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Orthopedic shoulder examination

Last updated: July 20, 2021

Summarytoggle arrow icon

The shoulder consists of three joints: the glenohumeral joint (commonly referred to as “shoulder joint”), the sternoclavicular joint, and the acromioclavicular joint. While the glenohumeral joint possesses three degrees of freedom of motion, the range of motion as a whole is further increased by the glenohumeral joint's interaction with the acromioclavicular joint and the sternoclavicular joint. Unlike in other joints, the shoulder's dynamic stability and control are provided primarily by muscles (the rotator cuff in particular) rather than ligaments. Exposure to a great deal of stress from constant movement and the fact that it is stabilized primarily by muscles with little ligament support make the shoulder susceptible to dislocation and degenerative changes. Clinical examination is the core element in orthopedic shoulder diagnostics. Besides basic anatomy and function of the shoulder, this article discusses the most important clinical examinations and tests of the shoulder, the shoulder girdle joints, muscles, and capsuloligamentous complex.

For anatomy and function of the shoulder, see "Shoulder, axilla, and brachial plexus."

  • Symptoms
    • Shoulder pain
      • How long?
      • Onset (acute/insidious)?
      • Chronological sequence (persistent/intermittent/change in pain intensity over time? Night pain?)
      • Radiation of pain
    • Restricted range of motion
      • Which movements are restricted in particular?
      • Which activities can no longer be performed on a daily basis?
      • Ask the patient to describe situations/movements.
  • Possible causes
    • In accidents: inquire about the circumstances of the accident
      • How or where did the accident occur?
      • What part of the body was injured?
      • Type and duration of force?
    • Occupational history: relevant especially if the patient presents with chronic complaints, e.g., repetitive overhead work is a typical cause of shoulder lesions
    • Pre-existing conditions: Family history for joint disease?
  • Other
    • Previous imaging
    • Previous treatment

General information

  • Be attentive to patient habitus and movement upon entering the room:
    • Uneven arm swing
    • Relieving posture
    • Unusual reactions to handshake
  • Ask the patient to undress so that both shoulders can be examined.

Procedure

Finger sign test and palm sign test

  • Short description: The patient is asked to point to the painful area with the palm or finger of the opposite (healthy) hand. The finger sign test and the palm sign can provide important information on the location of shoulder pathology in the early stages.
  • Findings and assessment

The shoulder region is initially palpated for signs of inflammation (warmth, swelling). A more detailed palpation of the muscle and bone structures of the shoulder region should be performed afterward.

Palpation of the most important shoulder regions
Method Findings and significance
Anterior examination
Sternoclavicular joint
  • The examiner holds the patient's clavicle between the ball of the thumb and index finger and moves the clavicle while the fingers of the other hand are firmly placed on the sternum.
Clavicular, AC joint, and acromion
Coracoid process
Bicipital groove
  • Pain indicates a degenerative or inflammatory lesion of the long head of the biceps tendon.
  • Palpable snapping indicates a tendon dislocation.
Lesser and greater tubercle
Posterior examination
Palpation of the scapula

Combined movements can be assessed in a preliminary examination, which provides a rough indication of potential pathological conditions. In subsequent detailed examinations, specific tests are used to examine individual joint components and their pathologies.

Combined shoulder joint movements

  • Apley scratch test [2]
    • Procedure: The patient is asked to make a fist with the hands and stretch out the thumbs. The hands are placed behind the neck or the back.
    • Findings and assessment: the test is positive if pain, side asymmetry appear, and/or limited range of motion occur

Range of motion of the shoulder

Active range of motion (the patient moves the shoulder without help from the examiner) should be performed before passive range of motion (with help from the examiner). Physiological range of motion in the shoulder (with movement of the scapula) comprises:

See also “Soft tissue lesions of the shoulder.”

Examination of the supraspinatus muscle: empty can test (Jobe test)

  • Procedure (dorsal examination)
    1. The patient's upper arm should be passively abducted (∼ 90°) and flexed horizontally with the elbow extended.
    2. The arm is internally rotated (thumb pointing downwards).
    3. Check the patient's ability to maintain the arm in this position.
    4. If the patient is able to maintain this position, the examiner applies pressure to the patient's arm and the patient is asked to resist.
  • Findings and significance: Inability to maintain the arm's position against resistance or pain when doing so (positive Jobe test) indicates a functional disorder of the supraspinatus muscle (e.g., tendon rupture, tendinopathy, or subacromial bursitis).

Examination of the subscapularis muscle: lift-off test

  • Procedure (dorsal examination)
    1. Place the patient's hand behind the lower back with the palm facing outwards.
    2. Check the patient's ability to lift the hand away from the back.
    3. If the patient is able to perform this movement, the examiner applies resistance to the patient's palm.
    4. The patient is asked to move the hand against resistance applied by the examiner.
    5. Check the other arm.
  • Findings and significance: Pain when returning the hand to the starting position or the inability to move the hand against resistance (positive lift-off test) indicates a functional disorder of the subscapularis tendon (e.g., rupture).

