clinicalexaminationofshoulder

1. Moderator
Dr.A.SENTHILNATHAN,MS
(ortho),DNB (ortho),
Prof & HOD,
Dept of ortho
RMMCH
Chidambaram

2. • Shoulder pain: a common
complaint in primary care
• 2ndonly to knee pain for specialist
referrals
• Most common causes in adults (peak
ages 40-60)
• Subacromial impingement syndrome
• Rotator cuff problems
• Athletic injuries
• Shoulder: 8-13% of all
athletic injuries

3. • 3 Bones
• Humerus
• Scapula
• Clavicle
• 3 Joints
• Glenohumeral
• Acromioclavicular
• Sternoclavicular
• 1 “Articulation”
• Scapulothoracic

4. • Glenohumeral joint
• “Ball and socket” vs “Golf
ball and tee”
• Very mobile
• Price: instability
• 45% of all dislocations
• Joint stability depends on
multiple factors

5. • Glenohumeral joint
25% of humeral head
surface in contact with
glenoid.
• Glenoid labrum (50%)
• Joint capsule
• Ligaments

7. • Rotator Cuff Muscles
• S – Supraspinatus
• I – Infraspinatus
• t - Teres minor
• S- Supscapularis

8. Primary Elevators of ST
joint
• Upper fiber of trapezius
• Levator scapulae
• Rhomboids
Primary Depressor of ST
joint
• Lower fiber of trapezius
• Latissimus dorsi
8

9. Primary upwards rotators of
ST joint
• Upper fiber of trapezius
• Lower fiber of trapezius
• Serratus anterior
Primary downward rotators
of ST joint
• Rhomboids
• Pectoralis minor
9

10. Primary protractors of ST
joint
• Serratus anterior
Primary retractors of ST
joint
• Rhomboids
• Middle fiber of trapezius
10

11. Primary GH Joint Abductors
• Anterior fiber of deltoid
• Middle fiber of deltoid
• Supraspinatus
Primary GH Joint Adductors
• Latissimus dorsi
• Teres major
• Pectoralis major (sternal head)
11

12. Primary GH Joint Flexors
• Anterior fiber of deltoid
• Pectoralis major (clavicular head)
• Coracobrachialis
• Biceps brachii
Primary GH Joint Extensors
• Latissimus dorsi
• Teres major
• Pectoralis major (sternal head)
• Posterior deltoid
• Long head of triceps
12

13. Primary GH Joint Internal Rotators
• Anterior fiber of deltoid
• Pectoralis major
• Latissimus dorsi
• Teres major
• Subscapularis
Primary GH Joint External Rotators
• Posterior deltoid
• infraspinatus
• Teres minor
13

16. • Bursae
• Subacromial
(Subdeltoid)
• Subscapular

17. • Coordinated
shoulder motion
• Glenohumeral motion
• Acromioclavicular
motion
• Sternoclavicular
motion
• Scapulothoracic
motion Scapular-humeral rhythm

18. • Characterize pain
• Location of pain
• Night pain
• Weakness
• Deformity
• Instability
• Locking / Clicking / Clunking
• Sport / Occupation
• Previous treatments
• Alleviating / Exacerbating
• Acute vs. Chronic
• Traumatic vs. Overuse
• History of prior injury

19. • Mechanism of Injury

20. • Observation
• Undress waist → up
• Palpation
• Active & passive ROM
• Strength testing
• Special tests

21. • Front & Back
• Height of shoulder &
scapulae
• Asymmetry
• Obvious deformity
• Ecchymosis
• Muscle atrophy
• Supraspinatus
• Infraspinatus
• Deltoid

22. • At rest & with movement
• Bony structures
• Joints
• Soft tissues

24. • Surface Anatomy
(Anterior)
• Clavicle
• SC Joint
• Acromion process
• AC Joint
• Deltoid
• Coracoid process
• Pectoralis major
• Trapezius
• Biceps (long head)
AC joint
SC joint
biceps

25. • Surface Anatomy
(Posterior)
• Scapular spine
• Acromion process
• Supraspinatus
• Infraspinatus
• Deltoid
• Trapezius
• Latissumus dorsi
• Scapula
• Inferior angle
• Medial border
Supraspinatus
Infraspinatus
Inferior angle
of scapula

27. • Forward flexion:
160 - 180°
• Extension: 40 - 60°
• Abduction: 180◦
• Adduction: 45 °
• Internal rotation:
60 - 90 °
• External rotation:
80 - 90 °
Apley Scratch Test

28. • Scapular dyskinesis
(Scapulothoracic dysfuntion)
• Compare scapular motion
through ROM on both sides
• Wall push-ups
• Symmetrical
• Smooth
• No or minimal winging

29. • Test & compare both sides
• Be specific to muscle or muscle
group
• 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

30. • External rotation
• Tests RTC muscles that ER
the shoulder
• Infraspinatus
• Teres minor
• Arms at the sides
• Elbows flexed to 90 degrees
• Externally rotates arms
against resistance

