Examination of the Shoulder Complex
RICHARD W. BOWLING,
PAUL A. ROCKAR, JR.,
and RICHARD ERHARD
This article presents a protocol for the examination of the shoulder complex. The
examination is divided into subjective and objective components. A primary focus
of this article is on the functional portion of the objective examination and its
interpretation. The functional examination consists of active and passive rangeof-motion tests, accessory mobility tests, resisted tests, and palpation. This
approach enables the examiner to classify movement disorders of the shoulder
complex into dysfunctions of the noncontractile tissues and of the contractile
tissues. Factors that enable the examiner to determine the severity of a pathological condition or to identify stages of the healing process are discussed. This
information will assist the physical therapist in establishing treatment goals and
in selecting appropriate strategies of therapeutic intervention.
Key Words: Physical therapy, Shoulder, Shoulder joint.
The ability of a physical therapist to
manage successfully problems involving
the shoulder complex depends on an
understanding of functional anatomy,
pathokinesiology, principles of examination, and principles of treatment of
the musculoskeletal system. The purpose of this article is to present a protocol for the examination of the shoulder
region. The primary focus is on those
components of the subjective and objective examinations that we believe are
most important to the physical therapist. Much of what we will describe is
based on the original work of Cyriax,1
and we feel compelled to acknowledge
his contribution to orthopedic medicine.
The objective of the examination of
any part of the musculoskeletal system
is to obtain data on which to base decisions regarding management. The naming of a disease process or specific injury
often is overemphasized and can be in-
Mr. Bowling is Assistant Professor, Department
of Physical Therapy, School of Health Related
Professions, University of Pittsburgh, Pittsburgh,
PA 15261 (USA), and is in private practice at Forest
Hills Orthopaedic and Sports Physical Therapy Associates, Inc, 2372 Ardmore Blvd, Pittsburgh, PA
15221.
Mr. Rockar is Adjunct Assistant Professor, Department of Physical Therapy, School of Health
Related Professions, University of Pittsburgh, and
is in private practice at Forest Hills Orthopaedic
and Sports Physical Therapy Associates, Inc.
Dr. Erhard is Assistant Professor, Department of
Physical Therapy, School of Health Related Professions, University of Pittsburgh and is in private
practice at 7 N Washington St, Masontown, PA
15461.
1866
adequate because individuals with the
same diagnosis may require different
treatment.
Movement dysfunctions may be classified logically into syndromes or clusters of signs and symptoms revealed by
a thorough and systematic examination.
Such information is useful in determining the severity of a client's pathological
condition or in identifying stages of the
healing process.
We must emphasize that the examination process is continuous. As an individual's condition progresses, or regresses, the signs and symptoms will
alter, therefore dictating changes in
management of the problem.
SCREENING EXAMINATION
One of the primary problems encountered by clinicians when dealing with
clients who complain of upper extremity
pain is localization of the disorder to a
specific region or structure. We have
adopted and modified a screening examination procedure developed by
Cyriax.1 This procedure is designed to
localize rapidly the area or areas of
involvement and is outlined in Appendix 1.
The screening examination is performed in a manner that allows a considerable amount of information to be
gathered in a brief timespan. All resisted
tests are performed after the individual
has completed his available range of motion. Resistance, thus, is applied with
the muscle group tested in a shortened
position and the joint at the limit of
motion. For example, when resisted ab-
duction of the shoulder is being tested,
the client is instructed to abduct his arm
as far as possible and maintain this position as the examiner attempts to force
the arm downward. This procedure enables the examiner to gain information
about the client's neuromuscular system, as well as his ROM.
Because the resisted tests are performed at the limit of the ROM, both
contractile and noncontractile tissues
may be stressed and reproduce symptoms. We emphasize, therefore, that the
screening examination indicates only
the area of involvement and not a
specific lesion or structure. The screening examination is designed only to
differentiate a shoulder problem from a
problem in the cervical spine or elbow
complex; further information about the
dysfunction will be obtained from the
specific examinations of the involved
area.
Information gathered from the
screening examination will indicate
whether a specific examination is
needed of the cervical spine, shoulder
complex, elbow complex, the wrist and
hand or more than one of these areas.
If one or more of the following findings
are present, a specific examination of
the shoulder complex is indicated: 1)
observable postural abnormality of the
shoulder girdle or glenohumeral joint;
2) deformity or wound in the area; 3)
abnormal response to active elevation
of the upper limb; 4) weakness, pain, or
limited ROM on resisted shoulder-girdle
elevation; 5) weakness, pain, or limited
ROM on resisted glenohumeral joint
PHYSICAL THERAPY
abduction; and 6) pain on resisted flexion or extension of the elbow joint that
is localized to the shoulder region.
If no movement or resisted test in the
screening examination reproduces or
exacerbates the symptoms of nonathletic clients, the examiner must be suspicious of pain referral from sources
other than the musculoskeletal system,
such as an inflammation of the gall bladder or heart disease.2 Athletes' symptoms often are reproduced only by the
application of stresses far greater than
those applied during the screening examination.
SPECIFIC EXAMINATIONS OF
THE SHOULDER COMPLEX
The examination protocol that is explained below for the shoulder complex
is outlined in Appendix 2.
