This site is intended for healthcare professionals Medscape Shoulder Examination Technique TECHNIQUE Approach Considerations Physical examinations should be performed in a systematic manner. |") General principles in approaching the physical examination of the shoulder and other areas are as follows: + Always start with careful visual inspection of the patient and the involved body parts. + Next, palpate the involved area and assess range of motion. Start with active range of motion first. Always test the uninvolved side first. Passive range of motion is assessed next if the patient has a limitation in active range of motion. During passive range of motion, assess the degrees of motion, capsular pattern, and end feel. + Strength testing is performed next. + After these tests, perform a functional assessment if itis indicated. An appropriate neurological assessment may be performed next. This may help identify other underlying sources of pain or dysfunction. This may include testing reflexes, dermatomes, and sensory nerves. + Finally, perform special tests. Painful movements should be performed last. With all aspects of the examination, compare the involved side to the uninvolved side to help determine if an abnormality is present. Inspection Shoulder physical examination starts with inspection. This begins during history taking. Observe the patient's behavior, comfort level, and functional impairments, if signs of malingering are present. During the examination, start with observing for discoloration, swelling, abrasions, scars, or any other abnormalities. Next, observe the contralateral shoulder for any signs of asymmetry, The dominant shoulder is often lower than the nondominant shoulder. Next, inspect the shoulder mass. Observe for atrophy of the deltoid or trapezius. Also note the effect the patient's posture, scolioses, or kyphosis has on the shoulder positioning. A glenohumeral joint dislocation may produce a prominent acromion and fullness of the deltoid. (2) A distal clavicle that is positioned superior to the acromion process is referred to as a step off deformity. A step off deformity may indicate an acromioclavicular joint dislocation. !"] This is sometimes also referred to as a shoulder separation. From a posterior position, assess for winging This may occur in either the medial or lateral direction, Serratus anterior paralysis results in medial winging of the scapula. Lateral winging is caused by trapezius and rhomboid paralysis. '3] In Sprengel deformity, the scapula is congenitally high or partially descended. '4] The scapula may also be smaller than normal and medially rotated.Palpation First, palpate the skin and subcutaneous tissue. Hoppenfeld's classic physical examination textbook recommends gentle but firm contact to instill a sense of security. {4] Assess the skin's temperature. Monitor for any signs or complaints of tendemess. Palpate for symmetry of the sternoclavicular joint. When the clavicle is dislocated is usually positioned superior and medially. 4] Palpate the acromioclavicular articulation. The acromioclavicular joint may be tender to palpation secondary to osteoarthritis or dislocation. Either of these conditions may also be associated with crepitus in the acromioclavicular joint. The bicipital groove is located anterior and medial to the greater tuberosity of the humerus. External rotation better exposes the bicipital groove for palpation. With bicipital tendinitis, tenderness and ‘swelling may be observed upon palpation. !2) The distal rotator cuff is partially palpable at its insertion on the greater tuberosity of the humerus. Passive extension of the shoulder moves the rotator cuff into a more palpable position. Passive extension also moves the subacromial bursa anteriorly. Palpate for any tenderness of these soft tissue structures. Other relevant musculoskeletal anatomy may be palpated for signs of pathology. Next, palpate the shoulder girdle musculature to assess the muscle tone, trigger points, or tender points, Range of Motion Range of motion is first actively assessed. In active movements, the patient performs the motion on their own. If active range of motion is limited, then range of motion is also assessed passively. In passive range of motion, the examiner moves the patient through the motion. During passive range of motion, assess the degrees of motion, capsular pattern, and end feel. During shoulder abduction assess for the patient's painful arc. Subacromial bursitis and supraspinatus tendinitis presents with a painful arc between 60-120°. Acromioclavicular joint pathology presents with pain in the last 30° of elevation. Also assess the scapulothoracic rhythm. During normal shoulder abduction, the ratio of abduction through the glenohumeral joint to scapular elevation through the scapulothoracic joint is 2:1 Increased scapular elevation may be a