Physical Examination of the Shoulder

General setup

 Patient will be examined in both the seated and supine position so exam table needed  360 degree access to patient  Expose neck and both shoulders (for comparison); female in gown or sports bra

Inspection

 Skin and tissues: evaluate for bruising, swelling, prior scars, etc.  Evaluate for muscle atrophy o Chronic RTC disease o Chronic scapular notch cysts causing nerve impingement o Chronic brachial plexopathy  Evaluate for deformity: biceps (popeye deformity), AC joint, SC joint, clavicle, chest wall (pectoralis injury)  Evaluate scapular position/winging (wall-pushups will expose this better if suspected) o Marked winging indicates weakness of serratus anterior (long thoracic nerve) o Observe how the scapula tracks with active forward elevation and active abduction . Medial border winging laterally is common cause of shoulder impingement pain: Tx with PT for scapular stabilizer strengthening to improve mechanics and decrease impingement pain

Palpation for tenderness/crepitus

 AC joint  SC joint  Biceps groove  Sub-acromial space/bursa  Posterior glenohumeral joint line  Superior and medial border of scapula- bursitis/snapping scapula

Physical Examination of the Shoulder

Neck

 Range of motion  Scoliosis/kyphosis  Tenderness  Spurling’s sign – Passive head rotation toward affected side, with neck extension and compression o Positive if dermatomal radicular pain occurs  Shoulder shrug-trapezius strength (spinal accessory nerve-cranial nerve XI)  Thoracic outlet syndrome examination: o Roos test – Hands held overhead, repeated hand clasps for 1 minute . Positive if arm symptoms are reproduced o Adson test – Arm extended with neck extension and rotation toward the affected side . Positive if loss of radial pulse or symptoms reproduced with inhaling

Neurologic exam

 C5- Deltoid and biceps strength; lateral deltoid sensation; biceps reflex  C6- Biceps and wrist extension strength; lateral forearm/thumb sensation; brachioradialis reflex  C7- Triceps strength; middle finger sensation; triceps reflex  C8- Interossei strength; ulnar forearm/5th finger sensation; no reflex

Shoulder range of motion (bilateral)

 Six basic shoulder motions are: Elevation (scaption), abduction, adduction, external rotation, internal rotation, extension  If stiffness is suspected with active ROM, supine position or sitting position while stabilizing the scapula is more accurate information about true glenohumeral joint range of motion. o Limited AROM and PROM . Causes: arthritis, frozen shoulder, deformity/facture o Limited AROM but normal PROM . Causes: pain, functional weakness

Physical Examination of the Shoulder

Strength evaluation

 Rotator cuff testing: o Supraspinatus . Jobes test  Arm abduction to 90 degrees in scapular plane (30 degrees FE), thumb pointing down, patient resists downward force on arm o If patient has a true drop arm = supraspinatus test o If patient has pain and/or weakness but not a complete drop arm = supraspinatus tear vs. subacromial bursitis . Drop sign  Same position as Jobes test above, but ask patient to lower arm slowly o If arm drops to their side = supraspinatus tear/dysfunction o Infraspinatus . ER weakness with elbow at side and neutral rotation . ER lag sign  Passively ER arm with elbow at side, and ask patient to maintain ER position o Positive for infraspinatus tear if patient can’t hold ER position o Subscapularis . Bear hug (superior subscapularis) – most specific  Affected side hand to opposite shoulder, patient resists examiner bringing hand off of shoulder o Positive if pain or weakness . Supine Napolean test (superior subscapularis) – most sensitive  Supine, examiner holds patients hand flat on abdomen and stabilizes shoulder, patient actively brings elbow forward o Positive if patient can’t bring elbow anterior to plan of body . Note: not reliable test in patients who have lost significant passive IR due to OA or frozen shoulder (ie. must have normal passive IR for test to be accurate)

Physical Examination of the Shoulder

Strength evaluation, Subscapularis (Continued)

. Napolean Belly press (superior subscapularis)  palm of hand against abdomen, internal rotation with elbow anterior to plane of body o Positive if elbow can’t reach or be maintained anterior to plane of body while palm remains flat on abdomen (patient may cheat by palm coming off of abdomen) . Lift off (inferior subscapularis)  Dorsum of hand placed on upper lumbar spine o Positive if patient unable to lift hand off of lumbar spine against resistance o Can modify test by passively lifting hand away from lumbar spine and releasing . Positive if patient can’t maintain hand off lumbar spine o Teres Minor . ER strength tested at 90 degrees abduction (in scapular plane ie. scaptation) and 90 degrees ER . Hornblower’s sign – positive when arm drifts into IR when put into 90 degrees scaptation and 90 degrees ER

