Shoulder Case: Short case: 70% of the case will be impingement syndrome

1. impingement

2. instability

3. laxity

Shoulder case is a spectrum of disease

“3 + 1”

3: Impingement Syndrome, Instability, Laxity – in Young patient

1: Frozen Shoulder (Adhesive Capsulitis) – in Elderly patient

Short Case

Statement:

“This patient is having shoulder pain at the left side or at the right side, please examine the shoulder and tell me your diagnosis.”

For examination of shoulder, must exam the spectrum of shoulder disease “3 + 1”

Exposure: umbilicus & above

Position: standing: always standing

Sequence of examination: Inspection, palpation, movement & special test (most important)

Special test guide you to the diagnosis

Impingement Syndrome

Short Case

a. Inspection
 Site for inspection:
From Medial to Lateral:
Start with: Sternoclavicular Joint, Clavicle & Shoulder Joint (acromioclavicular Joint)
Look for: Swelling, Deformity & Scars: mention all these 3 for both the joints
Shoulder:
- Compare both side
- Normally shoulder have a contour
- Flattening of deltoid muscle/ Deltoid muscle atrophy in the case of Brachial Plexus Injury
- No deltoid muscle atrophy in Impingement Syndrome & Adhesive Capsulitis
-
Before going into palpation, start with inspection of shoulder at the back for Winging of Scapula
 Inspection for Winging of Scapula: brachial plexus injury
(turn the patient facing the wall, ask the patient to push against the wall
& inspect the back for Winging of the Scapula)

b. Palpation
Short case approach
Site of palpation:
From Medial to Lateral: look for tenderness, deformity (old fractures), gap. Usually will have pain on the
acromioclavicular joint for impingement.
Sternoclavicular Joint, Clavicle, Shoulder Joint (acromioclavicular Joint) & Deltoid muscle (palpate for muscle atrophy)

Long case approach

a. Superficial palpation:
- Temperature of both side
- Deltoid muscle mass
b. Deep palpation:
- Sternoclavicular joint, clavicle, Shoulder joint (acromioclavicular joint) & Shoulder
- Palpate for tenderness, any gap & deformity

c. Movement

 Movement : patient always standing.

 Forward flexion
Examiner position: stand at the side of patient
Active Movement
- Elbow must be extended.
- You demonstrate to patient, then ask patient to follow.
- Then, ask patient to forward flex both shoulders.
- Normal person: can forward flex until 180°
- Impingement Syndrome: patient will have pain when forward flex > 90° (70-90 deg)
(Young: Impingement Syndrome; Elderly: Frozen Shoulder)
 Passive Movement
- Stabilizing the shoulder with one hand.
- Elbow must be extended.
- Then, another hand hold patient wrist and passively forward flex the shoulder.

 Extension
Examiner position: stand at the side of patient
Active Movement
- Elbow must be extended.
- You demonstrate to patient, then ask patient to follow.
- Then, ask patient to extend both shoulders.

Passive Movement
- Stabilizing the shoulder with one hand.
- Elbow must be extended.
- Then, another hand hold patient wrist and passively extend the shoulder.

 Abduction
Examiner position: stand in front of patient
Active Movement
- Elbow must be extended.
- You demonstrate to patient, then ask patient to follow.
 - Then, ask patient to abduction both shoulders.
- Normal person: can forward flex until 180°
- Impingement Syndrome: patient will have pain when forward flex > 90° (70-90deg): Painful arch
(Young: Impingement Syndrome; Elderly: Frozen Shoulder)

Passive Movement
- Stabilizing the shoulder with one hand.
- Elbow must be extended.
- Then, another hand passively abducts patient’s shoulder away from midline of the body.

 Adduction
Examiner position: stand in front of patient
Active Movement
- Elbow extended, then move both upper limb toward the midline of the body.
- you demonstrate to patient, then ask patient to follow.

Alternatively,
- if patient cannot do adduction using above method.
- ask patient to put both hand on the contralateral shoulder (adduction)

Passive Movement
- Stabilizing the shoulder with one hand.
- Then, another hand passively adducts patient’s shoulder toward midline of the body.
 Internal rotation
Examiner position: stand in front of patient
Active movement
- Elbow must be flex & put both hand at the back (at the sacrum).
- you demonstrate to patient, then ask patient to follow.
- Normal person: able to do internal rotation without limitation.
- Frozen shoulder: Internal rotation is limited.

