Clinical Examination of the Shoulder PDF

Here is the conversion of the image to markdown format: # Chapter 5 # Clinical Examination of the Shoulder Clinical examination aims to elicit signs that can supplement the clinical symptoms gathered from the clinical history and prove or disprove the working diagnosis. Examination of any joint i...

Here is the conversion of the image to markdown format: # Chapter 5 # Clinical Examination of the Shoulder Clinical examination aims to elicit signs that can supplement the clinical symptoms gathered from the clinical history and prove or disprove the working diagnosis. Examination of any joint in orthopaedics may follow look/feel/move/special tests sequence [1, 2], and this order is also applied to examination of the shoulder. The examiner inspects the patient and their shoulders, palpates the shoulder and scapular areas and then determines the active and passive range of shoulder motion. Individual muscle strength is subsequently examined along with special tests that are guided towards specific underlying conditions. The cervical spine, elbow and other upper limb joints are also examined as indicated. This chapter presents a structured shoulder clinical examination with special emphasis on some of the many special tests described for shoulder assessment. A structured clinical approach may ensure that any significant findings are not overlooked. A selection of special tests may be utilised according to the working diagnosis. Clinical examination of the shoulder follows a structured look, feel, move and special tests approach, and this is described next. ## 5.1 Look The patient is inspected overall: - Comfortable at rest or in discomfort - The patient is asked to stand and take a few steps to assess the overall posture, balance and mobility of lower and upper limbs - Ability to walk with or without a walking aid is noted The patient's upper trunk is exposed, and the patient is asked to stand or sit so that the examiner can move around the patient to inspect the shoulders, scapulae, spine, clavicles and chest wall. Look at the: - Front - Side - Back The image shows: - (a) Front - (b) Side - (c) Back (Referring to a woman wearing a tube top facing in different directions to show front, side and back). Look for: - Surgical or traumatic scars - Lumps or bumps - Abnormal posture or asymmetry – shoulder and arm, humeral head, scapula, cervical spine and clavicle - Muscle wasting - Skin - colour, rash or other cutaneous lesions - Rotator cuff arthropathy diffuse swelling of the glenohumeral joint with marked wasting of the supra-and infrspinous fossae. ## 5.2 Feel Palpate potential sources of pain: * Cervical and thoracic spine along with paraspinal muscles * Peri-scapular and shoulder muscles for tender spots * Sterno-clavicular joint * Acromio-clavicular joint * Anterior-lateral part of subacromial space * Bicipital groove * Anterior capsule * Coracoid * Posterior capsule ## 5.3 Move Movement may be described as: - Active - Preformed by the patient - Passive - Preformed by the examiner The patient is asked to perform a particular movement, and the extent (range) to which this can be achieved is observed. The examiner then tries to push the arm in the specified direction further, and any additional passive movement is observed. Under normal conditions most motion will be achievable actively, but in certain disorders the amount of passive motion may exceed the range achieved actively. In examining active motion, the examiner may: - Instruct verbally the patient as to what movement to perform - Instruct verbally and demonstrate to the patient the motion using own arms (preferable) ### 5.3.1 Shoulder Movements Assessed - Forward elevation - Abduction - External rotation with the elbow flexed $90^\circ$ and apposed to the trunk - External rotation with the arm in $90^\circ$ abduction and the elbow flexed $90^\circ$ - Internal rotation The image depicts active forward evaluation. The image depicts active abduction. The image depicts active external rotation. The image depicts: (a) forward elevation (b) external rotation Assessing passive motion (a) forward elevation, (b) external rotation Motion can be described: Quantitatively – range in degrees or in the case of internal rotation described as to how far the extended thumb can reach on the patients back: Qualitatively – smooth, interrupted Thumb positions: - Side of the thigh - Buttock - Lower lumbar spine - Upper lumbar spine - Lower angle of the scapula (normal) Cervical spine movements. The image has four movements. (a) Flexion (b) Extension (c) Lateral rotation (d) Lateral flexion ### 5.3.2 Cervical Spine Movements Assessed * Flexion * Extension * Lateral rotation * Lateral flexion ## 5.4 Special Tests in Shoulder Examination Special tests are clinical examination manoeuvres that aim to assess the presence of specific disorders or the specific source of an individual's symptoms. Such tests may examine: * Muscle strength * Pain provocation * Apprehension provocation * Instability provocation * Other symptom provocation Special test aim to isolate and specifically test on structure or group of structures at a time such as: * One muscle at a time in assessing muscle strength * One pain source structure at a time in assessing pain provocation * One process at a time n assessing apprehension * One group of structures in assessing instability An ideal special test is one which has high: * Sensitivity – the ability of a test to correctly identify diseased states * Specificity - the ability of a test to correctly identify on-diseased states However, the qualities of commonly used special tests in orthopaedic examination and specifically in examination of the shoulder have been questioned, as such tests are often not highly sensitive or specific [3-9]. This may be due to: * Close anatomical relationship of various structures that may make it difficult to isolate and thus test a single structure in order to implicate it in pathology * Multiple structures can have common origin of innervation, hence causing similar pain upon provocation * Multiple may have similar functions and can compensate for the loss of one of those structures such as one muscle compensating for the loss of another muscle * A test may identify the area of origin of symptoms, not the pathology in that area such as subacromioal pain being the find result of multiple conditions in the subcromial space * Certain tests may be positive certain disorders, but the anatomic basics upon which the test were developed has not been proven by cadaveric studies; hence the reasons as to why some tests are positive in some disorders is not fully understood * The amount of symptoms such as pain reported by individuals upon provocation tests may ot be all or none but hugely vary, with no specific cut point as to when a test is considered positive. With clinical experience it may become easier to quantify what is substantial pain, what is exacerbated pain or what is pain out of proportion * Some tests may be unreliable or cannot be performed in the presence of con- comitant pathology, as that pathology may: * Prevent the individual to place the arm in the position required in order to perform the special test * Cause symptoms similar to the ones that the special test aims to elicit A systematic review into special shoulder tests has shown that many tests for rotator cuff pathology inaccurate an may ot be useful in clinical practice [3]. These limitations of special tests must be considered in clinical examination. Special tests should us be used as another piece to the diagnostic jigsaw rather than a process that gives an absolute answer. A plethora of special tests have been described for shoulder disorders, but a description of all of these is beyond the scope of this book. In addition the use of all the previously described shoulder tests is practically impossible n routine clinical practice. Hence, clinicians often choose and utilise certain tests in their routine examination. Special tests used by the author in clinical examination of the shoulder are presented here. ## 5.5 Assessing Muscle Strength in Shoulder Examination Assessing muscle strength is challenging as: * It is essential to distinguish between true and apparent weakness * Several muscles may contribute to a motion; hence an attempt is made to isolate the activity of the muscle in question during examination In grading muscle strength, you may consider the: Medical Research Council grading system whereby muscle strength is graded 0-5 [10]: | Grade | Description | |-------|-----------------------------| | 0 | No muscle contraction | | 1 | Flicker / trace | | 2 | Movement with gravity eliminated | | 3 | Movement against gravity | | 4 | Movement against gravity and resistance | | 5 | Normal motor function | Alternatively, a more simplified grading system may be utilised, whereby three grades of muscle strength are described as: * Strong * Weak but can maintain preposition * Severely weak – cannot maintain preposition * In assessing muscle strength, the following approach may be utilised: * Ask the patient to perform the motion actively. From this you will get tan impression as to whether there is severe weakness or only some weakness. * Then place the arm passively to the position you would expect the patient to achieve, and ask them to maintain it there in the case of forward elevation, be ready to catch the patient's arm, to stop it from dropping suddenly and causing discomfort. If the patient cannot maintain such a preposition, then this is a lag sign positive, and it indicates a severe weakness (such as due to substantial tendon tear). * If they can maintain the position, the proceed to further examine the strength, and quantify it / compare it to the opposite healthy shoulder where applicable. This is achieved by asking the patient to maintain the arm in the position, whilst you apply an opposing force. ## 5.6 Testing Muscle strength : Individual