A Practical Guide to Clinical Medicine
A comprehensive physical examination and clinical education site for medical students and other health care professionals
|Introduction||Breast Exam||Write Ups|
|History of Present Illness||Male Genital/Rectal Exam||The Oral Presentation|
|The Rest of the History||The Upper Extremities||Outpatient Clinics|
|Review of Systems||The Lower Extremities||Inpatient Medicine|
|Vital Signs||Musculo-Skeletal Exam||Clinical Decision Making|
|The Eye Exam||The Mental Status Exam||Physical Exam Lecture Series|
|Head and Neck Exam||The Neurological Exam||A Few Thoughts|
|The Lung Exam||Putting It All Together||Commonly Used Abbreviations|
|Cardiovascular Exam||Medical Links||References|
|Exam of the Abdomen|
The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures.
|Video showing complete shoulder exam|
I think that the most daunting aspect of the shoulder exam is appreciating the functional anatomy of this incredibly mobile joint. The primary benefit of the ball and socket arrangement is that it allows the hand to be positioned precisely in space, maximizing our ability to function. In terms of functionality, the shoulder might be best described as having a golf ball-on-a-tee design.
The shoulder joint is created by the confluence of 3 bony structures: the scapula, humerus and clavicle. These are held together by ligaments and an intricate web of muscles. Critical external landmarks include the following:
Posterior View On Left, Anterior On Right.
Location Of The Muscle Groups Is Approximated In The Pictures Above.
Start by looking at the normal (or more normal) side. Note any scars, obvious asymmetry, discoloration, swelling, or muscle asymmetry.
Gently palpate around the shoulder, touching each of the landmarks noted above. Make note of pain.
University of Washington, Shoulder 1
University of Washington, Shoulder 2
Range of Motion (ROM)
If there are no symptoms, test both sides simultaneously. Otherwise, start with the normal side.
If there is pain with active ROM, assess the same movements with passive ROM. Have the patient relax and place one of your hands on their shoulder. Gently grasp the humerus in your other hand and move the shoulder through the range of motions described above. Note if there is pain, and if so which movement(s) precipitates it. Also note if you feel crepitus with the hand resting on the shoulder.
Pain/limitation on active ROM but not present with passive suggests a structural problem with the muscles/tendons, as they are firing with active ROM but not passive. Crepitus suggests DJD. Limitations in movement in any of the directions should be noted. Where exactly in the arc does this occur? Is it due to pain or weakness? How does it compare with the other side? Determining the precise etiology can be defined using the tests below, though realize that there is often a significant amount of overlap between several conditions.
Impingement, Rotator Cuff Tendonitis and Sub-Acromial Bursitis
Anatomy and Function: I have placed these processes under one heading as they are all linked. Impingement is a dynamic condition that can lead to tendonitis and bursitis. Shoulder pain in general is very common, with impingement as the root cause in a large number of cases. The 4 tendons of the rotator cuff all pass underneath the acromion en route to their insertions on the humerus. The space between the acromion/coracoacromial ligament and the tendons (in particular, the supraspinatus) can become relatively narrowed for any number of reasons (e.g. the growth of an oteophyte on the under surface of the bone). This causes the tendons to become "impinged upon." The resulting friction inflames the tendons as well as the subacromial bursa, which lies between the tendons and the acromion. The net result is shoulder pain, particularly when raising the arm over head (e.g. swimming, reaching for something on a top shelf, arm positioning during sleep). Over time, chronic irritation to the tendons can lead to fraying, tears, and even complete disruption.
Right Shoulder Anatomy (anterior view)
Several tests can be done to localize the problem:
Sub-acromial Palpation: First, identify the acromium by walking your fingers along the spine of the scapula until you reach its lateral endpoint, which is the acromium. Then gently palpate in the region of the sub-acromial space (see picture below). Palpation may cause pain if the tendons/bursa are inflamed.
The following two tests passively maneuver the tendons so that they are most likely to rub against the acromion, generating symptoms related to impingement if it is in fact present.
Neer's Test For Impingement
Hawkin's (for more subtle impingement)
Hawkins Test For Impingement
|Video Demonstrating Neer's and Hawkin's Tests.|
It's worth noting that defining the precise location of the problem (ie. bursitis, tendonitis or even partial rotator cuff tears) can be difficult to make on clinical grounds. One helpful adjunct is the diagnostic subacromial bursa injection. Local anesthetic and steroids are injected into the bursa. If the symptoms are due to bursitis, this provides significant relief. However, if the symptoms are predominantly caused by tendonitis or a partial rotator cuff tear, this will have little effect. MRI can also be extremely helpful in defining the precise nature of the pathology.
Evaluation of the Muscles of the Rotator Cuff
Anterior View On Left, Posterior On Right.
Anatomy and Function: There are 4 major muscles that allow shoulder movement. As mentioned above, symptoms caused by rotator cuff tears or tendonitis are often related to impingement. Acute shoulder trauma can also result in injury. Each of the 4 muscles can be tested individually as follows:
Supraspinatus: Connects the top of the scapula to the humerus. Contraction allows the shoulder to abduct. This is the most commonly damaged of the rotator cuff muscles. Testing (aka "empty can" test):
University of Washington, Supraspinatus
Supraspinatus (Empty Can) Test
Interpretation: If there is a partial tear of the muscle or tendon, the patient will experience pain and perhaps some element of weakness with the above maneuver. Complete disruption of the muscle will prevent the patient from achieving any forward flexion. These patients will also be unable to abduct their arm, and instead try to "shrug" it up using their deltoids to compensate.
