SHOULDER EXAMINATION

Dr Vinod KumarDr Dhananjaya Sabat

Department Of OrthopaedicsMaulana Azad Medical College & LN Hospital

New Delhi

Assessment: what is the primary problem ?

PAIN INSTABILITY LOSS OF MOTION

EXTRINSICOR

INTRINSIC

ACTIVEOR

PASSIVE

EVALUATION PRINCIPLESGet a History: Is this a new injury, old chronic injury

Evaluation Order

• History

• Inspection

• Palpation

• Movement : ROM & strength

• Special tests: Rotator cuff disease & impingement

Instability & Laxity

Biceps tendon & SLAP

AC & SC joint

SEE

FEEL

MOVE

INSPECTIONAnterior sidePosterior sideLateral OverheadAxillary

Sometimes too obvious

DeltoidAtrophyPain at insertion site-mostly referred from rotator cuff pathology; rarely due to deltoid tendinitis

Subacromial regionSwelling- bursitis

Biceps tendonRupture- Popeye bulge

Posterior sideScapula

Position High – Sprengel’sSpineFossae –supraspinatus & infraspinatus atrophy

Borders of scapula–lateral; prominent in LD

atrophysuperior; prominent in

supraspinatus & trapezius atrophy

Vertebral; prominent in serratus ant weakness/winging

PALPATIONTendernessSwelling Palpable gap in muscles

Acromioclavicular jointCoracoid processSubacromial bursaBiceps tendon

MOVEMENTSActive

Passive

Resistive

FORWARD FLEXION- 0-160/180°

EXTENSION- 0-45°

ABDUCTION-0-180°

ADDUCTION- 0-45°

CROSS BODY ADDUCTION

See scapulohumeral rhythm from backside

EXTERNAL ROTATION- 0-45°

INTERNAL ROTATION- 0-55°

Appley’s scratch testPatient attempts to touch the opposite scapula thus testing abduction & ER and adduction & IRGood screening test for ROM assessment

Muscle strength tests

Pectoralis major Latissimus dorsi

Deltoid

Trapezius Serratusanterior

Rhomboids

NEUROMUSCULAR EXAMINATIONMotor examinationSensory examinationDeep tendon reflexesCervical spineSpurling test, L-Hermitte sign

Thoracic outlet syndAdson’s test, Hyperabduction test, Roos test

Brachial Plexus InjuryBrachial Neuritis

Compression Neuropathies

Axillary nerve injuryAnaesthesia in the ‘Regimental badge area’

1. INSTABILITY2. IMPINGEMENT SYNDROME3. ROTATOR CUFF TEAR4. BICEPS TENDON PROBLEMS5. AC JOINT PROBLEMS6. STIFF SHOULDER

ANTERIOR DISLOCATION SHOULDER

Hamilton Ruler testDuga’s testCallaway’s test

POSTERIOR DISLOCATION SHOULDER

LIGHT BULB SIGN

ER restrictedProminence in posterior deltoid

Chronic InstabilityInstability can be-

Unidirectional- anterior, posterior, inferiorMultidirectional (MDI) – anterior &/ or posterior + inferior

TUBS AMBRI

•Traumatic•Unidirectional•Bankart’s lesion•Surgical t/t

•Atraumatic•Multidirectional•Bilateral•Rehabilitation•Inferior capsular shift

CHRONIC UNIDIRECTIONAL INSTABILITY

PROVOCATIVE TESTS to document the presence

& direction of instability

QUANTITATIVE TESTSTo quantitate the amount of laxity

Anterior Instability•Crank test•Fulcrum test•Jobe’s relocation testPosterior Instability•Jerk test•Circumduction test

•Drawer tests•Load & shift testfor both anterior and posterior instability

ANTERIOR INSTABILITYProvocative testsApprehension test

Crank test – Pt sitting; arm at 90° ABD. With increasing ER the examiner exerts an anterior translatory force with his thumb placed posteriorly on the humerus & watches for apprehension.Apprehension is diagnostic of instability. If only pain, subtle subluxation.

Fulcrum test –Pt supine with the scapula supported by the edge of the table. The arm is positioned in 90°ABD. With increasing ER the examiner watches for apprehension.

