Shoulder Pain and the Shoulder
Exam
CHA Ambulatory Didactics
Kate Lupton, MD
Shoulder Overview
• Very complex structure with tremendous ROM
• 4 joints – sternoclavicular, acromioclavicular,
glenohumeral, scapulothoracic
• Glenohumeral – ball and socket joint (golf ball
on a tee), glenoid only covers 25% of humeral
head
Anatomy
Shoulder Activity/ROM
• Static glenohumeral stability – joint surfaces, capsule and
labrum
• Dynamic stability – RC & scapular rotators (trapezius,
serratus anterior, rhomboids, levator scapulae)
• Rotator cuff – depress humeral head against glenoid
• Internal rotation - Subscapularis
• External rotation - Infraspinatus, teres minor
• Abduction - supraspinatous
• Scapular stability – trapezius, serratus anterior, rhomboids
• Upward scapular rotation – trapezius & serratus anterior
• Scapular retraction – trapezius & rhomboids
History
• Background – Handedness, occupation,
recreational activities
• CC: Pain vs instability vs decreased movement
• Characterize CC: “loose” arm, “dead” arm
• Injury? -> Mechanism
• Associated Sx – neurovascular, stiffness, crepitus
• Function – putting on jacket, overhead activities,
sleeping
Principles of the MSK Exam
• Good exposure (clothing removed, in gown)
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LOOK
FEEL
MOVE
SPECIAL TESTS
Look/Feel - Surface Anatomy
Look
• SEADS – swelling, erythema, atrophy, deformity,
scars
• Dominant shoulder usually slightly lower than
non-dominant side
• Head forward posture, shoulders rolled forward,
scapula protracted
• Squaring of shoulder – r/o dislocation
• SC joints, clavicle deformity - ?fracture
• AC joints – step deformity - ?separation
• Atrophy – trapezius, infraspinatus, teres minor
Feel
• Palpate joints – SC joint, along clavicle, AC
joint, coracoid process, along scapula
• Palpate muscles and tendons – trapezius,
posterior shoulder, biceps tendon,
supraspinatus insertion
• Feel for crepitus while rotating the arm
Move – Active Range of Motion
Flexion/Extension
• Trace arc while reaching
forward with elbow
straight
• Normal flexion to 160°180°, extension to -60°
Abduction/Adduction
• Trace arc reaching to
side with straight arm
• Normal range is 0°-180°
Move – Active Range of Motion
Abduction & internal
rotation
• Should be able to reach
to ~C-7 level (prominent
bump on C-spine)
Adduction & external
rotation
• Should be able to reach
lower border of scapula
(~T7 level)
Move – Passive ROM
• If pain or limitation w/ active ROM, assess with
passive ROM testing
• Grasp humerus, move through flexion/extension,
abduction, adduction
• Feel for crepitus with hand on shoulder
• Note movements that precipitate pain –
pain/limitation on active but not passive ROM
suggests muscle/tendon problem
• Note limitations in movement – where in arc
does it occur? Due to pain or weakness?
Symmetric or asymmetric?
Move
• Painful arc on abduction? Glenohumeral joint
from 60-120°, AC joint 170-180°
• Watch scapular motion – look for asymmetry,
jerky motion
• Wall push-up for scapular winging
Rotator Cuff Anatomy and Function
• 4 Major Muscles
• Depress humeral head, keep
it in contact with glenoid
throughout wide ROM
• Supraspinatus – abducts
shoulder (to ~80°)
• Infraspinatus – external
rotation
• Teres minor – external
rotation
• Subscapularis – internal
rotation
Special Tests - Supraspinatus
Empty/Full Can Test
• Hold arms at 1:00 and
11:00, abducted 30 °
• Internally rotate so thumbs
point down (“empty can”),
pt lifts up against resistance.
Repeat with thumbs
pointed up
• Note pain (tendinopathy,
partial tear), weakness
(tear)
• Deltoid is responsible for
abduction beyond 70-80 °
Special Tests – Infraspinatus
External Rotation
• Fully adduct arm, flex
elbow to 90 °, medially
rotate humerus 45 °
(hand at 12:00)
• Have pt try to externally
rotate while you resist
against their forearms
Special Tests - Subscapularis
Posterior (Gerber’s)Lift Off
• Pt places hand behind back,
palm facing out
• Pt lifts hand away from the
back
• Note pain, weakness
Belly Press
• Place hands on abdomen,
elbows out
• Press in on abdomen or keep
elbows out while posteriorly
directed force is applied to
elbows
• Positive test if unable to keep
elbows out
Shoulder Impingement/Bursitis
• 4 tendons of the RC pass
under the acromion and
coracoacromial ligament and
insert in the humeral head
• Space between arcromion,
coracoacromial ligament and
tendons can narrow, causing
impingement of tendons (esp
supraspinatus)
• Resulting friction inflames
tendons and subacromial
bursa
• Causes shoulder pain, esp
with reaching overhead
Special Tests - Impingement
Neer’s Test
• Place hand on pt’s
scapula, other on
forearm
• Pt fully internally rotates
(thumb pointed down)
• Passively forward flex
arm through full range of
motion
• Pain = impingement
Special Tests - Impingement
Hawkins-Kennedy Test
• Flex arm to 90°
• Stabilize shoulder with
one hand
• Forcibly internally
rotate shoulder, thumb
pointed down
• Pain = impingement
Special Tests - Bursitis
Subacromial Palpation
• Identify acromion by
following scapular spine
to distal end
• Palpate in subacromial
space
• Pain = inflamed bursa
and/or tendons
Biceps Tendon
• Long head of biceps
tendon runs in the bicipital
groove of humerus, inserts
at superior glenoid
• Biceps flexes and supinates
forearm
• Subject to similar stresses
as RC tendons
• Inflammation causes pain
in top and anterior
shoulder, especially with
flexion/supination
Special Tests – Biceps Tendon
Palpation
• Palpate along biceps
tendon/bicipital groove
• Confirm location by having
pt supinate while palpating
Yergason’s Test
• Flex elbow to 90°with arm
adducted (elbow against
side)
• Grasp pt’s hand, resist while
they supinate
• Pain = tendinopathy
Special Tests – AC Joint
Palpation
• Palpate point at which distal clavicle
articulates with acromion
O’Brien
• Flex shoulder to 90° while internally
rotated (thumb down)
• Adduct arm 10-15° from 12:00
• Apply downward force to arm while
pt resists
• Repeat with thumb pointed up
• If there is pain with first maneuver
and not second, indicates labral or
AC joint pathology
Cross Arm /Forced Flexion
• Flex shoulder to 90°, flex elbow,
then actively adduct
Special Tests – Shoulder Instability
Apprehension/Relocation
• With patient supine, abduct shoulder
90°, flex elbow 90°
• Externally rotate shoulder by moving
forearm from perpendicular to
parallel with body
• Pain or sense of instability with
further external rotation is a positive
test, indicating anterior shoulder
instability
• If sx are relieved with posterior force
applied to proximal humerus, that is
a positive relocation test and further
supports dx
Sulcus Sign
• Arm hangs relaxed at the side
• Pull arm straight down, look for stepoff under lateral acromion
• Indicates inferior instability
Many Thanks
• Anthony Luke, MD – UCSF
• Charlie Goldberg, MD - UCSD