Shoulder examination

Question 1

Special tests for shoulder examination?

Answer 1

1. Empty can test
2. Painful arc
3. External rotation against resistance
4. Internal roation against resistance
5. External rotation in abduction
6. Scarf test

Question 2

Empty can test

Answer 2

This clinical test assesses the function of the supraspinatus muscle.

1. Abduct the patient’s arm to 90° and then angle the arm forwards by approximately 30° so that the shoulder is in the plane of the scapula.
2. Internally rotate the arm so that the thumb points down towards the floor.
3. Now push down on the arm whilst the patient resists.

This test assesses for weakness and/or impingement of supraspinatus. Weakness may represent a tear in the supraspinatus tendon or pain due to impingement.

Question 3

Painful arc

Answer 3

This clinical test assesses for impingement of supraspinatus.

1. Passively abduct the patient’s arm to its maximum point of abduction.
2. Ask the patient to lower their arm slowly back to a neutral position.

Impingement or supraspinatus tendonitis typically causes pain between 60-120° of abduction, however, this test is not specific as many other conditions can cause pain in this arc of motion and therefore it should not be used in isolation for diagnosis.

Question 4

External rotation against resistance test

Answer 4

This clinical test assesses the function of the infraspinatus muscle and teres minor.

1. Position the patient’s arm with the elbow flexed at 90°and in slight abduction (the abduction tests whether the patient can keep the arm externally rotated against gravity).
2. Passively externally rotate the arm to its maximum.

Pain on resisted external rotation may suggest infraspinatus tendonitis.

If the arm falls back to internal rotation or there is a loss of power it may suggest a tear in the infraspinatus or teres minor tendon, muscle wasting and/or a lower motor neurone lesion (suprascapular or axillary nerve).

Question 5

External rotation in abduction?

Answer 5

This clinical test assesses the function of the teres minor muscle.

1. Position the arm in 90° of abduction and bend the elbow to 90°.
2. Passively externally rotate the shoulder to its maximum degree.

An inability to keep the arm in this position (i.e the arm falls back to internal rotation) is known as “Hornblower’s sign” and can be caused by teres minor pathology or an axillary nerve lesion.

Question 6

Internal rotation against resitance

Answer 6

This clinical test assesses the function of the subscapularis muscle.

1. Ask the patient to place the dorsum of their hand on their lower back.
2. Apply light resistance to the hand (pressing it towards their back).
3. Ask the patient to move their hand off their back.

If the patient is unable to move their hand off their back this may indicate pathology of the subscapularis muscle (e.g. tendonitis/tear) or a subscapular nerve lesion.

Question 7

Scarf test?

Answer 7

The scarf test assesses the function of the acromioclavicular joint.

1. Passively flex the shoulder joint to 90° and ask the patient to place the hand on the side you are examining on to the contralateral shoulder.
2. Apply resistance to the elbow in the direction of the contralateral shoulder.

If the patient experiences pain the test is considered positive and suggestive of acromioclavicular joint pathology (e.g. osteoarthritis).

Question 8

Completion of spinal examination?

Answer 8

Neurovascular examination of the upper limbs.
Examination of the joints above and below (cervical spine and elbow joint).
Further imaging if indicated (e.g. X-ray and MRI)

Question 9

LOOK aspect of shoulder examination?

Answer 9

Front: Head and neck posture, symmettry of shoulders, deltoid wasting, alignment of the shoulder girdle, scars
Side: Scars
Back: Scars, deltoid wasting, alignment of the shoulder girdle, trapezius wasting, paravertebral muscle wasting, scoliosis, winged scapula
Ask patient to press both hands against a wall, look for winged scapula

Question 10

FEEL aspect of shoulder examination?

Answer 10

Assess joint temp 
Palpate shoulder girdle 
Palpate acrimo-clavicular joint
Coracoid process
Head of humerus 
Greater tuberoscity of humerous 
(From behind) boarders of spine and scapula

Question 11

Active movements in shoulder examination?