Subjective Examination
The objective of the subjective examination is to determine 1) the possible
source or sources of the client's complaint, 2) the nature of the complaint,
and 3) the severity and stage of the
condition. This information is important in planning the objective portion of
the examination; that is, the client's
responses to specific questions will
determine which components of the
functional examination should receive
emphasis and whether the examination
movements will be performed cautiously or vigorously.
Most clients, when asked why they
consulted a physician, state that the reason was pain, inability to perform a
particular functional activity, or both. If
the primary problem is pain, its present
location must be determined. The location of the pain will provide the examiner with information regarding the
source of the problem. The glenohumeral joint and its associated soft tissues, for example, may refer pain into
the C5 dermatome. Other joints or
structures that refer pain into or that are
located in this area may be excluded by
a negative response on the screening
examination. The examiner, however,
must be aware that coexisting problems
are common. For example, degenerative
joint disease of the cervical spine may
refer pain into this area. This condition
occurs in the same age group in which
an impingement syndrome of the glenohumeral joint may occur. The sternoclavicular and acromioclavicular
joints, however, may generate local
Volume 66 / Number 12, December 1986
symptoms. The classical example is the
athlete who points directly to the acromioclavicular joint as the source of his
pain.
After the location of the present pain
has been determined, the client will be
asked whether the pain location has
changed since the onset of the problem
or whether the pain location changes
during the course of the day or with
particular movements or activities. If
the pain location has changed since the
onset of the problem, the pain likely will
have spread down the arm into the more
distal region of the C5 dermatome, or it
will have receded into a more proximal
zone of the dermatome. Pain that has
spread distally indicates that the problem is worsening, whereas receding pain
indicates that the problem is less severe.
Proximal pain that expands into the
distal portion of the C5 dermatome during the performance of a particular
movement or activity also indicates the
presence of acute inflammation. Determining the duration of pain is important
for providing information about the irritability of the condition and should
guide the application of testing movements during the objective examination.
If the pain is provoked easily by a light
movement or activity and remains for a
prolonged period of time, the examination movements should be performed
cautiously to avoid exacerbating the
condition. If considerable stress is required to elicit pain, however, the examination movements probably should
be performed vigorously.3
The examiner also must determine
whether the pain is constant or intermittent. If the pain is constant, it may
be caused by a nonmechanical disorder,
such as a malignancy. Alternatively,
constant pain may indicate a severely
inflamed joint that may require immobilization.
Intermittent pain usually indicates
that the problem is mechanical. The
pain, generally, is relieved by rest and
aggravated by activity. If the pain persists or increases at rest, a serious pathological condition such as a malignancy
or bacterial arthritis may be suspected,
especially if the pain awakens the client
from sleep.
If the client's chief complaint is a loss
of function, the examiner must determine the nature of the functional deficit.
Such deficits may range from an inability to perform simple activities of daily
living (eg, combing the hair, completing
personal hygiene, reaching into the hip
pocket, fastening a bra strap) to diffi-
culty performing specific athletic activities (eg, throwing a baseball).
Regardless of whether the client complains of pain, a loss of function, or
both, the examiner must determine how
the problem began. If trauma was associated with the onset of the problem,
details of the event may be helpful in
diagnosing the disorder and determining
its cause. If no specific traumatic incidents can be recalled, the examiner then
should consider certain types of activities or actions that may have precipitated the problem, such as overhead
painting, occupations involving prolonged abduction (hairdressing), or a
change in throwing motion in the athletic client.
The examiner also must determine
whether the client has problems with
other joints, which may indicate a systemic disorder such as rheumatoid arthritis. If the client has undergone surgery at the shoulder or other locations,
the nature of these procedures should be
ascertained. Particular attention should
be given to surgery or other treatment
for a malignancy because of the likelihood that the client will have a metastatic tumor. Other systemic disorders
such as diabetes mellitus are known to
affect the shoulder joint. Clients with
this disease are likely to have bilateral
involvement and, therefore, to be recalcitrant to treatment.
Objective Examination
Inspection. The examiner observes
the posture of the client's head, spine,
and upper limb. It is important to determine whether the client has an increased
upper thoracic kyphosis because this deformity may limit the range of upper
limb elevation. This limited range of
elevation is not caused primarily by
joint restriction but rather by the altered
starting position for sagittal plane motion of the glenohumeral joint. The altered starting position occurs because of
the change in the resting position of the
scapula (Figs. 1, 2). In younger clients,
the examiner also may observe a concomitant increase of hyperextension of
the glenohumeral joint.
The contour of the shoulder region
also is examined for obvious deformity
such as that caused by dislocation of the
glenohumeral joint or separation of the
acromioclavicular joint. Atrophy of the
deltoid, upper trapezius, supraspinatus,
and infraspinatus muscles also should
be noted. The client must be examined
for any limitation of functional activity
when being prepared for treatment. The
867
formed best in several planes because
pain may occur in one plane and not in
others.
Assessment of active movement alone
is not diagnostic because stress will be
placed on both contractile and noncontractile tissues. The contractile tissues
include muscles, tendons, and those of
the tenoperiosteal junction.1 All other
tissues are considered noncontractile.
Although both types of tissue will be
stressed with active movement, considerable information nevertheless will be
provided to the careful observer. These
data may be correlated with subsequent
portions of the examination to determine the cause of the problem. To clarify this procedure, we will describe the
clinical assessment of two distinctly dif-
Fig. 1. Normal active elevation of the upper
limb.
skin is checked for wounds, surgical
scars, contusions, or abrasions. The
client's use of an assistive device also
should be recorded.
