Physical Examination of the Shoulder

1. Physical Examination of the Shoulder By: Abdullah Radwan

2. Physical examination of the shoulder • Inspection • Bony palpation • Suprasternal notch • Sternoclavicular joint • Clavicle • Coracoid process • Acromioclavicular articulation • Acromion • Greater tuberosity of the humerus • Bicipital groove • Spine of the scapula • Vertebral border of the scapula cont.,

3. Cont., • Soft tissue palpation by clinical zones: Zone I – rotator cuff Zone II – subacromial and subdeltoid bursa Zone III – the axilla Zone IV – prominent muscles of the shoulder • Range of motion: Active ROM Passive ROM cont.,

4. Cont., • Neurological examination: • Muscle testing • Reflex testing • Sensation testing • Special tests • Examination of the related areas

5. Physical Exam – Observation / Inspection • Front & Back • Height of shoulder & scapulae • Asymmetry • Obvious deformity • Ecchymosis • Muscle atrophy • Supraspinatus • Infraspinatus • Deltoid

6. Physical Exam – Observation / Inspection • Front & Back • Height of shoulder & scapulae • Asymmetry • Obvious deformity • Ecchymosis • Muscle atrophy • Supraspinatus • Infraspinatus • Deltoid

7. Physical Exam – Observation / Inspection • Front & Back • Height of shoulder & scapulae • Asymmetry • Obvious deformity • Ecchymosis • Muscle atrophy • Supraspinatus • Infraspinatus • Deltoid

8. Physical Exam – Observation / Inspection • Front & Back • Height of shoulder & scapulae • Asymmetry • Obvious deformity • Ecchymosis • Muscle atrophy • Supraspinatus • Infraspinatus • Deltoid

9. Physical Exam – Observation / Inspection • Front & Back • Height of shoulder & scapulae • Asymmetry • Obvious deformity • Ecchymosis • Muscle atrophy • Supraspinatus • Infraspinatus • Deltoid

10. Physical Exam – Observation / Inspection • Front & Back • Height of shoulder & scapulae • Asymmetry • Obvious deformity • Ecchymosis • Muscle atrophy • Supraspinatus • Infraspinatus • Deltoid

11. Palpation • Surface Anatomy (Anterior) • Clavicle • SC Joint • Acromion process • AC Joint • Deltoid • Coracoid process • Pectoralis major • Trapezius • Biceps (long head) AC joint biceps SC joint

12. Palpation • Surface Anatomy (Posterior) • Scapular spine • Acromion process • Supraspinatus • Infraspinatus • Deltoid • Trapezius • Latissumus dorsi • Scapula • Inferior angle • Medial border Supraspinatus Infraspinatus Inferior angle of scapula

13. Range of Motion • Forward flexion: 160 - 180° • Extension: 40 - 60° • Abduction: 180◦ • Adduction: 45 ° • Internal rotation: 60 - 90 ° • External rotation: 80 - 90 °

14. Range of Motion Abduction 0-180o

15. Range of Motion Forward flexion: 0o – 180o

16. Range of Motion • Extension • 0o – 40 to 60o

17. Range of Motion • Internal rotation • T5 segment • External rotation • 80-90o

18. Neurological examination: • Muscle testing • Reflex testing • Sensation testing

19. Muscle (Strength) Testing • Test & compare both sides • Grade strength on 0 → 5 scale • 0: no contraction • 1: muscle flicker; no movement • 2: motion, but not against gravity • 3: motion against gravity, but not resistance • 4: motion against resistance • 5: normal strength

20. Muscle testing in the shoulder involves nine motions: • Flexion • Extension • Abduction • Adduction • External rotation • Internal rotation • Scapular elevation (shoulder shrug) • Scapular retraction (position of attention) • Shoulder protraction (reaching)

21. Flexion by: • Anterior portion of the deltoid • Coracobrachialis • Extension by: • latissimus dorsi • Teres major • Posterior portion of the deltoid

22. Abduction by: • Middle portion of the deltoid • Supraspinatus • Adduction by: • Pectoralis major • Latissimus dorsi

23. External rotation by: • Infraspinatus • Teres minor • Internal rotation by: • Subscapularis • Pectoralis major • Latissimus dorsi • Teres major

