Minggu, 07 Oktober 2007

Shoulder Examination


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


  • 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 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


  • 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


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

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