Musculoskeletal Curriculum

History & Physical Exam of the Shoulder

Copyright 2005

Authors
Kathleen Carr, MD Madison Residency Program
Kathleen.Carr@fammed.wisc.edu

Dennis Breen, MD Eau Claire Residency Program

Dennis.Breen@fammed.wisc.edu

Goal

Learn a standardized, evidence-based history and physical examination of patients with shoulder problems WHICH WILL:

Enable family medicine resident physicians to accurately diagnose common shoulder problems throughout the full age spectrum of patients seen in family medicine
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Competency-Based Objectives

Patient care focused history and exam

Professionalism respect, compassion

Interpersonal and communication skills
differential diagnosis

Medical knowledge base anatomy, injury

mechanisms

Systems based practice accuracy, time-efficiency

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Shoulder Pain Key Points

Shoulder pain is a common complaint in primary care

2nd only to knee pain for referral to Ortho or primary care sports med

Most common causes in adults (peak ages 40-60)

Subacromial impingement syndrome Rotator cuff problems

Athletic injuries

Shoulder accounts for 8-13% of athletic injuries

History and examination are keys to diagnosis

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Assessing shoulder pain

Components of the assessment include

1. 2. 3.

Focused history Attentive physical examination Thoughtfully ordered tests/studies

for future discussion

Focused History

Focused History Questions

Onset of Pain

When symptoms started* History of trauma/injury

Focused History Questions

Mechanism of Injury

Helps predict injured structure

Example: Fall directly onto anterior/superior shoulderAC joint injury (shoulder separation) Example: Arm forcefully abducted and externally rotated subluxation or anterior dislocation Example: If chronic pain, note activity that triggers pain, such as the cocking phase of throwing or the pull-through phase of swimming
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Focused History Questions

Mechanism of Injury, continued

Can determine radiological needs Likelihood of specific conditions varies

Setting (work, recreation, sports, traumatic, atraumatic) Age of the patient*

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Focused History Questions

Location of pain* Anterior Lateral Superior Posterior Radiation of pain Rotator cuff problems often include pain radiating to upper arm If pain starts in neck and radiates to shoulder, consider cervical spine disease
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Focused History Questions

Consider sources of referred pain

Cervical spine spondylolysis, arthritis, disc disease Cardiac - myocardial ischemia Diaphragmatic irritation Thoracic outlet syndrome Gallbladder disease Complex regional pain syndrome (a.k.a, reflex sympathetic dystrophy)
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Focused History Questions

Characteristics

of pain

Night pain when lying on affected Rotator cuff tear side, muscle atrophy

< 30 yo
> 45 yo, Hx of trauma Painful arc (60-120abduction) Pain > 120 abduction Catching, popping, clicking

Biomechanical, inflammatory
Rotator cuff tear - 35% of pts Subacromial impingement Acromioclavicular joint GH or AC joint arthritis, labral tear
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Focused History Questions

History of instability

Glenohumeral subluxation or dislocation Overhead work, repetitive movements, sports Rest, immobility, medications, other treatments

Aggravating factors

Relieving factors/treatments tried

History of Prior Shoulder Problems or Surgeries

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Differential Diagnosis
Diagnosis
Subacromial Impingement Syndrome Adhesive Capsulitis Acute Bursitis Calcific Tendonitis

Primary Care %
48-72 16-22 17 6

Age
23-62 53 -

Myofascial Pain Syndrome

Glenohumeral Joint Arthrosis Thoracic Outlet Syndrome Biceps Tendonitis

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2.5 2 0.8

64 -

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Physical Exam

Physical Exam - General

Develop a standard routine Alleviate the patient's fears Adequate exposure - bilateral
Males shirtless Females tank top or sports bra

Compare shoulders

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Physical Exam Steps*

Inspection Palpation Range of motion (ROM) Strength testing Special tests

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Inspection

Swelling, asymmetry, muscle atrophy, scars, ecchymosis and any venous distention Note posture (e.g., shoulder protraction) Deformities

Squaring of shoulder - anterior dislocation Scapular "winging" - shoulder instability and serratus anterior or trapezius dysfunction Atrophy - supraspinatus or infraspinatus consider rotator cuff tear, suprascapular nerve entrapment or neuropathy
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Palpation

Sternoclavicular joint Clavicle Acromioclavicular joint Subacromial bursa Coracoid process Bicipital groove Greater tuberosity Lesser tuberosity Scapula (spinatus muscles)

TIP: Start medially at the SC joint, proceed laterally, end posteriorly

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Anterior Shoulder

http://www.nismat.org/orthocor/exam/shoulder.html#Functions
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Posterior Shoulder

http://www.nismat.org/orthocor/exam/shoulder.html#Functions
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Palpation of AC Joint

Patient's arm at his/her side Note swelling, pain, and gapping.

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Palpation of Bicipital Groove

Patient sitting, beginning with the arm straight Patient actively flexes biceps muscle while examiner provides supination and ER Examiner palpates the bicipital groove for pain

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Range of Motion (ROM)

Evaluate active ROM

If movement limited by pain, weakness, or tightness, assist passively Lack of full ROM with active and passive exam is found in adhesive capsulitis and arthropathy

Evaluate bilaterally for comparison

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Range of Motion
Movement Forward flexion Extension (behind back) Abduction Adduction External rotation* Internal rotation* Normal range 180 40 180 (with palms up) 0 45 (arm at side, elbow flexed) 55 (arm at side, elbow flexed)

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Forward Flexion

Arm straight and brought upward through frontal plane, and move as far as patient can go above his head 0 is defined as straight down at patient's side, & 180 is straight up

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Abduction

Arm straight Hand palm up (arm supinated) ROM measured in degrees as for forward flexion

