- See:
-
Diff
Dx of Shoulder Pain:
-
Shoulder Examination Tests (from shoulderdoc.co.uk)
- History:
(questions for modified Simple Shoulder Test);
-
C-Spine:
- r/o
radiculopathy as well as axillary nerve hypaesthesia;
- Spurling's manuever:
- mechanical stress, such as excessive vertebral motion, may
exacerbate symptoms;
- gentle neck hyperextension w/ head tilted toward affected side will
narrow size of neuroforamen and
may
exacerbate symptoms or produce radiculopathy;
- Shoulder Tenderness:
- anterior capsule / biceps tendon;
- AC joint;
- posterior sulcus;
- ROM:
-
active and passive abduction of shoulder/scapular
thoracic complex;
- see
abductors of
the shoulder
- view from behind to note symmetry and possible
winging of scapula;
- combines glenohumeral and scapulothoracic motion;
- be sure to have patient abduct the arm in the scapular plane
(30-40 deg
anterior to the coronal plane);
- abduction should be measured with simultaneous maximal abduction of
both arms, as the angle
formed by
the humeral shaft and the midthoracic line;
- functional evaluation:
- bring hand actively behind the neck with the elbow above the
acromion;
- bring the elbow straight forward from that position,
actively positioning the hand on top of the
head with the elbow over the acromion;
- bring the elbow straight forward from that position, and
fully elevate the arm from that position;
- the hand is not allowed to touch the head or neck during
these functional movements;
- references:
- The movements of shoulder joint. A plea for use of 'plane
of scapula' as plane of reference for
movements occuring as humero-scapular joint. TB Johnson. Br. J. surg. Vol 25.
1937. 252-260.
-
IGHE: isolated glenohumeral elevation:
-
IR: internal rotation: (ability to touch thoracic spine);
- loss of internal rotation may be especially common in
throwing
shoulders;
- contracture of the posterior capsule will prevent the normal
posterior translation/rotation when
the arm is
elevated;
- the result is superior elevation of the humeral head with
elevation and accentuation of impingement; ;
- references:
-
Reliability, Precision, Accuracy, and Validity of Posterior
Shoulder Tightness Assessment in
Overhead Athletes
-
Posterior Capsular Contracture of the Shoulder
-
Quantification of Posterior Capsule Tightness and Motion Loss in Patients with
Shoulder Impingement
-
ER: external rotation: (both in adduction and abduction)
- particular attention should be paid to external rotation a 0 and 90
deg of abduction;
- loss of a small amount of external rotation can result in
subacromial impingement, and this impingement
prevents the
greater tuberosity from rotating clear of the acromion during arm elevation;
- when there is more external rotation in the injured shoulder than
the non injured shoulder, consider the
diagnosis of
subscapularis rupture;
- excessive ER with the arm at the side (rotation of >90 deg), may be
an indicator of shoulder hyperlaxity
and a risk factor
for postoperative instability
- ref:
Elbow Valgus Laxity May Result in an Overestimation of Apparent Shoulder
External Rotation
During Physical
Examination
- Motor Exam::
-
trapezius:
-
rhomboids:
-
supraspinatus:
- supraspinatus muscle is tested with the shoulder abducted 90
degrees, flexed 30 deg and then
maximally
internally rotated;
- downward pressure is resisted primarily by the supraspinatus;
-
infraspinatus:
- dropping sign:
- tests power of external rotation at 0 deg of abduction;
- patients forearm is placed in 45 deg of external rotation, and
patient is asked to externally rotate
against examiner's hand;
- if the patient's arm falls back to 0 deg of external rotation
then a positive test is recorded;
- 100% sensitivity and 100% specificity for irreparable
degeneration of the infraspinatus;
-
teres minor:
- responsible for 45% of power of external rotation;
- hornblower's sign:
- power of external rotation in 90 deg of abduction in the
scapular plane;
- the examiner places the patient's forearm in 90 deg flexion w/
maximal external rotation;
- the examiner's other hand is used to judge external rotation
force;
- when the examiner's hand is released a positive test is
recorded if the patient is unable to externally
rotate;
- 100% sensitivity and 93% specificity for irreparable
degeneration of teres minor;
-
subscapularis:
- positive lift-off test:
- indicates a tear of the subscapularis
- patient is unable to lift the hand away from his back while
maximally internally rotated
-
deltoid:
-
biceps:
- references:
- The "dropping" and "hornblower's" signs in evaluation of rotator cuff
tears. G. Walch et al.
JBJS Vol 80-B. No
4. July 1998. p 624.
- Impingement and Rotator Cuff Test::
-
impingement sign and test:
-
drop arm test: for rotator cuff tears;
- have the patient abduct his arm to 90 degrees and then ask him to
lower his arm to his side slowly
while the
examiner applies gentle pressure;
- at approximately 30 deg of abduction, the patient will no longer be
able to gradually lower his arm and
it
will fall to his side;
-
AC joint:
- arm is placed into forced adduction while surgeon palpates AC joint
and notes any possible instability
and or
tenderness;
- note that posterior tenderness from hyper-adduction of the shoulder
may result from posterior
capsular
tenderness;
- Tests for Instability::
-
sulcus sign: (for
multidirectional instability)
- a gap between the humeral head and undersurface of the acromion;
- appears when the longitudinal traction is placed on the humeral
shaft w/ arm at side while in a seated
position;
- the sulcus sign is felt to be pathognomonic of multidirectional
instability;
- upto 1 cm of displacement may be normal, where as displacement of 3
cm is severe;
-
exam for anterior instability:
-
rotatory stress test:
- for determining presence of
Bankart Lesion:
-
posterior instability:
-
jerk test: pt's arm is abducted to 90 deg
and internally rotated;
- the examiner axilly loads the humerus while the arm is moved
horizontally across the body
- the left hand stabilizes the scapula;
- look for a sudden jerk as the humeral head slides off the
back of glenoid;
- ref:
-
Painful jerk test: a
predictor of success in nonoperative treatment of posteroinferior instability
of the shoulder.
-
Capsulolabral augmentation for the the management of posteroinferior instability
of the shoulder.
-
SLAP tear:
-
speed's test:
- used to examine the proximal tendon of the long head of
the biceps
- forward flex the shoulder (60 deg) against resistance while
maintaining the elbow in extension and
the forearm in supination
- tenderness in the bicipital groove in dicates bicipital
tendinitiss
- obrien's test
maximal internal rotation;
- grab the patient's wrist and resists the patient's attempt to
horizontally adduct and forward
flex the shoulder
- ref::
-
An evaluation of the anatomic basis of the O'Brien active compression test for
superior labral
anterior and posterior (SLAP) lesions.
-
The crank test, the O'Brien test, and routine magnetic resonance imaging scans
in the diagnosis
of labral tears.
- Vascular Exam::
- need to rule out
thoracic
outlet syndrome;