Infraspinatus: Connects the scapula to the humerus. Contraction allows the arm to rotate externally. Specifics of testing:
University of Washington, Infraspinatus and Teres Minor
Interpretation: Tears in the muscle will cause weakness and/or pain.
Testing Infraspinatus And Teres Minor (External Rotators)
Teres Minor: Connects the scapula to the humerus. Provides the same function as the infraspinatus (external rotation). Testing is done as described for the Infraspinatus.
Subscapularis: Connects the scapula to the humerus, though the origin is on the anterior surface of the scapula (i.e. on the side opposite the origin of the other 3 muscles of the RC). Contraction causes internal rotation. Function can be tested using "Gerber's lift off test:"
University of Washington, Subscapularis
Gerbers Liftoff Test (Subscapularis)
|Video Demonstrating Rotator Cuff Testing.|
|Video Demonstrating Torn Supraspinatus.|
Drop Arm Test for Supraspinatus Tears: Adducting the arm depends upon both the deltoid and supraspinatus muscles. When all is working normally, there is a seamless transition of function as the shoulder is lowered, allowing for smooth movement. This is lost if the rotator cuff as been torn. Specifics of testing:
|Video Demonstrating Positive Drop Arm Test.|
Deltoid: Not a muscle of the rotator cuff, but important for the later aspects of abduction and flexion. The supraspinatus is responsible for the early component of abduction. The deltoid is readily visible on exam and not commonly injured.
University of Washington, Deltoid Anatomy
Acromioclaviular Arthritis Anatomy and Function: The A-C joint is minimally mobile. However, inflammation and degeneration can occur, causing pain. Specifics of Testing:
University of Washington, A-C Joint
AC Disruption: Trauma can cause disruption of the ac joint, also known as AC separation. Specifics of testing:
Acromio-clavicular Joint Separation: Disruption of the right A-C joint, in this case caused by trauma.
Biceps Tendonitis: The long head of the biceps tendon inserts on the top of the glenoid. The biceps muscle flexes and supinates the forearm and assists with forward flexion of the shoulder. Inflammation can therefore cause pain in the anterior shoulder area with any of these movements.
University of Washinton, Biceps
Specifics of testing:
Biceps Tendon Palpation
Resisted Supination (Yergason's Test):
Resisted Supination (Yergason's Test)
Speed's Maneuver for Bicipital Tendonitis:
Biceps Tendon Rupture: As a result of chronic tendonitis or truama, the long head of the biceps may rupture. When this occurs, the biceps muscle appears as a ball of tissue and there is a loss of function.
Balled Up Biceps Secondary to Tendon Rupture
The Glenohumeral Joint
Anatomy and Function: This joint is the actual place where the humerus articulates with the scapula (i.e. where the ball meets the socket). The cavity is lined by the labrum, which functions like the menisci of the knee, assuring smooth/cushioned contact between the bones. The joint is held together by the muscles of the rotator cuff as well as a tough capsule that surrounds the muscles.
Glenohumeral DJD: DJD usually results from an injury that has disrupted the normal articulating surfaces. Over time, movement of the shoulder causes additional wear and tear, leading to DJD. Patients experience pain and gradual limitation in movement. This is particularly noticeable on external rotation and abduction. Palpation of the joint with a hand placed on the shoulder during movement may reveal crepitus. Assessment is done as follows:
Glenohumeral Joint Anatomy-Humerus has been removed from its normal position of articulation.
|Video Demonstrating DJD of the Shoulder.|
Glenohumeral Instability: The rotator cuff, along with the outer joint capsule and the labrum, stabilize the joint. The labrum is a tough tissue that lines the cup formed by the scapular component of the glenohumeral joint. The rotator cuff and capsule surround the outside of the joint. Together, they allow the humerus enough freedom so that the shoulder maintains its full range of motion and function. Tears of the capsule or labrum can generate feelings of pain, instability, or a "dead arm" sensation. The patient may have a history of trauma or recurrent dislocation, where the humerus actually pops out of joint. Specifics of testing (The Apprehension Test):
Testing Glenohumeral Stability
Relocation Test (to be done if + apprehension test)
Crank Test (For Labral Injury)
Acute Inflammatory Arthritis: Inflammatory processes within the joint can be caused by a number of processes, including infection (septic) or autoimmune (e.g RA). When this occurs, the shoulder may appear swollen, red, and will be painful to the touch. Any movement will be limited by pain. Sampling of fluid from within the joint space allows definitive diagnosis.
Septic Shoulder: Intense Inflammation Over Shoulder Area As Seen In Picture On Left, Due To Intra-Articular Infection. Picture On Right Is Normal For Comparison.
|Video Demonstrating Examination of an Infected Shoulder.|
Adhesive Capsulitis: Also called a frozen shoulder, this is caused by idiopathic inflammation of the capspule around the shoulder. The net result is severe limitation of motion in any direction (active or passive). Pain is present with movement, and oftentimes when the shoulder is at rest. The etiology is unclear and it can be difficult to distinguish from a number of the above conditions.
Referred Pain to the Shoulder Area
It's important to recognize that not all shoulder pain is cause by shoulder pathology. A few sites that can cause referred symptoms:
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