Shoulder Examination

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== Shoulder Examination =

Subjective

Patient History:

• Self‐report
• The patient may report pain local to the

involved shoulder. The symptoms may extend toward the scapula, axilla, anterior chest, along the clavicle, or down the humerus. 

• The patient may report difficulty with

overhead activities, lifting objects, activities of daily living, sports or recreational activities. 

• There are several presentations that may

differ depending on the suspected pathology:

• Patients with suspected glenohumeral instability

or labral pathology may have feelings of “looseness or instability” particularly in abducted and externally rotated positions.

• Patients with suspected adhesive capsulitis may

report intense global shoulder pain initially combined with a progressive loss of range of motion.<o:p></o:p>

• Patients with suspected subacromial impingement

or rotator cuff lesions may report feelings of weakness, heaviness and/or pain.

·         Shoulder History Exam:³

• Does moving your neck change your symptoms?
• Screen the cervical spine, if yes.
• Do you ever feel unstable during arm movement?
• This could indicate instability.
• When you do actions with your arms over your

head, does this aggravate your pain level?

• Subacromial impingement syndrome could be

the problem.

• Is it hard to move your arm?
• Is this due to pain or difficulty moving the

arm far?

• When performing actions with your arms over

your head, do your arms feel heavier?

• Vascular compromise could be the problem.

• Outcome Measures²²
• Disabilities

of the Arm Shoulder and Hand (DASH)

• American Shoulder and Elbow Surgeons Self-Report (ASES)
• Upper

Extremity Disability Index

• Shoulder Pain

and Disability Index

• Simple Shoulder

Test

• Constant-Murley Shoulder Outcome Score (CMS)

• University of

Pennsylvania Shoulder Score (U-Penn)

Special Considerations

• Red Flags
• Determine if “patients symptoms reflective of

a visceral disorder or a serious potential life-threatening illness, such as cancer, visceral pathology, or fracture."²³

• Serious Medical Pathologies
• Potential Shoulder Regional Referral

Patterns: 

• Left Shoulder

• MI 68.7% of patients

reported shoulder pain during an acute myocardial infarction²⁴<o:p></o:p>

• Ruptured Spleen¹⁴

• Both Shoulders

• Pancoast’s Tumor¹⁵

• Right Shoulder

• Liver Disease¹⁶
• Carcinoma,

Cirrhosis, Hepatitis

• Stomach 
• Hiatal

Hernia¹⁷

• Post Bariatric Surgery
• Gastric

Perforation¹⁸

• Peptic

Ulcer

• Pancreas
• Pancreatitis
• Pancreatic

Cancer

• May

         be worse after fatty meal or associated with weight loss or Diabetes Mellitus
        <o:p></o:p>      

• Gall Bladder<o:p></o:p>
• Cholecystitis<o:p></o:p>
• Typically

         accompanied by fever, or nausea/ vomiting<o:p></o:p>      

o    Fractures<o:p></o:p>

§  Fractures may result from trauma such as falls onto an outstretched hand. These are known as FOOSH injuries. <o:p></o:p>

§  Commonly fractured both within the shoulder region<o:p></o:p>

·         Humeral Fractures<o:p></o:p>

§  Proximal or distal<o:p></o:p>

§  Clavicle Fractures²⁰<o:p></o:p>

·         Fractures of the clavicle usually result from a direct blow to the shoulder giving axial compression. The middle 1/3 of the clavicle is most often broken with an incidence of ~80%. Distal clavicle fractures have an incidence of 10-15% and medial clavicle fractures have and incidence of 3 to 5%. Significantly displaced fractures are managed surgically. Mid-shaft clavicle fractures have a lower rate of mal-union and better functional outcomes at one year.²¹ A trial of conservative management may be warranted for non-displaced clavicular fractures.<o:p></o:p>

·         Yellow Flags<o:p></o:p>

• Passive coping tendencies <o:p></o:p>
• Depression<o:p></o:p>
• Fear Avoidance Beliefs<o:p></o:p>
• Pain Syndromes<o:p></o:p>
• Concurrent Psychological Illness<o:p></o:p>
• Worker’s Compensation<o:p></o:p>
• Lack of family/community Support<o:p></o:p>

