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Inspection

Skin
Scars
Symmetry
Swelling
Atrophy
Hypertrophy
Scapular winging

Palpation

All bony prominences around shoulder girdle (AC joint)


Muscles and soft tissues including
deltoid
rotator cuff tendon insertion / greater tuberosity
trapezius
biceps tendon in groove

Range of Motion (patient supine)

Compare active and passive motion, both sides, with the patient in seated
or standing position
Six planes of motion should be examined and documented
forward elevation (150-180° considered normal)
active
external rotation at 90 degrees abduction
active
external rotation at side
active
abduction
active
internal rotation to vertebral height (T4-T8 considered normal)
active
internal rotation at 90 degrees abduction

Neurovascular Exam

Sensation
check dermatomes of following nerves
axillary
musculocutaneous
medial Brachial/Antebrachial Cutaneous
median
radial
ulnar
Motor
Deltoid, Biceps, Triceps, Extensor Pollicis Longus, Flexor Digitorum
Profundus, Dorsal Interossei
Vascular
brachial, radial, ulnar artery pulses
Differential
cervical radiculopathy
suprascapular neuropathy
brachial neuritits

Impingement

t Sign
indicative of impingement of rotator cuff tendon/bursa against the
coracoacromial arch
other abnormalities can produce a positive test including
stiffness
OA
instability
bone lesions
technique
use one hand to prevent motion of the scapula
raise the arm of the patient with the other hand in forced elevation
(somewhere between flexion and abduction)
pain is elicited (positive test) as the greater tuberosity impinges against
the acromion (between 70-110°)
note you must have full range of motion for "positive" finding.
Neer Impingement Test
positive when there is a marked reduction in pain from
above impingement maneuver following subacromial lidocaine injection
technique
usually a combination of
4cc 1% Lidocaine
4cc 0.50% Bupivicaine (Marcaine)
2cc corticosteroid)
Hawkins Test
positive with impingement
technique
performed by flexing shoulder to 90°, flex elbow to 90°, and forcibly
internally rotate driving the greater tuberosity farther under the CA
ligament.
Jobe’s Test
positive with supraspinatus weakness and or impingement
technique
abduct arm to 90°, angle forward 30° (bringing it into the scapular plane),
and internally rotate (thumb pointing to floor).
then press down on arm while patient attempts to maintain position
testing for weakness or pain.
Internal Impingement
patient supine or seated
abduct affected side to 90° and maximally externally rotate (throwing
position-late cocking phase) with extension
if this maneuver reproduces pain experienced during throwing (posteriorly
located) considered it is considered positive.
further confirmed with relief upon performing relocation test
re-perform test in abduction/max
ER with elbow in front of plane of body and pain disappears.

Rotator Cuff Pathology


Subscapularis Tests

Subscapularis Strength
do not test with isolated IR strength with the arm at the side due to
contribution of pectoralis major and latissimus dorsi
Internal Rotation Lag Sign
this tests is the most sensitive and specific test for subscapularis
pathology.
technique
stand behind patient, flex elbow to 90°, hold shoulder at 20° elevation
and 20° extension. Internally rotate shoulder to near maximum holding
the wrist by passively lifting the dorsum of the hand away from the
lumbar spine – then supporting the elbow, tell patient to maintain position
and release the wrist while looking for a lag.
Increased Passive ER
a person with a subscapularis tear may have increased Passive ER
rotation when compared to contralateral side
Lift Off Test
more accurate for inferior portion of subscapularis.
technique
hand brought around back to region of lumbar spine, palm facing
outward; Test patient’s ability to lift hand away from back (internal
rotation). Inability to do this indicates subscapularis pathology. Is
confounded by other muscles. More accurate if the tested hand can
reach the contralateral scapula.
Belly Press
test positive with subscapularis pathology
more accurate for superior portion of subscapularis
technique
patient presses abdomen with palm of hand, maintaining shoulder in
internal rotation. If elbow drops back (does not remain in front of trunk)

