History and Physical Exam of the Shoulder
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Transcript History and Physical Exam of the Shoulder
Musculoskeletal
Curriculum
History &
Physical Exam
of the Shoulder
Copyright 2005
Authors
Kathleen Carr, MD
Madison Residency Program
[email protected]
Dennis Breen, MD
Eau Claire Residency Program
[email protected]
2
Goal
Learn a standardized, evidence-based history
and physical examination of patients with
shoulder problems
WHICH WILL:
Enable family medicine resident physicians to
accurately diagnose common shoulder
problems throughout the full age spectrum of
patients seen in family medicine
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Competency-Based Objectives
Patient care – focused history and exam
Professionalism – respect, compassion
Interpersonal and communication skills –
differential diagnosis
Medical knowledge base – anatomy, injury
mechanisms
Systems based practice – accuracy, time-efficiency
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Shoulder Pain Key Points
Shoulder pain is a common complaint in primary
care
Most common causes in adults (peak ages 40-60)
Subacromial impingement syndrome
Rotator cuff problems
Athletic injuries
2nd only to knee pain for referral to Ortho or primary care sports
med
Shoulder accounts for 8-13% of athletic injuries
History and examination are keys to diagnosis
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Assessing shoulder pain
Components of the assessment
include
Focused history
Attentive physical examination
Thoughtfully ordered tests/studies
1.
2.
3.
for future discussion
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Focused History
Focused History Questions
Onset of Pain
When symptoms started*
History of trauma/injury
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Focused History Questions
Mechanism of Injury
Helps predict injured structure
Example: Fall directly onto anterior/superior
shoulderAC joint injury (shoulder separation)
Example: Arm forcefully abducted and externally
rotated subluxation or anterior dislocation
Example: If chronic pain, note activity that triggers
pain, such as the cocking phase of throwing or the
pull-through phase of swimming
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Focused History Questions
Mechanism of Injury, continued
Can determine radiological needs
Likelihood of specific conditions varies
Setting (work, recreation, sports, traumatic,
atraumatic)
Age of the patient*
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Focused History Questions
Location of pain*
Anterior
Lateral
Superior
Posterior
Radiation of pain
Rotator cuff problems often include pain
radiating to upper arm
If pain starts in neck and radiates to
shoulder, consider cervical spine disease
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Focused History Questions
Consider sources of referred pain
Cervical spine – spondylolysis, arthritis, disc
disease
Cardiac - myocardial ischemia
Diaphragmatic irritation
Thoracic outlet syndrome
Gallbladder disease
Complex regional pain syndrome (a.k.a, reflex
sympathetic dystrophy)
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Focused History Questions
Characteristics
of pain
Night pain when lying on affected Rotator cuff tear
side, muscle atrophy
< 30 yo
Biomechanical, inflammatory
> 45 yo, Hx of trauma
Rotator cuff tear - 35% of pts
Painful arc (60-120°abduction)
Pain > 120° abduction
Catching, popping, clicking
Subacromial impingement
Acromioclavicular joint
GH or AC joint arthritis, labral
tear
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Focused History Questions
History of instability
Aggravating factors
Overhead work, repetitive movements, sports
Relieving factors/treatments tried
Glenohumeral subluxation or dislocation
Rest, immobility, medications, other treatments
History of Prior Shoulder Problems or
Surgeries
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Differential Diagnosis
Diagnosis
Primary Care %
Age
Subacromial Impingement Syndrome
48-72
23-62
Adhesive Capsulitis
16-22
53
Acute Bursitis
17
-
Calcific Tendonitis
6
-
Myofascial Pain Syndrome
5
-
2.5
64
2
-
0.8
-
Glenohumeral Joint Arthrosis
Thoracic Outlet Syndrome
Biceps Tendonitis
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Physical Exam
Physical Exam - General
Develop a standard routine
Alleviate the patient's fears
Adequate exposure - bilateral
Males – shirtless
Females – tank top or sports bra
Compare shoulders
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Physical Exam – Steps*
Inspection
Palpation
Range of motion (ROM)
Strength testing
Special tests
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Inspection
Swelling, asymmetry, muscle atrophy, scars,
ecchymosis and any venous distention
Note posture (e.g., shoulder protraction)
Deformities
Squaring of shoulder - anterior dislocation
Scapular "winging" - shoulder instability and
serratus anterior or trapezius dysfunction
Atrophy - supraspinatus or infraspinatus consider rotator cuff tear, suprascapular nerve
entrapment or neuropathy
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Palpation
Sternoclavicular joint
Clavicle
Acromioclavicular joint
Subacromial bursa
Coracoid process
Bicipital groove
Greater tuberosity
Lesser tuberosity
Scapula (spinatus muscles)
TIP: Start medially at
the SC joint, proceed
laterally, end posteriorly
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Anterior Shoulder
http://www.nismat.org/orthocor/exam/shoulder.html#Functions
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Posterior Shoulder
http://www.nismat.org/orthocor/exam/shoulder.html#Functions
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Palpation of AC Joint
Patient's arm at his/her
side
Note swelling, pain, and
gapping.