<o:p> </o:p>

·         Clear the Cervical Spine<o:p></o:p>

o    See Cervical Examination<o:p></o:p>

o    The cervical spine can refer pain to the shoulder/scapular region. It is imperative that the cervical spine be screened appropriately as it may be contributing to the patient’s clinical presentation. <o:p></o:p>

Investigations<o:p></o:p>

Radiological Considerations<o:p></o:p>

Radiographs of the shoulder can be used to identify cysts, sclerosis, or acromial spurs, osteoarthritis of the acromialclavicular and glenohumeral joint, or calcific tendonitis.<o:p></o:p>

<o:p> </o:p>

Common radiographic views may include (this may vary depending on medical provider):<o:p></o:p>

Supraspinatus Outlet View<o:p></o:p>

Scapular Y-view<o:p></o:p>

Axillary view<o:p></o:p>

Anterior-Posterior (AP) view<o:p></o:p>

Observation<o:p></o:p>

• Observation of a patient with a primary

    complaint of shoulder pain may include:<o:p></o:p> 

• Static postures<o:p></o:p>
• Static scapular position<o:p></o:p>
• Cervico-thoracic spine postures<o:p></o:p>
• Dynamic movement patterns<o:p></o:p>
• Scapulo-humeral rhythm <o:p></o:p>
• Functional tests<o:p></o:p>
• Hand behind head<o:p></o:p>
• Hand behind back<o:p></o:p>
• Cross body adduction<o:p></o:p>

Palpation<o:p></o:p>

·         Palpation of the shoulder region may provider the physical therapist with valuable information. The physical therapist should note the presence of swelling, texture, and temperature of the tissue<o:p></o:p>

·         Additionally the physical therapist may observe asymmetry, sensation differences, and pain reproduction. <o:p></o:p>

·         Key palpable structures include:<o:p></o:p>

o   Acromioclavicular joint<o:p></o:p>

o   Sternoclavicular joint<o:p></o:p>

o   Rotator cuff muscle insertions<o:p></o:p>

o   Long head of the biceps tendon<o:p></o:p>

Neurologic Assessment <o:p></o:p>

        A comprehensive neurological examination may be warranted in patients that present with a primary complaint of shoulder pain. The presence of neurological symptoms including numbness and tingling may warrant this examination.<o:p></o:p>

<o:p> </o:p>

        Screening Examination:<o:p></o:p>

·         Myotome<o:p></o:p>

§  C4 – Shoulder Elevation<o:p></o:p>

§  C5 – Shoulder Flexion<o:p></o:p>

§  C6 – Elbow Flexion, Wrist Extension<o:p></o:p>

§  C7 – Elbow Extension, Wrist Flexion<o:p></o:p>

§  C8 – Thumb Abduction<o:p></o:p>

§  T1 – 2^nd finger Abduction<o:p></o:p>

·         Dermatome<o:p></o:p>

§  C4 – Top of Shoulders<o:p></o:p>

§  C5 – Lateral Deltoid<o:p></o:p>

§  C6 – Tip of Thumb<o:p></o:p>

§  C7 – Distal middle Finger<o:p></o:p>

§  C8 – Distal 5th Finger<o:p></o:p>

§  T1 – Medial Forearm<o:p></o:p>

·         Pathological Reflexes <o:p></o:p>

§  Hoffman’s Reflex<o:p></o:p>

§  Inverted Supinator Reflex<o:p></o:p>

·         Deep Tendon Reflexes<o:p></o:p>

§  Biceps Brachii – C5 Nerve Root<o:p></o:p>

§  Brachioradialis – C6 Nerve Root<o:p></o:p>

§  Triceps – C7 Nerve Root

             <o:p></o:p>

Movement Testing¹²<o:p></o:p>

• Active Range of Motion (ROM)<o:p></o:p>
• Glenohumeral Motions<o:p></o:p>
• Horizontal Adduction<o:p></o:p>
• Horizontal Abduction<o:p></o:p>
• Flexion<o:p></o:p>
• Extension<o:p></o:p>
• Internal Rotation<o:p></o:p>
• External Rotation<o:p></o:p>
• Abduction/Adduction<o:p></o:p>
• Abduction in 

      the plane of the scapula (scaption)<o:p></o:p>   

<o:p> </o:p>

• Scapular Motions <o:p></o:p>
• Abduction/Adduction <o:p></o:p>
• Upward/Downward Rotation<o:p></o:p>
• Elevation/Depression<o:p></o:p>

