Examination of the shoulder
In order to commence a clinical examination, the medical specialist relies on anatomical landmarks as a guidance for the inspection and palpation of the region of interest. These landmarks assist in identifying changes in the anatomical relationship of the bones forming the joints as well as abnormalities of soft tissues such as ligaments, muscles and tendons.
Acromio-clavicular (AC) joint and coracoid process
The detection of any abnormalities in the anatomy of the shoulder is facilitated by the palpation of two specific landmarks. The acromioclavicular (AC) joint, located between the acromion and the distal clavicle and the coracoid process located below the distal part of the clavicle.
Tip of the scapula
With the abduction of the straight arm, the tip of the scapula rotates outwards, away from the spine. This movement can be assessed manually as shown in the image, by placing the fingers below the tip of the scapula. Any pathology of the shoulder, e.g. frozen shoulder, will impair the normal abduction causing an early outwards rotation of the tip of the scapula.
Spine of the scapula
A key landmark for the examination of the shoulder is the spine of the scapula on the upper posterior side of the body. The scapula, commonly named shoulder blade, is a large flat bone in the shape of a triangle that is covered by strong muscles.
The medial border of the scapula is parallel to the spine and the lateral border is oblique. The spine of the scapula, which is the elevation located along the centre of the scapula, separates the supraspinatus from the infraspinatus muscle.
The characteristics of any musculoskeletal pathology are pain, redness (erythema), swelling, increased warmth, deformity, neurological symptoms and loss of function. The examiner will commence the inspection with a visual observation of the affected area, which will be compared to the contralateral, unaffected side. This will identify the presence of scars, rashes, lesions, asymmetry, deformity and atrophy.
The palpation of the compromised region involves the examination of each joint and muscle group as well as the identification of areas of tenderness and deformity.
Palpation is used to discriminate differences in tissue tension, texture and thickness, as well as recognise anatomical shapes, structures and abnormalities. The examiner will also detect variations in temperature, tremors, pulses and abnormal sensations (dysesthesia).
Tenderness over the shoulder joint indicates an injury or inflammation of part or the whole shoulder joint. By careful palpation, areas of tenderness can be identified and attributed to specific anatomical structures - for example at the insertion of the rotator cuff tendons. This simple examination leads the way to further investigations: conventional X-rays, ultrasound, Computer Tomogram and Magnetic Resonance Image
Range of movement
The crucial aspect for a thorough clinical examination by a medical specialist that is required for assessing the degree of impairment is to achieve an understanding of the functional capacity of the patient by analysing any abnormalities in the range of movement of the affected body part.
The examiner will ask the patient to actively move each joint to determine potential changes in function, presence of joint instability and level of pain triggered with motion. During the examination, it is critical to monitor the same range of movements of the non-injured/contralateral region of the body to obtain an overall functional status of the patient that may vary with age and pre-existing medical conditions.
If abnormalities are present, the patient is firstly subjected to a number of passive movements to evaluate any increased or reduced range of function. Subsequently, the examiner applies specific tests that have been developed for individual musculoskeletal pathologies to pinpoint the exact underlying cause of impairment and the physical structure involved.
Prior to describing the tests it is important to provide some basic information. Below is the definition of terms relative to movements of the upper extremities that are used by orthopaedic specialists during clinical examination. These expressions are encountered in the guidelines for impairment assessment as well as in the medical reports provided to personal injury lawyers.
The straight arm is moved in the frontal plane, parallel to the head or towards the centre of the torso. The normal range of motion is from 0º to 180º (90º - 0º - 180º shown in the image).
The straight arm is moved in the frontal plane parallel to the head or towards the centre of the torso. The normal range of motion is from 0º to 50º (0º - 20º - 50º shown in the image).
The arm is moved forward in the front of the body. The normal range of motion is from 0º to 180º (0º - 90º - 180º upper row).
The arm is moved backwards from the front of the body. The normal range of movement is from 0º to 50º (0º - 30º - 50º lower row).
The arm is bent in the elbow joint and the forearm is moved downwards. The normal range of movement is from 0° to 90° (Image shows External rotation at 90º, neutral at 0º, and internal rotation at 90º).
The arm is bent in the elbow joint and the forearm is moved upwards. The normal range of movement is from 0° to 90°.
This test is used secondary to apprehension test to assess the degree of anterior gleno-humeral instability including partial luxation and dislocation. The examiner uses posterior force on the humerus head while externally rotating the arm. The test is positive if the external rotation exceeds normal range.
