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Associate Professor, Sports Medicine & Arthroscopy Unit, Orthopaedics, Kasturba Medical College, Manipal, India

Shoulder joint examination

Brief anatomy and function

  • Synovial type ball and socket joint
  • Shoulder joint per se is formed by humeral head and glenoid cavity making it glenohumeral joint. However, functionally it is a combination of four joints named
  • Glenouhumeral
  • Acromioclavicular
  • Sternoclavicular
  • Scapulothoracic

Any disease or affection at any of the other three joints too affect the function of shoulder girdle as when GH joint moves, there is also some movement happening at other three joints.

  • Muscles around glenohumeral joint

Muscle

Insertion

Nerve supply

Action

Deltoid

Over upper 1/3rd of shaft humerus

axillary nerve

Abductor

Flexion

Extension

Subscapularis

Lesser tuberosity

Upper and lower subscapularis nerve

Internal rotator

Supraspinatus

Greater tuberosity

Suprascapular nerve

Abductor

Infraspinatus

Greater tuberosity

Suprascapular nerve

External rotator

Teres Minor

Greater tuberosity

Axillary nerve

External rotator

 

Overall function of rotator cuff (subscapularis, supraspinatus, infraspinatus and teres minor) is to keep the head of the Humerus centered onto the glenoid cavity. This enables deltoid to efficiently abduct the arm.

 

Chief complaints

The patients with shoulder pathology mostly come up with few specific complaints.

  1. Pain
  2. Difficulty in movement
  3. Subluxation or dislocation

1. Pain: Most common complaint

  • Mostly insidious in onset. However, few conditions cause acute pain
  1. Calcific tendinitis: very severe and acute
  2. Traumatic: H/O frank trauma
  3. Acute infection
  • Always in night: it is a very sensitive sign of shoulder pathology. The shoulder pain is almost always felt in night and increases with attempted sleeping over the affected side. Most patients will say that they have not slept over the affected side since weeks or months.
  • Radiation: Mostly to the tip of deltoid insertion and sometimes up to the elbow or mid forearm, and rarely towards neck or scapula. However, it never radiates towards fingers (thumb, index). If there is radiation of pain towards fingers, then the origin of pain is almost always from cervical spine or neurological origin.
  • Aggravates: in night/ attempted abduction/other movements

2. Difficulty in movements: Any difficulty in movement at the shoulder joint could be due to following common reasons:

  1. Pain: arising out of any pathology
  2. Stiffness: The tissues around the shoulder are tight (frozen shoulder)
  3. Rotator cuff tears: chronic tendinopathy makes the tendon weaker followed by smaller tears which later become bigger and cause loss of power to move the joint. A major or minor trauma can too lead to rotator cuff tear causing inability or difficulty to move the shoulder
  4. Nerve injuries/affection
  • Traumatic brachial plexus involvement: H/O RTA or fall over the tip of shoulder
  • Suprascapular nerve involvement in entrapment due to ganglion
  • Axillary nerve injury: especially after RTA/ acute shoulder dislocation
  1. A dislocated/subluxated/fracture around shoulder: H/O trauma

 

3.Dislocations/subluxation: patient himself/herself will come up with such history

4. Another complaint could be unable to throw

  • That the patient finds himself unable to throw an object (like a cricket ball from boundary) or difficulty in performing a smash while playing badminton. This is likely due to
  • weakness in external or internal rotators
  • superior labral tear (SLAP tear)

 

History should always include any neck pain as often neck pain with radiation towards shoulder and or scapula is confused as shoulder pain. However, while explaining his neck pain, patient will keep his hand over the neck or over the scapula or suprascapular region while he will keep his hand over shoulder if it is arising from shoulder per se. This helps in differentiating between neck and shoulder pain.

 

General & systemic examination: As per standard norms

 

Local examination

One dictum is important that local shoulder examination must be performed without clothes in the upper half of the body with appropriate privacy for the patients.
 

  1. Attitude: Most shoulder examination is performed in sitting. The attitude of the index shoulder and upper limb can be described.