Functional examination. To the physical therapist, the functional examination is the most important component
of the entire examination process. It
consists of 1) examination of active
movement, 2) examination of passive
movement, 3) examination of accessory
movement, 4) resisted tests, and 5) palpation.4
Active range of motion. The client's
AROM is assessed to determine his willingness or ability to move the joint and,
if the ROM is abnormal or painful, to
establish a baseline for measuring the
effectiveness of treatment. The movements examined actively at the shoulder
include 1) elevation of the upper limb;
2) elevation, depression, protraction,
and retraction of the shoulder girdle;
and 3) flexion, extension, abduction,
horizontal adduction, medial (internal)
rotation, and lateral (external) rotation
of the glenohumeral joint.
The term elevation is used to denote
the act of placing the upper limb in a
vertical position or as near to this position as possible. The client performs this
activity while the examiner records any
deviation from the normal scapulohumeral rhythm. The movement of elevation may be accomplished in the frontal plane, the sagittal plane, or in the
scapular plane. This movement is per1868
Fig. 2. Active elevation of the upper limb
when increased thoracic kyphosis is present.
Note the decreased range of motion compared with Figure 1.
ferent problems. Excessive scapular elevation and upward rotation may occur
in combination with limited active elevation of the upper limb in clients with
adhesive capsulitis or a rotator cuff tear.
Adhesive capsulitis is a lesion of the
noncontractile tissues, whereas a rotator
cuff tear involves the contractile tissues.
In clients with adhesive capsulitis, passive movement of the glenohumeral
joint also will be restricted, whereas the
resisted tests will be normal. If a rotator
cuff tear is present, the passive ROM
will be normal, but the resisted tests will
demonstrate weakness of the involved
muscles. The interdependence of the active motion examination, the examination of passive movement, and resisted
testing will be discussed further in subsequent sections of this article.
Passive overpressure is the application
of a passive stretch in the same direction
as the active movement. We do not
believe that it is appropriate to perform
passive overpressure to convert the
AROM test to a PROM test unless no
pain is reported by the client. The
PROM test, however, may be the most
important component of the functional
examination and should not be confined
to that portion of the passive range available beyond active motion.
Passive range of motion. Passive motion testing assesses the integrity of the
noncontractile elements of a joint.1 Passive motion testing at the shoulder, as
at any other joint of the musculoskeletal
system, provides the examiner with a
wealth of information.
The same movements, with the addition of scapular distraction, that were
performed in the examination of active
movements also are performed passively
(Figs. 3-14). While the client is performing the passive movements, the examiner must assess three factors: 1) ROM,
2) the nature of the motion barrier, and
3) the sequence of pain to the motion
barrier.1
1. Range of motion. Range of motion
may be excessive, normal, or limited. If
the ROM is excessive, instability should
be suspected. If the ROM is limited, if
may be limited in either a capsular or a
noncapsular pattern.
The term capsular pattern was introduced by Cyriax to denote a total joint
reaction to an inflammatory process (eg,
arthritis).1 An inflammatory process has
been shown to produce a reflex imbalance of the muscles that control the
knee.5 Preliminary research by Dunn (J.
S. Dunn, unpublished data, March
1980) leads us to believe that this muscle
imbalance may involve any joint with
facilitation of the physiological flexors
(flexors, adductors, and medial rotators)
and inhibition of the physiological extensors (extensors, abductors, and lateral rotators). This muscle imbalance
results in a proportional limitation of
movements of the joint. Each joint has
a characteristic capsular pattern of restriction. The capsular pattern of the
shoulder joint is such that the most restricted movement is lateral rotation followed by abduction and extension. The
least restricted movements are medial
rotation and adduction.
PHYSICAL THERAPY
Fig. 3. Passive elevation of the shoulder
girdle. The shoulder girdle is moved passively
in a cranial direction.
Fig. 4. Passive depression of the shoulder
girdle. The shoulder girdle is moved passively
in a caudal direction.
Fig. 5. Passive protraction of the shoulder
girdle. The shoulder girdleismoved passively
in an anterior direction.
Fig. 7. Passive distraction of the scapulothoracic joint. The scapula is moved away
from the thoracic wall.
Fig. 6. Passive retraction of the shoulder
girdle. The shoulder girdle is moved passively
in a posterior direction.
Although the concept of a capsular
pattern has proven valuable in the diagnosis of disorders of the musculoskeletal system, the term itself has caused
some confusion. The restriction may or
may not be caused by a contracture of
the joint capsule, and the presence of a
capsular pattern may or may not be an
indication for joint mobilization. In the
acute stages of an inflammatory process,
the pattern of restriction is produced
and maintained by abnormal muscle
tone, and the motion barrier at this time
is muscle guarding. During the natural
progression of the condition, a capsular
contracture will occur. The capsular pattern then will be maintained by contracVolume 66 / Number 12, December 1986
ture of connective tissue, and the motion barrier will be capsular (Tab. 1).
A capsular pattern is an indication of
a joint inflammation or arthritis, and its
most common cause is traumatic synovitis. If the client has no history of
trauma, systemic diseases such as rheumatoid arthritis, psoriatic arthritis, and
diabetes mellitus should be investigated
with an appropriate examination. Interestingly, clients with diabetes mellitus
often have bilateral involvement of the
shoulders.6-7 Additionally, the restriction of medial rotation often is greater
than the restriction that usually occurs
in a capsular pattern (H. Tien, unpublished data, March 1978).
