Shoulder Examination

Subjective

Patient Intake

Taking a detailed patient history is important. Listen carefully to the patient’s past medical history (PMHx) and history of presenting condition (Hx PC). The narrative given by the patient contains much of the information needed to rule out red flags and guide the shoulder examination.

The patient may report pain local to the involved shoulder. The symptoms may extend toward the scapula, axilla, anterior chest, along the clavicle, or down the humerus. When taking the patients history it is also important to ask if they have pain or symptoms in other regions such as their cervical or thoracic spine, or elbow. The patient may also report difficulty with overhead activities, lifting objects, activities of daily living, sports or recreational activities.& There are several presentations that may differ depending on the suspected pathology.

  • Patients with suspected glenohumeral instability or labral pathology may have feelings of “looseness or instability” particularly in abducted and externally rotated positions.&
  • Patients with suspected adhesive capsulitis may report intense global shoulder pain initially combined with a progressive loss of range of motion.&
  • Patients with suspected subacromial or rotator cuff related impairment may report feelings of weakness, heaviness and/or pain.
Shoulder History Exam Questions: These questions may assist the clinician in determining potential pathologies. Please refer to the User's Guide to Musculoskeletal Examination[1]&  &  for more information. 
  1. Does moving your neck change your symptoms?
  2. Do you ever feel unstable during arm movement?
  3. When you do actions with your arms over your head, does this aggravate your pain level?
  4. Is it difficult to move your arm?&
  5. When performing actions with your arms over& your head, do your arms feel heavier?

Mechanism of Injury

Asking about the mechanism of any specific injury is critical, particularly about three factors relating to the time of injury: anatomical site, limb position and subjective experiences. Take care to clarify the patient’s description of the anatomical site. A description of the arm position at the time of the injury is also valuable. For example, falling on an abducted and externally rotated arm increases the risk of shoulder dislocation or subluxation. Finally, exploring the subjective experiences of the patient at the time of injury can be useful. For example, a snapping or cracking sound may be related to a bone or ligament breaking; feeling something ‘pop out’ may suggest a joint dislocation or subluxation.

Outcome Measures

Special Questions

Patients with shoulder pain should be questioned for the presence of red or yellow flags. A thorough medical history and possibly the use of a medical screening form is the initial step in the screening process. The chart below highlights some of the most common red flag conditions for patients with shoulder pain.

Red Flags

Determine if patient's symptoms are reflective of a visceral disorder or a serious potential life-threatening illness such as cancer, visceral pathology or fracture.[2]

Potential Shoulder Regional Referral Patterns:

Left Shoulder

  • MI 68.7% of patients reported shoulder pain during an acute myocardial infarction[3]
  • Ruptured Spleen[4]

Both Shoulders

  • Pancoast’s Tumor[5]

Right Shoulder

  • Liver Disease[6]
  • Carcinoma,Cirrhosis, Hepatitis
  • Stomach
  • Hiatal Hernia[7]
  • Post Bariatric Surgery
  • Gastric Perforation[8]
  • Peptic Ulcer
  • Pancreas
  • Pancreatitis
  • Pancreatic Cancer
    • May be worse after fatty meal or associated with eight loss of Diabetes Mellitus
  • Gall Bladder
  • Cholecystitis
    • Typically accompanied by fever, or nausea/vomiting

Fractures

Fractures may result from trauma such as falls onto an outstretched hand. These are known as FOOSH injuries. Commonly fractured within the shoulder region

  • Humeral Fractures
    • Proximal or distal
  • Clavicle Fractures[9]
    • Fractures of the clavicle usually result from a direct blow to the shoulder giving axial compression. The middle 1/3 of the clavicle is most often broken with an incidence of ~80%. Distal clavicle fractures have an incidence of 10-15% and medial clavicle fractures have and incidence of 3 to 5%. Significantly displaced fractures are managed surgically.Mid-shaft clavicle fractures have a lower rate of mal-union and better functional outcomes at one year.[10]& A trial of conservative management may be warranted for non-displaced clavicular fractures.

