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 also 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. Patients with suspected subacromial impingement or rotator cuff lesions may report feelings of weakness, heaviness and/or pain.

·         Shoulder History Exam Questions:¹³

These questions may assist the clinician in determining potential pathologies. Please refer to the User's Guide to Musculoskeletal Examination¹³ for more information.

1. Does moving your neck change your symptoms?
2. Do you ever feel unstable during arm movement?
3. When you do actions with your arms over your head, does this aggravate your pain level?
   
4. Is it difficult to move your arm? 
5. When performing actions with your arms over your head, do your arms feel heavier?
   

Outcome Measures²² 

1. Disabilities of the Arm Shoulder and Hand (DASH)
2. American Shoulder and Elbow Surgeons Self-Report (ASES)
3. Upper Extremity Disability Index 
4. Shoulder Pain and Disability Index 
5. Simple Shoulder Test
6. Constant-Murley Shoulder Outcome Score (CMS)
7. 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

• 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 eight loss of Diabetes Mellitus
• Gall Bladder

• Cholecystitis
• Typically accompanied by fever, or nausea/vomiting

• Fractures
• Fractures may result from trauma such as falls onto an outstretched

hand. These are known as FOOSH injuries.

• Commonly fractured both within the shoulder region
• Humeral Fractures
• Proximal or distal
• Clavicle Fractures²⁰

·         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.

•  

Yellow Flags

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

Clear the Cervical Spine

o    See Cervical Examination

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.

Investigations

Radiological Considerations

Radiographs of the shoulder can be used to identify cysts, sclerosis, or acromial spurs, osteoarthritis of the acromialclavicular and glenohumeral joint, or calcific tendonitis.

Common radiographic views may include (this may vary depending on medical provider):

- Supraspinatus

Outlet View

- Scapular Y-view

- Axillary

view

- Anterior-Posterior (AP) view

Observation

• Observation of a patient with a primary complaint of shoulder pay may include:

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

Palpation

• 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

• Additionally the physical

therapist may observe asymmetry, sensation differences, and pain reproduction.

Key palpable structures include:

• Acromioclavicular joint
• Sternoclavicular joint
• Rotator cuff muscle insertions
• Long head of the biceps tendon

Neurologic Assessment

        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.

        Screening Examination:

Myotome

• C4 – Shoulder Elevation
• C5 – Shoulder Flexion
• C6 – Elbow Flexion, Wrist

Extension

• C7 – Elbow Extension, Wrist

Flexion

• C8 – Thumb Abduction
• T1 – 2^nd finger

Abduction

Dermatome

• C4 – Top of Shoulders
• C5 – Lateral Deltoid
• C6 – Tip of Thumb
• C7 – Distal middle Finger
• C8 – Distal 5th Finger
• T1 – Medial Forearm

Pathological Reflexes

• Hoffman’s Reflex
• Inverted Supinator Reflex

Deep Tendon Reflexes

• Biceps Brachii – C5 Nerve Root
• Brachioradialis – C6 Nerve Root
• Triceps – C7 Nerve Root

            

Movement Testing¹²

• Active Range of Motion (ROM)
• Glenohumeral Motions
• Horizontal Adduction
• Horizontal Abduction
• Flexion
• Extension
• Internal Rotation
• External Rotation
• Abduction/Adduction
• Abduction in the plane of the scapula (scaption)

• Scapular Motions
• Abduction/Adduction
• Upward/Downward Rotation
• Elevation/Depression

• Passive ROM
• May include each of the motions stated in the active ROM section

• The therapist may opt to include overpressure any or all of the motions to further stress the joint.

• Muscle length assessment
• Assessment of the flexibility of certain muscles may be warranted in patients with shoulder pain. 
• These muscles may include, but are not limited to:

• Latissimus Dorsi
• Pectoralis Minor/Major
• Levator Scapulae
• Upper Trapezius
• Scalenes (anterior/middle/posterior)

• Muscle Strength
• Resistive testing of the shoulder muscles typically includes the following motions:

• Shoulder Flexion
• Shoulder Extension
• Shoulder Abduction
• Horizontal Abduction
• Horizontal Adduction
• Internal Rotation
• External Rotation

• Scapular
• Resistive testing of the scapular stabilization muscles may include:
• Upper trapezius
• Middle trapezius
• Lower trapezius
• Serratus Anterior
• Rhomboids
• Levator Scapulae

• Joint mobility assessment
• Assessment of the mobility of the joint may indicate hypomobility with in the joint or elicit symptoms.

• Glenohumeral

• Anterior

• Posterior

• Inferior

• Distraction

• Acromioclavicular

Anterior

Posterior

• Sternoclavicular

Anterior

Posterior

Superior

Inferior

• Scapulothoracic joint (pseudo-joint)
• Elevation
• Depression
• Upward/downward rotation
• Protraction/Retraction

Special Tests:

·         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   Sub-Acromial Impingement^1,2,3

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

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

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

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 .