Arash Aminian
Jason Koh
Shoulder pain is one of the most common complaints seen by an orthopaedic surgeon. A careful physical examination can reveal a significant amount of information about the patient's complaint. Shoulder pain can be due to intrinsic diseases of the shoulder joint or pathology originating from the spine, chest, or visceral structures. Assessment of these regions along with a detailed history is important in the complete patient evaluation.
Patient History
History is a critical aspect of the patient evaluation (Table 29-1) and can help narrow the differential diagnosis of a patient presenting with shoulder pain. The history should include general questions about the patient's age, handedness, and activities, and more specific questions about the nature of the complaint. Hand dominance can give insight into mechanism of injury as well as determination of extent of disability and recovery. Activities, both work and recreational, again have important implications for cause of injury and treatment. Overhead workers or competitive athletes will have significantly higher demands on the shoulder compared with sedentary individuals. Age will also provide insight into potential causes of pain, with younger patients associated with instability and secondary impingement, and older patients with arthritis and outlet impingement.
The location and nature of the pain can aid in the diagnosis of shoulder injuries. Lateral arm pain, particularly with overhead activity, is often associated with rotator cuff pathology or impingement. Superior discomfort, especially with cross-arm adduction, can be associated with acromioclavicular (AC) joint pain. Deep shoulder pain or posterior shoulder pain at the glenohumeral (GH) joint is associated with labral pathology.
Anterior shoulder pain is associated with biceps tendonitis. Neck or periscapular pain is relatively nonspecific since many will have this secondary to abnormal compensatory scapulothoracic (ST) movement (shrug sign).
Mechanical symptoms, such as clicking, catching, or popping, may have multiple possible causes. However, it is sometimes possible to distinguish between subacromial crepitus (often owing to bursitis or rotator cuff pathology) and glenohumeral clicks and pops that may be related to labral tears or arthritis. Complaints of a “loose” shoulder or one that “comes apart” suggest instability that is more subtle than a frank dislocation. These may be accompanied by reports of neurologic symptoms such as numbness, tingling, or a “dead arm” feeling. These neurologic complaints in this context are usually nonradicular and may be related to subtle traction on the brachial plexus during an instability episode. Persistent pain associated with paresthesias in a radicular distribution suggests a cervical cause. (Table 29-1)
Physical Examination
Observation
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TABLE 29-1 History |
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The patient must be dressed so that the examiner can observe the normal bony and soft tissue contours of both shoulders, including the scapular border, and determine any asymmetry. When looking at the anterior view, the examiner should look for step-off deformity of the AC joint and any bumps on the clavicle indicative of prior fracture. Flattening of the normally round deltoid contour may indicate an anterior shoulder dislocation or paralysis of the deltoid muscle. A “Popeye” deformity (bulging of the upper arm) from a distally migrated biceps can occur after biceps tendon rupture. From the posterior view, the examiner can appreciate any atrophy of the supraspinatus or infraspinatus muscle indicative of a compressive neuropathy of the suprascapular nerve. Winging of the scapula in which the medial border of the scapula moves posterior to the chest wall is seen with long thoracic nerve injury.
Palpation
As with any assessment, the examiner is comparing one side of the body with the other. Initially palpate the bony landmarks around the shoulder starting at the sternoclavicular (SC) joint, the clavicle, the AC joint, and the coracoid. Tenderness along these anatomic landmarks can be indicative of arthritic changes, joint sprains or separation, and fracture.
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The biceps tendon can also be palpated in its groove proximally. Simultaneous palpation of bilateral biceps tendons in the groove proximally can reveal relatively increased pain consistent with tenosynovitis; absence would indicate proximal rupture. Tenderness along the anterior GH joint capsule can occur with adhesive capsulitis.
Range of Motion and Strength
Both shoulders are simultaneously examined for active range of motion to help identify side-to-side differences. If there is a loss of active range of motion, passive motion should be evaluated. The pattern of movement, such as an abnormal shrug sign in which scapulothoracic motion attempts to compensate for painful glenohumeral motion, should be noted.