<o:p> </o:p>

• Passive ROM<o:p></o:p>
• May include each of the motions stated in the

     active ROM section<o:p></o:p> 

• The therapist may opt to include overpressure

     to any or all of the motions to further stress the joint. <o:p></o:p>  

<o:p> </o:p>

• Muscle length assessment<o:p></o:p>
• Assessment of the flexibility of certain

     muscles may be warranted in patients with shoulder pain. These muscles
    may include, but are not limited to:<o:p></o:p> 

• Latissimus Dorsi<o:p></o:p>
• Pectoralis Minor/Major<o:p></o:p>
• Levator Scapulae<o:p></o:p>
• Upper Trapezius<o:p></o:p>
• Scalenes (anterior/middle/posterior)<o:p></o:p>

<o:p> </o:p>

• Muscle Strength<o:p></o:p>
• Resistive testing of the shoulder muscles

     typically includes the following motions:<o:p></o:p> 

• Shoulder Flexion<o:p></o:p>
• Shoulder Extension<o:p></o:p>
• Shoulder Abduction<o:p></o:p>
• Horizontal Abduction<o:p></o:p>
• Horizontal Adduction<o:p></o:p>
• Internal Rotation<o:p></o:p>
• External Rotation<o:p></o:p>

• Scapular<o:p></o:p>
• Resistive testing of the scapular

      stabilization muscles may include:<o:p></o:p>   

§  Upper trapezius<o:p></o:p>

§  Middle trapezius<o:p></o:p>

§  Lower trapezius<o:p></o:p>

§  Serratus Anterior<o:p></o:p>

§  Rhomboids<o:p></o:p>

§  Levator Scapulae<o:p></o:p>

<o:p> </o:p>

• Joint mobility assessment<o:p></o:p>
• Assessment of the mobility of the joint may

     indicate hypomobility within the joint or may elicit symptoms.<o:p></o:p> 

• Glenohumeral<o:p></o:p>

§  Anterior<o:p></o:p>

§  Posterior<o:p></o:p>

§  Inferior<o:p></o:p>

§  Distraction<o:p></o:p>

• Acromioclavicular<o:p></o:p>

§  Anterior<o:p></o:p>

§  Posterior<o:p></o:p>

• Sternoclavicular<o:p></o:p>

§  Anterior<o:p></o:p>

§  Posterior<o:p></o:p>

§  Superior <o:p></o:p>

§  Inferior<o:p></o:p>

• Scapulothoracic joint (pseudo-joint)<o:p></o:p>

§  Elevation<o:p></o:p>

§  Depression<o:p></o:p>

§  Upward/downward rotation<o:p></o:p>

§  Protraction/Retraction<o:p></o:p>

<o:p> </o:p>

Special Tests: <o:p></o:p>

·         Several special tests exist for particular disorders of the shoulder. Below are links to the specific pages for each pathology that describe the special tests.<o:p></o:p>

o   Sub-Acromial Impingement^1,2,3<o:p></o:p>

o   [http://www.physio-pedia.com/index.php5?title=Biceps_Tendonitis Biceps Tendinopathy] ^1,4<o:p></o:p>

o   [http://www.physio-pedia.com/index.php5?title=SLAP_Lesion Labral Tears] ^5,6,7<o:p></o:p>

o   [http://www.physio-pedia.com/index.php5?title=Shoulder_Instability#Examination.C2.A0 Laxity/ Instability] ^9,10,11<o:p></o:p>

References

1.       Calis M, et al. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis, 2000 59, 44-47.

2.       Park HB, et al. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am, 2005 87(7), 1446-1455 .

3.       Kelly S, Nicola B. The value of physical tests for subacromial impingement syndrome: a study of diagnostic accuracy. Clin Rehab, 2010 24: 149–158 .

