Shoulder Exam

last authored: 2009, David LaPierre and Susan Tyler
last reviewed:

 

 

Introduction

The shoulder has considerable range of motion, but this comes at a cost of instability. It is freqently injured, both acutely and chronically. Common pathologies include rotator cuff tendonitis, bicipital tendonitis, and rotator cuff tear or rupture.

 

NOTE

With shoulder pain, remember that it can be referred from the cervical spine or nerve roots, heart, or diaphragm. Shoulder pain may be a symptom of serious conditions such as myocardial infarction, liver abscess, ectopic pregnancy, or internal hemorrhage, and these should be considered.

 

 

 

 

 

 

 

 

 

 

 

 

Inspection

As with all aspects of the musculoskeletal exam, begin with inspection. It is important to completely visualize the shoulder and surrounding structures. Both shoulders should be examined simultaneously. Tie a Johnny shirt under the arms, which allows for bilateral comparison of the shoulders while covering the chest and breasts.

 

 

Observe the patient when they are walking and when they are removing their jacket and shirt. If movement is jerky or hesitant, it suggests pain or mechanical problems.

 

Specific signs to look for include:

• subtle effusion -> look for loss of deltopectoral groove due to swelling
• supraspinatus wasting: almost any chronic shoulder problem can cause this (C4/C5 or C5/C6 radiculopathy; rotator cuff tendonitis, disuse atrophy, joint disease)
• posterior winging of the scapulae
  

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Palpation

The shoulder has many bony landmarks, joints, and soft tissues to palpate. Go through these systematically, evaluating the paramaters listed (TEST CA).

 

Bony Landmarks and Joints

sternoclavicular joint: accentuate by extending, abducting, and rotating arm

clavicle

acromiclavicular joint

acromion: begin with the spine of the scapula, follow it laterally until it turns the corner. This is the posterior acromion.

spine of scapula

inferior edge of scapula

coracoid process: cup your hand over the shoulder, with the thumb pointing downwards. Palpate with the thumb just under the clavicle

greater and lesser humoral tuberosity: move approximately 2 cm down from the middle of the acromion. Rotate the arm, and the greater tuberosity should be obvious.

glenohumoral joint effusion

 

Soft Tissue

supraspinatus:

trapezius:

rotator cuff: shoulder in extension, anteriorly to acromion

subacromial and subdeltoid bursae

rotator cuff tendon: common insertion greater tuberosity of humerus; get pt to place their hand on their hip with elbow point posteriorly to palpate

long head of biceps tendon: useful to externally rotate shoulder with elbow flexed

other muscles: sternocleidomastoid, pectoralis, deltoid, trapezius, serratus anterior, lat dorsi, biceps

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Range of Motion (note: we will soon have images here)

Begin with active range of motion. Ask patient to mimic your own movements. If active movements are normal, it is likely that passive ROM is as well. However, if on active movement there is limitation, it is important to assess passively as well. Degrees are given for normal.

• flexion (165^o), extension (60^o)
• external (70^o), internal rotation (70^o)
• abduction (180^o), adduction (50^o)
  • feel for crepitus
  • pain between 60 and 120 degrees suggests rotator cuff impingement
  • pain above 120 degrees suggests acromioclavicular joint pathology
• external rotation/abduction: hands behind neck with elbows out at the side
• extension/ internal rotation: bring arms behind back and try to reach in between shoulder blades

The scapula normally swings up when the humerus is abducted ~ 90 deg. If there is early or very excessive movement of the scapula, think GH pathology.

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Power

Acute and chronic rotator cuff muscle tears (full thickness) can lead to reduced strength in abduction and external rotation. A quick screen is to place hands behind neck, which combines these 2 movements. Also ask about pain with combing hair or reaching for wallet in the back pocket.

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Special Tests

Is pain from the joint or the tendons? If it is the joint, as in the case of arthritis, all movements will hurt. If from tendons, localize the pain according to the following tests, which act to stress and stretch the tendon.

 

supraspinatus impingement/tendonitis (painful arc test): Rotator cuff is actively involved in external rotation and abduction of the shoulder. Resist abduction of the shoulder with palms facing the ceiling to test for this (simply make a fist with the thumb sticking up and then turn it up side down). Pain between 60-120 degrees suggests pinching between the humerus and the acromion.

 

supraspinatus impingement/tendonitis: internally rotate shoulder and resist abduction (ie, with thumb facing downwards). Pain is a positive test.

 

bicipital tendonitis (Speed’s test): Place the shoulder in 20-30 degrees flexion and have the entire arm extended, with forearm supinated. Resist the shoulder flexion with your hand over the pt’s distal radius. If they experience pain, this is a positive test. Pain may also be elicited by gently rolling the bicipital tendon within the groove.

 

teres minor and infraspinatus tendonitis: with elbow flexed, resist external rotation. Teres minor: arm 30 degrees abducted, resist external rotation.

 

subscapularis tendonitis: with elbow flexed, resist internal rotation. The lift-off test is also an option, though with many false negatives.

 

torn rotator cuff (drop arm test): If a patient has a severely torn rotator cuff, ask them to fully abduct their arm and then lower it. Slow adduction will result in a drop at ~90 degrees if torn. Inability to maintain the arm at 90 degrees when tapped is also a positive test.

 

labrum disease: Flex shoulder to horizontal, turn thumb down, and resist further flexion. Deep pain will be present. If the pain improves with supination, it is likely the labrum.

 

AC joint stress test: Ask patient to place hand on the opposite shoulder. Stress the joint by pressing up on the elbow into of the radius.

 

shoulder instabilty (apprehension test): With patient supine, support upper arm at shoulder and lower arm at wrist. Lift arm in 90 deg of abduction and gradually move arm into external rotation. 95% of dislocations are anterior, and patients may voice a great deal of concern if they feel their shoulder is about to dislocate again. Be cautious, as you may indeed dislocate it.

 

Winging: Ask patients to do a 'push-up' against you or the wall (serratus), or by asking patient to push behind them (rhomboids, trapezius).

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Resources and References

MMI Shoulder exam (excellent flash site)

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