Stacy M. Kingsland
Musculoskeletal Rotation
4/28/2006
The Shoulder: History, Exam and Diagnosis
The patient with shoulder pain; a frightening encounter to the Internal Medicine
Resident or at least it was to me until this month. Why is the shoulder so scary and
mysterious? Perhaps it is because of the complexity of the joint and our inexperience
with the exam. This month with the guidance and expertise of Dr. Gardner and Dr.
Nakamoto I have been fortunate enough to become more familiar with the exam, the
findings and how to proceed with a workup. Here is the way I have learned to break it
down so it both easy for me to remember and understand.
To begin with it helps to have a basic understanding of the anatomy of the
shoulder. The shoulder is made up of the humerus, glenoid, scapula, acromion and
clavicle plus the surrounding tissues. (1,2). The joints of the shoulder include the
glenohumeral joint, acromioclavicular (AC) joint, sernoclavicular joint and
scapulothoracic articulations. The tendons of the supraspinatus, infraspinatus, teres
minor and subscapularis make up the rotator cuff which stabilized the glenohumeral joint.
The muscles themselves provide movement about the joint.
Now that there is a very basic understanding of the shoulder anatomy, to begin
evaluating a patient with shoulder pain start with the history. In evaluating patients with
shoulder injuries you want to know about there dominant hand, sports activity, limitations
from the pain and occupation as these things will guide the aggressiveness of treatment
and help you understand the patient’s functional needs (1,2). Also, do not forget to ask
about other medical problems such as diabetes which can predispose you to adhesive
capsulitis or other disease that can cause referred pain to the shoulder such as cervical
neck injuries/arthritis, coronary artery disease, pneumonia, peptic ulcer disease,
malignancies or neurovascular diseases (2). Assuming the patient’s pain truly is a result
of shoulder pathology asking specific questions about possible trauma and the location,
duration, quality and type of pain is helpful. The following in table 1 are examples of
complaints and associated possible diagnoses (2):
Table 1:
History
Scapular winging, trauma, recent viral illness
Seizure and inability to passively or actively rotate affected
arm externally
Supraspinatus/infraspinatus wasting
Pain radiating below elbow; decreased cervical range of
motion
Shoulder pain in throwing athletes; anterior glenohumeral
joint pain and impingement
Pain or "clunking" sound with overhead motion
Nighttime shoulder pain
Generalized ligamentous laxity
Possible diagnosis
Serratus anterior or trapezius
dysfunction
Posterior shoulder dislocation
Rotator cuff tear; suprascapular
nerve entrapment
Cervical disc disease
Glenohumeral joint instability
Labral disorder
Impingement
Multidirectional instability
Chart taken from Woodward, Best (2)
Once you have the initial history the next step is the exam. Having a generalized
understanding of the anatomy is key to being able to perform and interpret the exam. The
exam begins with inspection, looking for asymmetry, deformity, bruising, masses or
other clues to the diagnosis. Next is palpation of the C-spine, AC joint, lateral acromion
and biceps tendon. Pain over the AC joint could represent arthritis, pain over the lateral
acromion could represent a bursitis and pain over the biceps tendon could represent a
biceps tendonitis.
After palpation comes ROM and muscle strength testing. This is where
knowledge of the rotator cuff anatomy makes the exam easier to remember and correlate
findings. The first rotator cuff muscle/tendon tested is the supraspinatus. Range of
motion is tested with forward flexion 0-180 degrees. Patients may have more pain with
eccentric contraction or on bringing the arm back from 180-0 degrees with a significant
supraspinatus injury. To test supraspinatous strength have the patient perform the “empty
can sign.” You have the patient abduct the shoulders to 90 degrees in forward flexion
with the thumbs pointing downward and then the patient attempts to elevate the arms
against examiner resistance (1,2). With this maneuver it is important to make sure the
patient’s thumbs are pointed downward to really isolate the supraspinatous muscle. The
next muscles/tendons evaluated are the infraspinatus and teres minor which work to
externally rotate the shoulder. Range of motion is tested by having the patient place their
elbows at their sides and externally rotate their arms between 0-80 degrees. To test
strength this maneuver is repeated against examiner resistance. The last muscle/tendon
tested is the subscapularis which is responsible for internal rotation. Range of motion is
first tested by examining how far the patient can internally rotate and reach up their back
with their thumb. Normal range of motion is ability to reach to about T7-T4. Next
strength is tested via the “lift off test.” The patient rests the dorsum of the hand on the
back in the lumbar area and then moves it out from the lumbar area and presses against
resistance (1,2). With all maneuvers it is important to determine true weakness versus
inability to perform the tests secondary to pain. True weakness is suggestive of a muscle
tear where as pain alone may represent only a tendonitis.
