Anthony Luke MD, MPH
The glenohumeral joint is the most mobile joint in the body, but the large multi-directional range of motion is a trade-off for joint stability. The lack of stability makes the shoulder more susceptible to a large spectrum of injuries, especially with overhead activities involved in sports such as baseball, volleyball, swimming and weight lifting. The shoulder girdle is important because is serves as the connecting joint between the arm and the axial skeleton. It serves as the base of support for movements occurring at the elbow, wrist and hand.
During an examination, taking a thorough history is as important as the physical exam itself. The clinician should inquire about the patient?s hand dominance, as well as their occupation and recreational activities. It is also important to establish their chief complaint, which may include pain, instability, weakness, or loss of range of motion. Complaints of numbness and tingling may be associated with neurovascular disorders, and stiffness may suggest adhesive capsulitis and/or arthritis. Furthermore, any crepitus may indicate bursa, osteoarthritis or rotator cuff pathology. It is also important to have patients try and establish an approximate timeline for when the injury occurred and what event or mechanism, if any, lead to the injury or onset of symptoms. For patients who report a dislocation, it should be asked what position the arm was in at the time of the dislocation, and what the frequency of dislocations or subluxations were. Finally it is important to establish what type of activities of daily living the patient can and cannot perform. Such activities include simple everyday tasks like getting dressed, lifting an object overhead, sleeping on the shoulder, brushing your teeth, combing your hair, putting on shoes, and carrying or lifting objects like groceries.
There are several important bony and soft tissue structures that need to be palpated during the shoulder physical exam. Bony structures should include: the sternoclavicular joint, the clavicle, the acromioclaviular joint, the coracoid process, the borders of the scapula, and the greater and lesser tuberosities of the humerus. Soft tissue landmarks should include: the subacromial bursae, the supraclavicular fossa, the long head of the biceps tendon, the trapezius, and other associated muscles and tendons.
Range of Motion
Active range of motion performed by the patient is typically assessed first, and can be affected by both pain and motor function. The patient can be either seated or standing during the assessment, and movements to be tested should include forward flexion, extension, internal/external rotation, and abduction/adduction.
Active Range of Motion: Forward Flexion and External Rotation
Active Range of Motion: Internal Rotation
Passive range of motion is performed by the clinician with the patient seated or supine in the same planes previously stated. This is used to isolate motion for an accurate evaluation of soft tissue.
Passive Range of Motion: Horizontal Adduction
Normal motion for forward flexion is considered to be 0° to 170-180°, while normal extension is said to be 60°. For internal and external rotation, the arm should be abducted to 90° for an accurate measurement. Normal internal rotation is said to be 90°, while normal external rotation is around 60-70°. It is important to keep in mind that these values can vary greatly with patients who are overhead athletes, such as baseball or softball players. For adduction, the assessment is normally limited due to the trunk, but typically 30° is considered normal. Abduction motion can range from 0° to 180°
An example of limited passive range of motion can be seen in cases of frozen shoulder.
Frozen Shoulder: External Rotation
To improve range of motion, special exercises such as Codman’s Pendulum can be performed to help relax the muscles around the shoulder, reduce pain, and increase motion.
Have the patient standing in a relaxed position, and tell them to swing their weak arm in a circular motion while keeping their shoulder nice and relaxed. Be sure they swing their arm in both the clockwise and counterclockwise directions.
Rotator Cuff Strength Testing:
Empty Can Test
Description: The empty can test is used to evaluate the strength and integrity of the supraspinatus muscle and tendon.
Maneuver: Have the patient stand with their shoulder abducted to 90° and horizontally adducted forward 30° with the thumbs pointing down towards the floor, as if they are pouring out a can. Ask the patient to maintain this position. Proceed to apply downward resistance to the patient’s forearm. A variation of this test can be done at 30° abduction instead of 90°, where the supraspinatus should function in relative isolation.
Positive findings: Decreased strength or pain on resisted testing.
Description: The external rotation test examines the strength of the infraspinatus and teres minor.
Maneuver: With the patient’s arms at their side, externally rotated 45° and elbow flexed to 90°, the examiner applies an internal rotation moment to assess the strength of the external rotators.
Positive Findings: Decreased strength or pain on resisted testing. Significant weakness of the infraspinatus may be indicative of suprascapular nerve palsy, where the infraspinatus become denervated. This can be due to trauma, ganglion cyst or illness.
