Shoulder examination

Motor physical examination of the shoulder
http://www.youtube.com/watch?v=VSrLbzZzJU8
Source from University of Wisconsin, Department of Family Medicine
STANDARD PROCEDURE OF JOINT EXAMINATIONS
The patient’s shoulders must be exposed for the examination and the affected side must be compared with the unaffected side.
1) Inspection
a. Inspect for gross abnormalities or deformities including evidence of trauma
b. Swelling of the AC joint, erythema, warmth,
c. Asymmetry of both shoulders,
d. Muscle atrophy especially of the supraspinatus, infraspinatus and deltoid muscles
2) Palpation
a. Begin from the SC joint, note any tenderness, palpate the clavicle laterally to the AC joint (soft spot to the distal end of the clavicle)
b. Move over the AC joint and palpate the subacromial bursa
c. Move anteriorly and laterally to the bicipital groove (intertubercular groove), if difficult to locate, externally rotate the humerus and palpating the anterior superior portion of the humeral head and feel the tendon move
d. Medial to the groove is the lesser tuberosity and laterally would be the greater tuberosity
e. Palpate the spine of the scapula and the supraspinatus and infraspinatus muscles


3) Range of motion
a. Ask patient to move both of the arms together
b. If pain limits the movement, then passively assist the patient
c. Useful to ask patient to mimic your own movements
d. First ask patient to lift both arm in front of them to 180 degrees
e. Next ask to extend arm behind back, should be able to reach approximately 40 degrees
f. With hands supinated, move arms in an arc movement, 180 degrees (should be painless) (Abduction)
g. Reverse the motion back to point of start (Adduction)
h. External rotation can be tested with the arms flexed at 90 degrees, ask patient to rotate the arms outwards, approximately 60 degrees is normal
i. Internal rotation can be tested next
j. Ask patient to reach to the neck region, hand should be able to reach the superior medial aspect of the opposite scapula, or just take note of the corresponding vertebrae level (index finger)
k. Reach both hand up back, note vertebrae level, should be able to reach the inferior angle of the scapula, T7 level
4) Strength test (All muscle testing should be graded with the 5 point scale and compared to the other side)
a. Stand to the side and slightly behind the patient, place hand on the shoulder to provide support for the patient, grasp arm with other hand
b. Ask for flexion of elbow and bring arm forward to test the strength of flexion
c. Next push back to you to test strength of extension
d. Ask patient to again flex both arms to test external and internal rotation strength (outward rotation is to test teres minor and infraspinatus, inward rotation test the subscapularis)
e. To test the supraspinatus perform the Jobes test, bring patient’s arm to 90 degrees of abduction and move arms forward by 30 degrees, point thumbs down to the floor like dumping out contents of cans and then ask patient to push up against your hands
f. Test subscapularis with the lift off test, ask patient to put hand with palm facing outwards at the lower back, place your palm with the patient’s palm to offer resistance and ask patient to push his/her hand away from his/her body
5) Special tests
a. Test integrity of the rotator cuff, impingement problems, problems of biceps tendons, labrum tears and shoulder instability
b. Do a drop arm test to test for a rotator cuff tear, specifically the supraspinatus. With palms supinated, ask patient to bring arms to the top (abduction) and slowly bring it down to 90 degrees, if there is a tear the arm would drop and not be able to hold the 90 degree position
c. An impingement test would require you to again stabilize the patient’s scapula and prone her hands. Passively lift the patient’s arms as high as possible, a positive test would be reported as pain by the patient as this moves the rotator cuff muscles under the coraco-acromial arch
d. The Hodkin’s test, flex patient’s arm to 90 degrees, flex elbow and forcibly internally rotate the arm, this moves the greater tuberosity under the coraco-acromial arch impinging the supraspinatus tendon
e. Speed’s test is performed with the arm supinated and raised to shoulder level in front of the patient. Press down and ask patient to resist. This test indicates bicep tendon or labrum pathology.
f. A more sensitive test for labral tear is the O’Brian’s test. Forward flex the patient’s to 90 degrees, adduct about 20 degrees and internally rotate the hand so that thumb faces down, ask patient to resist the downward pressure. Next externally rotate the arm and again ask them to resist the downward pressure. A positive test would be pain or painful clicking when the thumb is down but resolved when the thumb is up.
g. Crank test for labral pathology. Forward flex to 90 degrees, flex elbow. Apply force to the axial while internally and externally rotating the arm. A positive test is pain or painful clicking
h. Last test is for glenohumeral stability. The apprehension test could be done with the patient sitting or standing. Stabilize the scapula. Move to 90 degrees of abduction and externally rotate the humerus. A positive test is a look of apprehension on the patient’s face.
i. The test could be performed with the patient lying down. The relocation test is to apply pressure to the posterior on the proximal humerus and looking at the sense of relieve. The anterior release test for anterior shoulder instability could be shown by a patient’s report of instability or pain after release of the pressure.