McFarland article:
Sensitivity: measures the proportion of actual positives, which are correctly
identified
Specificity: measures the proportion of negatives, which are correctly identified as
such.
Purpose: review the current limitations of evidence based medicine with regard to
shoulder examination and to assess the rationale for and against the use of
diagnostic physical examination tests.
Shoulder is complex:
- Multiple bones moving
- Bones are not visible due to muscle attachments
EVIDENCE-BASED MEDICINE FOR
SHOULDER EXAMINATION
- Lacking gold standards (arthroscopic) comparison
DISORDER-SPECIFIC EXAMINATIONS
Step 1: look at back and front of shoulder. Looking for swelling, atrophy, or
disformity.
Step 2: Specific tests to differentiate and come up with a diagnosis
Scapular malpositioning:
- Evaluate scapula and see how scapulae sits on the thoracic wall (look at medial
border and inferior edge and compare to unaffected sholder)
- Observation for diagnosing scapular asymmetry (tennis shoulder, drooping of
dominant arm, hypertrophy of dominant arm, and protracted shoulder blade)
- Protracted shoulder blade  predispose to impingement on acromion
- Scapular winging has 2 features:
1) Lateral winging: rare in athletes, from lesion in Spinal Accessory (innervates
Upper Trapezius). Asymmetry can be seen at rest, and exacerbated with flexion of
the arms or a wall pushup. Severe cases cant stabilize shoulder blade and elevate
arm.
2) Medial winging: more common, lesion in Long Thoracic (innervates Serratus
Anterior)
- Screen for synchronistic shoulders view shoulder movement from behind and
observe the scapular motion with full adduction to full elevation
- Scapulothoracic rhythm should be smooth with no hitches
- Scapular Dyskinesis: side to side asymmetry
- Shrug sign: patient raises arm to 90 degrees. If they shrug it can indicate rotator
cuff tear, stiffness, and weakness
Rotator cuff disorders:
- Concept of RC tears caused by rubbing of tendon on structures (impingement) is
under the question due to lack of contact between superior glenoid and acromion.
Recently studies show that it could be caused by a degenerative disease that
worsens with age.
- Other causes: tenocyte apoptosis and collage fiber disorganization
- Can be asymptomatic with some people still having full ROM
- Massive RC tears: present with weakness and inability to lift arm, others can be
asymptomatic with full ROM
- ***An evidence-based review of physical examination of the shoulder for rotator
cuff disease shows that the tests are more helpful when the abnormality is more
severe. The detection of less severe rotator cuff abnormality by physical
examination is much more difficult.***
- Some tests show low sensitivity and specificity for less severe shoulder
diseases. Partial tears often test positive even when asymptomatic, and the
PT needs to take into account the hx, and radiography.
Anterior instability
- Anterior shoulder instability (humeral head subluxation or dislocation anterior to
the glenoid) can be traumatic or atraumatic
- Few shoulder conditions for which the history, physical examination and
radiographic studies are extremely accurate and diagnostically helpful
- Surprise test and anterior apprehension test: moderate sensitivity and high
specific for traumatic anterior instability when using apprehension as the criterion
not pain.
- Apprehension: sense of shoulder instability
- Shoulder laxity: the amount of translation of the humeral head on the glenoid.
Plays a role in diagnosing shoulder instability.
- However wide range of normal laxity
- Instability: abnormal laxity that produced sublaxation or dislocation of the
joint
- Load and shift test and anterior posterior drawer test: PT tries to translate the
humeral head over the rim of the glenoid
- Grade 1: does not dislocate
- Grade 2: dislocates but then reduces
- Grade 3: dislocates, and stays dislocated
- If test shows that the dislocation is occurring and it reproduces symptoms
of instability then test has 53% sensitivity and 58% specificity of anterior
instability
- Relocation test: also tests for anterior instability
- Patient in supine with shoulder in external rotation and abduction. The
examiner keeps pushing the shoulder into ER and ABD until apprehension
is felt. Upon apprehension PT applies posterior force stabilizing the
shoulder, which should reduce apprehension. High specificity and moderate
sensitivity
- Pain as a criterion: we still don’t understand shoulder pain in overhead throwing
athletes. Interpret pain as a caution not indication of RC disease.
Inferior instability:
- Recognition of the wide range of normal inferior laxity that is unrelated to instability.
- Evaluated with Sulcus Sign: sit, stand, or supine has PT pulls down on arm. Grades: 1
(<1.5 cm), 2 (1.5–2.0 cm) or 3 (>2 cm)
- It has never been validated nor has its reliability been adequately studied
- Hyperangulation sign: there are no level I studies that define the clinically appropriate
use of these two signs for making the diagnosis of inferior instability
Posterior instability:
- Posterior apprehension sign, Jerk test, and Posterior drawer test: have not
been adequately studied to determine their accuracy or clinical utility.
- ***Many patients with a demonstrable instability pattern have no subluxation-
related pain or activity limitation, so ‘demonstrability’ is not a sufficient criterion
for surgical intervention***
Acromioclavicular joint disorders: Diagnoses of injuries and conditions
affecting the acromio- clavicular joint can be made fairly reliably
- One finger test: patient points to AC joint and indicates that’s where the
pain in coming from
- Pain is often localized at AC joint
- There are few level I studies of the clinical usefulness of examination tests for
the acromioclavicular joint,
Lesions of the long head of the biceps tendon
- Abnormalities of the long head of the biceps tendon include full tears, partial
tears, tenosynovitis and subluxation
- Popeye observation: after hearing a pop or snap in the shoulder, have a lump in
bicep. Observation has never been studied.
- Difficulty in diagnosing long head of bicep tendon injury:
- Tendon is deep in anterior shoulder covered by transverse ligament
- Difficult to differentiate tendons in the shoulder due to proximity
- Long head is rarely unaffected without other RC abnormality
- Little level I evidence regarding the accuracy of physical examination tests for
biceps tendon abnormality
Superior labrum anterior to posterior lesions:
- Diagnosing superior labrum anterior and posterior (SLAP) lesions with physical
examination continues to be marked by controversy
- For most of these physical examination tests, a positive result is pain or a click in
the shoulder during the test, but a click has also been shown to occur in patients
without SLAP lesions.
- SLAP lesions rarely behave like meniscal tears, that is, with an entrapped
fragment or bucket handle of the labrum in the joint
- There seems to be some increased accuracy in making the diagnosis of a SLAP
lesion when multiple tests are positive
CONCLUSION:
- The diagnosis of traumatic anterior instability can be made reliably on physical
examination
- Most conditions of the acromioclavicular joint can be accurately diagnosed.
- Posterior shoulder instability can be diagnosed if the patient can show the
instability or if laxity testing reproduces the symptoms.
- Inferior: only reliable and valid if laxity produces symptoms
- Symptomatic full- thickness rotator cuff tears can be successfully diagnosed in
many instances, but lesser forms of rotator cuff disease are difficult to distinguish.
- Biceps tendon lesions are difficult to diagnose on physical examination, but
SLAP lesions might be more accurately diagnosed on physical examination if
multiple tests are positive.
- The evaluation of shoulder pain can present a diagnostic challenge to clinicians.
Multiple tests exist for the physical examination of the shoulder; however, many
are non-specific and do not point to a definite diagnosis. Furthermore, the cause of
many shoulder conditions is currently unclear.