The movements of the shoulder that are tested include the following (Fig. 29-1):
The combined internal and external arc of motion with the arm abducted 90 degrees should be symmetric. It is common that there is a relative lack of internal rotation of the dominant arm.
A discrepancy between active and passive motion suggests loss or inhibition of muscle activity, most likely owing to impingement or other rotator cuff pathology. Pain with forward flexion and abduction but maintained passive external rotation suggests impingement or rotator cuff pathology. A global loss of motion (forward flexion/abduction plus internal rotation plus external rotation) suggests arthritis or adhesive capsulitis. Loss of external rotation past neutral in the context of recent trauma suggests a posterior dislocation.
Muscle Testing
A full assessment of the cervical roots with motor testing is performed (Table 29-2).
Rotator cuff muscles are tested as follows:
Special Tests
Biceps Pathology
Speed and Yergason tests are performed for biceps pathology. The Speed test is performed by resisting forward elevation from 90 degrees with the arm in neutral abduction/adduction and the forearm in full supination. The Yergason test is performed with the arm at the side and elbow in 90 degrees of flexion and resisting supination. Pain with resisted movements during these tests is indicative of proximal biceps tendon pathology.
Impingement Signs/Rotator Cuff Pathology
Physical examination signs that aid in diagnosing subacromial impingement include the Hawkins-Kennedy and Neer impingement signs, the painful arc sign, cross-body adduction test, and the drop arm sign.
Neer Impingement Sign (Fig. 29-5).
The scapula is stabilized and the arm is passively forward flexed by the examiner until the patient reports pain or until full elevation is reached. Pain in the anterior or lateral part of
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the shoulder in the range of 90 to 140 degrees is considered a positive test
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Figure 29-1 Range of motion. |
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Figure 29-2 Internal rotation. |
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TABLE 29-2 Muscle Testing—Upper Extremity |
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Figure 29-3 Belly press. |
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Figure 29-4 Lift off. |
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Figure 29-5 Impingement—Neer. |
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Figure 29-6 Impingement—Hawkins. |
Hawkins-Kennedy Impingement Sign (Fig. 29-6).
The arm is placed in 90 degrees of forward flexion and then internally rotated. The end point of rotation is when the patient feels pain or when rotation of the scapula is felt. Pain with internal rotation is a positive sign.
Painful Arc Sign.
The patient is asked to elevate the arm in the scapular plane until full elevation is reached, and then the arm is brought down in the same arc. The test is considered positive if the patient has pain between 60 and 120 degrees of elevation.
Cross-Body Adduction Test.
The arm is put in 90 degrees of forward flexion and then adducted across the body by the examiner. The test is considered positive with pain produced by adduction.
Drop Arm Test.
The patient is asked to elevate the arm fully and then slowly reverse the motion. If the arm is dropped suddenly or the patient has pain, the test is considered positive.
The diagnostic value of these clinical tests for subacromial impingement is summarized in Table 29-3.
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TABLE 29-3 Diagnostic Value of Clinical Tests for Impingement |
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Superior Labrum Anterior-Posterior Lesions
The O'Brien test is used to assess superior labral anterior posterior (SLAP) lesions. The goal is to load the biceps tendon and transmit the force to the biceps anchor at the superior labrum. It is performed with the arm in 10 degrees of adduction, 90 degrees of forward flexion, and thumb pointing to the floor. Forward elevation is resisted in this plane and pain is assessed. If the patient has pain that is resolved with supination of the arm, the test is considered positive. Studies in the literature have shown this test to be sensitive but not specific.
The crank test (Fig. 29-7) is used to evaluate for posterior-superior labral tears. The patient is positioned supine, and the arm is abducted to 90 to 120 degrees and externally rotated. This generates internal impingement of the posterior-superior rotator cuff against the
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posterior-superior glenoid rim and labrum. Posterior pain at the GH joint line is positive.
Instability
Instability of the shoulder can be in different planes: anterior, posterior, inferior, or multidirectional. The direction of the instability is important to determine because of the treatment implications. When assessing for instability, the examiner should test for generalized joint laxity with thumb to forearm flexibility or forearm recurvatum. Instability is tested by several tests.