Any restriction of motion that does
not fit the capsular proportions is
termed a noncapsular pattern.1 In contrast with the total joint involvement of
the capsular pattern, noncapsular pat-
Fig. 8. Passive flexion of the glenohumeral
joint. Note that the examiner is stabilizing the
scapula to prevent scapulothoracic movement.
terns of restriction are caused by lesions
that affect isolated portions of the joint
or by extra-articular lesions. The most
common cause of a noncapsular pattern
of restriction of the shoulder is acute
subdeltoid bursitis. When this condition
is present, the client's ROM during glenohumeral abduction is disproportionately more limited than that occurring
during lateral rotation. Cyriax and Cyriax have described other causes of a
noncapsular pattern of restriction at the
shoulder; however, these are uncommon.8
2. Nature of the motion barrier. As
the client completes the passive movement being tested, the sensation im1869
TABLE 1
Correlation of Events in inflammatory Process with Clinical Examination Findings and Treatment of Synovial Joints
Stage of
Inflammation
Early
Intermediate
Late
constant
felt at rest
predominant feature
distal reference zone
before motion barrier
intermittent
felt during movement
synchronous with motion barrier
may become more intense and
more distal with repeated
forceful movement
pain not severe
only felt with forceful movement
after motion barrier
proximal extent of reference
zone
parted to the examiner's hands must be
assessed. Cyriax has described motion
barriers as different types of "end feel."1
He has identified the following types of
sensation: 1) bone-to-bone, 2) capsular,
3) muscle guarding, 4) springy, 5) soft
tissue-approximation, and 6) empty.
A bone-to-bone motion barrier is
caused by approximation of the bony
members of a joint. This approximation
causes the joint motion to come to an
abrupt stop with no give on forced
stretching. This type of barrier is not
present on any movement of the shoulder under normal circumstances. It
usually is caused by malalignment of
fracture fragments of the proximal humerus. This malalignment results in impingement of the humerus against the
acromion process of the scapula during
abduction or flexion. Regardless of the
cause, a finding of a bone-to-bone motion barrier is a contraindication to attempts at actively or passively increasing
the ROM in the direction of the motion
barrier.
A capsular motion barrier is the normal end feel for most motions of the
glenohumeral joint. Cyriax has described the capsular end feel as similar
to the sensation imparted by stretching
a piece of leather.1 This type of motion
barrier is abnormal when it occurs prematurely in the ROM and generally is
indicative of capsular contracture.
When this type of motion barrier is present concurrently with a capsular pattern
of limitation, it represents the late stage
of adhesive capsulitis. The capsular nature of the motion barrier is an important factor in the differentiation of the
late stage of this syndrome from the
1870
Range of
Motion
Pain
Motion Barrier
Treatment
capsular pattern
muscular
(fast guarding)
empty
pain control
modalities
immobilization
capsular pattern
muscular (fastslow guarding)
pain control
gentle movement
capsular pattern
capsular
vigorous mobilization
exercise (automobilization)
Fig. 9. Passive extension of the glenohumeral joint. The scapula is stabilized by the
table.
Fig. 10. Passive abduction of the glenohumeral joint. The examiner is stabilizing the
scapula with the right hand. The scapula also
can be stabilized by contacting the axillary
border.
acute and intermediate stages (Tab. 1).
In the acute and intermediate stages, the
motion barrier will be muscle guarding.
Two types of muscle guarding occur.
The "fast-guarding" type is characterized by sudden twinges of muscle activity as the joint is moved passively. Fast
guarding may occur at any point in the
ROM but becomes most severe as the
terminal range is approached. The other
type of muscular motion barrier is "slow
guarding." Slow guarding usually occurs
throughout the ROM and lacks the sudden twinges of fast guarding. A muscle
that is too short may produce an end
feel that is similar to a capsular motion
barrier. If a muscle's length is insufficient to permit the attainment of a full
PROM, the connective tissue components of the muscle will be stretched as
the joint is moved.
Another type of motion barrier that
commonly affects the shoulder joint is
the empty end feel. An empty end feel
implies that no motion barrier was felt.1
This type usually occurs because severe
pain prevents the client from attaining
sufficient ROM to enable the examiner
to sense a physical limitation to movement. This type of motion barrier typically occurs in clients with acute
subdeltoid bursitis. The movement of
glenohumeral abduction is limited by
intense pain before the full range of
abduction can be reached. We would
expect muscle guarding to accompany
this type of motion barrier, but it does
not. We have observed marked subluxation of the glenohumeral joint on anteroposterior radiographs of clients with
acute subdeltoid bursitis that did not
occur after the condition had been rePHYSICAL THERAPY
Fig. 13. Passive horizontal adduction of the
glenohumeral joint.
Fig. 11. Passive lateral rotation of the glenohumeral joint.
Fig. 12. Passive medial rotation of the glenohumeral joint.
solved. This inferior subluxation leads
us to believe that the activity of the
supraspinatus muscle is inhibited by the
pain and may provide an explanation
for the lack of muscle guarding.