Answer 11

1. Hands behind head - SHOULDER ABDUCTION & EXTERNAL ROTATION with elbow flexion
2. Hands behind back as far as possible - SHOULDER INTERNAL ROTATION
3. Palm down, bring arms forward to ceiling - ACTIVE SHOULDER FLEXION
4. Bring arms back and extend to behind - ACTIVE SHOULDER EXTENSION
5. Bring arms out to side and up to seiling (ACTIVE SHOULDER ABDUCTION)
6. Bring arms back down and across, and inwards - ACTIVE SHOULDER ADDUCTION
7. Make two fists and flex elbow to 90 degrees with elbows in, rotate outwards - ACTIVE SHOULDER EXTERNAL ROTATION
8. Bring back in all the way to chest - ACTIVE SHOULDER INTERNAL ROTATION
9. Move arm out to the side and to ceiling whilst feeling the scapular - SMOOTHNESS OF SCAPULAR MOVEMENT

Question 12

Normal range of shoulder flexion?

Answer 12

150-180 degrees

Question 13

Shoulder extension normal range?

Answer 13

40 degrees

Question 14

Normal range of shoulder abduction?

Answer 14

Up to 180

Question 15

Normal range of active shoulder adduction?

Answer 15

30-40 degrees

Question 16

Normal range for active shoulder external rotation?

Answer 16

80-90 degrees

Question 17

Normal range for active internal shoulder rotation?

Answer 17

80-90 degrees

Question 18

PASSIVE movements on shoulder examination?

Answer 18

Feel for creptis:

1. Flexion
2. Extension
3. Abduction
4. Adduction
5. External rotation
6. Internal rotation

Question 19

Summary of shoulder examination?

Answer 19

E.g. Normal

1. On visual examination no obvious deformities, muscle wasting or scars.
2. No palpation the patient had no pain.
3. Full range of motion on active and passive movements.
4. Special tests were all unremarkable.

Question 20

What might muscle wasting on general inspection of the shoulder joint suggest?

Answer 20

Wasting of muscles: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron lesion

Question 21

What might asymettry of the shoulder girdle suggest?

Answer 21

Scoliosis
Arthritis
Fractures
Dislocation

Question 22

What might cause asymetrical shoulder size?

Answer 22

Any evidence of asymmetry in the size of the shoulder joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, dislocation).

Question 23

What might an abnormal bony prominence on inspection of the shoulder suggest?

Answer 23

Abnormal bony prominence: may indicate fracture (e.g. clavicular fracture) or anterior dislocation of the glenohumeral joint.

Question 24

What might deltoid muscle wasting suggest on inspection of the shoulder?

Answer 24

Deltoid wasting: note any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary nerve injury.

Question 25

What might trapezius muscle asymmetry suggest on inspection of the posterior shoulder?

Answer 25

Trapezius muscle asymmetry: suggestive of muscle wasting secondary to disuse atrophy or a spinal accessory nerve lesion.

Question 26

On inspection of the posterior shoulder, what might supraspinatus and infraspinatus asymettry suggest?

Answer 26

Suggestive of muscle wasting secondary to chronic rotator cuff tear or a suprascapular nerve lesion.

Question 27

How to look for winged scapula and what causes it?

Answer 27

ask the patient to push against a wall with both hands spaced shoulder-width apart whilst you inspect the back. The protrusion of a scapula (known as scapular winging) is suggestive of ipsilateral serratus anterior muscle weakness, typically secondary to a long thoracic nerve injury.

Question 28

Examination features of rotator cuff tare?

Answer 28

Pain over the lateral aspect of the shoulder
Inability to abduct the arm above 90 degrees
Tenderness over the greater tuberosity and subacromial bursa regions
Supraspinatus and infraspinatus atrophy
Positive empty can test
Positive Gerber’s lift off test
Positive posterior cuff test

Question 29

Investigation of a rotator cuff tare?

Answer 29

X ray - r/o fracture

USS/ MRI

Question 30

How to manage rotator cuff tare?

Answer 30

Conservative management is preferred in patients who are not limited by pain or loss of function, or those who have significant co-morbidities and unsuitable for surgery.