Passive movement
- Stabilizing the shoulder with one hand.
- Elbow must be flex.
- Then, another hand passively internal rotate or move patient’s hand toward the midline of body.

 External rotation
Examiner position: stand in front of patient
Active movement
- Elbow must be flex & rotate outward or away from midline of the body.
- you demonstrate to patient, then ask patient to follow.
- Normal person: able to do external rotation without limitation.
- Frozen shoulder: 50% limitation of external rotation.

Passive movement
- Stabilizing the shoulder with one hand.
- Elbow must be flex.
- Then, another hand passively external rotate or move patient’s hand away from the midline of body.
***Frozen Shoulder: gradual development of global limitation of active and passive shoulder motion (flexion, extension,
abduction & adduction all limited)

d. Special Test: must do all the tests even if you know its impingement

Each of the spectrum of shoulder disease have their own special test.
A. YOUNG Patient
1. Impingement Syndrome
4 Rotator Cuff muscles: Supraspinatus, Infraspinatus, Subscapularis & Teres Minor + Long head of biceps
a. Supraspinatus muscles : most commonly involved muscle.
i. Drop Arm Sign Test: only for those who can fully abduct arm.
Examiner position: stand in front of patient.
- you demonstrate, then ask patient to follow.
- ask patient to fully abduct the arm.
- Then, ask patient to slowly lower the abducted arm to the side.
- Drop Arm Sign Test positive when patient slowly lower the abducted arm at position of 90°, patient
will drop his arm immediately, this indicate Supraspinatus Impingement Syndrome.
- Can be complete or partial tear: with partial tear will drop the arm with pain

Reference:
- https://youtu.be/kZ8hhuHjZag

ii. Hawkins Kennedy Test

Examiner position: stand in front of patient.
- you demonstrate, then ask patient to follow.
- Shoulder must be forward flex 90°
 - Elbow must be flex 90°
- one hand hold & support patient’s elbow
- another hand hold patient’s forearm or wrist & internally rotate
- Look for patient’s facial grimace (feel pain) while internally rotate the forearm
- Hawkins Test positive when patient’s show facial grimace (feel pain),
this indicated Supraspinatus Impingement Syndrome.

Reference:
- https://youtu.be/KYn4Jj349nw

iii. Jobe’s Test/ empty can test.

Examiner position: stand in front of patient
- you demonstrate, then ask patient to follow. Abduction 60 deg Forward flex 30 deg, thumb pointing
down. Apply downward pressure on the forearm and ask patient to resist. Compare both side
weakness and look at face.
- ask patient to elevate both arm to 90° of forward flexion in scapular plane, which is called Scaption.

- Then, fully internally rotate the arm and have the thumbs point towards the floor.
- Then, apply downward pressure on both upper limbs.
- Jobe’s Test positive when patient have pain or weakness on the injured site, this indicated
Supraspinatus Impingement Syndrome. Also positive when there is facial grimace.

Reference:
- https://youtu.be/5BjDQ-jcBek

iv. Neer Impingement Test

Examiner position: stand at the side of patient
- you demonstrate, then ask patient to follow. One hand stabilize shoulder in extended position,
another hand hold patents wrist. Now internally rotate the wrist. Now, quickly forward flex forearm.
- one hand hold & stabilize patient’s shoulder.
- another hand hold & internally rotate patient’s arm.
- Then, perform maximally forced forward flexion in the shoulder joint.
- Look for patient’s facial grimace (feel pain) while maximally forward flexion of the shoulder joint.
- Neer Impingement Test positive when patient have facial grimace (feel pain) on the injured site, this
indicated Supraspinatus Impingement Syndrome.
 Reference:
- https://youtu.be/bXA8cblZUok

b. Infraspinatus & Teres Minor muscles

i. Hornblower’s Test
Method 1:
Examiner position: stand in front of patient
- you demonstrate, then ask patient to follow.
- ask patient to abduct arm to 90° in scapula plane, flex elbow to 90°.
- Then, ask patient to put his or her hand near to the mouth almost like blowing a horn. Maintain
position for a few seconds.
- In normal person able maintain in the above horn blowing position.
- Hornblower’s Test positive when patient arm drops when doing the horn blowing position, this
indicated Infraspinatus or Teres Minor muscle injury.

