Shoulder examination for orthopedic students; one of the famous lectures of MAMC PG course - over last 6 years.

1. SHOULDER EXAMINATION
Dr Vinod Kumar
Dr Dhananjaya Sabat
Department Of Orthopaedics
Maulana Azad Medical College & LN Hospital
New Delhi

2. EVALUATION PRINCIPLES
Get a History: Is this a new injury, old chronic
injury
Assessment: what is the primary problem ?
PAIN INSTABILITY LOSS OF MOTION
EXTRINSIC ACTIVE
OR OR
INTRINSIC PASSIVE

3. Evaluation Order SEE
• History FEEL
• Inspection
• Palpation MOVE
• Movement : ROM & strength
• Special tests: Rotator cuff disease & impingement
Instability & Laxity
Biceps tendon & SLAP
AC & SC joint

4. INSPECTION
Anterior side
Posterior side
Lateral
Overhead
Axillary
Sometimes too obvious

5. Deltoid
Atrophy
Pain at insertion site-
mostly referred from
rotator cuff pathology;
rarely due to deltoid
tendinitis

6. Subacromial
region
Swelling- bursitis
Biceps tendon
Rupture- Popeye
bulge

7. Posterior side
Scapula
Position
High – Sprengel’s
Spine
Fossae –
supraspinatus &
infraspinatus atrophy

8. Borders of scapula–
lateral; prominent in LD
atrophy
superior; prominent in
supraspinatus &
trapezius atrophy
Vertebral; prominent in
serratus ant
weakness/winging

9. PALPATION
Tenderness
Swelling
Palpable gap in muscles
Acromioclavicular joint
Coracoid process
Subacromial bursa
Biceps tendon

10. MOVEMENTS
Active
Passive
Resistive

11. FORWARD EXTENSION
ABDUCTION- ADDUCTION CROSS
FLEXION- 0- - 0-45°
160/180° 0-180° - 0-45° BODY
ADDUC
TION

12. See scapulohumeral rhythm from
backside

13. EXTERNAL ROTATION- 0-45°

14. INTERNAL ROTATION- 0-55°

15. Appley’s scratch test
Patient attempts to touch the opposite
scapula thus testing abduction & ER and
adduction & IR
Good screening test for ROM assessment

16. Muscle strength tests
Latissimus
Deltoid Pectoralis major
dorsi

17. Rhomboids Trapezius Serratus
anterior

18. NEUROMUSCULAR EXAMINATION
Motor examination
Sensory examination
Brachial Plexus Injury
Deep tendon reflexes Brachial Neuritis
Compression Neuropathies
Cervical spine
Spurling test, L-Hermitte sign
Thoracic outlet synd
Adson’s test, Hyperabduction test, Roos test

19. Axillary nerve injury
Anaesthesia in the
‘Regimental
badge area’

20. 1. INSTABILITY
2. IMPINGEMENT SYNDROME
3. ROTATOR CUFF TEAR
4. BICEPS TENDON PROBLEMS
5. AC JOINT PROBLEMS
6. STIFF SHOULDER

22. ANTERIOR DISLOCATION SHOULDER
Hamilton Ruler
test
Duga’s test
Callaway’s test

23. POSTERIOR DISLOCATION SHOULDER
ER restricted
Prominence
in posterior
deltoid
LIGHT BULB SIGN

24. Chronic Instability
Instability can be-
Unidirectional- anterior, posterior, inferior
Multidirectional (MDI) – anterior &/ or
posterior + inferior
TUBS AMBRI
•Traumatic •Atraumatic
•Unidirectional •Multidirectional
•Bankart’s lesion •Bilateral
•Surgical t/t •Rehabilitation
•Inferior capsular shift

25. CHRONIC UNIDIRECTIONAL INSTABILITY
PROVOCATIVE TESTS QUANTITATIVE TESTS
to document the presence To quantitate the
& direction of instability amount of laxity
Anterior Instability •Drawer tests
•Crank test •Load & shift test
•Fulcrum test for both anterior and
•Jobe’s relocation test posterior instability
Posterior Instability
•Jerk test
•Circumduction test

26. ANTERIOR INSTABILITY
Provocative tests
Apprehension test
Crank test – Pt sitting; arm at
90° ABD. With increasing ER
the examiner exerts an
anterior translatory force with
his thumb placed posteriorly on
the humerus & watches for
apprehension.
Apprehension is diagnostic of
instability. If only pain, subtle
subluxation.

27. Fulcrum test –Pt supine
with the scapula supported
by the edge of the table.
The arm is positioned in 90°
ABD. With increasing ER the
examiner watches for
apprehension.