Muscles ### 5.6.1 Supraspinatus #### 5.6.1.1 Drop-Arm Sign [11] The patient's arm is elevated by the examiner to about $90^\circ $ in the scapular plane. The patient is warned that the examiner will let go and is asked to maintain the arm in that position. The examiner lets go but with the examiner's hand staying close in order to catch the arm if the patient cannot maintain this position. Inability to maintain the arm in that position is suggestive of substantial supraspinatus weakness. #### 5.6.1.2 Supraspinatus Resistance Strength Test [12] With the patient stanidng, the arm is elevated to $90^\circ$ in the scapular plane and internally rotated, so the thumb is pointing downwards. The patient is asked to maintain the arm in that position resisting a downward force applied by the examiner. The test is repeated with arm n external rotation (thumb pointing upwards). It is preferable for the examiner to use one or two fingers to apply force rather then the fill and and also to apply the force proximal to the elbow to minimise the moment arm effect (monent exerted at the joint is the product of the source multiplied by the distnace at which this force applied from the joint). the auther prefers to perform this test with the arm in $30^\circ$ forward elevation, as graeter elevation my cause pain. The images are of the Supraspinatus strength test with arm in a) internal rotation and b) external rotation In cases of massive supraspinatus tendon rupture, whereby arm forward elevation or abduction cannot be initiated, if the arm is assisted passively for the first $15-30^\circ$ of motion, the deltoid may then takeover and complete the movement. The patient may be able to demonstrate that they assist their bad arm with the opposite good one in the initiation of motion, or the examiner may assist the patient in this initial stage. Similarly, some patients learn to use their upper body to throw their arm forwards to a degree that the deltoid can take over further elevate the arm, hence compensating for the loss of supraspinatus. The image relates to cases of supraspinatus dysfunction, the patient may (a) throw the weak arm forwards using their body or (b) may assist the weak arm with the opposite arm in early evaluation to facilitate the initiation of further active motivation. ### 5.6.2 Infraspinatus and Teres Minor #### 5.6.2.1 Ipsraspinatus External Rotation Lag Sign [11, 13] With the patient standing, the elbow is flexed at $90^\circ$, with the elbow kept by the trunk (or with the arm elevated $20^\circ $ in the scapular plane). The arm is passively externally rotated to the maximum that can be achieved, and the patient is asked to hold this position once the examiner lets go. The test is positive if the aprintei is unable to hold the arm in this position, and the arm internally rotates back towards the trunk. External rotation lag test - the examiner places the patient's arm passively n external rotation. When the examiner lets go, the arm cannot stay in the preposition and drifts towards internal rotation. #### 5.6.2.2 Hornblower's Sign [13, 14] The patient is asked to bring the hand to their mouth, and the examiner observes whether this s achieved or how t s achieved. This sign s positive when in order to achieve this motion, the patient abducts the affected arm to raise the elbow to same or higher than the hand level. This is due to lack of active external rotation of the shoulder. Such external rotation deficit can hinder or prevent eating and prinking. Images depict Hornblower's sign: (a, b) Patient can bring the hand to mouth of left but not right side. (c) On the right the hand can reach the mouth only by abductive the shoulder. An image of hornblower's sign on right arm. #### 5.6.2.3 Infraspinatus Resistance Strength Test [13] With the patient standing, the elbow is flexed at $90^\circ$ and placed by the trunk . The shoulder is externally rotated $45^\circ$. The patent s asked to maintai this position, whistle examiner applies an internal rotation force to the distal forearm. An image shows the external rotation resistance strength test for ifraspinatus. #### 5.6.2.4 External Rotation Strength at $90^\circ$ of Abduction [13] ### The patient's is passively elevated to $90^\circ$ of adduction in the scapular plane. The elbow is then flexed to $90^\circ$, and the patient is asked to externally rotate the shoulder. The patient is asked to maintain the arm in external rotation resisting an internal rotation force applied by the examiner. The main external rotators of the shoulder are the infraspinatus and teres minor. Teres minor may be responsible for up to $45\%$ of the power of external rotation. Hence, n the presence of a massive nfraspintatus tear, an intact teres minor an contribute enough power tot external rotation to avoid the hornblowers sign. By assessing the external rotation ag sign and Hornlbower's sign the extent of external rotators dysfunction may be determined: * Extrnal rotation lag sign positive suggestive