compensatory strategy, which suggests the presence of underlying pathology. Active and Passive Movements See the list below: + Forward flexion of the arm Abduction of the arm Scapular elevation Internal rotation External rotation Adduction of the arm Horizontal adduction and abduction Circumduction Normal range of motion findings !")Abduction - 170-180" ‘Scapular elevation — 170-180° Internal rotation — 60-100° External rotation - 80-90° Adduction — 50-75° Horizontal adduction and abduction - 130° Circumduction - 200° Muscle testing Manual muscle testing evaluates the muscle strength. Strength grades are based the following: [5] 5 (Normal) - Complete range of motion against gravity and maximal pressure by the examiner 4 (Good) - Complete range of motion against gravity with moderate pressure by the examiner 3 (Fair) - Complete range of motion against gravity only 2 (Poor) - Complete range of motion with gravity eliminated or in the horizontal plane 1 (Trace) - Contraction can be palpated but no movement occurs 0 (Zero) - No evidence of contraction These shoulder and arm movements are produced by the following muscles: !"] Forward flexion - Anterior deltoid, pectoralis major, coracobrachialis, biceps Extension - Posterior deltoid, teres major, teres minor, latissimus dorsi, triceps Horizontal adduction - Pectoralis major, anterior deltoid Horizontal abduction — Posterior deltoid, teres major, teres minor, infraspinatus Abduction - Deltoid, supraspinatus, infraspinatus, subscapularis, teres minor Adduction - Pectoralis major, latissimus dorsi, teres major, subscapularis Internal rotation - Pectoralis major, deltoid, latissimus dorsi, teres major, subscapularis External rotation - Infraspinatus, posterior deltoid, teres minor. ‘Scapular elevation - Upper trapezius levator scapulae, rhomboid major, rhomboid minor Scapular depression - Serratus anterior, pectoralis major, pectoralis minor, latissimus dorsi, lower trapezius Scapular protraction - Serratus anterior, pectoralis major, pectoralis minor, latissimus dorsi Scapular retraction - Trapezius, rhomboid major, rhomboid minor. ‘Scapular lateral rotation - Trapezius, serratus anterior Scapular medial rotation - Levator scapulae, rhomboid major, rhomboid minor, pectoralis minor Elbow flexion - Brachialis, biceps brachii, brachioradialis, pronator teres, flexor carpi ulnaris Elbow extension - Triceps, anconeus Functional Assessment Functional assessment may help assess and address patient specific deficits and goals. Awareness of functional abilities may also better identify impairment, disability, and/or handicap associated with the patient's underlying condition. The Simple Shoulder Test is a series of 12 "yes" or "no" questions the patient answers about the function of the involved shoulder. The UCLA Shoulder Scoring Scale and the Constant-Murley Shoulder Scoring Scale are other shoulder function assessment tools. [6] The simple shoulder test begins with instructions to answer the questions based on shoulder comfort and function as they have affected lifestyle and ability over the prior week. [7] After answering which hand is most dominant and which shoulder is being evaluated, the questions are as follows:. Is your shoulder comfortable with your arm at rest by your side? Does your shoulder allow you to sleep comfortably? Can you reach the small of your back to tuck in your shirt with your hand? Can you place your hand behind your head with the elbow straight out to the side? . Can you place a coin on a shelf at the level of your shoulder bending your elbow? . Can you lift one pound (a full pint container) to the level of your shoulder without bending your elbow? . Can you lift 8 Ibs (a full gallon container) to the level of your shoulder without bending your elbow? 8 Can you carry 20 Ibs at your side with the affected arm? 9. Do you think you can toss a softball underhand 20 yards with the affected arm? 10, Do you think you can toss a softball overhand 20 yards with the affected extremity? Yes_ No__ 11. Can you wash the back of your opposite shoulder with the affected extremity? 12. Would your shoulder allow you to work full-time at your regular job? PAReNs ~ Neurological assessment Neurological assessment involves both dermatomal and cutaneous sensory nerve distribution. It also involves manual muscle testing as described above. The examiner should be aware of the dermatomal distribution of the nerve roots affecting the shoulder. Dermatomes involving the shoulder and surrounding areas can be reviewed through Dermatomes Anatomy. The C4 dermatomes distribution is over the trapezius muscles. The C5 dermatomal distribution encompasses shoulder and upper lateral arm. Dermatomal distribution is noted to vary between individuals, and overlap of adjacent dermatomes is observed. See the image below. Dermatomes Shoulder View Media Gallery Cutaneous sensory distribution to shoulder area is supplied by the supraclavicular nerve, upper lateral brachial cutaneous nerve (cutaneous branch of the axillary nerve), and intercostobrachial nerve. See the image below.Cutaneous nerve distribution of upper extremity. View Media Gallery Special Tests Special tests may be used to confirm a diagnosis, provide a differential diagnosis, differentiate between various structures, or to better understand the etiology of unusual signs or symptoms. !