Method 2:
Examiner position: stand at the side or stand behind the patient
- you demonstrate, then ask patient to follow.
- ask patient to abduct arm to 90° in scapula plane, flex elbow to 90°.
- then, one hand support patient’s elbow and another hand apply pressure on patient’s forearm.
- then, ask patient to do external rotation of shoulder against your resistance.
- Positive test when patient have pain or weakness when doing external rotation in above position,
this indicated infraspinatus or Teres Minor muscle injury.

Reference:
- Method 1: https://youtu.be/5YndmSKtEaA
- Method 2: https://youtu.be/am5XZ1VnoLc

c. Subscapularis muscles
i. Gerber’s Lift off Test
Examiner position: stand behind the patient
 - you demonstrate, then ask patient to follow.
- ask patient to put the hand at the back, then ask patient to lift his hand off from the back.
- While patient lift off his hand from the back, you apply resistance to the hand. If left side is weak the
left side is affected.
- Geber’s Lift off test positive when patient feel pain at the shoulder or weakness when you apply
resistance to the lift off hand at the back, this indicated Subscapularis muscle problem.

Reference:
- https://youtu.be/AgkTH52_PBI

ii. Napoleon Belly Press Test

Examiner position: stand in front the patient
- you demonstrate, then ask patient to follow.
- ask patient to put his or her hand at the belly.
- Then, you put your hand underneath, in between the patient’s hand and belly.
- Then, ask patient to press his or her hand toward belly.
- At the same time, you apply resistance with the hand that is between the hand and belly.
- Napoleon Belly Press Test positive when patient feel pain at the shoulder or weakness, this
indicated Subscapularis muscles problem.

Reference:
- https://youtu.be/RDfStbLsj6Q

d. Long head of biceps : not under rotator cuff but have to still test.
i. Yergason’s Test
Examiner Position: stand in front of patient
- you demonstrate, then ask patient to follow. Handshake patient. Elbow must be 90 deg flexion. Ask
patient to supinate and you apply resistance. While applying resistance, then palpate the anterior
aspect of the shoulder.
- ask patient to flex the elbow in 90° and forearm in pronation position.
- Then, one of your hand holding patient’s hand in hand shake position or holding patient’s wrist.
- Another hand hold, stabilize and palpate the anterior aspect of the shoulder (biceps tendon in the
bicipital groove)
- Then, ask patient to supinate his or her forearm.
- At the same time, you applied resistance while patient is doing supination.
- Yergason’s Test positive is when patient have facial grimace (pain in the shoulder) and you feel a
click sound or click sensation or crepitus at the anterior aspect of the shoulder, this indicated long
head of biceps tendon problem.
 Reference:
- https://youtu.be/_Cjahul5yuI

ii. Speed’s Test

Examiner Position: stand in front of patient
- you demonstrate, then ask patient to follow.
- elbow fully extended.
- fully supinate the forearm.
- shoulder forward flexion until 60 deg.
- one of your hand apply downward pressure on patient’s forearm and ask patient to push against
your resistance.
- another hand palpate anterior aspect of patient’s shoulder.
- Speed’s Test positive is when patient have facial grimace (pain in shoulder) and you feel a click
sound or click sensation, this indicated long head of biceps tendon problem.

Reference:
- https://youtu.be/gbG_O9Gv8aQ

2. Instability
i. Apprehension Test
Examiner Position: stand behind the patient
- you demonstrate, then ask patient to follow.
- ask the patient to abduct 90°
- elbow must be flex 90°
- one hand holding patient’s wrist
- another hand hold posterior aspect of shoulder and thumb must be palpating the posterior aspect of the
head of humerus.
- then, you extend the shoulder and you external rotate the forearm
- at the same time, you push the humeral head forward.

- Apprehension Test positive is when patient have pain at the shoulder or patient is Apprehended
“Terkejut” (because of fear of luxation or dislocation)
- The principle behind apprehension test is when you try to push the humeral head when there is instability, the
humeral head will be luxated or dislocated. Therefore, patient will have an apprehended reaction when he or she fear
of humeral head is going to be luxated or dislocated.
 Reference:
- https://youtu.be/qKqJRrms4u8

ii. Drawer Test/ Load and Shift Test

Examiner Position: stand behind the patient
- you demonstrate, then ask patient to follow.
- one of your hand hold on the shoulder and shape of hand will become a curve.
- Then, you divide the curve into 3 part.
- another hand, you hold the humeral head.
- Then, you try to move the head forward and see how much is the humeral head travel.
- In a normal person, movement of humeral head must not exceed 1/3.
- If the humeral head can move > 1/3, this indicate the patient having shoulder instability.