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Palpation of Bicipital Groove
Patient sitting,
beginning with the arm
straight
Patient actively flexes
biceps muscle while
examiner provides
supination and ER
Examiner palpates the
bicipital groove for pain
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Range of Motion (ROM)
Evaluate active ROM
If movement limited by pain, weakness, or
tightness, assist passively
Lack of full ROM with active and passive exam
is found in adhesive capsulitis and arthropathy
Evaluate bilaterally for comparison
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Range of Motion
Movement
Forward flexion
Extension (behind back)
Abduction
Adduction
External rotation*
Internal rotation*
Normal range
180°
40°
180° (with palms up)
0°
45° (arm at side, elbow flexed)
55° (arm at side, elbow flexed)
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Forward Flexion
Arm straight and
brought upward
through frontal plane,
and move as far as
patient can go above
his head
0° is defined as straight
down at patient's side,
& 180° is straight up
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Abduction
Arm straight
Hand – palm up (arm
supinated)
ROM measured in
degrees as for forward
flexion
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External and Internal Rotation
Arm at side, elbow flexed to 90° and held at waist
Examiner externally or internally rotates arm
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Apley scratch test for ER/IR*
External rotation and abduction
Reach for upper scapula
Compare bilaterally – note level
reached
Internal rotation and adduction
Reach for lower scapula
Compare bilaterally – note level
reached
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Strength Tests
Flexion
Extension
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Strength Tests*
External rotation
Infraspinatus
Teres minor
Internal rotation
Subscapularis
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Strength tests
Empty can test*
Supraspinatus
Lift off test*
Subscapularis
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Special Tests
Rotator cuff
Drop arm test
Labral tear
Impingement tests
Neer’s sign
Hawkin’s test
Instability tests
O’Brien’s test
Crank test
Anterior release
Relocation test
Speed’s test
Biceps tendon
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Rotator Cuff
Empty Can Test
Supraspinatus
Lift off test
Subscapularis integrity
Drop Arm Test
Rotator cuff tear or supraspinatus dysfunction
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Drop Arm Test
Purpose: tears in the rotator
cuff, primarily supraspinatus
muscle
Method: patient abducts (or
examiner passively abducts)
arm and then slowly lowers it
May be able to lower arm slowly to 90°
(deltoid function)
Arm will then drop to side if rotator cuff
tear
Positive test: patient unable to
lower arm further with control
If able to hold at 90º, pressure on
wrist will cause arm to fall
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Video of Drop Arm Test
Click on
image for video
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Impingement - Neer’s Sign*
Patient seated with arm
at side, palm down
(pronated)
Examiner standing
Examiner stabilizes
scapula and raises the
arm (between flexion
and abduction)
Positive test = pain
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Video of Neer’s Sign
Click on
image for video
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Impingement - Hawkin's Test*
Patient standing
Examiner forward
flexes shoulder to 90°,
then forcibly internally
rotates the arm
Positive test = pain in
area of superior GH
joint or AC joint
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Video of Hawkin’s Test
Click on
image for video
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Speed’s Test - Biceps tendon
Forward flex shoulder
against resistance
while maintaining
elbow in extension
and forearm in
supination
Positive test = tender
in bicipital groove
(bicipital tendinitis)
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Video of Speed’s Test
Click on
image for video
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Labral Tear (SLAP) - O'Brien's
Active Compression Test
Patient standing
Arm forward flexed 90°, adducted