4.       Holtby R, Razmjou H. Accuracy of the Speed's and Yergason's tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy, 2004 3, 231-6 .

5.       SH Kim et al. A Novel Test for Posteroinferior Labral Lesion of the Shoulder—A Comparison to the Jerk Test. Am J Sports Med, 2005 33(8): 1188-92.

6.       Munro et al. The validity and accuracy of clinical tests used to detect labral pathology of the shoulder--a systematic review. Man Ther. 2009 Apr;14(2):119-30.

7.       Kim SH, Ha KI, Ahn JH, Kim SH, Choi HJ. Biceps load test II: a clinical test for SLAP lesions of the shoulder. Arthroscopy 2001 February; 17(2):160-164 .

8.       Dessaur WA, Magarey ME. Diagnostic accuracy of clinical tests for superior labral anterior posterior lesions: a systematic review. J Orthop Sports Phys Ther. 2008 June;38(6):341-52. Epub 2008 Feb 22 .

9.       Lo IK, et al, An evaluation of the apprehension, relocation, and surprise tests for anterior shoulder instability. 2004 Mar;32(2):301-7.

10.  Gross ML, Distefano MC. Anterior release test. A new test for occult shoulder  instability. Clin Orthop Relat Res. 1997 Jun;(339):105-8 .

11.  Nakagawa MD, et al. Forced Shoulder Abduction and Elbow Flexion Test: A New Simple Clinical Test to Detect Superior Labral Injury in the Throwing Shoulder. J arthro.  2005 November; 21(11): 1290-1295 .

12.    Hislop HJ, Montgomery J.  Daniels and Worthingham's Muscle Testing: Techniques of Manual Examination.  Saunders 2007, 8^th edition .

13.    Flynn T, et al. Users’ guide to the musculoskeletal examination fundamentals for the evidence-based clinician. Evidence in Motion; 2008 .

14.    Rutkow IM.  Rupture of the spleen in infectious mononucleosis:  a critical review.  Arch Surg. 1978 Jun;113(6):718-20 .

15.    Tamura M, Hoda MA, Klepetko W.  Current treatment paradigms of superior sulcus tumours.  Eur J Cardiothorac Surg. 2009 Oct;36(4):747-53. Epub 2009 Aug 20 .

16.    Strauss E. Flanagin BA, Mitchell MT, Thistlethwaite WA, Alverdy JC. Usefulness of liver biopsy in chronic hepatitis C.  Ann Hepatol 2010;9 Suppl:39-42 .

17.    Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery.  Obes Surg. 2010 Mar;20(3):386-92. Epub 2009 Oct 24. 

18.    Pappano DA, Bass ES. Referred shoulder pain preceding abdominal pain in a teenage girl with gastric perforation. Pediatr Emerg Care. 2006 Dec;22(12):807-9 .

19.    Handoll HH, Ollivere BJ.  Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD000434 .

20.    McKee MD.  Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation? [http://www.ncbi.nlm.nih.gov/pubmed/clipboard Orthop Clin North Am.] 2010 Apr;41(2):225-31 .

21.    Altamimi SA, McKee MD.  Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures.  J Bone Joint Surg Am. 2008 Mar;90 Suppl 2 Pt 1:1-8 .

22.    S Bot, C Terwee, D A W M van der Windt, L Bouter, J Dekker, and H C W de Vet.  Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature.  Ann Rheum Dis. 2004 April; 63(4): 335–341 .

23.    Murphy D, Hurwitz R. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. 2007; 8: 1, 75 .

24.    Song L, Yan HB, Yang JG, Sun YH, Hu DY.  Impact of patients' symptom interpretation on care-seeking behaviors of patients with acute myocardial infarction. Chin Med J (Engl). 2010 Jul;123(14):1840-5 .

25.    Bahrs et al.  Indications for Computed Tomography (CT-) Diagnostics in Proximal Humeral Fractures: A Comparative Study of Plain Radiography and Computed Tomograph.  BMC Musculoskeletal Disorders, 2009 .