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External and Internal Rotation

Arm at side, elbow flexed to 90 and held at waist Examiner externally or internally rotates arm
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Apley scratch test for ER/IR*

External rotation and abduction Reach for upper scapula Compare bilaterally note level reached

Internal rotation and adduction Reach for lower scapula Compare bilaterally note level reached
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Strength Tests
Flexion

Extension

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Strength Tests*
External rotation
Infraspinatus Teres minor

Internal rotation
Subscapularis

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Strength tests
Empty can test*
Supraspinatus

Lift off test*

Subscapularis

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Special Tests

Rotator cuff

Labral tear

Drop arm test

OBriens test Crank test

Impingement tests

Neers sign Hawkins test

Instability tests

Anterior release Relocation test

Speeds test

Biceps tendon

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Rotator Cuff
Empty Can Test

Supraspinatus Subscapularis integrity

Lift off test

Drop Arm Test

Rotator cuff tear or supraspinatus dysfunction

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Drop Arm Test

Purpose: tears in the rotator cuff, primarily supraspinatus muscle Method: patient abducts (or examiner passively abducts) arm and then slowly lowers it

May be able to lower arm slowly to 90 (deltoid function) Arm will then drop to side if rotator cuff tear

Positive test: patient unable to lower arm further with control

If able to hold at 90, pressure on wrist will cause arm to fall

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Video of Drop Arm Test

Click on image for video

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Impingement - Neers Sign*

Patient seated with arm at side, palm down (pronated) Examiner standing Examiner stabilizes scapula and raises the arm (between flexion and abduction) Positive test = pain

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Video of Neers Sign

Click on image for video

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Impingement - Hawkin's Test*

Patient standing Examiner forward flexes shoulder to 90, then forcibly internally rotates the arm Positive test = pain in area of superior GH joint or AC joint

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Video of Hawkins Test

Click on image for video

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Speeds Test - Biceps tendon

Forward flex shoulder against resistance while maintaining elbow in extension and forearm in supination Positive test = tender in bicipital groove
(bicipital tendinitis)

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Video of Speeds Test

Click on image for video

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Labral Tear (SLAP) - O'Brien's Active Compression Test

Patient standing Arm forward flexed 90, adducted 15 to 20 with elbow straight Full internal rotation so thumb pointing down Examiner applies downward force on arm - patient resists Patient externally rotates arm so thumb pointing up Examiner applies downward force on arm - patient resists Positive test = Pain or painful clicking elicited with thumb down and decreased or eliminated with thumb up
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Video of OBriens Test

Click on image for video

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Labral Tear - Crank Test

Shoulder elevated to 160 in the scapular plane A gentle axial load is applied through glenohumeral joint with one hand, while other hand does IR and ER Positive test = pain, catching, or clicking in the shoulder
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Video of the Crank Test

Click on image for video

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Glenohumeral Joint Stability

Anterior Glenohumeral Instability

Apprehension test Relocation test Anterior release test

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Apprehension Test - Sitting

90 of abduction Examiner applies slight anterior pressure to humerus and externally rotates arm Positive test = patient expresses apprehension

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Apprehension Test

Patient in supine position with affected shoulder at edge of table, arm abducted 90 Examiner externally rotates by pushing forearm posteriorly. Positive test = patient expresses apprehension
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Relocation Test

Performed after positive result on anterior apprehension test Patient supine Examiner applies posterior force on proximal humerus while externally rotating patients arm Positive test = patient expresses relief
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Video of the Apprehension & Relocation Tests Seated & Supine

Click on image for video

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Anterior Release Test

Patient in supine position, arm abducted 90 Examiner performs Relocation Test, then releases downward pressure Positive test = patient expresses pain or instability when the humeral head is released
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Video of Anterior Release Test

Click on image for video

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The Current Evidence Base for History Questions and Physical Exam Tests

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Rotator Cuff Tear

History / Maneuver History of trauma Night pain Study Sens Spec Qual (%) (%)
2b 36 73

LR+
1.3

LR- PV+ PV(%) (%)

0.88 72 37

2b 2b
1b 1b

88 33
84 89 21

20 81
50 58 100

1.1 1.7
1.7 2 >25

0.6 0.83
0.22 0.28 0.79

70 81
36 98 100

43 33
22 93 32
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Painful arc
Empty can test Drop arm

Impingement / Instability
Test
Impingement Hawkins Instability Relocation Apprehension

Study Sens Spec LR+ LR- PV+ PVQual (%) (%) (%) (%)
1b 87 89 57 68 60 2.2 0.18 71 83

2b 2b

100 100

>25 0.43 >25 0.32

100 100

73 78
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AC / SLAP
History / Maneuver AC Active compression SLAP Crank Active compression
1b 100 97 >25 0.01 89 100

Study Sens Spec LR+ LR- PV+ PVQual (%) (%) (%) (%)

2b 1b

91 100

93 99

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0.10

94 95

90 100
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>25 0.01

References
Luime JJ, Verhagen AP, Miedema HS, et al. Does This Patient Have an Instability of the Shoulder or a Labrum Lesion? JAMA. 2004;292:1989-1999.

Stetson WB, Templin K. The crank test, the OBrien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. Am J Sports Med. 2002;30:806-809.
Stevenson JH, Trojian T. Evaluation of shoulder pain. Journal of Family Practice. 2002;51:605-11. Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with Shoulder Examination Part I: The Rotator Cuff Tests. Am J Sports Med. 2003;31:154160. Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with Shoulder Examination Part II: Laxity, Instability, and Superior Labral Anterior and Posterior (SLAP) Lesions. Am J Sports Med. 2003;31:301-307.
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Video of Shoulder Exam

http://www.fammed.wisc.edu/our-department/media/musculoskeletal

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