24. Scapular elevation (shoulder shrug) by: • Trapezius • Levator scapulae • Scapular retraction (position of attention) by: • Rhomboid major • Rhomboid minor • Shoulder protraction (reaching) by: • Serratus anterior

25. Reflex testing: • Biceps reflex (C 5) • Triceps reflex (C 7)

26. Sensation testing: • Lateral arm C5 nerve root • Medial arm T1 nerve root • Axilla T2 nerve root • From axilla to nipple T3 nerve root • Nipple T4 nerve root +Sensation is performed by pin brick and brush and compared bilaterally. • Abnormal sensations (paresthesia) may be: • Hypersthesia • Hyposthesia • anesthesia

27. Special Tests • Empty can test • Lift off test • Impingement Signs • Drop-Arm Test • Speed’s Test • Yergason Test • Cross-Arm Adduction • Sulcus Sign • Apprehension test • O’Brien’s Test

28. “Empty can" test Tests Supraspinatus • Arms straight out • Elbows locked straight • Thumbs down • Arm at 30 degrees (in scapular plane) • Attempts to elevate arms against resistance

29. (Lift-Off Test) • Resisted Internal rotation • Tests Subscapularis • Arms at the sides • Elbows flexed to 90 degrees • Internally rotates arms against resistance

30. Subacromial Impingement Syndrome • Impingement of: • Subacromial bursa • Rotator cuff muscles and tendons • Biceps tendon • Between • Acromion • Coracoacromial ligament • AC joint • Coracoid process • Humeral head • Rotator cuff tendonosis

31. Impingement Signs • Neer’s Sign • Arm fully pronated and placed in forced flexion • Trying to impinge subacromial structures with humeral head • Pain is positive test

32. Impingement Signs • Hawkin’s Sign • Arm is forward elevated to 90 degrees, then forcibly internally rotated • Trying to impinge subacromial structures with humeral head • Pain is positive test

33. Rotator Cuff Tear: Drop-Arm Test • Abducted arm slowly lowered • May be able to lower arm slowly to 90° (deltoid function) • Arm will then drop to side if rotator cuff tear • Positive test • patient unable to lower arm further with control • If able to hold at 90º, pressure on wrist will cause arm to fall 

34. Biceps Tendonosis: Speed’s Test • Forward flex shoulder to about 90° • Abduct shoulder to about 10° • Arm in full supination • Apply downward force to distal arm • Pain is positive test • Weakness without pain: muscle weakness or rupture

35. Biceps Tendonosis: Yergason’s Test • Elbow flexed to 90° • Start in pronated position • Active supination & flexion against resistance • Palpate biceps tendon • Pain or painful pop is positive test • Tendonosis • Subluxation

36. AC Joint: Cross-Arm Adduction Test • Arm flexed to 90° • Arm adducted to > 45° • Hyperadduct shoulder • Positive test is pain in AC joint

37. Shoulder Instability Sulcus Sign • Inferior instability • Arm relaxed in neutral position • Arm pulled downward at wrist • Positive test is a visible sulcus at infra-acromial area • Compare to contralateral side

38. Shoulder Instability Apprehension Test • Anterior instability • Shoulder abducted to 90° • Slight stress to humeral head directed in anterior direction • While externally rotating shoulder • Positive test is apprehension due to feeling of instability or impending dislocation

39. O’Brien’s Active Compression Test • Labral, AC, or biceps pathology • Arm flexed to 90° • Arm cross-arm adducted 10-15° • Elbow extended • Max pronation • Resist downward force • Positive test if painful • Beware location of pain • AC • Biceps • Internal +/- click

40. O’Brien’s Active Compression Test • For labral pathology • Repeat testing with • Max supination • Should be pain free

41. Examination of the related areas

42. Shoulder pain isn’t always the shoulder!!Get more history… Gall bladder disease Peptic Ulcer Disease Cervical radiculopathy Cardiac ischemia Pulmonary conditions ie Pancoast’s tumor, Pneumonia

43. THANK YOU