of a substantial tear of infraspinatus * Hornblowers sign psotive substantial terr of infraspinatus Image show Left arm external rotation weakness and positive Hornblower's sign. ### 5.6.3 Subscapularis #### 5.6.3.1 Belly-Off Lag Sign [15] The arm tot eh patent brought passively o flexion and mmacmcmu internal rotation, with the elbow flexed $90^\circ$. The eblwi of the aptient is supported n this positon by one hand of the examiner, whilst the axiemrs other hand presses the patients hand on the aptients abdomen. The patient is then akesd to maintain that potion with the wrest straight sas the examiner releases the hand whlst still sporting the elbow. The s positive if the patient cannot maintain the potion and the had lifts off the abdomen. #### 5.6.3.2 Belly Press Test [16] The arm is on the side of the bdy with the elbow flexed $90^\circ$. The patient is asked to press their hand aginst the belly whilst keeping the wrest striagth dad the elbow forwards and the forearm at $90^\circ$. Image shows belly press test for subsclapaursl. subscalaprs tearf the right shoulder pt can only press on the abodomen by arm extension and wrist flexion #### 5.6.3.3 Internal Rotation Lag Sign [11] The paatinet is asked top put their hand one their loner ac bak with the bak of the hand toucing te lumbar region. In thsi postin teh arms interanlly rotates and extensd. The hans i sppssively fit lited away from the body, and the ptient is asked to maintain thsi spotin . #### 5.6.3.4 Lift-Off Test [17] THE PTINET is asked to put their hand on tehiw loer bak with the back of hand touching the lumbar groin. In this postino te armis itnrlay rotated and extended. Image shoes The lift off trst for ubscaau ### 5.6.4 Rhmboods #### 5.6.4.1 Rhomboids Resistance Test [18] The patient si fading away from the examiner. The aims re placed in $90^\circ$ abduction and light itnral rotation with the elbosw $90^\circ$. The axil press on the eptaient s psorteir aprst the arm juts above the elbow dad appli esan ante roer medial directed foruc wich the ptient is askesd to resist ### 5.6.5 Trapezious #### 5.6.5.1 Shrug Test [19] Teh ptinet shirsug trhrih shoulder against a doanrd foruc applied by the cxmeaire this sts the cupper tepeizu. ## 5.7 Pain Provoking Tests ### 5.7.1 Subacromial Pain Provoking Tests #### 5.7.1.1 Painful Arc Sign [20] Tisis describees a range of motion which brings on are worsens with pain wti ht ptaient sting t eh tpent is aksesd too atcvly abduct eht ami nte scalaualr palen eyp ti flle elatdton aad htne rbngt eh arm back diw.o. Pain felt on the leetral arp of the cupper arminte region tht dltd muscal and this is reitno beten $60^\circ$ and $120^\circ$ of ealaitnois susggestsediveof sculaibn.on. It is cintrea ts a a pafull ace for $120^circ$ too $180^\circ$ ealito felt overt the trp to s houlld eis ssggestiveof ACJT origin.On oasiosn more pain is eerienced during arm decesn ads ocmareedto asenednd. ### 5.7.1.2 Neer Impingement Sign [21] the aptinet s s iaplcexed ti teh cscaulpalar pane wirh t ehmb facilng dwsnward nternal rotations. Injjection of local anethtc suchsligicadine itn eth aysibrcmaaiol space y aimprove are ltieaitnethis pnai dueuing ehat aove mtnurvre tihti snikwne taht eheer pimt test whcih hfuitrhelp scntomofthhe r uiacromial Image subsclomai impngemtn test wit ht aimitnranl an extenal rotation a b #### 5.7.1.3 Hawinks kemmry impigmetnrt tst hte icaimis apssleievly eletavetd fwrsd to ty 9$0$ ####### the image shows hawkins test iwht hte armin fwsdfwrt te armin abudtion image shows cross #### 5.7.2 ACTJ Pain Provinoking Tsts #### 5.7.2.1 Cross Body Adduction Test [23] With a patient standing, the are is passively elevated forwards to 9, and internally rotated Image O'Brien's test Kim's Test fro Posteror-Inferoor Labrum Tear.[27] the patent is sitting against the back of chair the arm is Placed in $90^\circ$ of abduction and internal rotation with the elbow flexed ### 5.7.4 Long Head of Biceps Tendon Pain Provoking Tests Image Shows Seepds test #### 5.7.4.1 Speed's Test [28] The amis leeavted frsrwards to90 it the elbwi fully extenderd and the foreman suplinatee falcn uggrd cThe examitapplies a dawrmd forc eon to the fore aim whch theaptien tis aksred to resist Image Shows seepds test #### 5.7.4.2 Yergason's Test [29] Image Shows The with the am by thi side and the elbow fexed 90 the patent is askd to maintain hte elbow in full suponination against a promating force applied bt hte excamire ## 5.8 Laxity Assessment The is also Image shows assesmetnof shoulder laxity Image shows ## 5.9 Laxity Assessment #### 5.8.1.1 Load nd Shift Test [30] ####### shows assessment opf knee hyerrexston Testing the cost-clavicula span te armis placed in ### 5.9.7.5 Costo-Clavicular Test [51] The patient stands by the side the radial plse ifthe patent plls te shoulder ### 5.9.7.6 Upper Limb Tension Test [52] ## 5.9.8 Core Balance Tests Image shows ability ot pure plams flats The presenceso ech of the four ## 5.9 Shoulder Insatiablity Test Referentes