 

  1. Inspection:

General findings like

  • Swelling
  • Scar
  • Sinus

 

Specifics to look for

  1. From front
  • Contour of shoulder
  • Muscle wasting of deltoid
  • Shoulder drooping
  • Prominences at Sternoclavicular joint and Acromioclavicular joint
  1. From side
  • Dorsal spine curvature: Kyphosis
  1. From back
  • Spine and its curvature: Scoliosis
  • Scapula
  • Level
  • Winging
  • Distance of medial border from spine
  • Muscle wasting of supraspinatus/infraspinatus

 

  1. Palpation
  1. Local rise in temperature
  2. Tenderness: always palpate in a sequence to look for tender spots in following area
  • Sternoclavicular joint
  • Clavicle
  • Acromioclavicular joint
  • Coracoid process
  • Anterior joint line
  • Lesser tuberosity
  • Bicipital groove
  • Greater tuberosity
  • Posterior joint line
  • Acromion
  • Spine of scapula
  • Medial border of scapula
  • Inferior angle
  • Lateral border

 

  1. Movements: First, one must ask patient to do the active ROM followed by passive ROM
  • Flexion
  • Extension
  • Adduction
  • Abduction
  • External rotation
  • Internal rotation

Before the ROM of shoulder is performed, one must understand two concepts.

  1. When shoulder moves in flexion-extension or abduction-adduction, there is movement at the GHJ but there is also quite a movement at the scapulothoracic joint (STJ). Now one must minimize the movement at the STJ to assess the ROM at the GHJ. This can be done by firmly keeping the hand over the scapula to avoid movement at the STJ. However, after 900 of flexion or abduction, this cannot be prevented any further and then the scapula moves.
  2. The shoulder movements like flexion-extension and abduction is performed in the plane or perpendicular to the scapula. The scapular plane lies 300 anterior to the coronal plane of body as scapula is tilted 300 forward.

Hence, flexion-extension is in plane perpendicular to the scapular plane while abduction is in the plane of scapula

 

Crepitus is also elicited during passive ROM of shoulder. 

Click is also elicited during passive/active ROM

 

  1. Neurovascular examination of upper limbs
  2. Joint above and below: Cervical spine and Elbow
  3. Special test:

 

  1. For dislocation/subluxation of shoulder
  • Apprehension test: The patient is made to STAND and examiner stands behind the patient’s index shoulder. The shoulder is brought in 900 abduction and 900 external rotation. For right shoulder, the examiners right hand supports elbow and can further rotate externally whereas the fingers of left hand are kept in front of the anterior joint line of the shoulder while the thumb is kept over the posterior part of head of the Humerus. Then the head is pushed forward gently which may push the head out in abducted and externally rotated position leading to the apprehension over the face of patient.
  • Relocation-release test: Same test is done in SUPINE. The arm is taken in 900 abduction and 900 ER. The examiner holds right elbow by his left hand and keeps his right hand over patient’s right shoulder. The right hand is used to push (relocated) the head posteriorly and arm is kept in AB-ER position. Gradually, extension is increased while keeping hand still in front of shoulder, and patient remains relaxed. However, then the examiner gently releases his hand in front of shoulder to let the head of humerus move anteriorly. This causes release of head anteriorly and makes patient apprehensive of dislocation
  1. For Impingement and subacromial bursitis:
  • Neer’s Sign: In a normal situation, Patient’s shoulder can be brought in gradual forward flexion till 1800 flexion. However, in case of impingement, he/she complains of pain usually after 140-1500 of flexion indicating impingement.

Neer’s test: when 2-5 ml of xylocaine is injected in the subacromial space is injected, the pain due to impingement decreases.

  • Hawkin’s sign: It is performed to test “subacromial bursitis”. The shoulder is brought in 900 forward flexion followed by elbow flexion till 900. Then shoulder is internally rotated. Patient complains of pain in internal rotation indicating subacromial bursitis.
  1. For rotator cuff tear:
  • Full can test: For supraspinatus tear

The shoulder is brought in 60-700 of flexion and abduction with neutral rotation such that the thumb points upwards. Then, patient is asked to lift his arm in flexion or upward position while examiner gives resistance to his movement. Any pain and weakness in this maneuver is suggestive of supraspinatus tear

  • External rotation-lag test: For infraspinatus tear

The shoulder is kept adducted and then externally rotated, and then it is released with a jerk. If shoulder returns in internal rotation, it indicates weakness in external rotator i.e. infraspinatus.

  • Belly press sign: For subscapularis tear

Patient is asked to press his belly with both hands and he is asked to bring his elbows forward while examiners pushes the elbow backwards. Any weakness or tears of subscapularis leads to elbow falling backwards.