Subscapularis Lift-Off Test
Description: The lift off test evaluates the muscular strength of the subscapularis.
Maneuver: With the patient seated or standing, have them internally rotate their arm behind their back. Then ask the patient to lift the back of their hand off their lower back. If they are unable to complete this task, apply resistance to the palm to assess the strength of the subscapularis.
Positive findings: Inability to lift the dorsum of hand off the back.
Impingement/Rotator Cuff Special Tests:
Description: The Neer impingement test assesses the presence of impingement of the rotator cuff, primarily the supraspinatus, as it passes under the subacromial arch during forward flexion.
Maneuver: Stabilize the scapula with one hand while applying passive forced flexion of the arm.
Positive findings: Pain in the anterior shoulder or reproduction of the patient’s symptoms.
Hawkin’s Kennedy Impingement Test
Description: The Hawkin’s test is used to evaluate impingement of rotator cuff and subacromial bursa.
Maneuver: The patient is seated or standing and with their arm forward flexed to 90°and their elbow bent to 90°. Stabilize the top of he shoulder while internally rotating the arm at the forearm.
Tip: Stand at the side of the patient with one hand on top of the shoulder and keep the patient from elevating the shoulder. The other hand should be positioned close to the elbow with the thumb down, making it more comfortable for the examiner to internally rotate the arm. The test should not be done with the arm abducted.
Positive Findings:Pain in the anterior shoulder or reproduction of the patient?s symptoms with the test.
Instability Special Tests:
Load and Shift Test
Description: The Load and Shift test examines integrity of shoulder stability in the anterior and posterior directions.
Maneuver: Have the patient seated or supine with their arm relaxed and resting at their side. Grasp the head of the humerus with thumb and fingers and apply an anterior and posterior glide from the resting position.
Positive Findings: Excessive gliding of the humeral head is considered to be a positive test. The degree of stability can be graded based on the following: Grade 0 is no gliding from the center of the glenoid, Grade 1 equals translation to the glenoid rim, Grade 2 translation of the head over the glenoid rim but no locking, and Grade 3 results in the head of the humerus locking over the glenoid rim.
Description: The apprehension test, described by Row and Zarin, tests for anterior instability of the shoulder. The relocation test, described by Jobe, is used in conjunction with the apprehension test to distinguish between anterior instability and primary impingement of the shoulder.
Maneuver: : To perform the apprehension test, have the patient supine, with their arm abducted and elbow flexed to 90°. Gently externally rotate the arm. Once the patient becomes apprehensive or complains of pain, proceed with the relocation and surprise test by applying a posterior force to the humeral head.
Positive Findings: For the apprehension test, the patient may complain of pain or be apprehensive that their arm may dislocate as it is externally rotated. The relocation test is positive if the symptoms of apprehension reduce, or if the clinician is able to externally rotate the shoulder further without any increase in pain or apprehension. If the symptoms persist following the posterior directed force, the pain is associated with primary impingement and not anterior shoulder instability.
Description: The sulcus sign tests for inferior instability caused by laxity of the inferior glenohumeral ligament complex.
Maneuver: : Have the patient seated with their arm resting at their side. Grasp the patient’s upper arm and apply a distal force to it.
Positive Findings: Increased inferior movement of the humeral head or the visible development of a sulcus at the glenohumeral joint are positive findings. A positive test can often suggest that the patient has multidirectional instability, espeically if there are other signs of join instability.
Labral Special Tests:
Description: This test examines the integrity of the glenoid labrum and the acromioclavicular joint.
Maneuver: With the patient seated or standing, instruct the patient to raise their arm into 90° of forward flexion with their elbow extended, and then adduct their arm 10-15°. Have the patient internally rotate their arm and point their thumb down to the ground. Apply a downward force to the arm. Then instruct the patient to externally rotate their arm and point their thumb towards the ceiling. Again, apply a downward force.
Positive Findings: Positive findings for labral pathology occur when the first test reproduces pain, while the second test decreases or eliminates pain. The pain associated with labral tears is described as being deep in the shoulder. Pain situated over the acromioclavicular joint is associated with acromioclavicular joint pathology such as osteoarthritis or a shoulder separation, rather than labral pathology. Pain in the AC joint is usually equal with the palm down or the palm up.