Clinical Examination of the

Shoulder
Anatomy
Anatomy
 Take Home Points
• Use the patient’s history to focus your examination.
• Always be gentle and reassuring in your manner and respect the personal
sensitivities of each patient
• During inspection, carefully compare one side with the other to detect
subtle deformities or abnormalities.
• Compare each patient with your “memory bank of the normal range of
variation of each physical findings
• Evaluate the overall alignment of the limb or spine before focusing on the
specific area of complaint.
• In the case of lower extremity problems, always assess the effect of the
condition on the patient’s gait
• Quantitate measurable parameters such as range of motion, muscle
strength and the size of masses for comparison with past and future
examinatioun.
• In cases of suspected joint instability, look for signs of generalized
ligamentous laxity
 Common Symptoms
Pain Stiffness
• Typical shoulder joint and RC pain • Progressive and severe
is localized to anterior, lateral • Frozen shoulder
aspects and extends to mid-arm Swelling
• Referred pain from the neck and • Soft tissue (e.g. muscle)
mediastinal disorders
Weakness • Joint swelling
• Neurological loss of power • Bony swelling
• Sudden due to ruptured RC Deformity
tendon • Muscle wasting
Instability • Prominence of the ACJ
• My shoulder junmps out
• Click or jerk • Winging of the scapula
• Dead arm sensation • Abnormal position of the arm
Loss of function
 Physical Examination plan
LOOK • Bones and joints
• Skin – Suprasternal Notch
• Soft tissue – Sterno-clavicular joint
– Clavicle
• Bony prominences – Coracoid process
FEEL – Acromioclavicular articulation
• Skin – Acromion
• Soft tissue – Greater tuberosity of the
– Subacromial and subdeltoid humerus
bursa – Bicipital groove
– Rotator cuff – Spine of the scapula
– Biceps brachii – Vertebral border of the
– The axilla scapula
– Prominent muscles of the
shoulder girdle
 Physical Examination Plan
RANGE OF MOTION
• Active range of motion tests
• Quick tests
• Passive movements
– Flexion ……............ 180°
– Extension……………. 40°
– Abduction…………… 180°
– Adduction…………… 40°
– External rotation…. 45°
– Internal rotation….. 50°
 Physical Examination Plan
NEUROLOGIC EXAMINATION SPECIAL TESTS
• Muscle testing
– Tone
EXAMINATION OF
– Power (MRC Grading)
RELATED AREAS
• Reflex testing
– Superficial
– Deep
– Plantar reflex
• Sensation testing
Look: General Appearance, Posture,
attitude and gait
 Look: Skin and Soft Tissue
• Skin:
– blebs, discoloration, abrasions, and Oedema,
– sinus, scars, and other signs of present or previous pathology.
– Webbing of the skin at the base of the neck. (Klippel-Feil syndrome)
• Soft tissue:
– Normally the shoulder mass is full and round (deltoid and humral
head)
– Abnormal contour of the shoulder soft tissue:
• Congenital muscle absence. (e.g. pectoralis major muscle)
• Muscle wasting (e.g. deltoid with axillary injury and supraspinatus
and infraspinatus as with chronic tendinitis or ruptured rotator
cuff)
• Swelling (e.g. bursitis, rupture of biceps)
Look: Skin, Soft Tissue and Bone

Absence of pectoralis major muscle Webbing or shortening of the

neck with low hair line
 Look

Rupture of long head of Webbing of the neck and Left high

biceps brachii scapula “Sprengel’s deformity”
 Look: Bony prominences
1) Clavicle:
• A deformity if fractured
• A prominent clavicular end –
either sternal or acromial - as the
case with subluxation or
dislocation at SC or AC joints.
• Absent clavicular contour.
2) Humeral head
• Abnormality of shoulder contour
may also be caused by shoulder
dislocation
2) Scapula
• The position of the scapula as
traced by its ridges upon the skin.
• It covers ribs two to seven and its
medial border lies about 5 Cm.
from the spinous processes.
• Scapular asymmetry is noted with
serratus anterior deficiency as
“winging scapula”
• A high scapula as in “Sprengel’s
deformity” with an apparent
webbing or shortening of the
neck
Acromioclavicular Joint (ACJ) Dislocation
 Look

Loss of normal shoulder contour Bilateral winging scapula

due to right shoulder dislocation
 Look

A lateral curvature of the spine Kyphosis leads to protruded

(scoliosis) leads to asymmetry in shoulders (e.g. Scheuermann’s
shoulder level disease or juvenile kyphosis)
 Feel
• Skin for temperature
• Soft tissue
– The muscles of the shoulder girdle should be assessed for
tone, consistency, size, shape, condition (whether they are
hypertrophic or atrophic) and any tenderness.
– Subacromial and subdeltoid bursa
– Rotator cuff
– The axilla
– Prominent muscles of the shoulder girdle
 Feel: Soft tissue
(a) Subacromial Space
 Feel: Soft tissue
(b) Rotator Cuff
• Rotator Cuff
– Supraspinatus
– Infraspinatus
– Teris minor
– Subscapularis

