Evaluation of the Shoulder
Physical examination of the shoulder involves
Inspection includes observation for erythema, deformity, or skin lesions, including surgical scars, and for asymmetry compared to the unaffected shoulder (suggesting muscle wasting).
Because pain can be referred from other areas to areas around the shoulder, shoulder palpation should include the glenohumeral, acromioclavicular, and sternoclavicular joints, the coracoid process, clavicle, acromion process, subacromial bursa, biceps tendon, and greater and lesser tuberosities of the humerus (see Figure: Shoulder anatomy (anterior view)), as well as the scapula and the neck. The neck is examined as part of any shoulder evaluation because pain can be referred to the shoulder from the cervical spine (particularly with C5 radiculopathy).
Glenohumeral joint effusions may cause a bulge between the coracoid process and the humeral head. Possible causes include rheumatoid arthritis, osteoarthritis, acute infectious arthritis, Milwaukee shoulder, calcium pyrophosphate arthritis (pseudogout), and other arthropathies.
Limited range of motion, weakness, pain, and other disturbances of mobility caused by rotator cuff impairment can be quickly identified by having the patient attempt—by both abduction and flexion—to raise both arms above the head and then to slowly lower them. Specific maneuvers against resistance can help determine which tendons are affected. Strength and sensation should be assessed:
The infraspinatus and teres minor are assessed by having the patient resist external rotation pressure with the arms held at the sides with elbows flexed to 90°; this position isolates rotator cuff muscle function from that of other muscles such as the deltoid. Weakness during this test suggests significant rotator cuff dysfunction (eg, a complete tear).
The supraspinatus is assessed by having the patient resist downward pressure on the arms held in flexion (forward) with the thumbs pointing downward and the elbow extended (empty can, or Jobe test).
The subscapularis is assessed by having the patient place the hand behind the back with the back of the hand resting on the lower back. The examiner lifts the hand off the lower back. The patient should be able to keep the hand off the skin of the back (Gerber lift-off test).
The Apley scratch test assesses combined shoulder range of motion by having the patient attempt to touch the opposite scapula: Reaching overhead, behind the neck, and to the opposite scapula with the tips of the fingers tests abduction and external rotation; reaching under, behind the back, and across to the opposite scapula with the back of the hand tests adduction and internal rotation.
Impingement tests are considered if pain is elicited. They include the following:
The Neer test is done to check for impingement of the rotator cuff tendons under the coracoacromial arch. It is done by placing the arm in forced forward flexion, lifted overhead, and fully pronated.
The Hawkins test is done also to check for impingement. It is done by flexing the arm to 90°, flexing the pronated elbow 90°, and then forcibly rotating the shoulder internally (moving the hand downward).
Rotator cuff tendinitis is the most common cause of shoulder pain. The supraspinatus tendon is most frequently involved and the subscapularis is second. Active abduction in an arc of 40 to 120° and internal rotation cause pain (see symptoms and signs of rotator cuff injury). Passive abduction causes less pain, but abduction against resistance can increase pain.
Bicipital tendinitis causes pain in the biceps tendon that is aggravated by shoulder flexion or resisted supination of the forearm. Examiners can elicit palpable tenderness proximally over the bicipital groove of the humerus by rolling (flipping) the bicipital tendon under their thumb. Also, the Speed test may be done. In this test, the arm is extended behind the body plane while the elbow is straight and the forearm is supinated.
Acromioclavicular joint injury is tested for using the cross-body adduction test. In this test, the examiner stabilizes the shoulder with one hand, flexes the shoulder forward to 90° with the elbow pronated, and brings the arm straight across the front of the body, toward the opposite side. Elicitation of pain is a positive test.
Anterior glenohumeral joint instability is tested by stabilizing the joint by holding it from behind and then pulling back on the arm with the shoulder abducted to 90° and the elbow flexed to 90° (increasing abduction and external rotation). A positive result is apprehension of joint instability (not pain).
The usual approach is anterior. Needle entry is inferior and lateral to the coracoid process and medial to the humeral head. A 25- to 30-gauge needle is used to place a wheal of local anesthetic over the needle entry site. More anesthetic is then injected into the deeper tissues along the anticipated trajectory of the arthrocentesis needle. A 2-inch (5.08 cm), 20-gauge needle is used to aspirate the joint. The skin is entered perpendicularly and the needle is directed posteriorly toward the glenoid rim, with back pressure on the syringe plunger during the advance. Synovial fluid will enter the syringe when the joint is entered. All fluid is drained from the joint. The needle is redirected at a different angle if it hits bone. Shoulder arthrocentesis can be technically difficult.