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Figure 29-7 Crank. |
In the apprehension sign test (Fig. 29-8), with the shoulder in 90 degrees of abduction and the elbow in 90 degrees of flexion, the shoulder is externally rotated. Patients with anterior instability will have a feeling of possible anterior shoulder dislocation, subluxation, or pain with this maneuver. For posterior instability the arm is adducted, internally rotated, and a posterior force is applied. If pain is elicited, this may signal a posterior labral tear.
The load and shift test for anterior instability (Fig. 29-9). is performed with the shoulder in 90 degrees of abduction and 90 degrees of elbow flexion. The examiner loads the humeral head into the glenoid and translates it anteriorly and posteriorly. This test is graded based on the amount of translation of the humeral head on the glenoid. Translation is 1+, 2+, or 3+ (1+, humeral head to the rim; 2+, humeral head over the rim and reduces by itself; 3+, the humeral head dislocates and does not reduce).
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Figure 29-8 Apprehension. |
Sulcus sign testing (Fig. 29-10) is performed with the arm to the side, and inferior translation of the humeral head is assessed from the acromion. Typically, inferior translation is maximized with internal rotation of the arm. Translation is graded based on the amount of translation (1+, <1 cm of translation; 2+, 1 to 2 cm of translation; 3+, >2 cm of translation). When patients have a large sulcus sign, the examiner should consider the diagnosis of multidirectional instability. Alternatively, a significant SLAP tear may result in clinically evident inferior translation.
Posterior instability (Fig. 29-11) is assessed by bringing the arm into 90 degrees of forward flexion, internal rotating, and applying a posterior force. This may elicit pain or apprehension, and posterior translation of the humeral head may be appreciated. If there is pain that is relieved by bringing the arm into 90 degrees of abduction, there may be a posterior labral tear (Kim test).
Cervical Spine
A complete examination of the shoulder should always include an assessment of the cervical spine. Cervical radiculopathy can present as shoulder pain and must be evaluated. Range of motion of the cervical spine and a motor
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and sensory evaluation of the cervical roots and dermatomes is needed for completeness.
Pain distribution of patients with cervical pathology is mostly over the trapezial region, whereas pain due to primary shoulder pathology is typically located over the deltoid. The Spurling test and Lhermitte test can help delineate nerve root compression. The Spurling test involves extending, laterally flexing, and rotating the neck to the affected side with axial compression. This causes narrowing of the neural foramina and produces nerve root compression. The Lhermitte test involves vertical pressure on the head, which causes a shocklike sensation in the affected extremity.
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Figure 29-9 Load and shift. |
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Figure 29-10 Sulcus. |
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Figure 29-11 A and B: Posterior instability—Kim test. |
Authors' Step-by-Step Physical Examination
Have the patient expose both shoulders. Stand in front of the patient. Evaluate the neck (Spurling, Lhermitte) and palpate the shoulders (SC, AC, biceps tendon). Have the patient go through bilateral active forward flexion, abduction, and external rotation. Note range of motion and if there is any dyskinesis (shrug sign, painful arc test). If there is a lack of active motion in a plane, evaluate passive range of motion. Perform Neer and Hawkins impingement tests. Test resisted abduction. Test cross-arm adduction. Test for the O'Brien sign. Test Speed and Yergason. Test active internal and external rotation. Perform belly press test. Have patient turn around and evaluate scapular position and motion with abduction and forward flexion. Evaluate internal rotation. Evaluate lift-off test.
Have the patient lie supine with the shoulder at the edge of the bed. Evaluate passive external rotation, sulcus sign, and load and shift test. Abduct the arm to 90 degrees. Externally rotate the arm, assessing for any apprehension and noting range of motion. If there is apprehension, test relocation. Evaluate crank test. Evaluate internal rotation at 90 degrees. Adduct the arm with the arm flexed 90 degrees and test posterior instability.
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Suggested Readigns
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