• Why does it call a

rotator cuff?
 Feel: Soft Tissue
(C) Axilla
Posterior fold
Anterior fold Latissimus dorsi
Pectoralis major
 Feel: Soft Tissue
(c) Axilla

Apical Axillary
Coracobrachialis
lymph nodes
Axillary Artery

Medially Serratus anterior

over thoracic cage
 Feel: Soft Tissue
(d) Prominent Muscles of the Shoulder
Sternocleidomastoid
Girdle
Pectoralis major
Feel Pectoralis major Feel thoracic cage
 Feel: Soft Tissue
(d) Prominent Muscles of the Shoulder
Girdle
Biceps Brachii muscle Long head of
Biceps Brachii
 Feel: Soft Tissue
(d) Prominent Muscles of the Shoulder Girdle

Anterior and Middle Deltoid Muscle Posterior Deltoid Muscle

Trapezius Rhomboids
 Feel: Bones
A systematic approach is
followed to feel the bones
around the shoulder. Position
yourself behind the seated
patient and start anteriorly at
the suprasternal notch and end
by the vertebral border of the
scapula.
Suprasternal Notch
Sternoclavicular joint
Clavicle
Acromioclavicular
articulation
Acromion
Coracoid process
Greater tuberosity of the
humerus
Bicipital groove
Lesser tuberosity of the
humerus
Spine of the scapula
Vertebral border of the
scapula
 Movements of the Shoulder
• Active range of motion tests
• Quick tests
• Passive movements

– Flexion / Extension
– Abduction / Adduction
– Internal rotation / External rotation
Use of the goniometer to measure elbow motion
 Quick Test
Apley Scratch
 Quick Test
Internal Rotation
with adduction with abduction
Range of Motion
A and B, Passive shoulder rotation to elicit soft tissue crepitus
Scapulo-Humeral Rhythm
Neurological Examination - Power

Resist shoulder flexors Resist shoulder extensors

Neurological Examination - Power

Resist shoulder abductors Resist shoulder adductors

 TESTS FOR ISOLATED WEAKNESS
• Supraspinatus strength –
a. The ‘empty can’ test
• The arms abducted to 90 degrees
• 30 degree forward flexion at
shoulder
• Thumb directed downward
• The arms are resisted

b. What is ‘full can’ test?

A T Makki (May 2014) 42

Neurological Examination - Power

Resist shoulder external rotators Resist shoulder internal rotators

 TESTS FOR ISOLATED WEAKNESS
• Infraspinatus Strength
– resisted external
rotation

A T Makki (May 2014) 44

 TESTS FOR ISOLATED WEAKNESS
• Infraspinatus strength Normal

and posterior cuff – the

‘lag sign’ and the ‘drop
sign’

Abnormal

A T Makki (May 2014) 45

 Lift-Off (Gerber) Test
Determine Subscapularis tear
Neurological Examination - Power

Resist shoulder elevation Resist shoulder protrusion

Neurological Examination - Power

Resist serratus antrior Winging scapula

 Lesions of the Biceps Tendon
Rupture Long Head Tendon of the Biceps

The lump in the front of the arm becomes even more prominent when
the patient contracts the biceps against resistance
A T Makki (May 2014) 49
Neurological Examination- Sensation
 Special Tests
• Painful arc test • Speed test
• Neer’s test • Yeargason test
• Hawkins and Kennedy
test
• Apprehension Test for
Recurrent Shoulder
Dislocation
• Drawer test
• Sulcus test
• Drop arm test
Painful Arc
 Painful Arc

On active abduction scapulohumeral rhythm is disturbed and pain is

aggravated as the arm traverses an arc between 60 and 120 degrees
(Right arm is the affected one)
A T Makki (May 2014) 53
 TESTS FOR CUFF IMPINGEMENT PAIN
NEER’S TEST
• Purpose: Test for impingement
• Position: Seated Neer’s Test
• Technique: Passively take UE into
full shoulder flexion with
humerus in IR
• Interpretation: + test = pain may
be indicative of impinge-ment of
the supraspinatus or long head of
the biceps
• Statistics: Sensitivity = 68%–95%
& specificity = 25%–68%

A T Makki (May 2014) 54

 TESTS FOR CUFF IMPINGEMENT PAIN
HAWKINS/KENNEDY TEST Hawkins – Kennedy Test
• Purpose: Test for impingement
• Position: Seated
• Technique: Place shoulder in 90°
of flexion, slight horizontal
adduction, & maximal IR
• Interpretation: + test = shoulder
pain due to impingement of
supraspinatus between greater
tuberosity against coracoacromial
arch
• Statistics: Sensitivity = 72%–92%
& specificity = 25%–66%