 Can grade strength out of 5 o 5/5 – full o 4/5 – weakness detected o 3/5 - able to hold against gravity only o 2/5 – can’t hold against gravity o 1/5 – visible muscle contraction only o 0/5 – no muscle contraction

 Test general upper extremity strength if suspect neurologic process (along with sensation and reflexes)

Physical Examination of the Shoulder

Shoulder stability evaluation

 Asses for generalized ligament laxity with Beighton scale: 4/9 or greater score suggests hypermobility syndrome: o Thumb-forearm test 0-2 points o 5th finger hyperextension beyond 90 degrees 0-2 points o Elbow recurvatum beyond 10 degrees 0-2 points o Knee recurvatum beyond 10 degrees 0-2 points o Hands flat on floor with knees extended 0-1 points

 Sulcus test for inferior capsular laxity (often positive in multi-directional instability/rotator interval disease (seated) o Patient is seated, arm relaxed, examiner pulls down on arm and looks for sulcus off lateral acromion . >1cm sulcus that stays with ER at side positive for pathologic rotator interval lesion

 Anterior and posterior load-shift test (supine) o 40 degrees abduction, 90 degrees FE; examiner applies axial load to the arm along with anterior/posterior forces . Positive if increased translation to contralateral side

 Anterior and posterior apprehension tests (supine) o 90 degrees abduction, >90 degrees ER (maximum) . Positive if patient experiences apprehension/feelings of instability (typically anterior) . Relocation test – posterior force on humeral head in position of apprehension  Positive if patient’s apprehension is relieved

 Jerk test (posterior instability) o Sitting position, 90 degrees FE and 90 IR; posteriorly directed force in this position . Positive if maneuver causes a “clunk” or pain

Physical Examination of the Shoulder Special tests

Hawkin’s Test – shoulder impingement

Patient Position Sitting or standing.

Examiner Position Standing lateral or slightly forward of the involved shoulder.

Procedure Position the shoulder in 90° flexion (in the scapular plane) and elbow in 90° flexion. Support underneath the elbow and grasp the distal forearm on the dorsal surface. Internally rotate the shoulder until pain or limit of range of motion is achieved.

Positive Test Pain or limitation of range of motion due to pain. Indicates pathology of the rotator cuff group (particularly the supraspinatus) or long head of biceps tendon = impingement of these structures under the acromion process.

Neer’s Test – shoulder impingement

Patient Position Sitting or standing.

Examiner Position Standing lateral or slightly behind patient.

Procedure Stabilize scapula with one hand, rotate arm in thumb down position and forward elevate arm.

Positive Test Pain or decreased ROM due to pain. Pain localizes along lateral subacromial space.

Physical Examination of the Shoulder

Cross-body Adduction Test – AC joint

Patient Position Seated or standing.

Examiner Position At side or behind patient.

Procedure Position the arm at 90° flexion and then adduct across front of body.

Positive Test Localized pain at AC joint.

Speed’s Test – Biceps

Patient Position Sitting or standing, elbow extended, palm towards the ceiling, with shoulder slightly flexed.

Examiner Position Lateral to patient. Palpate the bicipital groove with one hand. Then place other hand over top of distal forearm.

Procedure Instruct the patient to move arm upward against your resistance, moving through the full range of motion.

Positive Test Pain on the biceps tendon in the bicipital groove or pain in the superior portion of the glenohumeral joint.

Indicates inflammation of the biceps tendon, or possible biceps tendinopathy (SLAP lesion)

Physical Examination of the Shoulder

O’Driscoll Test – SLAP test

Patient Position Seated or standing.

Examiner Position Beside or behind patient.

Procedure Bring arm to abducted and externally rotated position – raise and lower arm.

Positive Test Deep seated superior shoulder pain +/- popping.

Yergason’s Test

Patient Position Sitting or standing, elbow flexed to 90°, and forearm midway between pronation and supination (thumb towards ceiling), humerus alongside trunk.

Examiner Position Lateral to patient. Palpate the bicipital groove to orient the patient to the location of pain related to the evaluation. Place other hand over top of distal forearm.

Procedure Instruct the patient to actively flex their elbow and supinate their forearm while examiner resists the motion.

Positive Test Pain or snapping in the bicipital groove or pain in the superior portion of the glenohumeral joint.

Indicates tear or laxity of bicipital tendon in groove, or possible bicep tendinopathy (SLAP lesion).

Physical Examination of the Shoulder

O’Brien’s Test – SLAP lesion

Patient Position Seated or standing.

Examiner Position Behind or beside patient.

Procedure Position arm at 90° of flexion, adduct 10° past neutral, with thumbs down. Have patient elevate arm against resistance.

Positive Test Pain at anterior superior shoulder.

Repeat test with palm upwards. Pain should be decreased in second position.