Physical Examination of the Shoulder James A. Tom, MD Sports Medicine and Shoulder Dept. of Orthopaedic Surgery Drexel University College of Medicine Philadelphia, PA

Evaluation of the Shoulder Thorough history of presenting complaint Information regarding surrounding anatomy Neck Elbow Chest Diaphragm Imaging studies based on clinical suspicion Not simply ordered “to make the diagnosis”

Anatomy Bony anatomy Glenohumeral joint Acromioclavicular (AC) joint

Anatomy Glenoid labrum Rim of fibrocartilage “Deepens socket”

Anatomy Joint capsule

Anatomy Rotator Cuff 4 muscles that enable shoulder flexion, abduction, ER, and IR SPN = most commonly injured

History Age Occupation Hand dominance Chief complaint

History Subsequent questions directed to specific patient population Young Acute injuries, instability, AC joint injury Middle-agedInflammatory conditions, impingement, adhesive capsulitis OlderArthritis, impingement, RTC pathology

History History of injury Acute Chronic Mechanism of injury (MOI) Secondary gain Litigation Worker’s Compensation Psychiatric illness

History Pain Character Location Intensity Duration Radiation Factors associated with exacerbation / relief Interference with work / daily activities (ADLs) Objective measures VAS Validated scoring systems

History Associated symptoms N / T / P Weakness Level of disability Work Athletics

History Previous treatment NSAIDs Injection PT Surgery

Physical Exam Inspection / Palpation General appearance Gross anatomy Observation of simple tasks (e.g., disrobing) General muscle tone / symmetry Bony prominences Skin coloration (e.g., Raynaud’s, CRPS) Systemic laxity (e.g., Th-forearm flexibility, knee-elbow recurvatum)

Physical Exam ROM Normal shoulder motion from both GH joint & scapulothoracic articulation in 2:1 ration Comparison with contralateral shoulder

Physical Exam Active / Passive ROM Discrepancy indicative of specific disease Abduction180° Adduction 45° Flexion180° Extension 45° IR 55° ER 45°

Physical Exam Strength Graded system of manual muscle testing Objective description of strength 5/5FROM vs. gravity & full resistance 4/5FROM vs. gravity & some resistance 3/5 FROM vs. gravity but no resistance 2/5FROM at gravity neutral 1/5 Muscle contracts but no motion 0/5Muscle unable to contract Neurologic problem or muscle injury

Impingement Neer’s impingement sign Subacromial impingement Passive FE of arm  impingement of SPN tendon under CA arch (+) test = reproduction of pain

Impingement Not Neer’s impingement test Subacromial injection with local anesthestic Most sensitive / specific test for impingement (+) = pain relief after injection

Impingement Hawkin’s impingement sign Subacromial impingement Adducted shoulder flexed forward to 90° with IR (+) test = reproduction of pain

Rotator Cuff Tear SPN stress test ~ “empty (beer / soda) can sign” Supraspinatus tear Resisted abduction of internally rotated and forward flexed arm (in scapular plane) Performed in supination to eliminate sx of impingement (+) = pain and weakness

Rotator Cuff Tear Drop arm test RTC tear – larger Passively abducting shoulder 90° and asking pt to hold it in that position and then slowly lower it to the side (+) = inability to hold arm up or lower it slowly and smoothly

Rotator Cuff Tear Lift off test Subscapularis tear Eliminates pectoralis major as internal rotator ~ “belly press test” with hand pressed against abdomen while attempting to maintain elbow position anterior to midaxillary line (+) = unable to lift arm off back

Instability Apprehension test Shoulder instability Best performed supine to stabilize scapula Shoulder placed in unstable position of abduction / ER May produce posterior shoulder pain with “internal impingement” (+) = resistance & apprehension as humeral head subluxates anteriorly

Instability Relocation test Extension of apprehension test for instability Shoulder placed in apprehensive position and then applying posteriorly directed force to proximal humerus (+) = relief of apprehension and greater degree of ER

Instability Load and shift test Shoulder instability Seated position with arm adducted while examiner holds proximal humerus and attempts to translate it ant / post Supine position with arm abducted to position in scapular plane with axial load applied to elbow to concentrically reduce humeral head. Followed by attempt to translate ant / post Graded on degree of translation

Instability Sulcus sign Inferior shoulder laxity Downward traction of arm as it hangs at side (neutral rotation and neutral flex-ext) (+) = gap between humerus and acromion

Instability Jerk test Posterior instability Posteriorly directed force on forward flexed and adducted arm produces post sublux Then placement of arm in coronal plane may relocate subluxated humeral head with audible / palpable “clunk”

Biceps Tendon Disease O’Briens’s test “Active compression test” Superior labral – biceps pathology (SLAP lesions) Shoulder forward flexed 90° and slightly adducted across body while elbow kept straight and arm internally rotated. Resists downward force on arm. (+) = reproduction of pain and relative relief with supination

Biceps Tendon Disease Yergason’s test Bicipital tendonitis Resisted forearm supination with slightly flexed elbow (+) = reproduction of pain

Biceps Tendon Disease Speed’s test Bicipital tendonitis Elbow extended as patient forward flexes shoulder against resistance (+) = reproduction of pain

AC Joint Degeneration Cross-body adduction test AC joint degeneration Passively adducting arm across chest while palpating AC joint (+) = pain in area of AC joint

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