As stated previously, two other types
of motion barriers are encountered. Soft
tissue approximation may limit movement as opposing body surfaces come
into contact. This type of end feel occurs
commonly during knee flexion and elbow flexion. This motion barrier may
occur in the shoulder with horizontal
adduction as the anterior surface of the
arm contacts the pectoral region of the
chest. A springy motion barrier usually
results from an internal derangement of
the joint. It is common at the knee and
elbow. The sensation that is imparted to
the examiner's hand is that of a rebound
Volume 66 / Number 12, December 1986
Fig. 14. Passive elevation of the upper limb.
as the movement is forced through the
last few degrees of the ROM.
3. Sequence of pain in relation to the
motion barrier. The final factor to be
considered in the examination of passive movement is the sequence of pain
to the motion barrier. The client's experience of pain may be related temporally to the motion barrier in three
ways1: It can occur 1) after the motion
barrier has been met, 2) at the same
time the motion barrier is met, or 3)
before the motion barrier is met.
Pain that occurs after the motion barrier has been met usually is caused by
stretching contracted connective tissue.
This is a common finding in the late
stage of adhesive capsulitis. Pain that
occurs concurrently with the motion
barrier is indicative of a more acute
lesion. It commonly occurs in the intermediate stage of adhesive capsulitis and
usually is associated with an end feel of
muscular guarding. Pain occurring before the motion barrier is met is indicative of an acute condition. Clients with
such pain must be handled cautiously
because the symptoms may be exacerbated by the examination. The motion
barrier must be examined carefully to
ensure that the pain is not the result of
a painful arc.
A painful arc usually occurs between
70 and 110 degrees of abduction as the
greater tuberosity of the humerus is
passing under the coracoacromial arch.
Sensitive tissues located between these
bony structures are compressed and produce pain. As the movement progresses
and the greater tuberosity clears the coracoacromial arch, movement will become pain free.
A painful arc usually is associated
with the following disorders: 1) chronic
subdeltoid bursitis, 2) supraspinatus tendinitis, 3) subscapularis tendinitis (upper portion of insertion), and 4) infraspinatus tendinitis.1 Cyriax also has described other, less common conditions
that cause a painful arc at the shoulder.1
Examiners sometimes encounter athletic clients who complain of pain during the performance of a specific activity
or event, but whose symptoms cannot
be reproduced by PROM tests. The examiners also may be unable to reproduce these clients' symptoms with accessory movements or with resisted
tests. Maitland has described two examination procedures—the quadrant
and locking tests—that may be useful in
the examination and treatment of these
individuals.3
Accessory motion (mobility tests).
The purpose of mobility testing is to
examine the range of "joint play" or
accessory movements.4,9 These procedures further assess the condition of the
ligaments and capsule of the joint. The
accessory motions that are examined at
the shoulder complex are shown in Figures 15 through 23.
The ROM of the accessory movements of the involved upper limb must
be compared with that of the uninvolved contralateral limb. Examination
of these movements may reveal normal,
limited, or excessive ROM. Limited mobility indicates contracture of connective tissue, whereas excessive mobility
indicates connective tissue laxity or rupture.
The ROM of the accessory movements also must be correlated with the
results of passive movement testing to
determine the status of the joint. For
example, a client may demonstrate a
capsular pattern of limitation of the glenohumeral joint secondary to a recent
anterior dislocation. After the reduction
of the dislocation, the individual may
have a capsular pattern of restriction
associated with a muscle-guarding motion barrier. Accessory movements most
likely will reveal excessive gliding (hypermobility) of the humeral head in
both anterior and inferior directions.
The client with a recent anterior dislocation may be compared with a client
with a similar injury who is examined
after reduction and a sufficient period
1871
Fig. 15. Superior glide of the medial clavicle. The medial end of the clavicle is moved
in a cranial direction by the examiner's left
hand. The examiner palpates the movement
at the sternoclavicular joint with the right
index finger.
Fig. 18. Anterior glide of the medial clavicle. The medial end of the clavicle is pulled in an
anterior direction by the examiner's left hand. The examiner palpates the movement at the
sternoclavicular joint with the right index finger.
Fig. 16. Inferior glide of the medial clavicle.
The medial end of the clavicle is moved in a
caudal direction by the examiner's right hand.
The examiner palpates the movement at the
sternoclavicular joint with the left index finger.
Fig. 17. Posterior glide of the medial clavicle. The medial end of the clavicle is pushed
in a posterior direction.
Fig. 19. Hand placement for performance
of anterior and posterior glide of the lateral
clavicle on the acromion process. The distal
end of the clavicle can be moved in an anterior and a posterior direction.
Fig. 20. Distraction of the humeral head
from the glenoid fossa. The examiner attempts to move the humeral head in a lateral
direction.
of immobilization. The period of immobilization may have allowed the
damaged portion of the articular capsule
to heal in a shortened position. Passive
testing again may reveal a capsular pattern of restriction, but the motion barrier is most likely to be capsular, and
the accessory movements are likely to
be restricted. The clients, thus, must be
treated quite differently even though
they both exhibit a capsular pattern of
restriction of passive movements after
an anterior dislocation of the shoulder
joint.