This test confirms whether the biceps tendon is held in the groove during motion by the transverse humeral ligament. With the examiner standing close to the patient, the elbow is flexed at 90º and the forearm is pronated. The patient is asked to supinate the arm, while the examiner opposes the supination while holding firmly the wrist and the elbow. The test is positive when the movement triggers pain at the bicipital groove.
This is a test for the diagnosis of bicipital tendonitis and biceps muscle pathology. The patient’s arm is flexed forward at 90º. Then the examiner exerts an extension movement while the patient attempts to oppose the force by keeping the arm supinated and then pronated. The test is positive when the patient feels increased soreness in the bicipital groove, particularly with a supinated arm.
This test is employed to detect inferior instability of the gleno-humeral joint. The examiner palpates the shoulder by placing the thumb and fingers on the anterior and posterior aspects of the humeral head. Subsequently the examiner grasps the patient’s elbow with the other hand and pulls it downward. The formation of a sulcus between the acromion and the humeral head when the arm moves inferiorly, under the force applied, is a positive test for the condition
This test is used to determine the presence of glenoid, labral tears within the shoulder joint. The patient’s arm is rotated and loaded (force applied) from extension to forward flexion. A positive test consists of an audible clunk sound or clicking sensation indicating a labral tear even without the presence of instability.
Cervical disc disease testing
No physical examination in a patient with shoulder pain is complete without excluding any cervical spine disease. In a patient with neck pain or pain that radiates below the elbow, Spurling’s Test is a useful manoeuvre to evaluate the status of the cervical spine. This testis designed specifically to assess any cervical nerve root disorder. The neck is extended and rotated toward the affected shoulder while an axial load is placed on the spine. The test is considered positive when the patient complains about radicular arm pain.
The examiner exerts force to abduct the patient’s arm producing a forward flexion and thus causing the friction of the greater tuberosity of the humerus head against the acromial surface. The test is positive if the patient feels pain, suggesting an inflammation or tear of the supraspinatus tendon or biceps tendon.
Neurology is a medical specialty dealing with disorders of the nervous system. It comprises the diagnosis and treatment of all categories of diseases involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue, such as muscles.
The complex array of skin and muscle areas innervated by specific nerves, also named dermatomes, is examined to diagnose the existence of neurological deficits. Pain, numbness, and muscular atrophy/loss of strength of particular dermatomes are signs of pathology to a specific vertebral level. This can be the result of nerve impingement arising from a disc herniation, trauma or a neurodegenerative condition.
Nerves of the lumbar spine
Sensory and motor function controlled by the nerves of the lumbar and sacral spine and their corresponding dermatomes:
L4 medial leg
L5 1st / 2nd toes
S1 lateral foot
Muscle strength can be assessed using an empirical scale ranging from Grade 0 to 5:
5 Normal strength
4 Active power against both resistance and weight
3 Active power against gravity but not resistance
2 Active movement only with gravity elimination
1 Flicker or trace of contraction
0 No movement or contraction
Assessing paraplegia and tetraplegia
The level of paralysis is based on the ASIA Impairment Scale of The American Spinal Cord Injury Association. In order to help classify differing degrees of spinal cord injury, the ASIA impairment scale is used to compare and understand residual function.
A - Complete: No motor or sensory function in the lowest sacral segment (S4-S5)
B - Incomplete Sensory function below neurologic level and in S4-S5, no motor function below neurologic level
C - Incomplete Motor function is preserved below neurologic level and more than half of the key muscle groups have a muscle grade less than 3
D - Incomplete Motor function is preserved below neurologic level and at least half of the key muscle groups below neurologic level have a muscle grade 3
E - Normal Sensory and motor function.
Levels of paralysis
Methods to define the level of the paralysis:
Biceps jerk C5 /C6
Supinator jerk C6
Extensor digitorum reflex C7
Triceps jerk C7/ C8
Abdominal reflex T8-T12
Knee jerk L2 / L4
Ankle jerk L5 / S1 / S2
Bulbo-spongiosus reflex S2-S4
Anal reflex S5
Plantar reflex L5-S
This test is used to detect a torn labrum or an anterior instability problem. The examiner stands at the side of interest and grasps the wrist with one hand. The shoulder is then passively externally rotated the shoulder in 90º of abduction. Then the examiner applies forward pressure to the posterior side of the humeral head. The test is positive for anterior instability when the patient reports pain.
