to push their arms outward (externally rotate) while you resist.

Interpretation: Tears in the muscle will cause weakness and/or pain.

Testing Infraspinatus And Teres Minor (External Rotators)

Teres Minor: Connects the scapula to the humerus. Provides the same
function as the infraspinatus (external rotation). Testing is done as described
for the Infraspinatus.

Subscapularis: Connects the scapula to the humerus, though the origin
is on the anterior surface of the scapula (i.e. on the side opposite the origin
of the other 3 muscles of the RC). Contraction causes internal rotation. Function
can be tested using “Gerber’s lift off test:”

1. Have the patient place
   their hand behind their back, with the palm facing out.
2. Direct them to lift their hand away from their back. If the muscle is partially torn, movement will
   be limited or cause pain. Complete tears will prevent movement in this direction
   entirely.

Gerbers Liftoff Test (Subscapularis)

Drop Arm Test for Supraspinatus Tears: Adducting the arm depends upon
both the deltoid and supraspinatus muscles. When all is working normally, there
is a seamless transition of function as the shoulder is lowered, allowing for
smooth movement. This is lost if the rotator cuff as been torn. Specifics of
testing:

1. Fully abduct the patient’s arm, so that their hand is over their head.
2. Now ask them to slowly lower it to their side.
3. If the suprapinatus is torn, at ~ 90 degrees the arm will seem to suddenly drop towards the body. This is
   because the torn muscle cant adequately support movement thru the remainder of the arc of adduction.

Deltoid: Not a muscle of the rotator cuff, but important for the later
aspects of abduction and flexion. The supraspinatus is responsible for the early
component of abduction. The deltoid is readily visible on exam and not commonly
injured.

Acromioclaviular Arthritis Anatomy and Function: The A-C joint is minimally
mobile. However, inflammation and degeneration can occur, causing pain. Specifics
of Testing:

1. Identify by palpation the point at which the end of the clavicle
   articulates with the acromion.
2. Gently push on the area, noting if it causes
   pain similar to what the patient was describing.

1. Ask the patient to move
   their arm across their chest. This stresses the a-c joint and will cause pain
   in the setting of DJD.

AC Disruption: Trauma can cause disruption of the ac joint, also known
as AC separation. Specifics of testing:

1. Look at the area in question. If
   there has been significant disruption (or a fracture to the clavicle itself),
   the area will appear swollen and deformed compared with the other side. The patient will avoid movement, as this causes pain.

Acromio-clavicular Joint Separation: Disruption of the right A-C joint, in this case caused by trauma.

1. Gently have the patient
   move their arm across their chest while you palpate in the AC region. This will
   cause pain specifically at the AC joint if there is separation.

The Glenohumeral Joint

Anatomy and Function: This joint is the actual place where the humerus
articulates with the scapula (i.e. where the ball meets the socket). The cavity
is lined by the labrum, which functions like the menisci of the knee, assuring
smooth/cushioned contact between the bones. The joint is held together by the
muscles of the rotator cuff as well as a tough capsule that surrounds the muscles.

Glenohumeral DJD: DJD usually results from an injury that has disrupted
the normal articulating surfaces. Over time, movement of the shoulder causes
additional wear and tear, leading to DJD. Patients experience pain and gradual
limitation in movement. This is particularly noticeable on external rotation
and abduction. Palpation of the joint with a hand placed on the shoulder during
movement may reveal crepitus. Assessment is done as follows:

1. Perform active ROM maneuvers as described previously, noting degree to
   which movement is limited.
2. Perform passive ROM, again noting limitations and degree of pain.
3. You may feel crepitus by placing your hand on the patient’s shoulder during
   passive ROM.

Glenohumeral Joint Anatomy-Humerus has been removed from
its normal position of articulation.

Glenohumeral Instability: The rotator cuff, along with the outer
joint capsule and the labrum, stabilize the joint. The labrum is a tough tissue
that lines the cup formed by the scapular component of the glenohumeral joint.
The rotator cuff and capsule surround the outside of the joint. Together, they
allow the humerus enough freedom so that the shoulder maintains its full range
of motion and function. Tears of the capsule or labrum can generate feelings
of pain, instability, or a “dead arm” sensation. The patient may have
a history of trauma or recurrent dislocation, where the humerus actually pops
out of joint. Specifics of testing (The Apprehension Test):

1. Have the
   patient lie on their back with the arm hanging off the bed.
2. Grasp their elbow
   in your hand and abduct the humerus to 90 degrees.
3. Gently externally rotate
   their arm while pushing anteriorly on the head of the humerus with your other
   hand.
4. Instability will give the sense that the arm is about to pop out of
   joint.

Testing Glenohumeral Stability

Acute Inflammatory Arthritis: Inflammatory processes within the joint
can be caused by a number of processes, including infection (septic) or autoimmune
(e.g RA). When this occurs, the shoulder may appear swollen, red, and will be
painful to the touch. Any movement will be limited by pain. Sampling of fluid
from within the joint space allows definitive diagnosis.

Septic Shoulder: Intense Inflammation Over Shoulder Area As Seen In
Picture On Left, Due To Intra-Articular Infection.

Picture On Right Is Normal For Comparison.

Biceps Tendonitis: The long head of the biceps tendon inserts on the
head of the humerus. Inflammation can therefore cause pain in the shoulder area.
The biceps muscle flexes and supinates the forearm. Specifics of testing:

1. Palpate the biceps tendon where it sits in a bony groove formed by the
   greater and lesser tubercles of the humeral head. Pain suggests tendonitis.

Biceps Tendon Palpation

Resisted Supination (Yergason’s Test):

1. Elbow should be flexed to 90 degrees, shoulder adducted (ie elbow bent at right
   angle, arm against body).
2. Grasp the patient’s hand and direct them to try and rotate their arm such
   that the hand is palm up (supinate) while you provide resistance. Pain suggests
   tendonitis of the biceps.

Resisted Supination (Yergason’s Test)

Biceps Tendon Rupture: As a result of chronic tendonitis or truama,
the long head of the biceps may rupture. When this occurs, the biceps muscle
appears as a ball of tissue and there is a loss of function.

Balled Up Biceps Secondary to Tendon Rupture

Adhesive Capsulitis: Also called a frozen shoulder, this is caused by
idiopathic inflammation of the capspule around the shoulder. The net result
is severe limitation of motion in any direction (active or passive). Pain is
present with movement, and oftentimes when the shoulder is at rest. The etiology
is unclear and it can be difficult to distinguish from a number of the above
conditions.

Referred Pain to the Shoulder Area

It’s important to recognize that not all shoulder pain is cause by shoulder
pathology. A few sites that can cause referred symptoms:

1. Intra-abdominal inflammation
   can cause pain to be referred to the shoulder. In particular, inflammation that
   takes place just below the diaphragm (e.g. splenic abscess) may be referred
   to the shoulder. Examination and history would suggest that the pathology lies
   outside the shoulder.
2. Intrathoracic processes can also cause referred symptoms.
   MI, for example, can generate pain that radiates to the shoulder. As above,
   H&P should be revealing.
3. Cervical spine pathology can cause irritation of
   the cervical nerve roots, in particular C5 and C6. This causes a burning or
   tingling type pain to be referred to the deltoid area. Appropriately directed
   history and neuro examinations help to pin down the cervical spine as the location
   of the pathology.