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Introduction
  • This topic is broken down into
    • general shoulder exam
      • inspection
      • palpation
      • ROM
      • neurovascular exam
    • impingement tests
    • rotator cuff tests
    • labral injury tests
    • biceps injuries tests
    • AC joint
    • instability
    • other
Inspection
  • Skin
  • Scars
  • Symmetry
  • Swelling
  • Atrophy
  • Hypertrophy
  • Scapular winging
Palpation
  • All bony prominences around shoulder girdle (AC joint)
  • Muscles and soft tissues including
    • deltoid
    • rotator cuff tendon insertion / greater tuberosity
    • trapezius
    • biceps tendon in groove
Range of Motion (patient supine)
  • Compare active and passive motion, both sides, with the patient in seated or standing position
  • Six planes of motion should be examined and documented
    • forward elevation (150-180° considered normal)
      • active 
    • external rotation at 90 degrees abduction
      • active 
    • external rotation at side
      • active 
    • abduction
      • active
    • internal rotation to vertebral height (T4-T8 considered normal)
      • active 
    • internal rotation at 90 degrees abduction
Neurovascular Exam
  • Sensation
    • check dermatomes of following nerves
      • axillary
      • musculocutaneous
      • medial Brachial/Antebrachial Cutaneous
      • median
      • radial
      • ulnar
  • Motor
    • Deltoid, Biceps, Triceps, Extensor Pollicis Longus, Flexor Digitorum Profundus, Dorsal Interossei
  • Vascular
    • brachial, radial, ulnar artery pulses
  • Differential
    • cervical radiculopathy
    • suprascapular neuropathy
    • brachial neuritits
Impingement 
  • t Sign
    • indicative of impingement of rotator cuff tendon/bursa against the coracoacromial arch
      • other abnormalities can produce a positive test including
        • stiffness
        • OA
        • instability
        • bone lesions
    • technique
      • use one hand to prevent motion of the scapula 
      • raise the arm of the patient with the other hand in forced elevation (somewhere between flexion and abduction) 
      • pain is elicited (positive test) as the greater tuberosity impinges against the acromion (between 70-110°) 
      • note you must have full range of motion for "positive" finding.
  • Neer Impingement Test
    • positive when there is a marked reduction in pain from above impingement maneuver following subacromial lidocaine injection
    • technique
      • usually a combination of 
        • 4cc 1% Lidocaine
        • 4cc 0.50% Bupivicaine (Marcaine)
        • 2cc corticosteroid)
  • Hawkins Test  
    • positive with impingement
    • technique
      • performed by flexing shoulder to 90°, flex elbow to 90°, and forcibly internally rotate driving the greater tuberosity farther under the CA ligament.
  • Jobe’s Test
    • positive with supraspinatus weakness and or impingement
    • technique
      • abduct arm to 90°, angle forward 30° (bringing it into the scapular plane), and internally rotate (thumb pointing to floor). 
      • then press down on arm while patient attempts to maintain position testing for weakness or pain.
  • Internal Impingement
    • patient supine or seated
    • abduct affected side to 90° and maximally externally rotate (throwing position-late cocking phase) with extension
    • if this maneuver reproduces pain experienced during throwing (posteriorly located) considered it is considered positive. 
    • further confirmed with relief upon performing relocation test
    • re-perform test in abduction/max
    • ER with elbow in front of plane of body and pain disappears.
Rotator Cuff Pathology
Subscapularis Tests
  • Subscapularis Strength
    • do not test with isolated IR strength with the arm at the side due to contribution of pectoralis major and latissimus dorsi
  • Internal Rotation Lag Sign
    • this tests is the most sensitive and specific test for subscapularis pathology.
    • technique
      • stand behind patient, flex elbow to 90°, hold shoulder at 20° elevation and 20° extension. Internally rotate shoulder to near maximum holding the wrist by passively lifting the dorsum of the hand away from the lumbar spine – then supporting the elbow, tell patient to maintain position and release the wrist while looking for a lag.
  •  Increased Passive ER
    • a person with a subscapularis tear may have increased Passive ER rotation when compared to contralateral side
  • Lift Off Test 
    • more accurate for inferior portion of subscapularis.
    • technique
      • hand brought around back to region of lumbar spine, palm facing outward; Test patient’s ability to lift hand away from back (internal rotation). Inability to do this indicates subscapularis pathology. Is confounded by other muscles. More accurate if the tested hand can reach the contralateral scapula.
  • Belly Press
    • test positive with subscapularis pathology