Yellow Flags

Yellow flags are factors that increase a patient’s risk for developing long-term disability. Psychosocial Factors may be contributing to a patient’s persistent pain and disability, or that may contribute to the transition of an acute condition to a chronic, disabling condition. Some attitudes and beliefs to look out for are: [11]

  • Pain is harmful or disabling
  • Pain must be eliminated before returning to activity
  • Passive attitudes towards therapy
  • Patient utilization of extended rest, reduced activity level and withdrawal from daily activities
  • Patient reports of extreme pain intensity
  • High intake of alcohol or other substances

The Fear Avoidance Belief Questionnaire (FABQ) is a tool to assess yellow flags among patients. The FABQ predictive validity is debatable, and is best for the FABQ-W when evaluating workers compensation patients. The overall test-retest reliability is excellent, ICC= .97.

Depression Screening tools such as the Beck Depression Inventory (BDI) or the Depression Anxiety Screening Scale (DASS) are useful in screening patients for depression. Psychometric properties of the BDI: a cut-off score of ≥5 for screening, Sn = 90.9%, Sp = 17.6 %. A cut-off score of ≥22 for diagnostic utility, Sn = 27.3%, Sp = 90%.

The Pain Catastrophizing Scale, helps determine if the patient is exaggerating their pain and symptoms and the severity of the situations as a whole. Cronbach alpha values reported for the total Pain Catastrophizing Scale (PCS) (α=.87) and factor scales (Rumination α=.87; Magnification α=.60; Helplessness α=.87) were found to be satisfactory. The total PCS score showed strong temporal validity [12]. In a patient population with acute whiplash there was found to be a significant moderate correlation between pain pressure threshold and the pain catastrophizing scale as well as cold pain threshold and the pain catastrophizing scale [13].

Clear the Cervical Spine

The cervical spine can refer pain to the shoulder/scapular region. It is imperative that the cervical spine be screened appropriately as it may be contributing to the patient’s clinical presentation.

See Cervical Examination

Objective

Observation

Observation of a patient with a primary complaint of shoulder pain may include:

  • Static Postures
  • Static Scapular Position
  • Cervico-thoracic spine postures
  • Dynamic movement patterns
  • Scapulo-humeral rhythm
  • Functional tests
  • Hand behind head
  • Hand behind back
  • Cross body adduction
[14]
[15]
[16]
[17]

Palpation

Palpation of the shoulder region may provider the physical therapist with valuable information. The physical therapist should note the presence of swelling, texture, and temperature of the tissue. Additionally the physical therapist may observe asymmetry, sensation differences, and pain reproduction. Key palpable structures include:

  • Acromioclavicular Joint
  • Sternoclavicular Joint
  • Rotator Cuff Muscle Insertions
  • Long Head of the Biceps Tendon

Neurologic Assessment

A comprehensive neurological examination may be warranted in patients that present with a primary complaint of shoulder pain. The presence of neurological symptoms including numbness and tingling may warrant this examination.

Myotomes

[18]
  • C4 – Shoulder Elevation/Shrug
  • C5 – Shoulder Abduction
  • C6 – Elbow Flexion, Wrist Extension
  • C7 – Elbow Extension, Wrist Flexion
  • C8 – Thumb Abduction/Extension
  • T1 – Finger Abduction

Dermatomes

[19]
  • C4 – Top of Shoulders
  • C5 – Lateral Deltoid
  • C6 – Tip of Thumb
  • C7 – Distal middle Finger
  • C8 – Distal 5th Finger
  • T1 – Medial Forearm

Pathological Reflexes

  • Hoffman’s Reflex
[20]
  • Inverted Supinator Reflex
[21]

Deep Tendon Reflexes

[22]
  • Biceps Brachii – C5 Nerve Root
  • Brachioradialis – C6 Nerve Root
  • Triceps – C7 Nerve Root
[23]
[24]
[25]
[26]

Movement Testing[27]

Active Range of Motion (ROM)

Glenohumeral Joint Motions

  • Horizontal Adduction
  • Horizontal Abduction
  • Flexion
  • Extension
  • Internal Rotation
  • External Rotation
  • Abduction/Adduction
  • Abduction in the plane of the scapula
  • Abduction/Adduction
  • Upward/Downward Rotation
  • Elevation/Depression

Passive ROM

May include each of the motions stated in the active ROM section. The therapist may opt to include overpressure to further stress the joint.