15° to 20° with elbow straight
Full internal rotation so thumb
pointing down
Examiner applies downward force on
arm - patient resists
Patient externally rotates arm so
thumb pointing up
Examiner applies downward force on
arm - patient resists
Positive test = Pain or painful
clicking elicited with thumb down
and decreased or eliminated with
thumb up
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Video of O’Brien’s Test
Click on
image for video
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Labral Tear - Crank Test
Shoulder elevated to 160°
in the scapular plane
A gentle axial load is
applied through
glenohumeral joint with
one hand, while other
hand does IR and ER
Positive test = pain,
catching, or clicking in the
shoulder
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Video of the Crank Test
Click on
image for video
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Glenohumeral Joint Stability
Anterior Glenohumeral Instability
Apprehension test
Relocation test
Anterior release test
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Apprehension Test - Sitting
90° of abduction
Examiner applies slight
anterior pressure to humerus
and externally rotates arm
Positive test = patient
expresses apprehension
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Apprehension Test
Patient in supine
position with affected
shoulder at edge of
table, arm abducted
90°
Examiner externally
rotates by pushing
forearm posteriorly.
Positive test = patient
expresses
apprehension
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Relocation Test
Performed after positive
result on anterior
apprehension test
Patient supine
Examiner applies
posterior force on
proximal humerus while
externally rotating
patient’s arm
Positive test = patient
expresses relief
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Video of the Apprehension &
Relocation Tests – Seated & Supine
Click on
image for video
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Anterior Release Test
Patient in supine
position, arm abducted
90°
Examiner performs
Relocation Test, then
releases downward
pressure
Positive test = patient
expresses pain or
instability when the
humeral head is
released
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Video of Anterior Release Test
Click on
image for video
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The Current Evidence Base
for History Questions and
Physical Exam Tests
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Rotator Cuff Tear
History /
Maneuver
Study Sens Spec
Qual (%)
(%)
LR+
LR- PV+ PV(%) (%)
History of
trauma
Night pain
2b
36
73
1.3
0.88
72
37
2b
88
20
1.1
0.6
70
43
Painful arc
2b
33
81
1.7
0.83
81
33
Empty can
test
1b
84
89
50
58
1.7
2
0.22
0.28
36
98
22
93
Drop arm
1b
21
100
>25
0.79
100
32
56
Impingement / Instability
Test
Study Sens Spec LR+ LR- PV+ PVQual (%) (%)
(%) (%)
Impingement
Hawkin’s
1b
87
89
60
2.2
0.18
71
83
Instability
Relocation
2b
57
100
>25 0.43
100
73
2b
68
100
>25 0.32
100
78
Apprehension
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AC / SLAP
History /
Maneuver
Study Sens Spec LR+ LR- PV+ PVQual (%)
(%)
(%) (%)
AC
1b
100
97
>25 0.01
89
100
Crank
2b
91
93
13
0.10
94
90
Active
compression
1b
100
99
>25 0.01
95
100
Active
compression
SLAP
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References
Luime JJ, Verhagen AP, Miedema HS, et al. Does This Patient Have an Instability of the
Shoulder or a Labrum Lesion? JAMA. 2004;292:1989-1999.
Stetson WB, Templin K. The crank test, the O’Brien test, and routine magnetic resonance
imaging scans in the diagnosis of labral tears. Am J Sports Med. 2002;30:806-809.
Stevenson JH, Trojian T. Evaluation of shoulder pain. Journal of Family Practice.
2002;51:605-11.
Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with
Shoulder Examination Part I: The Rotator Cuff Tests. Am J Sports Med. 2003;31:154160.
Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with
Shoulder Examination Part II: Laxity, Instability, and Superior Labral Anterior and
Posterior (SLAP) Lesions. Am J Sports Med. 2003;31:301-307.
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Video of Shoulder Exam
http://www.fammed.wisc.edu/our-department/media/musculoskeletal
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