      • more accurate for superior portion of subscapularis
    • technique
      • patient presses abdomen with palm of hand, maintaining shoulder in internal rotation. If elbow drops back (does not remain in front of trunk) 
Supraspinatus Tests
  • Supraspinatus Strength
    • strength is assessed using Jobe’s Test (see below) – pain with this test is indicative of a subacromial bursitis/irritation – not necessarily a supra tear. Only considered positive for tear with a true drop arm. i.e. arm is brought to 90° and literally falls down.
  • Jobe’s Test
    • tests for supraspinatus weakness and/or impingement
    • technique
      • abduct arm to 90°, angle forward 30° (bringing it into the scapular plane), and internally rotate (thumb pointing to floor). Then press down on arm while patient attempts to maintain position testing for weakness or pain.
  • Drop Sign
    • tests for function/integrity of supraspinatus
    • technique
      • passively elevate arm in scapular plan to 90°. Then ask the patient to slowly lower the arm. The test is positive when weakness or pain causes them to drop the arm to their side. 
Infraspinatus
  • Infraspinatus Strength
    • external rotation strength tested while the arm is in neutral abduction/adduction
  • External Rotation Lag Sign
    • positive when the arm starts to drift into internal rotation
    • technique
      • passively flex the elbow to 90 degrees, holding wrist to rotate the shoulder to maximal external rotation. Tell the patient to hold the arm in that externally rotated position. If the arm starts to drift into internal rotation, it is positive.
Teres Minor
  • Teres Minor Strength
    • external rotation tested with the arm held in 90 degrees of abduction
  • Hornblower's sign
    • positive if the arm falls into internal rotation it may represent teres minor pathology
    • technique
      • bring the shoulder to 90 degrees of abduction, 90 degrees of external rotation and ask the patient to hold this position
Pectoralis
  • Axillary Webbing
    • look for a defect in the normal axillary fold. A deformity may be indicative of an pectoralis major muscle rupture
Labral Injuries and SLAP lesions
  • Active Compression test ("O'Brien's Test") 
    • positive for SLAP tear when there is pain is "deep" in the glenohumeral joint while the forearm is pronated but not when the forearm is supinated. technique
      • patient forward flexes the affected arm to 90 degrees while keeping the elbow fully extended. The arm is then adducted 10-15 degrees across the body. The patient then pronates the forearm so the thumb is pointing down. The examiner applies downward force to the wrist while the arm is in this position while the patient resists. The patient then supinates the forearm so the palm is up and the examiner once again applies force to the wrist while the patient resists. 
  • Crank Test
    • positive when there is clicking or pain in the glenohumeral joint
    • technique
      • hold the patient's arm in an abducted position and apply passive rotation and axial rotation.
Biceps Injuries
  • Bicipital Groove Tenderness
    • may be present with any condition that could lead to an inflamed long head biceps tendon and a SLAP lesion
  • Speed's Test
    • positive when there is pain elicited in the bicipital groove
    • technique
      • patient attempts to forward elevate their shoulder against resistance while they keep their elbow extended and forearm supinated. 
  • Yergason's Sign
    • positive when there is pain in the bicipital groove
    • technique
      • elbow flexed to 90 degrees with the forearm pronated. The examiner holds the hand/wrist to maintain pronated position while the patient attempts to actively supinate against this resistance. If there is pain located along the bicipital groove the test is positive for biceps tendon pathology.
  • Popeye Sign
    • present when there is a large bump in the area of the biceps muscle belly. Consistent with long head of biceps proximal tendon rupture.
AC Joint
  • Acromioclavicular joint tenderness
    • tenderness with palpation of the acromioclavicular joint
  • Cross-Body Adduction 
    • positive when there is pain in the AC joint
    • technique
      • patient forward elevates the arm to 90 degrees and actively adducts the arm across the body.
  • Obrien's Test (Active Compression test) 
    • positive when there is pain "superficial" over the AC joint while the forearm is pronated but not when the forearm is supinated
    • technique
      • patient forward flexes the affected arm to 90 degrees while keeping the elbow fully extended. The arm is then adducted 10-15 degrees across the body. The patient then pronates the forearm so the thumb is pointing down. The examiner applies downward force to the wrist while the arm is in this position while the patient resists. The patient then supinates the forearm so the palm is up and the examiner once again applies force to the wrist while the patient resists. 
Instability
 