Next are the “provocative maneuvers.” These tests can help you distinguish
impingement versus AC joint compression versus biceps tendonitis. There are multiple
“provocative maneuvers” (see table 2) (2); however, the ones I am going to discuss are
the techniques I became familiar with under the direction of Dr. Nakamoto. The tests for
impingement I a going to discuss are the Hawkins’ test and Neers’ test. Hawkins’ test is
performed by elevating the patient's arm forward to 90 degrees while forcibly internally
rotating the shoulder. Pain with this maneuver suggests subacromial impingement or
rotator cuff tendonitis (2). Neers’ test is performed by placing the arm in forced flexion
with the arm fully pronated. The scapula should be stabilized during the maneuver to
prevent scapulothoracic motion. Pain with this maneuver is a sign of subacromial
impingement (2). To test for AC joint compression have the patient raise the affected
arm to 90 degrees and then place the arm in active adduction providing force across the
acromion into the distal end of the clavicle. Pain in the area of the AC joint suggests a
disorder in this region (1,2). Lastly, to test for pain coming from the biceps tendon, do the
Yergason’s test. To perform this test have the patient flex the elbow to 90 degrees with
the forearm pronated (1,2). Pain with this maneuver suggests biceps tendonitis or
instability.
TABLE 2
Tests Used in Shoulder Evaluation and Significance of Positive Findings
Test
Provocative 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
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
Table 2 taken from Woodward, Best (2)
The last part of the shoulder exam is to test for glenohumeral instability. This can
be done using the anterior apprehension test and the relocation test (1,2) The anterior
apprehension test is performed by placing the patient supine and the shoulder in a neutral
position at 90 degrees of abduction. Next, apply slight anterior pressure to the humerus
and externally rotates the arm. Pain or apprehension about the feeling of impending
dislocation indicates anterior glenohumeral instability (1,2). If the apprehension test is
positive one continues on with the relocation test. To perform this test keep the patient
supine, and apply posterior force on the proximal humerus while externally rotating the
patient's arm. A decrease in pain or apprehension suggests anterior glenohumeral
instability (1,2). When looking for instability one is also looking for asymmetry in laxity
between each of the shoulder joints.
If the above exam is negative do not forget to look for other things that could be
causing the patient’s shoulder pain, again paying close attention to the possibility of Cspine pain or other referred pain. Putting together the history and physical exam should
guide you toward a diagnosis. Fractures for the most part will have specific tenderness,
may be associated with swelling, bruising and x-ray findings. Shoulder dislocations will
reveal shoulder asymmetry and weakness. AC joint arthritis will reveal AC tenderness,
pain with provocative maneuvers and x-ray findings. Glenohumeral joint arthritis will
reveal decreased range of motion, pain and x-ray findings. Impingement will show
decreased range of motion and positive impingement signs with “provocative
maneuvers.” Rotator cuff tendonitis will reveal decreased range of motion and pain that
may limit strength on testing range of motion and strength of the rotator cuff tendons.
Definite weakness in the rotator cuff exam is concerning for a tear. Adhesive capsulitis
shows decreased range of motion in all direction with both passive and active range of
motion of the shoulder joint. Shoulder instability will reveal a positive apprehension and
relocation test.
The above guidelines have given me the basics to understand the shoulder
pathology and how to at least start an evaluation, what parts of the shoulder to be
suspicious of as causing the patient’s difficulties and what to do next. At least now I may
not be so scared of the shoulder exam
References:
1.Baker CL, Merkley MS. Clinical Evaluation of the Athlete’s Shoulder. Journal of
Athletic Training. 2000 July:35 (3):256-260.
2. Woodward TW, Best TM. The painful shoulder: part I. Clinical evaluation.
American Family Physician. 2000 May 15;61(10):3079-88.
Special thank you to Dr. Greg Gardner and Dr. Greg Nakamoto for their instruction in
how to evaluate shoulder pathology!!