Comprehensive Shoulder Examination Guide

Physical Examination of the Shoulder By: Abdullah Radwan

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.,

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.,

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

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

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

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

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

Range of Motion Abduction 0-180o

Range of Motion Forward flexion: 0o – 180o

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

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

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

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

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)

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

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

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

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

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

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

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

“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

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

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

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

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

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

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

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

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

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

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

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

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

Examination of the related areas

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

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Comprehensive Shoulder Examination Guide