Individuals with normal or excessive
PROMs may demonstrate hypermobility on examination of passive movements. These clients must be questioned
in detail concerning previous injuries of
the shoulder joint. On close questioning,
these clients often report a past traumatic episode. They may describe re-
current episodes involving a "locking"
sensation with a subsequent "clicking"
during particular postures or movements. Such episodes may be indicative
of an anteriorly subluxating glenohumeral joint, which, in contrast with a
recurrent dislocating joint, often is difficult to diagnose. Special studies have
been described in the literature that may
be helpful in determining the cause of
1872
PHYSICAL THERAPY
TABLE 2
Interpretation of Resisted Test Resultsa at Glenohumeral Joint for Common Contractile
Lesions
Resisted Test
Muscle
Deltoid
Supraspinatus
Infraspinatus
Subscapularis
Pectoralis major
Teres minor
Teres major
Latissimus dorsib
Biceps brachii
Triceps brachii
Abduction
Adduction
+
++
+
+
+
+
External
Rotation
Internal
Rotation
+/+/++
+/-
Elbow
Flexion
Elbow
Extension
++
+
+
+/-
+
+
+/-
++ c
+
a
Key: + = muscle performs function but rarely involved, + / - = muscle can produce pain
with test but more painful with a different resisted test, ++ = muscle usually responsible for
positive test results.
b
Also produces pain with resisted shoulder-girdle depression.
c
Many false negative test results.
Fig. 21. Posterior glide of the humeral head,
The examiner attempts to move the humeral
head in a posterior direction.
Fig. 22. Anterior glide of the humeral head.
The examiner attempts to move the humeral
head in an anterior direction.
Fig. 23. Inferior glide of the humeral head.
The examiner attempts to move the humeral
head in an inferior direction.
these problems, which appears to be an
injury of the glenoid labrum.10
Resisted testing. Resisted tests are designed to stress the contractile tissues of
a joint. The resisted tests performed at
the shoulder complex are outlined in
Appendix 2, and the resisted tests of the
glenohumeral joint are depicted in Figures 24 through 29. Resisted tests in a
specific examination of a joint are performed differently from the procedures
described for the screening examination.
In a specific examination, the resisted
tests are performed in a mid-range or
neutral position, in contrast with the
end-range position that was used in the
screening examination. The purpose of
placing the joint in a neutral position is
to eliminate any stress on the noncontractile tissues. When the patient performs an isometric contraction of a
muscle group with the joint in this position, tensile stress is produced in the
contractile tissues. If a painful condition
involves the contractile tissues, the patient's symptoms will be reproduced
with this maneuver. We must emphasize that the examiner is seeking replication of the client's symptoms. Although a test may produce slight pain,
Volume 66 / Number 12, December 1986
the client will be able to distinguish it
from the pain produced by his disorder,
and it must not be interpreted by the
examiner as a positive test result. The
joint to be tested should be stabilized as
much as possible. We generally place
our clients in the supine position to
achieve this stabilization.
Theoretically, resisted testing of a
muscle with an isometric contraction
will produce pain only if a lesion is
located within that muscle. In practice,
difficulties sometimes arise that may
lead to false positive test results. An
isometric contraction of a muscle produces compressive stresses across the articular surfaces of the joint, in addition
to shear stresses of the joint. Thus, acute
inflammatory conditions around the
joint may produce false positive resisted
test results. Another source of error during resisted testing is a fracture near the
insertion of the tested muscle, such as
an avulsion fracture of the greater tuberosity.
When administering resisted testing,
we generally instruct the client to begin
with a minimal contraction and gradually increase the resistance to elicit the
symptoms of a painful condition. If the
client begins with an initial contraction
that is too strong, other muscles that
also perform the movement may become involved. We have not found that
standard muscle testing procedures are
useful in the isolation of muscles that
perform similar movements. Muscles
that perform one movement often perform other movements at multiaxial
joints, such as the shoulder, and this fact
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Fig. 25. Resisted glenohumeral adduction.
The client resists the examiner's attempt to
pull the elbow away from the side.
Fig. 24. Resisted glenohumeral abduction.
The client resists the examiner's attempt to
force the elbow into the side.
can be used to isolate the involved muscle after all resisted tests have been
performed (Tab. 2).
The problems associated with a painful resisted contraction can be minimized by careful performance of the
procedures and by correlation of the test
results with other portions of the examination. When false positive test results
are produced by an acute inflammation
of the joint, passive movements usually
are more painful than the resisted tests.
When false positive test results are produced by a fracture near the insertion of
the tested muscle, the fracture usually is
the result of a traumatic injury. When a
client with a history of traumatic injury
has positive resisted test results, therefore, the examiner must ensure that an
adequate radiological examination has
been performed.
False negative test results also may
occur. Pain that is reproduced by resisted elbow flexion indicates tendinitis
of the long head of the biceps brachii
muscle (Tab. 2). The occurrence of pain
on this test, however, is uncommon. We
do not believe that pain produced by
elbow flexion always is symptomatic of
bicipital tendinitis. We have found clinically that this test will produce positive
results in only the most acute cases and
that symptoms of bicipital tendinitis can
be reproduced best by movement of the
humerus in the sagittal plane. These
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symptoms can be reproduced either
with activeflexionin the supine position
or with active extension in the erect
position. Resistance applied during flexion may be required to reproduce symptoms in less acute cases. Bicipital tendinitis can be confirmed by palpation for
tenderness of the tendon.
During the performance of resisted
testing, the examiner should record
whether the contraction elicits pain and
also whether the contraction is strong or
weak. Five patterns or possible combinations of strength and pain have been
described by Cyriax.1 The test results
may be 1) strong and painless, 2) strong
and painful, 3) weak and painless, 4)
weak and painful, or 5) all test results
may be painful (Tab. 3).