Pulses of the Upper Extremity
There are different types of vascular pulses and additional tests that are used to assess vascular damage. An absent or weak pulse is a critical sign that requires immediate action as it may reduce or impede blood flow to one part or the entire limb. Impaired blood flow can have detrimental consequences that cannot be reversed if detected too late.
The pulse is measured in areas where an artery passes close to the skin. To measure the pulse of the radial artery at the wrist, the examiner places the index and middle finger over the underside of the wrist, proximal to the base of the thumb. Then the examiner presses firmly with flat fingers until detecting the pulse. The number of beats is counted for one full minute. A normal count should range between 60-72 beats per minute in non-athletes. At the wrist there are two pulses:
Pulse of the radial artery over the distal end of the radius on the palmar side.
Pulse of the ulnar artery over the palmar side of the distal ulna side.
This is a test performed to investigate the rate at which blood refills empty capillaries. Pressure is applied to the finger until it turns white, indicating that the blood has been forced from the tissue. The examiner takes note of the time needed for the colour to return once pressure is released. Normally it should be less than 3 seconds.
If capillary refill requires longer, it indicates poor peripheral perfusion or dehydration.
Oedema is caused by fluid accumulation in the body’s tissue and usually occurs in the lower extremities, feet, ankles and legs. Less frequently oedema can be observed in the upper extremities.
Cyanosis manifests when the oxygen level in blood is below normal. It is a condition where the fingers, toes and lips appear blue.
Clubbing is a sign resulting from chronic low blood-oxygen levels. The ends of the finger appear enlarged and the nails curve downwards.
Lymphoedema refers to fluid retention in peripheral tissues. The lymphatic system is a network of tissues and organs that play a key role in the circulatory system and immune defence. It keeps body fluids in balance by draining interstitial fluid to the bloodstream and assists in clearing pathogen infections. Impairment of the lymphatic system results influidbuild up, causing local swelling or lymphoedema.
Functional Testing of the Rotator Cuff 1
The arm is bent at the elbow joint and the forearm is moved outwards and inwards across the body. The normal range of movement is from 0° to -90° and from 0° to 90°.
Functional Testing of the Rotator Cuff 2
Both arms are raised and outstretched at shoulder height and moved forward and upward. The arms are then stretched backwards away from the body. See image
Apley’s Scratch Test
This is a method to determine the range of movement of the shoulder. It consists of a combination of different functions such as extension and internal rotation. When reaching the superior and inferior aspects of the scapula with the opposite hand, the patient should be able to touch the lumbar and thoracic spine. A reduced range of movement indicates a rotator cuff problem.
Over the Head Test
This is another test to assess the function of the shoulder. It consists of a combination of different movements from the previous test, including abduction, flexion and external rotation. The patient must be able to place the hand over the head under different angles.
This is an additional method for assessing the range of movement of the shoulder with the patient placing both hands symmetrically behind the neck, behind the ears and above the head. The observation of the asymmetric, limited movement indicates an underlying pathology of the shoulder.
Empty Can Test
This test is used to determine the integrity of the supraspinatus tendon. The patient attempts to elevate both arms against resistance by the examiner while the elbows are extended, the arms abducted and the thumbs are pointing downward. Pain to the subacromial region and muscle weakness is a positive sign for supraspinatus tendon pathology.
This is a test to assess the integrity of the infraspinatus tendon. The patient attempts to externally rotate the arm against the examiner’s resistance while the arm is kept close to the waist and the elbow is flexed at 90*. The test is positive when the patient feels pain or is unable to oppose a medial rotation.
Drop Arm test
The examiner abducts the patient’s shoulder to 90º and then asks the patient to slowly lower the arm to the side in the same arc of movement. A positive test is indicated if the patient is unable to hold the arm elevated (drop arm) or feels pain when attempting to do so, suggesting a tear in the rotator cuff complex.
Cross Arm Test
This test is employed to detect changes in the acromio-clavicular joint. With the guidance of the examiner, the patient elevates the arm to 90º and then actively adducts it. The test is positive when the patient feels pain, which is indicative for an acromio-clavicular pathology.
This test reveals an impingement of the rotator cuff tendons under the acromion. The arm is fully pronated and placed in forced flexion. This movement causes an impingement sign when the patient’s rotator cuff tendons are pinched under the acromial arch.
This test is commonly performed to assess subacromial impingement or rotator cuff tendonitis. The arm is forward elevated to 90º and then forcibly internally rotated. If the patient feels pain at the superior, lateral aspect of the shoulder the test is positive for an impingement of the supraspinatus tendon.