GRADING OF TRANSLATION OF HUMERAL HEAD
1+ translation to glenoid rim
2+ translation over glenoid rim but reduces
3+ translates and locks out of glenoid

Anterior Instability
  • Anterior Load and Shift
    • positive when there is increased translation compared to the contralateral side
    • technique
      • have the patient lie supine with the shoulder at 40-60 degrees of abduction and 90 degrees of forward flexion. Axially load the humerus and apply anterior/posterior translation forces. Compare to the contralateral side.
  • Apprehension and Relocation
    • positive test if the patient experiences the sensation of instability
    •  technique
      • have the patient lie supine. Apprehension test performed by bringing the arm in 90 degrees of abduction and full external rotation and patient experiences sense of instability. Relocation test performed by placing examiner's hand on humeral head applying a posterior force on the humeral head. Patient will experience reduction or elimination of sense of instability.
  • Anterior Release
    • positive test if the patient experiences instability when examiner's hand is released
    • technique
      • have the patient lie supine. Examiner places hand on humeral head to keep reduced as arm is brought into abduction/external rotation. Examiner's hand is removed and the humeral head subluxes causing sense of instability. NOTE: positive anterior release is really a "3 in 1" test - if it is positive, apprehension and relocation are also positive.
  • Anterior Drawer
    • positive if there is sense of instability when compared to the contralateral side
    • technique
      • stablize the scapula and apply an anteriorly directed force against the humeral head with the contralateral hand. NOTE: graded 1+, 2+, and 3+ but this only documents amount of laxity, not pathologic unless causes symptoms.
Posterior Instability
  • Posterior Load and Shift 
    • positive if there is increased translation compared to contralateral side
    • technique
      • lie the patient supine with the shoulder in 40-60 degrees of abduction and 90 degrees of forward elevation. Load the humerus with an axial load and apply anterior/posterior forces to the humeral head. Compare the amount of translation with the contralateral side.
  • Jerk Test
    • positive if there is a 'clunk' or pain with the maneuver
    • technique
      • have the patient sit straight up with the arm forward elevated to 90 degrees and internally rotated to 90 degrees. Apply an axial load to the humerus to push it posteriorly. 
  • Posterior Drawer
    • positive if there is increased translation when compared to the contralateral side
    • technique
      • stabilize the scapula and apply a posteriorly directed force against the humeral head with the contralateral hand.
  • Posterior Stress Test
    • positive if there is pain and sense of instability with the maneuver
    • technique
      • Place the patient's arm in flexion, adduction, and internal rotation and apply a posteriorly directed force.
  • Loss of External Rotation
    • a shoulder that is locked in internal rotation may be subluxed posteriorly.
Multidirectional Instability (MDI)
  • Sulcus Sign
    • have the patient stand relaxed with their arms at their side. Grab their affected arm and pull it inferiorly. If there is a sulcus that forms at the superior aspect of the humeral head, the test is positive. Sulcus is considered positive if it stays increased (2+ or 3+) with ER at side (pathologic rotator interval).
 
Sulcus grading
1+ acromiohumeral interval < 1cm
2+ acromiohumeral interval 1-2 cm
3+ acromiohumeral interval > 2cm

Other
  • Wright's Test
    • test for thoracic outlet syndrome
    • positive if the patient losses their radial pulse 
    • technique
      • passively externally rotate and abduct the patient's arm while having the patient turn their neck away from the tested extremity.
  • Medial Scapular Winging
    • test for serratus anterior weakness or long thoracic nerve dysfunction. 
    • positive if the inferior border of the scapula migrates medially 
    • technique
      • while standing, have the patient forward flex their arm to 90 degrees and push against a wall (or other stationary object).
  • Lateral Scapular Winging
    • test for trapezius weakness or spinal accessory nerve (CNXI) dysfunction
    • positive if the inferior boarder of the scapula migrates laterally
    • technique
      • while standing, have the patient forward flex to 90 degrees and push against a wall (or other stationary object).
 

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