Examiner repeats apprehension test and notes the amount of ER before the onset of apprehension. Then apply a posterior stress over the humeral head & repeat the ER maneuver and again note amount of ER at onset of apprehension.Increase in the external rotation range = +veRelease test- apprehensionreappears on release

Jobe’s Relocation test

POSTERIOR INSTABILITYProvocative testsJerk test

Pt supine with 90° forward flexion of shoulder & elbow flexed to 90°, examinor applies posterior directed force by holding the forearm.Jerk/Jump = diagnostic of instabilityPain/apprehension= subtle instability

Circumduction testPt standing, examiner standing behind & holds the arm in extension & abduction; performs circumductionVisible subluxation/ apprehension in position of foreward flexion 160° & adduction (position of risk) = instability

Inferior laxitySulcus sign

Patient in sitting or standing; the shoulder is in neutral position, muscles are relaxed. Downward traction applied+ = dimpling of the skin below the acromion or widening of the subacromial space on palpation; >2cm translationMDI

Multidirectional instabilityInstability in more than one direction including inferior laxity

Voluntary dislocationAbnormal generalized laxityAbnormal scapular mechanicsPsychiatric illness

Painful arc syndromeIn abduction arc of motion, patient feels pain in the range 60-120°.

O’Brien testThe patient flexes the arm to 90° with the elbow fully extended and then adducts the arm 10-15° medial to sagittal plane. The arm is then maximally internally rotated and the patient resists the examiner's downward force.

Hawkins-Kennedy Testpatient sitting with arm at 90° forward elevation and elbow flexed to 90°. Examiner then quickly moves the arm into internal rotation. +ve = Pain located to the sub-acromial spaceSubacromial impingement, rotator cuff tendinitis

Neer Impingement SignExaminer performs maximal passive forward flexion with internal rotation whilst stabilizing the scapula.+ = Pain located to the sub-acromial space or anterior edge of acromionSubacromial impingement of supraspinatius & anterior part of infraspinatus

Neer’s Impingement Test

Examiner after eliciting impingement sign, injects local anesthetic soln. to subacromial space.Disappearance of pain is diagnostic

Inability to abduct or flex forewardAtrophy of supra & infraspinatus fossaeEmpty can test - for supraspinatusER at arm at side with elbow flexed- for infraspinatusLift off test/ abdominal compression test – for subscapularisDrop Arm signExternal rotation lag sign

Supraspinatus “Empty Can Test”Pt attempts to elevate the arms against resistance with arms at 90°abduction in a plane 30°anterior true coronal plane and full IR (thumb pointing downward) with elbows extended. Positive = supraspinatus tear

Patient’s arms at the sides with elbows flexed to 90, attempts to do ER

Infraspinatus & Teres minor

Subscapularis 1. “Lift off test/ Gerber’s test”Patient standing with hand behind back with the dorsum of the hand resting on the back. The hand is raised off the back by maintaining or increasing internal rotation of the humerus and extension at the shoulder. Full passive internal rotation is prerequisite. Inability = subscapularis tear/ dysfunction

Subscapularis2. Abdominal compression test

Patient attempts to press the hand down against abdomen with examiner preventing it. Useful when IR restricted.Inability = subscapularis tear/ dysfunction

Drop Arm signExaminer abducts patient’s shoulder to maximum. After warning the patient, examiner releases pt’s arm & asks him to lower the arm back to the side. Pt able to lower the arm part way & then suddenly loses control- arm drops suddenly to the side.Indicates large rotator cuff tearAlso seen in axillary nerve palsy

External rotation lag signPt’s arm is externally rotated maximally and released- arm rotates internally spontaneously (passive ER>active ER).Seen when subscapularis is intact but infraspinatus & teres minor is torn.

Yergasson’s testThe patient's elbow is flexed and their forearm pronated. The examiner holds their arm at the wrist. Patient actively supinates against resistance.Pain located to bicipital groove = +ve

Speed’s testThe patient's elbow is extended, forearm supinated and the humerus elevated to 60°. The examiner resists humeral forward flexion.Pain located to bicipital groove = +ve

Cross chest adduction testPt. elevates the affected arm to 90°, then actively adducts it.

Restriction of all range of motion, esp-Abduction & ERPain on attempted movements

Note –ER restriction occurs in 2 conditions only

1. Stiff shoulder2. Posterior dislocation

Overhead athletes may have restriction of IR due to posterior capsular tightness

SUMMARYInstability Instability Provocative

QuantitativeImpinge-ment

Pain O’Brien, Hawkins-Kennedy, Neer’s

Cuff tear Painloss of motion

Drop arm test, Test for SS, IS & SS

Biceps tendinitis

PainInstability

Yergasson, Speed, Biceps instability

AC jt injury Pain Tenderness, Cross chest abduction

Stiff shoulder

Painstiffness

Passive motion restriction

Conclusion

Clinical examination of shoulder should be guided according to patient's age, chief complains and professional activities.All tests needn’t be performed to clinch the diagnosis.Merely knowledge of test is not enough, good practice is essential to perform the tests.

“It is more important to knowwhat patient the disease has rather than what disease the patient has”

William Osler