The classic positive finding for a contractile lesion or tendinitis is a strong,
painful contraction on one or two resisted tests. The common tendinous inflammations at the shoulder complex
involve the supraspinatus, infraspinatus,
subscapularis, and long head of the biceps brachii muscles. Table 2 lists the
specific resisted tests that are painful for
each of these muscles.
If the results are pain and weakness,
a serious disorder may exist. At the
shoulder complex, these findings may
be produced by a recent tear of the
rotator cuff, a fracture of one of the
tuberosities of the humerus, or a neoplasm near the joint.1 A painless and
weak contraction may indicate a neurological disorder or a long-standing tear
of a musculotendinous unit.
A painless and strong response usually
indicates that the musculotendinous
Fig. 26. Resisted glenohumeral internal rotation. The client resists the examiner's attempt to move the hand in a lateral direction.
The hand that applies resistance is proximal
to the client's wrist joint.
unit is not involved. In some overuse
syndromes, particularly in those involving athletes, however, manually applied
resistance does not produce sufficient
stress to reproduce the subject's symptoms. In these cases, examining the individual after the condition has been
aggravated by activity may be helpful.
These problems may be evaluated further with isokinetic testing and, in cases
that are particularly difficult to diagnose, referral to a sports medicine specialist may be indicated. Pain reported
on all resisted tests at a joint may indicate an acute inflammation of the joint
or a surrounding structure, or the possible existence of a psychogenic problem.1
Palpation. Palpation for tenderness of
involved structures should be reserved
until the preceding components of the
functional examination have been completed. This precaution prevents implicating a structure as being involved
before completing a systematic, logical
examination. Palpation, thus, is used as
a confirmatory test of earlierfindingsof
the functional examination.
The following structures are palpated
for tenderness at the shoulder girdle: 1)
sternoclavicular joint, 2) clavicle, and 3)
acromioclavicular joint. At the glenohumeral joint, the following structures
PHYSICAL THERAPY
TABLE 3
Interpretation of Pattern of Responses to Resisted Testing1
Combined Test
Results
Strong and painless
Strong and painful
Weak and painless
Weak and painful
All tests painful
Status of Nervous System
Status of Muscular System
no abnormality
no abnormality
nerve compression or peripheral neuropathy
serious pathological condition
(fracture, tumor)
no abnormality
contractile lesion present
longstanding rupture or tendon avulsion
serious pathological condition
(fracture, tumor, recent severe tear)
acute inflammation
or psychogenic condition
APPENDIX 1
Upper Quarter Screening Examination
Fig. 27. Resisted glenohurneral external rotation. The client resists the examiner's attempt to move the hand in a medial direction.
The hand that applies resistance is proximal
to the client's wrist joint.
Fig. 28. Resisted elbow flexion. The client
resists the examiner's attempt to extend the
elbow.
Fig. 29. Resisted elbow extension. The
client resists the examiner's attempt to flex
the elbow.
Volume 66 / Number 12, December 1986
Observation
Posture of head, spine and rib cage, and upper limb
Contour (atrophy or deformity)
Skin (color, wounds, abrasions)
Active range of motion
Elevation of upper limbs
Cervical spine (passive overpressure on rotation)
Resisted testing
Shoulder-girdle elevation
Shoulder abduction
Elbow flexion
Elbow extension
Wrist extension
Wrist flexion
Thumb extension
Finger adduction
are palpated: 1) the subdeltoid bursa, 2)
the supraspinatus tendon, 3) the subscapularis tendon, 4) the infraspinatus
tendon, 5) the teres minor tendon, and
6) the tendon of the long head of the
biceps brachii muscle. Cyriax and Hoppenfeld have described specific palpation techniques.1,11
Neurological examination. A neurological examination should be conducted if indicated by the screening or
specific examinations. Factors that indicate the necessity of a neurological
examination include 1) weakness of a
muscle on resisted testing, 2) subjective
complaints of paresthesia or anesthesia
in the upper limb, and 3) a history of an
injury that is known to produce neurological insult.
The neurological examination includes testing of the client's motor function, sensation, and reflexes. If one or
more muscles are found to be weak, the
examiner must test the deep tendon
reflexes of the upper limb, including
reflexes of the biceps brachii, triceps brachii, and brachioradialis muscles. Sensation of all dermatomes from the C4
segment through the Tl segment are
examined, as are the distributions of all
peripheral nerves of the upper limb.
Common neurological disorders of
the shoulder complex include 1) axillary
nerve injury secondary to fracture or
dislocation of the proximal humerus
and 2) brachial plexus involvement secondary to traction injury or to compromise at the thoracic outlet. In the latter
case, investigation of the circulatory status of the upper limb is warranted.
A complete description of the syndromes associated with these neurological insults is beyond the scope of this
article. These and other neurological
problems of the shoulder complex have
been described thoroughly by Haymaker and Woodhall12 and by Pratt (see
the article by N. E. Pratt in this issue).
Additional examinations. Clinical
signs that indicate the need for neurological assessment also may require electrophysiological testing for a definitive
diagnosis. Any familial history of a systemic disease such as rheumatoid arthritis or diabetes mellitis should be investigated further by an appropriate
specialist. Further required evaluation
procedures may include various radiological techniques and aspiration of
joint fluid.
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APPENDIX 2
Examination of the Shoulder Complex
Subjective Examination
Specific Questions
General Questions
What caused you to consult a physician?
If pain:
Where is the pain felt?
