W3 physical exam of shoulder

Question 1

• Shoulder pain key points

Answer 1

o Common complaint – second to knee pain
o Most commonly due to subacromial impingement syndrome and rotator cuff problems
o 8-13% of athletic injuries
o History and exam are keys to diagnosis

Question 2

• Physical exam steps

Answer 2

o	Inspection
o	Palpation
o	ROM
o	Strength testing
o	Special tests

Question 3

• Inspection

Answer 3

o	Swelling, asymmetry, scars, ecchymosis/bruising
o	Posture
o	Deformities (atrophy, scapular winging)

Question 4

o Acromioclavicular joint palpation

Answer 4

 Patient’s arm at side
 Note swelling, pain, gapping
 Indicates joint separation or pathology

Question 5

o Bicipital groove palpation

Answer 5

 Patient sitting with arm straight
 Patient flexes biceps muscle while examiner provides supination and external rotation
 Examiner palpates bicipital groove for pain
 Indicates pathology associated with long head of biceps tendon

Question 6

• Range of motion

Answer 6

o Evaluate active ROM
o If movement is limited by pain, weakness, or tightness, assist passively
o Lack of full ROM with active and passive exam is common with shoulder pathology
o Evaluate bilaterally

Question 7

• ROM normal ranges

Answer 7

o Forward flexion – 160-180 degrees
o Extension – 40 degrees
o Abduction – 170-180 degrees (palms up)
o Adduction – 0 degrees
o External rotation – 45 degrees (arms at side, elbow flexed)
o Internal rotation – 55 degrees (arm at side, elbow flexed)

Question 8

• Forward flexion evaluation

Answer 8

o Arm straight and brought upward through frontal plane
o Move as far as patient can go above head
o 0 degrees is defined as straight down at patient’s side, 180 degrees is straight up

Question 9

• Abduction evaluation

Answer 9

o Arm straight
o Palm up, arm supinated
o ROM measure in degrees as for forward flexion
o Normal is 180

Question 10

• External and internal rotation evaluation

Answer 10

o Arm at side, elbow flexed at 90 and held at waist
o Examiner internally and externally rotates arm
o Normal ER is 45
o Normal IR is 55

Question 11

• Apley scratch test for ER

Answer 11

o External rotation and abduction
o Reach for upper scapula
o Compare bilaterally and note level of reach

Question 12

• Apley scratch test for IR

Answer 12

o Internal rotation and adduction
o Reach for lower scapula
o Compare bilaterally and note level of reach

Question 13

• Strength tests flexion and extension

Answer 13

o Compared bilaterally and graded on a 5 point scale and presence or absence of pain
o 5 ROM against gravity with full resistance of examiner
o 1 is no joint motion

Question 14

• Strength test for ER and IR

Answer 14

o Sitting, arms at sides with elbows at 90
o Maintain elbow position at sides while external or internal rotations is attempted by patient against resistance
o ER tests infraspinatus and teres minor
o IR tests subscapularis

Question 15

• Empty can test

Answer 15

o Supraspinatus
o Patient sitting with arms out straight, elbows locked, thumbs down and arm at 30 degrees in scapular plane
o Patient should attempt to abduct arms against examiner’s resistance

Question 16

• Lift off test

Answer 16

o Subscapularis
o Patient rests dorsum of hand on back in lumbar area
o Patient attempts to push examiner’s hand of their hand
o Note weakness or pain
o Modify by putting hand on abdomen and resisting ER by examiner

Question 17

• Drop arm test

Answer 17

o Rotator cuff
o Primarily supraspinatus
o Patient abducts arm and slowly lowers it, arm will drop if cuff is injured
o Positive test: patient unable to lower arm further without control
o Can compensate to 90 degrees with deltoid
o Can hold at 90 with wrist but then will drop

Question 18

• Neer’s sign

Answer 18

o Impingement
o Rotator cuff
o Patient seated with arm at side, palm down
o Examiner stabilizes scapular and raises arm (between flexion and abduction)
o Positive test: pain
o Occurs when rotator cuff tendons are pinched under coracoacromial arch

Question 19

• Hawkin’s test

Answer 19

o Impingement
o Rotator cuff
o Patient is standing
o Examiner flexes shoulder to 90 and then forcibly IRs
o Positive test: pain in area of superior glenohumeral or AC joint
o Pain with this suggests subacromial impingement or rotator cuff tendonitis
o May be more sensitive than Neer’s test

Question 20

• Speed’s test

Answer 20

o Biceps tendon
o Forward flex shoulder against resistance while maintaining elbow in extension and forearm in supination
o Positive test: tender in bicipital groove (bicipital tendonitis)

Question 21

• O’Brien’s active compression test

Answer 21

o Labral tear (SLAP lesion)
o Patient standing
o Arm forward flexed 90 degrees, adducted to 15 or 20 with elbow straight
o Full IR so thumb is down
o Examiner applies downward force on arm and patient resists
o Patient ER are so thumb is up
o Examiner applies downward force
o Positive: pain or painful clicking elicited with thumb down and decreased with thumb up

Question 22

• Crank test

Answer 22

o Labral tear (SLAP lesion)
o Shoulder elevated to 160 in scapular plane
o Gentle axial load is applied through glenohumeral joint with one hand will other does IR and ER
o Positive: pain, catching, or clicking in shoulder

Question 23

• Apprehension test – sitting

Answer 23

o Glenohumeral joint stability
o 90 degrees of abduction
o Examiner applies slight anterior pressure to humerus and ERs
o Positive: patient expresses apprehension (concern that it will dislocated)
o May indicate a loose capsule and or ligaments

Question 24

• Apprehension test – supine

Answer 24

o Glenohumeral joint stability
o Patient in supine with affected shoulder at edge of table, arm abducted 90 degrees
o Examiner ERs by pushing forearm posteriorly
o Positive: patient expression apprehension

Question 25

• Relocation test

Answer 25

o Glenohumeral joint stability
o Performed after positive on anterior apprehension test
o Patient supine
o Examiner applies posterior force on proximal humerus while ERing patient’s arm
o Positive test: patient expresses relief