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SHOULDER EXAMINATION
Introduction
Shoulder disorders are can be broadly classified into the following types:
- Pain
- Stiffness
- Instability The common disorders arise from diseases of the following structures:
- The Rotator Cuff
- The Glenohumeral joint
- The Acromioclavicular joint
- The Clavicle
- The Neck Naturally there are combinations of the above, but it is worth keeping the above system in mind when examining a shoulder disorder.
Look
From the front, side and above
- Asymmetry, scars, deltoid wasting, SCJ or ACJ deformity, swelling of the joint
From behind
- Look and feel for rotator cuff wasting, scapula shape and situation e.g. winging, Sprengel shoulder etc
Feel
- SCJ to the ACJ and acromion
- Greater and lesser tuberosity, feel for rotator cuff defects
- Glenohumeral joint: anterior and posterior aspects
- Biceps tendon/bicipital groove
- Spine of scapula
Move
ALWAYS EXAMINE THE CERVICAL SPINE FIRST
- Move both arms at the same time. Active then passive ROM.
- Quick screening test: "Arms above the head and behind the back "
- Flexion : 0-180°
- Abduction : 0-180° check for painful arc and watch the scapulohumeral rhythm
- If restricted then repeat with the scapula fixed to check for the amount of glenohumeral movement
- Internal rotation: T
- External rotation : 70°
Feel for crepitation during passive motion
Special tests
1. Subacromial Impingement - Hawkin's test: Shoulder flexed 90º, elbow flexed 90o; internal rotation will cause pain. - Neer's test: Pain eliminated by local anaesthetic injection into the subacromial bursa. - Copeland Impingement Test: Passive abduction in internal rotation (in the scapula plane) painful; pain eliminated with passive abduction in external rotation.
Hawkin’s Test Copeland Empty Can Test
- Drop test : Hold arm fully ER by side and release. If arm drops forward = massive infraspinatus tear.
- Patte's test: 90º flexion, flexed elbow and resisted external rotation
- Hornblower's sign (Emery): similar to Patte's test. Inability to ER & Abduct from hand in front of mouth (against gravity)
- Hornblower's sign (JBJS, 1998) / Drop test: with arm in 90º abduction & ER, elbow 90º (+ve = massive tear of both infraspinatus and teres minor and operative repair will result in 50% failure)
- Yokum Pointing elbow test: place hand on opposite shoulder and ask pt to hold shoulder flexed to 90º
Patte’s test Yokum test
3.3 Subscapularis/anteroinferior cuff:
- Gerber's lift off test: push examiner's hand away from 'hand behind back position' (eliminates pectoralis major)
- Internal rotation lag sign: inability to hold hand away from back
- Napoleon / LaFosse Belly-Press test: if patient cannot fully internally rotate, push on their belly, elbow will drop backwards if positive
Gerber’s Lift Off test Belly-Press test (LaFosse)
4. Biceps - Check for long head of biceps rupture - Speed's test: supinated arm flexed forwards against resistance pain felt in the bicipital groove indicates biceps tendon pathology - Yergason's test: feel for subluxation of the biceps tendon out of the bicipital groove when the arm is gently internally and externally rotated in adduction - AERS test: Abduction External Rotation Supination test. Pt feels pain on resisted supination in this position. Test with elbow abducted & ER to 90o.
Speed’s test AERS test (LaFosse)
5. Deltoid: resisted abduction at 90º 6. Serratus anterior : "Winging" test – performed best with arms at waist level pushing forward against a wall.
Laxity Grade Description Normal Mild Translation (0-25%) Grade 1 Feeling of Head riding onto rim (25-50%) Grade 2 Head over rim, reduces spontaneously (>50%) Grade 3 Head over rim, remains dislocated
7.2. STABILITY TESTS
o These tests examine the ability of the shoulder to resist challenges to stability in positions where the ligaments are normally under tension.
7.2.1. Apprehension Test
The patient sits with the back toward the examiner. The arm is held in 90 degrees of abduction and external rotation. The examiner pulls back on the patient's wrist with one hand while stabilising the back of the shoulder with the other. The patient with anterior instability usually will become apprehensive with this maneuver. No translation is expected in the normal shoulder because this test is performed in a position where the anterior ligaments are placed under tension.
7.2.2. Relocation Test (Jobe)
The relocation test is performed immediately after a positive result on the anterior apprehension test. With the patient supine, the examiner applies posterior force on the proximal humerus while externally rotating the patient's arm. A decrease in pain or apprehension suggests anterior glenohumeral instability.
Anterior Apprehension Jobes Relocation
7.2.3. Posterior Apprehension Test (Jerk Test)
The patient sits with the arm internally rotated and flexed forward to 90 degrees. The examiner grasps the elbow and axially loads the humerus in a proximal direction. While axial loading of the humerus is maintained, the arm is moved horizontally across the body. A positive test is indicated by a sudden jerk as the humeral head slides off the back of the glenoid. When the arm is returned to the original position of 90-degree abduction, a second jerk may be observed, that of the humeral head returning to the glenoid.