A T Makki (May 2014) 55

Apprehension Test for Shoulder
Recurrent Dislocation
 Shoulder Anterior Instability
The Apprehension Test
The apprehension test is for
the anterior subluxation or
dislocation of the shoulder.
1. Abduct, externally rotate
and extend the patient’s
shoulder while pushing on
the head of the humerus.
2. If the patient feels that the
joint is about to dislocate,
she will forcibly resist the
manoeuvre.
3. The manoeuvre is
performed at 45°, 90° and
135° of shoulder abduction

A T Makki (May 2014) 57

 Shoulder Anterior / Posterior Instability
Drawer Test

With the patient supine, the scapula is stabilized with one

hand while the upper arm is grasped firmly with the other so
as to manipulate the head of the humerus forwards and
backwards (like a drawer).
A T Makki (May 2014) 58
 SULCUS SIGN
• Purpose: Assess for inferior
instability or AC px
• Position: Sitting with
shoulder in neutral & elbow
flexed to 90°
• Technique: Palpate shoulder
joint line while using
proximal forearm as a lever
to inferiorly distract
humerus
• Interpretation: + test = ≥ 1
finger-width gap @ the
shoulder joint line or AC
joint
 SPEED’S TEST
• Purpose: Assess for biceps
tendonitis or labrum problem
• Position: Seated with shoulder
elevated 75°–90° in the sagittal
plane, elbow extended, &
forearm supinated
• Technique: Resist elevation
• Interpretation: + test = pain with
biceps tendonitis & sense of
instability with labral px
• Statistics: Sensitivity = 9%–100%
& specificity = 61%–87%
 Yeargason Test
Determine instability and tendinitis of LH of Biceps Brachii
 YERGASON’S TEST
• Purpose: Assess THL
• Position: Seated with shoulder
in neutral, elbow flexed to 90°,
& forearm supinated
• Technique: Resist elbow
flexion with supination
• Interpretation: + test = pain
with
• tenosynovitis; clicking or
snapping with torn LHT (with
resistance from pronation to
supination)
• Statistics: Sensitivity = 9%–
37% & specificity = 86%–96%
 Tests for SLAP Lesion
O’Brien’s Test
Pain elicited when the arm
internally rotated and
elevated against resistance, is
reduced or eliminated when
the arm in supination and
elevated against resistance
 Neer’s Test
Determine a Supraspinatus tear
 Drop Arm Test
Detertmine if there is a tear in the
rotator cuff
Referred Pain From Surrounding Areas
• Cardiovascular Exam.
– Myocardial infarction
• Chest and abdominal
Exam.
– Diaphragm irritation
• Neck Exam.
– Herniated disc
– Spinal injury
• Elbow Exam.
• Wrist Exam.
 Diagnostic imaging
Radiographic examination
• Identify the x-ray film
• Examine methodically the X-
ray film according to a
standard routine
• Interprete the radiographic
findings.
Special Radiographic Techniques
• Find out x-rays using contrast
media (sinography,
arthrography, myelography
and radiography).
• Identify tomography
• identify computed
tomography (CT)
• Identify magnetic resonance
imaging (MRI)
• Identify diagnostic ultrasound.
• Identify radionuclide imaging.
Identification and interpretation
of Radiographs in Orthopaedics
 Identify the General Findings
A. Identify the patient C. Identify the View
• Name • AP view
• Age • Lateral view
• Sex • Oblique view
• Date • Other special views
B. Identify the film D. Identify the side (Left / Right)
• Plain E. Identify the site (metaphyseal
/diaphyseal/proximal/middle/distal)
• Using contrasts (e.g. F. Identify the quality of the film
arthrography) • Well contrasting the soft
• Tomography tissue and bony tissue
• Computed Tomography • including one joint above
(CT) and one joint below
• Magnetic Resonance • comparing one side to the
Imaging (MRI other
 Identify the local findings
1. Soft tissue
– shadow of subcutaneous layer
– Shadow of muscular layer.
– Shadow of soft tissue swelling
2. BONE
A. Cortex
3.
• Alignment and Regularity
• Bone cortical density
(sclerosis, rarefaction,
osteoporosis and
osteolysis)
• Continuity
B. Medulla:
• Alignment and Regularity
• Bone medullary density
(rarefaction/ homogeneous
/ heterogeneous)
• Continuity
JOINTS
• Articular space (narrow /
obliterated)
• Articular surfaces
(Incongruity)
• Articular margins
(Irregularity/spurs)
• Sub-chondral bone
– Subchondral cyst
– Rarefaction / sclerosis