[28]

Muscle Length Assessment

Assessment of the flexibility of certain muscles may be warranted in patients with shoulder pain. These muscles may include, but are not limited to:

  • Latissimus Dorsi
  • Pectoralis Minor/Major
  • Levator Scapulae
  • Upper Trapezius
  • Scalenes (anterior/middle/posterior)
[29]

Muscle Strength

Resistive testing of the shoulder muscles typically includes the following motions:

  • Shoulder Flexion
  • Shoulder Extension
  • Shoulder Abduction
  • Horizontal Abduction
  • Horizontal Adduction
  • Internal Rotation
  • External Rotation


Resistive testing of the scapular stabilization muscles may include:

  • Upper trapezius
  • Middle trapezius
  • Lower trapezius
  • Serratus Anterior
  • Rhomboids
  • Levator Scapulae
[30]
[31]
[32]

Joint Mobility Assessment

Assessment of the mobility of the joint may indicate hypomobility with in the joint or elicit symptoms.

  • Glenohumeral
    • Anterior
    • Posterior
    • Inferior
    • Distraction
[33]
  • Acromioclavicular
    • Anterior
    • Posterior
  • Sternoclavicular
    • Anterior
    • Posterior
    • Superior
    • Inferior
  • Scapulothoracic
    • Elevation
    • Depression
    • Upward/downward rotation
    • Protraction/Retraction

Special Tests

Several special tests exist for particular disorders of the shoulder. Below are links to the specific pages for each pathology that describe the special tests:

Diagnostic Imaging

Radiographs of the shoulder can be used to identify cysts, sclerosis, or acromial spurs, osteoarthritis of the acromioclavicular and glenohumeral joint, or calcific tendonitis. Common radiographic views may include (this may vary depending on medical provider):

  • Supraspinatus Outlet View
  • Scapular Y-View
  • Axillary View
  • Anterior-Posterior (AP) View