Examination of the subscapularis muscle: belly press test (abdominal compression test, Napoleon test)

  • Procedure (dorsal examination)
    1. The patient's hand is placed flat on their abdomen with the hand, wrist, and elbow in a straight line.
    2. The patient's elbow is flexed to 90°.
    3. The examiner places the patient's flat hand onto the abdomen.
    4. The examiner checks that the angle between the patient's hand and forearm is 0°.
    5. The examiner asks the patient to firmly press the palm against the abdomen.
  • Findings and significance

Examination of the infraspinatus muscle: infraspinatus test

  • Procedure
    1. The test can be performed in two positions:
      • Position 1: The patient's elbow is bent to 90°.
      • Position 2: The patient's arm is abducted to 90° and the humerus is medially rotated to 30°.
    2. The examiner applies resistance against the back of the patient's hand. The patient is asked to maintain his or her position.
  • Findings and significance: Inability to perform external rotation against resistance (positive infraspinatus test) indicates an impaired infraspinatus muscle, e.g., in suprascapular nerve lesion.

The long head of the biceps tendon traverses from the supraglenoid tubercle of the scapula through the bicipital groove of the humerus, a common site of tendon irritation. The most common pathologies, whose symptoms may be apparent upon clinical examination, include degenerative changes of the tendon with concomitant biceps tendonitis, fibromyalgia, and dislocation derived from the bicipital groove. After palpation of the biceps tendon in the bicipital groove, which should be performed with upper arm rotation, specific tests can be performed for further evaluation of biceps tendinopathy.

Palm-up test

Speed test

O'Brien test (active compression test)

  • Procedure (ventrolateral examination)
    1. The examiner fully extends the patient's elbow. The arm to be tested is in 90° flexion and 10–15° adduction. The patient fully internally rotates the arm with the thumb pointing downwards.
    2. The examiner exerts downward pressure on the proximal lower arm while the patient resists.
    3. The patient's arm is then externally rotated. The examiner exerts downward pressure again while the patient resists.
  • Findings and significance

Yergason test

References:[2]

Painful arc test

Neer test

  • Procedure (dorsal examination)
    1. The examiner places the patient's arm in the internal rotation position and uses the hand to stabilize the patient's scapula.
    2. Using the other hand, the examiner raises the patient's arm and moves it in a scapular range of motion.
  • Findings and significance: Pain during flexion between 90–120° (positive Neer test) and pain reduction in external rotation is a nonspecific indication of impingement syndrome.

Hawkins-Kennedy test

Anterior/posterior drawer test of the shoulder

Sulcus sign (inferior drawer test of the shoulder)

  • Procedure (dorsal examination in a sitting position)
    1. The patient's arm is relaxed and placed on the lap or on the examiner's arm.
    2. The examiner stabilizes the patient's shoulder with one hand and grasps the patient's arm just above the elbow with the other.
    3. The examiner applies a distal force to the patient's arm and inspects the patient's shoulder for the appearance of depression between the acromion and humerus (sulcus).
  • Findings and significance: A visible depression between the edge of the acromion and the humeral head (positive sulcus sign) indicates hyperlaxity of the glenohumeral joint.

Shoulder apprehension tests

Anterior apprehension test

  • Procedure (dorsal examination in a sitting position)
    1. The examiner stabilizes the patient's scapula with one hand.
    2. The patient's shoulder is abducted to 90° and the elbow flexed to 90°.
    3. The examiner positions the patient's arm to 90° abduction and external rotation and observes the patient's reaction upon inspection and palpation of the shoulder.
  • Findings and significance: A palpable shoulder subluxation (anterior shoulder instability), a sense of apprehension against external rotation, or a look of concern or discomfort by the patient that the shoulder will dislocate (positive anterior apprehension test) indicate capsuloligamentous complex lesions.

Posterior apprehension test

  • Procedure (optimally in a supine position)
    1. The patient's arm is passively flexed to 90° and rotated maximally internally. The elbow is flexed to 90°.
    2. The examiner places one hand on the patient's scapula and applies posterior force on the patient's elbow.
  • Findings and significance: A palpable shoulder subluxation (posterior shoulder instability), a sense of apprehension against external rotation, or a look of concern or discomfort by the patient that the shoulder will dislocate (positive posterior apprehension test) indicate capsuloligamentous complex lesions.

Relocation test

References:[2]

  1. Woodward TW, Best TM. The painful shoulder: part I. Clinical evaluation.. Am Fam Physician. 2000; 61 (10): p.3079-88.
  2. Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis.. Am Fam Physician. 2009; 80 (5): p.470-6.
  3. Morell DJ, Thyagarajan DS. Sternoclavicular joint dislocation and its management: A review of the literature.. World journal of orthopedics. 2016; 7 (4): p.244-50. doi: 10.5312/wjo.v7.i4.244 . | Open in Read by QxMD