Supraspinatus Tests

Supraspinatus Strength
strength is assessed using Jobe’s Test (see below) – pain with this test is
indicative of a subacromial bursitis/irritation – not necessarily a supra tear.
Only considered positive for tear with a true drop arm. i.e. arm is brought
to 90° and literally falls down.
Jobe’s Test
tests for supraspinatus weakness and/or impingement
technique
abduct arm to 90°, angle forward 30° (bringing it into the scapular plane),
and internally rotate (thumb pointing to floor). Then press down on arm
while patient attempts to maintain position testing for weakness or pain.
Drop Sign
tests for function/integrity of supraspinatus
technique
passively elevate arm in scapular plan to 90°. Then ask the patient to
slowly lower the arm. The test is positive when weakness or pain causes
them to drop the arm to their side.

Infraspinatus

Infraspinatus Strength
external rotation strength tested while the arm is in neutral
abduction/adduction
External Rotation Lag Sign
positive when the arm starts to drift into internal rotation
technique
passively flex the elbow to 90 degrees, holding wrist to rotate the
shoulder to maximal external rotation. Tell the patient to hold the arm
in that externally rotated position. If the arm starts to drift into internal
rotation, it is positive.

Teres Minor

Teres Minor Strength


external rotation tested with the arm held in 90 degrees of abduction
Hornblower's sign
positive if the arm falls into internal rotation it may represent teres minor
pathology
technique
bring the shoulder to 90 degrees of abduction, 90 degrees of external
rotation and ask the patient to hold this position

Pectoralis

Axillary Webbing
look for a defect in the normal axillary fold. A deformity may be indicative
of an pectoralis major muscle rupture

Labral Injuries and SLAP lesions

Active Compression test ("O'Brien's Test")


positive for SLAP tear when there is pain is "deep" in the glenohumeral
joint while the forearm is pronated but not when the forearm is
supinated. technique
patient forward flexes the affected arm to 90 degrees while keeping the
elbow fully extended. The arm is then adducted 10-15 degrees across
the body. The patient then pronates the forearm so the thumb is pointing
down. The examiner applies downward force to the wrist while the arm is
in this position while the patient resists. The patient then supinates the
forearm so the palm is up and the examiner once again applies force to
the wrist while the patient resists.
Crank Test
positive when there is clicking or pain in the glenohumeral joint
technique
hold the patient's arm in an abducted position and apply passive rotation
and axial rotation.

Biceps Injuries

Bicipital Groove Tenderness


may be present with any condition that could lead to an inflamed long
head biceps tendon and a SLAP lesion
Speed's Test
positive when there is pain elicited in the bicipital groove
technique
patient attempts to forward elevate their shoulder against resistance
while they keep their elbow extended and forearm supinated.
Yergason's Sign
positive when there is pain in the bicipital groove
technique
elbow flexed to 90 degrees with the forearm pronated. The examiner
holds the hand/wrist to maintain pronated position while the patient
attempts to actively supinate against this resistance. If there is pain
located along the bicipital groove the test is positive for biceps tendon
pathology.
Popeye Sign
present when there is a large bump in the area of the biceps muscle belly.
Consistent with long head of biceps proximal tendon rupture.

AC Joint

Acromioclavicular joint tenderness


tenderness with palpation of the acromioclavicular joint
Cross-Body Adduction
positive when there is pain in the AC joint
technique
patient forward elevates the arm to 90 degrees and actively adducts the
arm across the body.
Obrien's Test (Active Compression test)
positive when there is pain "superficial" over the AC joint while the
forearm is pronated but not when the forearm is supinated
technique
patient forward flexes the affected arm to 90 degrees while keeping the
elbow fully extended. The arm is then adducted 10-15 degrees across
the body. The patient then pronates the forearm so the thumb is pointing
down. The examiner applies downward force to the wrist while the arm is
in this position while the patient resists. The patient then supinates the
forearm so the palm is up and the examiner once again applies force to
the wrist while the patient resists.

