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General setup
Patient will be examined in both the seated and supine position so exam table needed 360 degree access to patient Expose neck and both shoulders (for comparison); female in gown or sports bra
Inspection
Skin and tissues: evaluate for bruising, swelling, prior scars, etc. Evaluate for muscle atrophy o Chronic RTC disease o Chronic scapular notch cysts causing nerve impingement o Chronic brachial plexopathy Evaluate for deformity: biceps (popeye deformity), AC joint, SC joint, clavicle, chest wall (pectoralis injury) Evaluate scapular position/winging (wall-pushups will expose this better if suspected) o Marked winging indicates weakness of serratus anterior (long thoracic nerve) o Observe how the scapula tracks with active forward elevation and active abduction Medial border winging laterally is common cause of shoulder impingement pain: Tx with PT for scapular stabilizer strengthening to improve mechanics and decrease impingement pain
Palpation for tenderness/crepitus
AC joint SC joint Biceps groove Sub-acromial space/bursa Posterior glenohumeral joint line Superior and medial border of scapula- bursitis/snapping scapula
Neck
Range of motion Scoliosis/kyphosis Tenderness Spurling’s sign – Passive head rotation toward affected side, with neck extension and compression o Positive if dermatomal radicular pain occurs Shoulder shrug-trapezius strength (spinal accessory nerve-cranial nerve XI) Thoracic outlet syndrome examination: o Roos test – Hands held overhead, repeated hand clasps for 1 minute Positive if arm symptoms are reproduced o Adson test – Arm extended with neck extension and rotation toward the affected side Positive if loss of radial pulse or symptoms reproduced with inhaling
Neurologic exam
C5- Deltoid and biceps strength; lateral deltoid sensation; biceps reflex C6- Biceps and wrist extension strength; lateral forearm/thumb sensation; brachioradialis reflex C7- Triceps strength; middle finger sensation; triceps reflex C8- Interossei strength; ulnar forearm/5th^ finger sensation; no reflex
Shoulder range of motion (bilateral)
Six basic shoulder motions are: Elevation (scaption), abduction, adduction, external rotation, internal rotation, extension If stiffness is suspected with active ROM, supine position or sitting position while stabilizing the scapula is more accurate information about true glenohumeral joint range of motion. o Limited AROM and PROM Causes: arthritis, frozen shoulder, deformity/facture o Limited AROM but normal PROM Causes: pain, functional weakness
Strength evaluation, Subscapularis (Continued)
Napolean Belly press (superior subscapularis) palm of hand against abdomen, internal rotation with elbow anterior to plane of body o Positive if elbow can’t reach or be maintained anterior to plane of body while palm remains flat on abdomen (patient may cheat by palm coming off of abdomen) Lift off (inferior subscapularis) Dorsum of hand placed on upper lumbar spine o Positive if patient unable to lift hand off of lumbar spine against resistance o Can modify test by passively lifting hand away from lumbar spine and releasing Positive if patient can’t maintain hand off lumbar spine o Teres Minor ER strength tested at 90 degrees abduction (in scapular plane ie. scaptation) and 90 degrees ER Hornblower’s sign – positive when arm drifts into IR when put into 90 degrees scaptation and 90 degrees ER
Can grade strength out of 5 o 5/5 – full o 4/5 – weakness detected o 3/5 - able to hold against gravity only o 2/5 – can’t hold against gravity o 1/5 – visible muscle contraction only o 0/5 – no muscle contraction
Test general upper extremity strength if suspect neurologic process (along with sensation and reflexes)
Shoulder stability evaluation
Asses for generalized ligament laxity with Beighton scale: 4/9 or greater score suggests hypermobility syndrome: o Thumb-forearm test 0-2 points o 5 th^ finger hyperextension beyond 90 degrees 0-2 points o Elbow recurvatum beyond 10 degrees 0-2 points o Knee recurvatum beyond 10 degrees 0-2 points o Hands flat on floor with knees extended 0-1 points
Sulcus test for inferior capsular laxity (often positive in multi-directional instability/rotator interval disease (seated) o Patient is seated, arm relaxed, examiner pulls down on arm and looks for sulcus off lateral acromion >1cm sulcus that stays with ER at side positive for pathologic rotator interval lesion
Anterior and posterior load-shift test (supine) o 40 degrees abduction, 90 degrees FE; examiner applies axial load to the arm along with anterior/posterior forces Positive if increased translation to contralateral side
Anterior and posterior apprehension tests (supine) o 90 degrees abduction, >90 degrees ER (maximum) Positive if patient experiences apprehension/feelings of instability (typically anterior) Relocation test – posterior force on humeral head in position of apprehension Positive if patient’s apprehension is relieved
Jerk test (posterior instability) o Sitting position, 90 degrees FE and 90 IR; posteriorly directed force in this position Positive if maneuver causes a “clunk” or pain
Cross-body Adduction Test – AC joint
Patient Position Seated or standing. Examiner Position At side or behind patient. Procedure Position the arm at 90° flexion and then adduct across front of body. Positive Test Localized pain at AC joint.
Speed’s Test – Biceps
Patient Position Sitting or standing, elbow extended, palm towards the ceiling, with shoulder slightly flexed.
Examiner Position Lateral to patient. Palpate the bicipital groove with one hand. Then place other hand over top of distal forearm.
Procedure Instruct the patient to move arm upward against your resistance, moving through the full range of motion.
Positive Test Pain on the biceps tendon in the bicipital groove or pain in the superior portion of the glenohumeral joint. Indicates inflammation of the biceps tendon, or possible biceps tendinopathy (SLAP lesion)
O’Driscoll Test – SLAP test
Patient Position Seated or standing. Examiner Position Beside or behind patient. Procedure Bring arm to abducted and externally rotated position – raise and lower arm. Positive Test Deep seated superior shoulder pain +/- popping.
Yergason’s Test
Patient Position Sitting or standing, elbow flexed to 90°, and forearm midway between pronation and supination (thumb towards ceiling), humerus alongside trunk.
Examiner Position Lateral to patient. Palpate the bicipital groove to orient the patient to the location of pain related to the evaluation. Place other hand over top of distal forearm.
Procedure Instruct the patient to actively flex their elbow and supinate their forearm while examiner resists the motion.
Positive Test Pain or snapping in the bicipital groove or pain in the superior portion of the glenohumeral joint. Indicates tear or laxity of bicipital tendon in groove, or possible bicep tendinopathy (SLAP lesion).
