Shoulder Examination

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 ^o
• Abduction : 0-180 ^o check for painful arc and watch the scapulothoracic rhythm
• If restricted then repeat with the scapula fixed to check for the amount of glenohumeral movement
• Internal rotation: T4
• External rotation : 70 ^o

Feel for crepitation during motion

Special tests

1. Impingement

• Neer's sign: Hold scapula down, pronate forearm and flexion will cause pain
• Hawkin's test: Flexion to 90 ^o internal rotation will cause pain
• Neer's test: Pain caused by Neer's test eliminated by local anaesthetic injection
• Scarf test: forced cross body adduction in 90 ^o flexion, pain at the extreme of motion indicative of ACJ pathology

2. Rotator cuff Integrity

Supraspinatus/anterosuperior cuff:

• Resisted abduction with arms by side
• Jobe's test: arm abducted to 20, in the plane of the scapula, thumb pointing down

Infraspinatus+teres minor/posterior cuff:

• Resisted ER with the arms by side
• Drop test : with arms fully ER by side (= massive infraspinatus tear)
• Patte's test: 90 ^o 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 90 ^o abduction & ER, elbow 90 ^o (+ve = massive tear of both infraspinatus and teres minor and operative repair will result in 50% failure)
• Pointing elbow test: place hand on opposite shoulder and ask pt to hold shoulder flexed to 90 ^o

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 test: if pt cannot fully internally rotate, push on their belly, elbow will drop backwards if +ve

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 90 ^o .

Deltoid: resisted abduction at 90 ^o

Serratus anterior : "Winging" test

3. Instability testing

Patient supine

• Anterior and posterior draw "Lachmann of the shoulder"(Gerber and Ganz)

Patient seated

• Inferior draw "sulcus sign"

• Anterior subluxation test: abduction and external rotation "apprehension test" with thumb posteriorly and fingers anteriorly over humeral head
• Posterior subluxation test: internal rotation, adduction, flexion and push posteriorly

• More Detail on Instability Tests

Imaging

XR: AP, Lateral/axial/trans-scapular/Wallace, sub-acromial view

CT: good for glenoid fractures

MR: Good for labral tears anteriorly-inferiorly-posteriorly. Not superiorly

OK for rotator cuff pathology

USS: Now thought to be superior to MR for rotator cuff pathology but operator dependent