28. Jobe’s Relocation test
Examiner repeats apprehension
test and notes the amount of
ER before the onset of
apprehension.
Then apply a posterior stress
over the humeral head & repeat
the ER maneuver and again
note amount of ER at onset of
apprehension.
Increase in the external rotation
range = +ve
Release test- apprehension
reappears on release

29. POSTERIOR INSTABILITY
Provocative tests
Jerk test
Pt supine with 90° forward
flexion of shoulder &
elbow flexed to 90°,
examinor applies posterior
directed force by holding
the forearm.
Jerk/Jump = diagnostic of
instability
Pain/apprehension=
subtle instability

30. Circumduction test
Pt standing, examiner
standing behind & holds
the arm in extension &
abduction; performs
circumduction
Visible subluxation/
apprehension in position of
foreward flexion 160° &
adduction (position of risk)
= instability

31. Inferior laxity
Sulcus sign
Patient in sitting or standing;
the shoulder is in neutral
position, muscles are relaxed.
Downward traction applied
+ = dimpling of the skin
below the acromion or
widening of the subacromial
space on palpation; >2cm
translation
MDI

32. Multidirectional instability
Instability in more than one direction
including inferior laxity
Voluntary dislocation
Abnormal generalized laxity
Abnormal scapular mechanics
Psychiatric illness

34. Painful arc syndrome
In abduction arc of
motion, patient feels
pain in the range 60-
120°.

35. O’Brien test
The patient flexes the arm
to 90° with the elbow fully
extended and then adducts
the arm 10-15° medial to
sagittal plane. The arm is
then maximally internally
rotated and the patient
resists the examiner's
downward force.

36. Hawkins-Kennedy Test
patient sitting with arm at
90° forward elevation and
elbow flexed to 90°.
Examiner then quickly
moves the arm into
internal rotation.
+ve = Pain located to the
sub-acromial space
Subacromial
impingement, rotator cuff
tendinitis

37. Neer Impingement Sign
Examiner performs maximal
passive forward flexion with
internal rotation whilst
stabilizing the scapula.
+ = Pain located to the sub-
acromial space or anterior
edge of acromion
Subacromial impingement of
supraspinatius & anterior part
of infraspinatus

38. Neer’s Impingement Test
Examiner after
eliciting
impingement sign,
injects local
anesthetic soln. to
subacromial space.
Disappearance of
pain is diagnostic

40. Inability to abduct or flex foreward
Atrophy of supra & infraspinatus
fossae
Empty can test - for supraspinatus
ER at arm at side with elbow
flexed- for infraspinatus
Lift off test/ abdominal
compression test – for
subscapularis
Drop Arm sign
External rotation lag sign

41. Supraspinatus “Empty Can Test”
Pt attempts to elevate the
arms against resistance
with arms at 90°
abduction in a plane 30°
anterior true coronal
plane and full IR (thumb
pointing downward) with
elbows extended.
Positive = supraspinatus
tear

42. Infraspinatus & Teres minor
Patient’s arms at
the sides with
elbows flexed to 90,
attempts to do ER

43. Subscapularis
1. “Lift off test/ Gerber’s test”
Patient standing with hand behind
back with the dorsum of the hand
resting on the back. The hand is
raised off the back by maintaining or
increasing internal rotation of the
humerus and extension at the
shoulder.
Full passive internal rotation is
prerequisite.
Inability = subscapularis tear/
dysfunction

44. Subscapularis
2. Abdominal compression test
Patient attempts to press
the hand down against
abdomen with examiner
preventing it.
Useful when IR restricted.
Inability = subscapularis
tear/ dysfunction

45. Drop Arm sign
Examiner abducts patient’s
shoulder to maximum. After
warning the patient, examiner
releases pt’s arm & asks him to
lower the arm back to the side.
Pt able to lower the arm part
way & then suddenly loses
control- arm drops suddenly to
the side.
Indicates large rotator cuff tear
Also seen in axillary nerve palsy

46. External rotation lag sign
Pt’s arm is externally
rotated maximally and
released- arm rotates
internally spontaneously
(passive ER>active ER).
Seen when subscapularis
is intact but infraspinatus
& teres minor is torn.

48. Yergasson’s test
The patient's elbow is
flexed and their
forearm pronated. The
examiner holds their
arm at the wrist.
Patient actively
supinates against
resistance.
Pain located to bicipital
groove = +ve

49. Speed’s test
The patient's elbow is
extended, forearm
supinated and the
humerus elevated to 60°.
The examiner resists
humeral forward flexion.
Pain located to bicipital
groove = +ve

51. Cross chest adduction test
Pt. elevates the affected
arm to 90°, then actively
adducts it.

53. Restriction of all
range of motion, esp-
Abduction & ER
Pain on attempted
movements

54. Note –
ER restriction occurs in 2 conditions
only
1. Stiff shoulder
2. Posterior dislocation
Overhead athletes may have
restriction of IR due to posterior
capsular tightness

55. SUMMARY
Instability Instability Provocative
Quantitative
Impinge- Pain O’Brien, Hawkins-
ment Kennedy, Neer’s
Cuff tear Pain Drop arm test, Test for
loss of motion SS, IS & SS
Biceps Pain Yergasson, Speed,
tendinitis Instability Biceps instability
AC jt injury Pain Tenderness, Cross chest
abduction
Stiff Pain Passive motion
shoulder stiffness restriction

56. Conclusion
Clinical examination of shoulder should
be guided according to patient's age,
chief complains and professional
activities.
All tests needn’t be performed to clinch
the diagnosis.
Merely knowledge of test is not enough,
good practice is essential to perform the
tests.

57. “It is more important to know
what patient the disease has
rather than what disease the
patient has”
William Osler