*] Apprehension test The examiner abducts the patient's arm to 90° and externally rotates the shoulder slowly. A positive result is noted by the patient's sensation of apprehension or resistance to further passive motion applied by the examiner. This tests for anterior glenohumeral instability. !") Sulcus sign The patient is seated or standing with the arm at the side. Traction is applied through the patient's arm in the inferior direction. The sulcus sign indicates inferior glenohumeral laxity or instability. 1] Acromioclavicular Shear This tests acromioclavicular joint pathology. The patient places one hand anteriorly over the clavicle and the other hand posteriorly over the spine of scapula. The examiner interlocks their fingers and squeezes hands together. A positive test result is indicated by pain or abnormal movement. Cross-body adduction The shoulder is elevated to 90°. The shoulder and arm are horizontally adducted across the body. A positive test is indicated pain at the acromioclavicular joint. This may indicate acromioclavicular jointarthritis. [21 Yegason Test This tests stability of the biceps tendon in the bicipital groove and bicipital tendinitis. The patient flexes the elbow to 90°. The patient is instructed to flex the elbow, supinate, and medially rotate the shoulder against the examiner's resistance. A positive test result is indicated by either pain in the bicipital groove or movement of the biceps tendon out of the bicipital groove. Drop arm test The examiner abducts the shoulder to 90°. The patient is then instructed to slowly lower the arm. A positive test result is indicated by the inability to slowly lower the arm. A positive result indicates either a supraspinatus or rotator cuff tear. [1] Empty can test The shoulder is abducted to 90° and internally rotated. The shoulder is brought forward horizontally 30°. The patient's thumb should be in a position off pointing downward. The examiner applies pressure, while the patient attempts to abduct the shoulder. A positive result is indicated by pain or weakness. A positive test result indicates a tear in the supraspinatus tendon or muscle. !1] Hawkin’s test The examiner forward flexes the shoulder and elbow to 90°. Force is applied to the forearm to internally rotate the shoulder at the glenohumeral joint. A positive test result is indicated by pain in the ‘subacromial. A positive finding may indicate supraspinatus tendinitis. !"] Neer's impingement test The shoulder is internally rotated while at the side. The examiner passively forward flexes. The examiner may use the other hand to depress the scapula, This maneuver forces the greater tuberosity against the inferior aspect of the acromion. Pain reflects a positive test. This indicates subacromial or rotator cuff pathology. [1] Speed's test The patient shoulder is forward flexed to 90° while the elbow is extended and the forearm is supinated. The examiner applies a downward force as the patient resists. A positive result elicits pain in the bicipital groove. This suggest bicipital tendinitis of the long head of the biceps. !" This test may also be positive with superior labral anterior-posterior lesions. Adson's maneuver The examiner palpates the radial pulse. The patient's head is rotated toward the ipsilateral shoulder. The patient then extends the neck. The examiner lateral rotates and extends the patient's shoulder. The patient takes a deep breath and holds it. A positive result is indicated by a decreased radial pulse. A positive finding suggests thoracic outlet syndrome. !"] Costoclavicular maneuverThe examiner palpates the radial pulse. The examiner places the patient's shoulder down and back. A positive is indicated by an absence of the pulse. A positive test result suggests thoracic outlet syndrome. !1] Spurling's test (foraminal compression) The patient's cervical spine is laterally flexed to the ipsilateral side. The examiner applies a downward axial force on the head. Pain radiating from toward the shoulder and arm may indicate nerve root impingement. This may implicate the cervical spine as the source of shoulder and/or arm pain. Neck pain without radicular symptoms does not constitute a positive test result. The test may also be performed by additional placing the cervical spine in a position of extension and ipsilateral rotation. 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