Has the pain spread?
Does it go below the elbow?
Does it reach the wrist?
Is it constant or intermittent?
If constant:
Does it vary in intensity?
What makes it worse?
Can you sleep on the involved side?
What eases the pain?
What brings on the pain?
Once present, how long does it remain?
At what time of day is the pain worst?
Does the pain awaken you from sleep?
If intermittent:
If loss of function:
What are your functional limitations?
Do you have difficulty combing your hair?
Do you have difficulty with personal hygiene?
What other specific tasks give you difficulty?
How did this problem begin?
Was there an injury? If so, when and how did it occur?
If not, can you identify a precipitating factor (habitual, repetitive, or
uncommon, prolonged activity)?
How long has this problem been present?
Have you ever had this problem or a similar problem in the past?
Do you have any related problems?
How is your health other than the problem with your shoulder?
Are you diabetic?
Do you have problems with other joints?
Have you had any operations?
If so, why were they performed?
Objective Examination
Inspection
Posture
Contour
Activities of daily living
Skin
Assistive devices
Accessory movements
Sternoclavicular joint
superior glide of medial clavicle
inferior glide of medial clavicle
posterior glide of medial clavicle
anterior glide of medial clavicle
Functional examination
Active range of motion
Shoulder girdle
elevation
depression
protraction
retraction
Shoulder
flexion
extension
abduction
external rotation
internal rotation
horizontal adduction
elevation
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Acromioclavicular joint
anterior glide of lateral clavicle
posterior glide of lateral clavicle
inferior glide of acromion (stress test)
Glenohumeral joint
distraction of humeral head
posterior glide of humeral head
anterior glide of humeral head
superior glide of humeral head
inferior glide of humeral head
PHYSICAL THERAPY
APPENDIX 2
Examination of the Shoulder Complex
Objective Examination
Resisted tests
Shoulder girdle
elevation
depression
protraction
retraction
Passive ROM
Shoulder girdle
elevation
depression
protraction
retraction
distraction (scapulothoracic)
Shoulder
flexion
extension
abduction
adduction
internal rotation
external rotation
elbow flexion
elbow extension
Shoulder
flexion
extension
abduction
external rotation
internal rotation
horizontal adduction
elevation
Neurological examination
Reflexes
Motor
Sensory
Palpation
Sternoclavicular joint
Clavicle
Acromioclavicular joint
Subscapularis tendon
Biceps brachii tendon (long head)
Supraspinatus tendon
Infraspinatus tendon
Teres minor tendon
Palpable portion of subdeltoid bursa
CONCLUSION
An outline of the examination of the
shoulder complex has been provided
with emphasis on the functional examination and interpretation of this portion of the examination. Attention to
the details of this examination should
enable the physical therapist to identify
movement disorders of the shoulder
complex. These disorders can be divided
into dysfunctions of the contractile tissues and dysfunctions of the noncontractile tissues.
Interpretation of the results of the examination is important. The physical
therapist must determine not only
which tissues are involved but also the
stage of the pathological process. Appropriate treatment goals then may be esVolume 66 / Number 12, December 1986
Additional examinations
Radiology
Laboratory examination
Electrodiagnosis
Punctures (biopsy, aspiration)
Special examination (referral to other specialists)
tablished on the basis of this evaluation.
If the examination principles we have
described are followed, they will lead to
treatment with the potential to optimize
the client's function.
REFERENCES
1. Cyriax J: Textbook of Orthopaedic Medicine:
Diagnosis of Soft Tissue Lesions, ed 5. Baltimore, MD, Williams & Wilkins, 1970, vol 1, pp
217-274
2. Cailliet R: Shoulder Pain. Philadelphia, PA, F A
Davis Co, 1966
3. Maitland GD: Peripheral Manipulation. Boston,
MA, Butterworth Publishers, 1977
4. Kaltenborn FM: Manual Therapy for the Extremity Joints: Specialized Tests, Techniques,
and Joint Mobilization, ed 2. Oslo, Norway,
Olaf Norlis Bokhandel A/S, 1976
5. deAndrade JR, Grant C, Dixon SJ: Joint distension and reflex muscle inhibition in the knee. J
Bone Joint Surg [Am] 47:313, 1965
6. Lequesne M:Increasedassociation of diabetes
mellitus with capsulitis of the shoulder and
shoulder-hand syndrome. Scand J Rheumatol
6:53-56, 1977
7. Laul VS, referred to in Gray RC, Gottlieg NL:
Rheumatic disorders associated with diabetes
mellitus: Literature review. Semin Arthritis
Rheum 6:19-34, 1976
8. Cyriax J, Cyriax P: Illustrated Manual of Orthopaedic Medicine. London, England, Butterworth & Co Ltd, 1983, pp 29-46
9. Mennell JM: Joint Pain: Diagnosis and Treatment Using Manipulative Techniques. Boston,
MA, Little, Brown & Co, 1964
10. McGlynn FJ, El-Khoury G, Albright JP: Arthrotomography of the glenoid labium in shoulder
instability. J Bone Joint Surg [Am] 64:506518,1982
11. Hoppenfeld S: Physical Examination of the
Spine and Extremities. East Norwalk, CT, Appleton-Century-Crofts, 1976
12. Haymaker W, Woodhall B: Peripheral Nerve
Injuries: Principles of Diagnosis, ed 2. Philadelphia, PA, W B Saunders Co, 1953
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