Clinical Picture

Shouler Assessment.png

References

  1. Flynn T, et al. Users’ guide to the musculoskeletal examination fundamentals for the evidence-based clinician. Evidence in Motion; 2008 .
  2. Murphy D, Hurwitz R. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. 2007; 8: 1, 75 .
  3. Song L, Yan HB, Yang JG, Sun YH, Hu DY. Impact of patients' symptom interpretation on care-seeking behaviors of patients with acute myocardial infarction. Chin Med J (Engl). 2010 Jul;123(14):1840-5
  4. Rutkow IM. Rupture of the spleen in infectious mononucleosis: a critical review. Arch Surg. 1978 Jun;113(6):718-20 .
  5. Tamura M, Hoda MA, Klepetko W. Current treatment paradigms of superior sulcus tumours. Eur J Cardiothorac Surg. 2009 Oct;36(4):747-53. Epub 2009 Aug 20 .
  6. Strauss E. Flanagin BA, Mitchell MT, Thistlethwaite WA, Alverdy JC. Usefulness of liver biopsy in chronic hepatitis C. Ann Hepatol 2010;9 Suppl:39-42.
  7. Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery. Obes Surg. 2010 Mar;20(3):386-92. Epub 2009 Oct 24.
  8. Pappano DA, Bass ES. Referred shoulder pain preceding abdominal pain in a teenage girl with gastric perforation. Pediatr Emerg Care. 2006 Dec;22(12):807-9 .
  9. McKee MD. Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation? Orthop Clin North Am. 2010 Apr;41(2):225-31
  10. Altamimi SA, McKee MD. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2008 Mar;90 Suppl 2 Pt 1:1-8
  11. Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion. 2008
  12. Osman A et al. The Pain Catastophizing Scale:Further Psychometric Evaluation with Adult Samples. Journal of Behavioral Medicine. 2000; Vol.23(4): 351-365.
  13. Rivest K et al. Relationships between pain thresholds, catastrophizing and gender in acute whiplash injury. Journal of Manual Therapy. 2010; Vol 15:154-159.
  14. BJSM Videos. Shoulder Exam (2 of 9): Inspection and Palpation. Available from: http://www.youtube.com/watch?v=Xf52jbNA7wg [last accessed 25/01/14]
  15. BJSM Videos. Shoulder Exam (3 of 9): Range of motion. Available from: http://www.youtube.com/watch?v=d7HfaAlgaro [last accessed 25/01/14]
  16. BJSM Videos. Shoulder Exam (4 of 9): Scapular control (Is there scapular dyskinesia?). Available from: http://www.youtube.com/watch?v=pEY93k5XXL0 [last accessed 25/01/14]|}
  17. BJSM Videos. Shoulder Exam (5 of 9): AC joint examination. Available from: http://www.youtube.com/watch?v=-y_NUVmHe-E [last accessed 25/01/14]|}
  18. Physiotutors. Myotomes Upper Limb | Peripheral Neurological Examination. Available from: https://www.youtube.com/watch?v=kPuQPqBMGj0
  19. Physiotutors. Dermatomes Upper Limb | Peripheral Neurological Examination. Available from: https://www.youtube.com/watch?v=VlPpdRTGH-o
  20. Physiotutors. Hoffmann's Sign or Reflex | Upper Motor Neuron Lesion. Available from: https://www.youtube.com/watch?v=uVI55amnVuk
  21. Physiotutors. Inverted Supinator Sign | Upper Motor Neuron Lesion. Available from: https://www.youtube.com/watch?v=_H5Pv8istcI
  22. Physiotutors. Upper Limb Deep Tendon Reflexes | Peripheral Neurological Examination. Available from: https://www.youtube.com/watch?v=FZsexSwddc0
  23. BJSM Videos. Shoulder Exam (6 of 9): Ruling out a SLAP tear (Kuhn's tests). Available from: http://www.youtube.com/watch?v=YMPZi2_Jy9o [last accessed 25/01/14]
  24. BJSM Videos. Shoulder Exam (7 of 9): Exam to detect a SLAP tear. Available from: http://www.youtube.com/watch?v=beVd-cX_TX8 [last accessed 25/01/14]
  25. BJSM Videos. Shoulder Exam (8 of 9): Examination for impingement (rotator cuff). Available from: http://www.youtube.com/watch?v=r8Rl0_KE3OA [last accessed 25/01/14]|}
  26. BJSM Videos. Shoulder Exam (9 of 9): Testing for instability. Available from: http://www.youtube.com/watch?v=Fz2g5gI3RGg [last accessed 25/01/14]|}
  27. Hislop HJ, Montgomery J. Daniels and Worthingham's Muscle Testing: Techniques of Manual Examination. Saunders 2007, 8th edition
  28. Physiotutors. Shoulder Passive Range of Motion (PROM). Available from: https://www.youtube.com/watch?v=n9HQIw1LHDY
  29. Physiotutors. Pectoralis Major and Minor Muscle Tightness Tes. Available from: https://www.youtube.com/watch?v=6WSybz0modY
  30. Physiotutors. Trapezius Strength Test. Available from: https://www.youtube.com/watch?v=9tfVeIhlY-o
  31. Physiotutors. Rhomboid Strength Test. Available from: https://www.youtube.com/watch?v=Gn3s7sVtyWo
  32. Physiotutors. Rhomboid Strength Test. Available from: https://www.youtube.com/watch?v=jatVx3v7qDI
  33. Physiotutors. Joint Play: Shoulder. Available from: https://www.youtube.com/watch?v=hKjQw-blrZ4
  34. Calis M, et al. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis, 2000 59, 44-47.
  35. Murphy D, Hurwitz R. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. 2007; 8: 1, 75
  36. Song L, Yan HB, Yang JG, Sun YH, Hu DY. Impact of patients' symptom interpretation on care-seeking behaviors of patients with acute myocardial infarction. Chin Med J (Engl). 2010 Jul;123(14):1840-5
  37. Flynn T, et al. Users’ guide to the musculoskeletal examination fundamentals for the evidence-based clinician. Evidence in Motion; 2008
  38. Rutkow IM. Rupture of the spleen in infectious mononucleosis: a critical review. Arch Surg. 1978 Jun;113(6):718-20
  39. Tamura M, Hoda MA, Klepetko W. Current treatment paradigms of superior sulcus tumours. Eur J Cardiothorac Surg. 2009 Oct;36(4):747-53. Epub 2009 Aug 20
  40. Strauss E. Flanagin BA, Mitchell MT, Thistlethwaite WA, Alverdy JC. Usefulness of liver biopsy in chronic hepatitis C. Ann Hepatol 2010;9 Suppl:39-42.
  41. Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery. Obes Surg. 2010 Mar;20(3):386-92. Epub 2009 Oct 24.
  42. McKee MD. Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation? Orthop Clin North Am. 2010 Apr;41(2):225-31
  43. Altamimi SA, McKee MD. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2008 Mar;90 Suppl 2 Pt 1:1-8
  44. BJSM Videos. Shoulder Exam (2 of 9): Inspection and Palpation. Available from: http://www.youtube.com/watch?v=Xf52jbNA7wg [last accessed 25/01/14]