Reference:
- https://youtu.be/txARar71h5E

3. Laxity
i. Sulcus Test
Examiner Position: stand at the side of patient
- you demonstrate, then ask patient to follow.
- one of your hand stabilizing the shoulder.
- one of your hand holding patient’s wrist and pull the wrist downward.
- Then, you see is there any indentation or depression at the shoulder or not.
- Sulcus Test Positive is when you see a sulcus, depression or indentation at the shoulder.
- Because if there is laxity in the shoulder, the humeral head will go down and result in empty space at
shoulder joint. Thus, the empty space will show like a sulcus or a depression.
 Reference:
- https://youtu.be/vV7u2JtdYWI

B. ELDERLY PATIENT
1. Frozen Shoulder (Adhesive Capsulitis)
History:
History taking for Frozen Shoulder case must include Codman criteria (which is part of analysis of chief complaint)
+ Differential Diagnosis (to rule out other cause of pain)

Codman criteria of Frozen Shoulder

1. Limitation of Internal Rotation
- female patient cannot unhook the bra
2. Limitation of External Rotation
- 50% limitation of external rotation
3. No history of Trauma to Shoulder
4. Cannot sleep on affected side
5. Site of pain at the site of insertion of deltoid muscle
(lateral aspect of mid-shaft of humerus)

Differential Diagnosis
 5 causes of pain
5 Inflammatory Joint disease
- Rheumatoid Arthritis
- Ankylosing Spondylitis
- Gouty Arthritis
- Reiter’s Syndrome
- Psoriatic Arthritis

Examination:
All the Special test for Impingement Syndrome will be positive in Frozen Shoulder case.

Investigation

Frozen Shoulder (Elderly)

Laboratory Investigation:

1. Full Blood Count

2. Liver Function Test
3. Fasting Sugar
4. Renal Profile
5. Inflammatory Marker (ESR, CRP) – MUST do in shoulder pain case

Radiological Investigation:

1. X-ray (Normal Shoulder X-ray)

Normal Shoulder X-ray

 In Normal Shoulder X-ray,
There will be Joint space between Acromion Process and
Humeral Head.

Shoulder Impingement Syndrome

In Shoulder Impingement Syndrome,
Shoulder X-ray will show narrowing of Joint Space between
Acromion Process & Humeral Head.

In Frozen Shoulder,
Frozen Shoulder (Adhesive Capsulitis) Shoulder X-ray will look normal but the symptom is there.
Normal Shoulder X-ray is one of the Codman criteria for
frozen shoulder.

2. Ultrasound
- If MRI scan is not available in the Hospital, you do an ultrasound for supraspinatus tear.
- See the condition of rotator cuff muscle whether there is tear or not.

3. MRI scan
- If MRI scan available, then no need to do ultrasound.
- GOLD STANDARD for Shoulder Impingement Syndrome to see for evidence of rotator cuff muscle tear or not.

Treatment

Non-operative

1. Medication: Painkiller
2. Physiotherapy
- Deltoid Muscle Strengthening Exercise
- Short wave diathermy
- Heat therapy
- Ultrasound wave
- TENS
3. Immobilization (NO NEED)
4. Injection
a. Corticosteroid Injection under acromium (Subacromium corticosteroid injection to relief pain)
b. Intraarticular hyaluronic acid – improve the function & relief the pain
Operative

Shoulder Impingement Syndrome

- Most common muscle affected in shoulder impingement syndrome is Supraspinatus Muscles. So, you need to do a
Supraspinatus Repair. Supraspinatus Impingement Syndrome mean supraspinatus muscle is impinged, then torn. So, you need
to repair the tear part.

 Open method: Open repair of the supraspinatus muscle

 Closed method: Arthroscopic repair of the supraspinatus muscle.

Frozen Shoulder

- Principle of treatment in Frozen Shoulder is to release the Capsule because capsule is swollen and become sticky that is why
Frozen Shoulder is called Adhesive Capsulitis.

 Open method: Open Surgical Release

(cut through the adhesions, scar tissue, and other structures that interfering the motion of the shoulder)
 Closed method: Arthroscopic release