Instability

GRADING OF TRANSLATION OF HUMERAL HEAD


1+ translation to glenoid rim
2+ translation over glenoid rim but reduces
3+ translates and locks out of glenoid

Anterior Instability

Anterior Load and Shift


positive when there is increased translation compared to the contralateral
side
technique
have the patient lie supine with the shoulder at 40-60 degrees of
abduction and 90 degrees of forward flexion. Axially load the humerus
and apply anterior/posterior translation forces. Compare to the
contralateral side.
Apprehension and Relocation
positive test if the patient experiences the sensation of instability
technique
have the patient lie supine. Apprehension test performed by bringing the
arm in 90 degrees of abduction and full external rotation and patient
experiences sense of instability. Relocation test performed by placing
examiner's hand on humeral head applying a posterior force on the
humeral head. Patient will experience reduction or elimination of sense
of instability.
Anterior Release
positive test if the patient experiences instability when examiner's hand is
released
technique
have the patient lie supine. Examiner places hand on humeral head to
keep reduced as arm is brought into abduction/external rotation.
Examiner's hand is removed and the humeral head subluxes causing
sense of instability. NOTE: positive anterior release is really a "3 in 1"
test - if it is positive, apprehension and relocation are also positive.
Anterior Drawer
positive if there is sense of instability when compared to the contralateral
side
technique
stablize the scapula and apply an anteriorly directed force against the
humeral head with the contralateral hand. NOTE: graded 1+, 2+, and 3+
but this only documents amount of laxity, not pathologic unless causes
symptoms.
Posterior Instability

Posterior Load and Shift


positive if there is increased translation compared to contralateral side
technique
lie the patient supine with the shoulder in 40-60 degrees of abduction
and 90 degrees of forward elevation. Load the humerus with an axial
load and apply anterior/posterior forces to the humeral head. Compare
the amount of translation with the contralateral side.
Jerk Test
positive if there is a 'clunk' or pain with the maneuver
technique
have the patient sit straight up with the arm forward elevated to 90
degrees and internally rotated to 90 degrees. Apply an axial load to the
humerus to push it posteriorly.
Posterior Drawer
positive if there is increased translation when compared to the
contralateral side
technique
stabilize the scapula and apply a posteriorly directed force against the
humeral head with the contralateral hand.
Posterior Stress Test
positive if there is pain and sense of instability with the maneuver
technique
Place the patient's arm in flexion, adduction, and internal rotation and
apply a posteriorly directed force.
Loss of External Rotation
a shoulder that is locked in internal rotation may be subluxed posteriorly.

Multidirectional Instability (MDI)

Sulcus Sign
have the patient stand relaxed with their arms at their side. Grab their
affected arm and pull it inferiorly. If there is a sulcus that forms at the
superior aspect of the humeral head, the test is positive. Sulcus is
considered positive if it stays increased (2+ or 3+) with ER at side
(pathologic rotator interval).

Sulcus grading
1+ acromiohumeral interval < 1cm
2+ acromiohumeral interval 1-2 cm
3+ acromiohumeral interval > 2cm

Other

Wright's Test
test for thoracic outlet syndrome.
positive if the patient losses their radial pulse
technique
passively externally rotate and abduct the patient's arm while having the
patient turn their neck away from the tested extremity.
Medial Scapular Winging
test for serratus anterior weakness or long thoracic nerve dysfunction.
positive if the inferior border of the scapula migrates medially
technique
while standing, have the patient forward flex their arm to 90 degrees and
push against a wall (or other stationary object).
Lateral Scapular Winging
test for trapezius weakness or spinal accessory nerve (CNXI) dysfunction
positive if the inferior boarder of the scapula migrates laterally
technique
while standing, have the patient forward flex to 90 degrees and push
against a wall (or other stationary object).