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.
Important Landmarks of the shoulder:
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°.
Special tests are carried out to confirm nerve irritation of the spine.
Passive neck flexion
With the patient supine, the examiner places the hands on the posterior side of the head over the occiput. Next, the head is passively flexed anteriorly with the chin reaching the chest. A positive result is reproduction of neurological symptoms to the lower extremities.
Vertebral artery test
The patient is in a supine position and the head gently pulled and twisted to each side. If blurred vision, dizziness, slurred speech, level of consciousness (LOC) appear it may indicate a partial or complete obstruction of the vertebral artery.
Spurling test - Foraminal compression
With the patient in a sitting position, the examiner exercises pressure with both hands on the patient’s head pushing downwards and flexing and the head laterally.
If pain arises on the flexed side it may indicate pressure on cervical nerve roots caused by osteoarthritis, osteoporosis, spinal stenosis or instability of the cervical spine. If the vertebral artery test is also positive it suggests damage to the vessel.
Neck distraction test - Manual traction test
With the patient lying on a supine position, the examiner places one hand under the patient’s chin and the other on the occiput. The head is gently lifted and an axial traction force is gradually applied up to 30 pounds. The test is positive if the pain is relieved or decreased when the head is lifted or distracted, indicating pressure on nerve roots.
Shoulder abduction test
The patient places the hand of the affected extremity on the head to support the arm in the scapular plane. A positive response is alleviation of patient symptoms that are associated with the relief of a sensory sign (also named Bakody’s sign) possibly due to a disc protrusion, impinging on the nerve or the nerve root. When positive, this test is also combined with motor weakness, radicular paraesthesia, lateral extradural lesions and a good response to surgical treatment.
When the patient has difficulties in swallowing (dysphagia), this could be due to the obstruction of the cervical spine caused by subluxation, osteophyte protrusion, soft tissue swelling, tumors of the anterior spine or a pathology of the esophagus (i.e. herniation of the mucous membrane). Lateral views of the cervical spine demonstrated approximately 25% anterolisthesis in a bilateral facet subluxation. There is a narrowing of the central canal secondary to the anterolisthesis.
Tinel’s sign - Brachial plexus test
This test determines the status of the brachial plexus, which is a group of nerves exiting the vertebrae from C4 to T1 innervating the shoulder and the arm. The patient is sitting with the head slightly bent to the side. The examiner taps the brachial plexus of the same side along the nerves from the neck to the shoulder. A positive sign shows a tingling sensation on the nerve fibres, indicating a pathology of the brachial plexus.
Mechanisms of “burners.”
(A) Traction to the brachial plexus from ipsilateral shoulder depression and contralateral lateral neck flexion.
(B) Direct blow to the supraclavicular fossa at Erb's point
(C) Compression of the cervical roots or brachial plexus from ipsilateral lateral flexion and hyperextension.
Brachial plexus stretch test
Pathologies of the brachial plexus produce a feeling of electric shock, numbness or burning sensation at the neck radiating to the arm. (In most severe cases when the nerves are severed the movement of the shoulder, arm and fingers may be impaired). For the stretch test, the patient is seated and the examiner places one hand on the shoulder and the other onto the head and stretches the brachial plexus by flexing the patient’s head. By stretching the neck to the right the pain radiating to the left shoulder indicates a pathology of the plexus. Conversely, a pain sensation radiating on the opposite right shoulder, is indicative of possible impingement of the nerve roots.
The patient holds both arms at shoulder level and bent at the elbows. The hands are opened and closed to a fist. The test is positive if the patient is unable to maintain the position, shows reduced hand function, or loss of sensation in the upper extremities? This may indicate a thoracic outlet syndrome (disorders caused by compression to vessels or nerves between collarbone and first rib (thoracic outlet). This causes pain in shoulders and neck and finger numbness.
Straight leg raise
Straight leg raise (SLR) is used to determine the irritation of the lumbosacral nerve. While lying on the back, passively flex the straight leg from the hip up to 90 degrees. Pain should be felt at an angle between 30º and 70º and disappear when lowering the leg at 10º. If positive, this test demonstrates a possible herniated disk and irritation of the sciatic nerve.
Test for lumbosacral nerve root irritation. Patient is supine, and the physician passively elevates each of the patient's legs in turn, keeping the knee extended, and flexing at the hip to an angle of 90º.
This test is used for lumbosacral nerve root irritation and to discriminate between a nerve or muscle origin of lower back pain. The patient is supine, and the examiner lowers the patient's leg about an inch from the position in which pain was elicited. While holding the leg elevated, the patient's foot is passively dorsiflexed. If pain is increased, a nerve aetiology is likely at L4, L5, or S1 levels; conversely a muscle aetiology is likely if no pain arises.
Variations of straight leg raise test:
Once reached the leg elevation causing the pain, flex the knee. If no pain is felt with straight leg raise, flex the cervical spine to the chest and repeat the test. Pain should be relieved by flexing the knee (Kerning) or aggravated by flexing the neck (Brudinski). Used for herniated disk and dural sheath irritation.
Well straight leg raising test
The patient straightens and raises the opposite leg to the one causing pain. If pain is felt on the leg lying low, it may indicate a herniated disk.
Seated at table edge, bend forward, flex the neck, extend one knee and dorsiflex the foot. If sciatic pain occurs it indicates a problem to the sciatic nerve.
Tension sign/Bowstring test
Passive straight leg rise until pain is felt, flex the knee to release symptoms, apply pressure to the popliteal fossa (depression behind the knee joint). If pain returns it means sciatic nerve issues.
This test is used to determine if patient is malingering. The examiner cups the calcaneus of each leg with his/her hands. When the patient raises the leg straight, the examiner should feel pressure on calcaneus remaining onto the bed, which is used as leverage for the opposite, elevating leg. If no pressure is felt, the patient is simulating the spine problem.
Femoral nerve stretch test
Lying on the side, passively extend the leg at the hip with the knee bent at 90º. If pain, numbness or tingling is felt at the anterior/lateral thigh, it shows femoral nerve root impingement.
Stork/Single stance test
While balancing on leg, arch the spine backwards. If pain occurs, it indicates spondylolysis or spondylolisthesis.
A blunt object is run along the lateral side of the inner foot from the heel to the big toe (fanning of toes). The test is positive if the big toe extends and the other toes abduct. This is a plantar reflex and may indicate brain or spinal cord trau
The examiner runs fingernails gently along the crest of the patient’s calf bone (tibia). If the big toe extends and the other toes abduct, and plantar reflex it can indicate brain or spinal cord trauma.
The patient holds a deep breath and blows into the closed fist by strongly contracting the abdominal muscles. If spinal pain increases it may indicate a herniated disk.
The patient is asked to lift the feet of 2-6 inches off the bed for 30 seconds. If the patient is unable to lift, hold the legs or feels spinal pain, it may indicate herniated disk and impinged lumbar nerve.
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.
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.
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.