Conservative Management
Those who are presenting within 2 weeks since injury can be managed conservatively, including analgesia and physiotherapy with activity modification.

Surgical Management
For those presenting 2 weeks since the injury or remaining symptomatic despite conservative management may be referred for surgical intervention. Large and massive tears should also be considered for surgical repair.

Repairs can be done arthroscopically (allowing for earlier recovery) or via open approach (preferred in large or complex tears)

Prognosis following surgical repair overall tends to be very good, however those with large or massive tears, age >65yrs, poor compliance with rehabilitation programs, or current smokers often have worse outcomes.

Question 31

Clinical features of frozen shoulder?

Answer 31

Generalised deep pain - radiates to biscep - disturbs sleep
Joint stiffness
Loss of arm swing
Atrophy of deltoid muscle
Generalised tenderness on palpation
Limited ROM - external roatation and flexion of the shoulder

Question 32

How is frozen shoulder diagnosed?

Answer 32

The diagnosis of adhesive capsulitis is typically a clinical one, therefore can be made by clinical features alone.

Plain film radiographs are generally unremarkable, but importantly can be used to rule out acriomioclavicular pathology or atypical presentations of fractures.

MRI imaging can reveal a thickening of the glenohumeral joint capsule in adhesive capsulitis (Fig. 2), but also can be used to rule out other conditions affecting the shoulder, such as subacromial impingement syndrome.

The condition is more common in diabetic patients, therefore anyone presenting with adhesive capsulitis without any risk factors or precipitating events, HbA1c and blood glucose measurements may be useful.

Question 33

Management of frozen shoulder?

Answer 33

Adhesive capsulitis is a self-limiting condition however recurrence is not uncommon. Recovery usually occurs over months to years and a proportion of patients will never recover full range of movement.

Initial management of the patient involves education and reassurance. Patients should be encouraged to keep active; all patients should receive physiotherapy and advice concerning appropriate shoulder exercises.

Management of pain initially begins with simple analgesics. Glenohumeral joint corticosteroid injections may be considered for those patients failing to improve.

Surgical Intervention
For patients with no improvement following prolonged engagement with full conservative treatment efforts and when symptoms significantly affect quality of life, surgical intervention may be considered.

Potential surgical interventions include joint manipulation under general anaesthetic to remove capsular adhesions to the humerus, arthrogaphic distension, or surgical release of the glenohumeral joint capsule.

Question 34

Clinical features of subacromial impingement syndrome?

Answer 34

Progressive anteriour superior shoulder pain
Exaccerbated by abduction
Relieved by rest
Secondary weakness and stiffness

Neers Impingement test – The arm is placed by the patient’s side, fully internally rotated and then passively flexed, and is positive if there is pain in the anterolateral aspect of the shoulder.

Hawkins test – The shoulder and elbow are flexed to 90 degrees, with the examiner then stablising the humerus and passively internally rotates the arm, and the test is positive if pain is in the anterolateral aspect of the shoulder.

Question 35

SIAS diagnosis

Answer 35

The diagnosis of impingement is a clinical one, however it is often confirmed via additional imaging.

MRI imaging of the affected shoulder is often the mainstay of imaging for SAIS. Features that can be seen in affected individuals include formation of subacromial osteophytes and sclerosis, subacromial bursitis, humeral cystic changes, and narrowing of the subacromial space.

Adapted from RSatUSZ (Own work) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Question 36

SIAS management?

Answer 36

Conservative management is the mainstay of treatment in most cases. Patients should have sufficient analgesia, typically non-steroidal inflammatory drugs, and regular physiotherapy, including postural, stability, mobility, stretching and strength exercises.

For those who require further intervention, corticosteroid injections in the subacromial space can be trialled. Patients should be educated appropriately with adequate warm-up techniques and monitoring for early signs of worsening impingement.

Surgical Intervention
If SAIS persists beyond 6 months without response to conservative management, surgical intervention is recommended.

Surgical intervention is particularly useful in patients with a reduced range of movement and is most commonly arthroscopic