Shoulder Joint Examination History Cuff Examination Instability Examination AC Joint Examination Biceps Tendon Examination Superior Labrum Examination Shoulder Joint Examination Inspection Palpation Movement Look Feel Move Front View trapezius contour deltoid contour Inspection pectoralis contour Observe wasting, scars Inspect axilla (lumps, scars) 1
Inspection Side-on View spinal contour resting posture of shoulder Behind View trapezius relative heights of scapulae deltoid triceps Palpation Bony Landmarks clavicle sternoclavicular joint (sternal notch) AC joint coracoid process acromion (anterior, posterior aspects) scapula spine medial border of scapula Palpation Soft Tissues biceps tendon (external rotation) sub-acromial bursa sub-deltoid bursa 2
Active Movements Anterior Full elevation Full extension External rotation Posterior Movement Scapulothoracic rhythm Internal rotation Abduction (scapulohumeral rhythm) Observe face Inspecting Abduction Posterior View glenohumeral movement (first phase) scapulothoracic movement (beyond 90 all scapulothoracic) Comparison of Active & Passive Movements Stiff Shoulder passive range = reduced active range Suspected Cuff Tear passive range > active range Passive (Anterior) Elevation External rotation Extension Passive (Posterior) Internal rotation (90 abduction, elbows flexed forward) Posterior capsular contracture 3
Posterior Capsular Contracture Decreased internal rotation Decreased adduction Cross-body adduction test Clinical Testing (*History*) Rotator Cuff Impingement Signs 1. Neer s sign - pain during elevation 2. Hawkin s sign Abduction, 90 elbow flexion, varying degrees of internal rotation Best sign for sub-acromial impingement Rotator Cuff - Muscle Power Testing Supraspinatus ( empty-can test) Abduct arm in plane of scapula + internal rotation Findings Pain Weakness ( drop-arm sign) 4
Rotator Cuff - Muscle Power Testing Infraspinatus (+ teres minor) 1. Elbow flexed 90 push against examiner s hand 2. Arm external rotation unable to maintain posture ( lag sign ) Rotator Cuff - Muscle Power Testing Subscapularis (internal rotation + pec. minor) 1. Elbow flexed 90 - painful internal rotation 2. Gerber s lift-off test - isolate subscapularis by pushing hand off back 3. Subscapularis Lag sign - unable to maintain liftoff position 4. Belly-press test - palms flat on belly with wrists in 0 flexion Press against abdomen: +ve for wrist flexion Long Head of Biceps Tendon +ve superior labral pathology as well Palpate over biciptal groove (slight external rotation) Speed s test: 90 forward elevation Resist downward pressure (+ve if localised pain response) Yergason s test: shake hands with 90 elbow flexion ~ resisted supination (+ve if localised pain response) 5
AC Joint Disease Posterior, anterior, superior aspects Local tenderness Asymmetry (dislocation) Anterior / posterior instability Cross-body Adduction test (+ve localised pain response) O Brien test: often positive in AC pathology Forward elevation 90, slight adduction Resist downward pressure (deep pain for superior labrum) Shoulder Instability 1. Anterior Apprehension sign 90 abduction, external rotation (+ve if patient apprehensive) 2. Jerk test Observe face Posterior / mulit-instability Arm 90 forward elevation into adduction Humeral head slides over glenoid Humeral head jerks back during abduction Anterior Instability Jobe Relocation Sign (patient supine) Shoulder abducted / external rotation position Examiner relocates - sign of apprehension Pain response -? Internal impingement 6
Instability Sulcus sign 1. Forearm flat, shoulder neutral rotation Downward traction 2. Repeat in external rotation +ve sulcus sign Multi-directional instability Rotator interval incompetence Superior glenohumeral ligament laxity Coracohumeral ligament laxity Instability Drawer sign (patient totally relaxed) Grasp acromion and coracoid Grasp humeral head Anterior translation (less than 50% translation - normal limits) Posterior translation (sublux upto 50% translation - common) Further Examinations History Pain distribution - cervicogenic pain radiating distal to elbow parathesia / numbness?? neurological cause Cervical spine examination (active / passive ROM) Neurological examination e.g., recurrent instability - axillary nerve involved Upper plexus 7