31. • Internal rotation
• Tests RTC muscle that IR the
shoulder
• Subscapularis
• Arms at the sides
• Elbows flexed to 90 degrees
• Internally rotates arms
against resistance
• Subscapularis Lift-Off Test
• Other techniques

32. • Supraspinatus
• “Empty can" test
• Jobe’s Test
• Tests Supraspinatus
• Attempt to isolate from deltoid
• Positioned sitting
• Arms straight out
• Elbows locked straight
• Thumbs down
• Arm at 30 degrees
(in scapular plane)
• Attempts to elevate arms
against resistance

33. • Impingement Signs
• Drop-Arm Test
• Speed’s Test
• Yergason Test
• Cross-Arm Adduction
• Sulcus Sign
• Apprehension test
• Relocation test
• O’Brien’s Test
• Crank test

34. Impingement of:
– Subacromial bursa
– Rotator cuff muscles and
tendons
– Biceps tendon
Between
– Acromion
– Coracoacromial ligament
– AC joint
– Coracoid process
– Humeral head
Rotator cuff tendonosis

35. Neer’s Sign
– Arm fully pronated
and placed in forced
flexion
– Trying to impinge
subacromial
structures with
humeral head
– Pain is positive test

36. 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

37. • Partial thickness tear
• Full (Complete) thickness
tear
• May be due to:
• Impingement
• Degeneration
• Overuse
• Trauma
• Partial tears
• Conservative
• Complete tears
• Surgery

38. • Injury to long head of
biceps tendon
• Typically an overuse
injury
• Repetitive (overhead)
lifting
• Impingement

39. • 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

40. • 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

41. AC Sprain /
Separation
– Typically due to
fall onto tip of
shoulder
(acromion)
– Arm tucked into
side
– Treatment
depends on type

43. Failure to keep humeral
head centered in glenoid
Dislocation
– Complete disruption of
joint congruity or
alignment
Subluxation
– Partial or incomplete
dislocation
Laxity
– Slackness or looseness in
joint
– May be normal or
abnormal

44. • 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

45. • 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
• Beware if false positives

46. • Anterior instability
• After a positive
apprehension
• Apply posteriorly directed
force over externally
rotated humeral head
• Positive test is relief of
apprehension
• Anterior release test

47. Tear in glenoid labrum
Usually due to instability
SLAP Tear (Superior Labrum
Anterior to Posterior)
– Superior labral tear
– Fall on outstretched hand or
shoulder
– Rotator cuff tendonosis or
tears
Bankart Lesion
– Anterior-inferior labral tear
– Anterior shoulder
dislocation / subluxation

48. • 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

49. • For labral pathology
• Repeat testing with
• Max supination
• Should be pain free

50. • Abduct arm to 90-120°
• Stabilize shoulder
• Elbow secured with one
hand
• Axially load with ER / IR
at shoulder
• Positive test: audible or
painful click / catch /
grind

51. • AC joint
• Subacromial space
• Glenohumeral joint
• Biceps tendon (long head)

52. PROBABLE DIAGNOSIS
Serratus anterior or trapezius dysfunction
Posterior shoulder dislocation
FINDING
Scapular winging, trauma, recent viral illness
Seizure and inability to passively or actively rotate affected arm
externally
Supraspinatus/infraspinatus wasting Rotator cuff tear; suprascapular nerve entrapment
Pain radiating below elbow; decreased cervical range of motion Cervical disc disease
Shoulder pain in throwing athletes; anterior glenohumeral joint pain
and impingement
Glenohumeral joint instability
Labral disorder
Impingement
Pain or “clunking” sound with overhead motion
Nighttime shoulder pain
Generalized ligamentous laxity Multidirectional instability
Key Findings in the History and Physical Examination

53. TEST MANEUVER
DIAGNOSIS SUGGESTED BY
POSITIVE RESULT
Apley scratch test Patient touches superior and inferior
aspects of opposite scapula
Loss of range of motion: rotator cuff
problem
Neer's sign Arm in full flexion Subacromial impingement
Hawkins' test Forward flexion of the shoulder to 90
degrees and internal rotation
Supraspinatus tendon impingement
Drop-arm test Arm lowered slowly to waist Rotator cuff tear
Cross-arm test Forward elevation to 90 degrees and
active adduction
Acromioclavicular joint arthritis
Spurling's test Spine extended with head rotated to
affected shoulder while axially loaded
Cervical nerve root disorder
Tests Used in Shoulder Evaluation and Significance of Positive Findings

54. Apprehension test Anterior pressure on the
humerus with external rotation
Anterior glenohumeral
instability
Relocation test Posterior force on humerus
while externally rotating the
arm
Anterior glenohumeral
instability
Sulcus sign Pulling downward on elbow or
wrist
Inferior glenohumeral
instability
Yergason test Elbow flexed to 90 degrees
with forearm pronated
Biceps tendon instability or
tendonitis
Speed's maneuver Elbow flexed 20 to 30 degrees
and forearm supinated
Biceps tendon instability or
tendonitis
“Clunk” sign Rotation of loaded shoulder
from extension to forward
flexion
Labral disorder