 

  1. For superior labral anterior-posterior tear (SLAP)
  • O’Brien test: The shoulder is brought in 900 flexion, adducted by 100 and then internally rotated completely with thumb pointing downwards. Then patient is asked to lift his hand upwards while examiner gives downwards resistance. Any weakness and or pain is indicative of SLAP tear

(Note: SLAP tears present in young patient with pain and inability to throw objects)

 

  1. For biceps tendon pathology: bicipital tendinitis
  • Speed’s test: The shoulder is brought in 900 flexion with neutral in abduction or adduction with forearm in supination. Then, patient is asked to further flex the shoulder. Any pain in bicipital groove or forearm is considered to be pathologic for bicipital tendinitis

 

  1. For acromioclavicular joint arthritis
  • Cross chest adduction test (scarf test): With elbow flexed, the shoulder is 900 flexed and adducted and hand is made to touch the opposite shoulder. Any pain over the ACJ area is considered to be quite specific for ACJ arthritis.

 

 

Common conditions affecting shoulder with salient features

  1. Recurrent anterior dislocation
  • Affects young patients
  • May be associated ligament laxity
  • Presents with: Mostly traumatic recurrent dislocation, occasionally atraumatic
  • Apprehension & relocation-release test positive
  • Pathologically: Antero-inferior labral tear (Bankart lesion) along with posterolateral head impaction injury (Hill Sach’s lesion)
  • Needs surgical stabilization: Arthroscopic/open Bankart repair

*Posterior dislocation is often seen in epileptics, after electric shock!

 

  1. Frozen shoulder/ adhesive capsulitis/periarthritis shoulder
  • Affects middle age: 40-55 years
  • Presents with: Pain and severe loss of ROM (active and passive)
  • Pathologically: Three stages affecting capsule and synovium
  • Freezing: severe pain
  • Frozen: pain & loss of ROM
  • Thawing: decreased pain, increasing ROM
  • Clinical: severe loss of ROM and painful ROM
  • Diagnosis by MRI/USG
  • Treatment: NSAIDs, physiotherapy, intraarticular steroid injection, manipulation under general anaesthesia or arthroscopic capsular release.

 

  1. Rotator cuff tendinopathy
  • Affects middle age: 40-55 years
  • Presents with: Mostly pain and mild loss of ROM mostly at extremes (active and passive)
  • Pathologically: tendinopathy of supraspinatus & or infraspinatus
  • Clinical signs: Neer’s and Hawkins positive
  • Cuff integrity test: equivocal
  • Diagnosis by MRI/USG
  • Treatment: NSAIDs, physiotherapy, subacromial steroid injection, rarely arthroscopic subacromial decompression with debridement of frayed tendon and subacromial bursa excision.

 

  1. Rotator cuff tear
  • Affects old age: 50 years onwards unless traumatic which can happen at any age
  • Presents with: Pain with difficulty in elevating arm
  • Pathologically: Tear of one or more rotator cuff tendons from its attachment over the tuberosity
  • Clinically:
  • Gross loss of active movements but usually passive ROM is preserved
  • Full can and / ER lag test and/ belly press sign positive
  • Diagnosis by MRI/USG
  • Treatment:
  • Smaller tears: conservative treatment: reduce pain, physiotherapy
  • Larger tears or one which do not respond to rehabilitation need surgical repair

 

  1. Acromioclavicular joint arthritis
  • Affects adults, manual workers: mostly after 45 years
  • Presents with: Pain with active abduction usually beyond 900 abduction
  • Tenderness + over ACJ
  • Pathologically: Acromioclavicular joint arthritis
  • Diagnosis: plain radiograph, MRI
  • Treatment:
  • Conservative: NSAIDs, physiotherapy, intra ACJ steroid injection, activity modification
  • Surgical excision of ACJ if conservative treatment fails

 

 

 

  1. Glenohumeral joint (GHJ) arthritis
  • Affects older patient: mostly after 65 years
  • Presents with: Pain and difficulty in movement (similar to frozen shoulder but duration is longer and age is usually more than that of frozen shoulder)
  • Pathologically: GH joint arthritis
  • Clinically:
  • Both active and passive ROM decreased
  • Crepitus while ROM
  • Tenderness + over anterior joint line
  • Diagnosis: plain radiograph, CT scan, MRI
  • Treatment:
  • Conservative: NSAIDs, physiotherapy, intra articular steroid injection, activity modification
  • Arthroscopic debridement of GH joint for early stages of GH arthritis
  • Total shoulder replacement for advanced cases

 

  1. Painful arc syndrome (PAS)

It is NOT a diagnosis per se. Many conditions can cause painful arc syndrome. It is characterized by painful abduction only in an arc of complete abduction wherein initial and later part of abduction is painless.

Following conditions can cause PAS

  • Subacromial bursitis
  • Rotator cuff tendinopathy
  • Rotator cuff tears
  • Greater tuberosity avulsion malunion

 

The clinical features, diagnosis and treatment of PAS are dependent upon the underlying condition.