Shoulder History and Physical Exam
written by David LaPierre and Susan Tyler, Dal med students, 2009
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: impingement syndrome c/ shoulder pain on activity, sharp pain with putting arm in overhead position, chronic use hx or trauma
- rotator cuff tear/rupture: sharp pain post trauma, pain over greater tuberosity, attempted abduction gives you the classic shoulder shrug/pain, ext rotation weakness
- bicipital tendonitis: anterior tenderness over long head of biceps brachii, pain at night dislocation, RA, adhesive capsulitis (frozen shoulder)
With shoulder pain, remember that it can be referred from the neck (radiculopathy or impingement) or from the chest (heart) or even diaphragm. Shoulder pain may be the only symptom of an MI. Spurling’s sign can be used to rule out cervical root impingemen. Rotate and laterally flex neck toward affected side with reproduction of radicular sx indicating possible impingement.
History
Ask about previous injuries.
Inspection
(SEADS)
S: Swelling
E: Erythema, ecchymosis
A: Atrophy/asymmetry (muscle bulk)
D: Deformity
S: Skin changes/scars/bruising
Tie a Johnny shirt under the arms, which allows for bilateral comparison of the shoulders while covering the chest and breasts.
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; SITS tendonitis, etc. )
Posterior winging of the scapulae
Palpation
feel for:
- tenderness
- effusion
- swelling
- temperature
- crepitus
- atrophy
bony landmarks and joints:
- sternoclavicular joint
- clavicle
- acromiclavicular joint
- acromion
- spine of scapula
- coracoid process
- long head of biceps tendon - useful to externally rotate shoulder with elbow flexed
- greater and lesser humoral tuberosity
- glenohumoral joint effusion
soft tissue:
- supraspinatus
- tarpezius
- 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 this!) and biceps tendon (bicipital groove)
- muscles: SCM, pectoralis, deltoid, trapezii, serratus anterior, lat dorsi, biceps
Range of Motion
Active range of motion ( ask patient to mimic your own movements)
- flexion (165o), extension (60o)
- external (70o), internal rotation (70o)
- abduction (180o), adduction
(50o)
- feel for crepitus
- if pain between 60 and 120 degrees, think rotator cuff impingement
- inf pain above 120 degrees, thing acromioclavicular joint
- shoulder should move to 90 degrees if scapula is held in place
- if scapula moves during initial 30 degrees, implies glenohumoral joint disease
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
N.B. If there is GH joint pathology, often the scapula is engaged early to help in movement. The scapula normally swings up when the humerus is abducted ~ 90 deg. Early or very excessive movement here -> think GH pathology.
Power
Acute and chronic rotator cuff muscle tears can lead to reduced strength in abduction and external rotation. Classic example, limitation or complete inability 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 on hx.
Special Tests
Is it the joint or tendons? If it is the joint (ie arthritis), all movement will hurt. If tendons, discriminate between biceps and rotator cuff. Stress and stretch. Maximize the muscle length and give it a workout!
Impingement test (supraspinatus tendonitis): Fix scapula with one hand, flex GH joint with other hand while standing behind patient. Alternatively, passively abduct to 90 degrees and flex elbow, then slowly internally rotate shoulder. As you impinge the subacromial bursa between the greater tuberosity of the humerus and the acromion, pain elicited is a positive test.
Painful arc test (supraspinatus tendonitis): Rotator cuff is actively involved in external rotation and abduction of the shoulder. Resist abduction of the shoulder with internal rotation of the shoulder to test for this (simply make a fist with the thumb sticking up and then turn it up side down).
Speed’s test (bicipital tendonitis): Place the shoulder in 20-30 deg 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.
Teres minor and infraspinatus tendonitis: with elbow flexed, resist external rotation.
Subscapularis tendonitis: with elbow flexed, resist internal rotation.
Drop arm test: If a patient has a severely torn RC, slow adduction will result in a drop after 30 degrees. Alternatively, actively abduct shoulder to 90 degs. Inability to maintain this position or tapping limb with sudden drop are positive tests.
AC joint stress test: Get patient to place one hand on the opposite shoulder. You stress the joint by pressing up on the elbow into of the radius.
Test for Shoulder Instabilty (apprehension test): With patien 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 than their shoulder is about to dislocate.