(English captions by Andrea Matsumoto from the University of Michigan)
To ensure a thorough assessment it is best to perform the musculoskeletal exam of the
shoulder in a systematic way.
The following is a suggested order of exam that incorporates the common techniques for
diagnosing shoulder injuries.
The shoulder exam begins with inspection.
In an anterior view assess the shoulders for asymmetry, clavicle deformity, muscular atrophy,
or skin changes.
In a posterior view assess for the same.
Next evaluate for active range of motion.
If pain or limitation exists, repeat the motion passively.
To rule out cervical causes of referred shoulder pain, evaluate neck range of motion: flexion,
extension, lateral flexion, and rotation.
Next evaluate active range of motion of the shoulders: flexion, extension, abduction,
adduction, external rotation, and internal rotation.
From the posterior view we can further assess the combined adduction and external rotation
with Apley scratch test of external rotation.
Have the patient reach overhead and down the spine.
Most patients can reach past C7.
Combine adduction and internal rotation with the Apley scratch test of internal rotation.
Have the patient reach behind the back and up the spine.
Most patients can reach to T7 or the lower border of the scapula.
Next assess the strength of the rotator cuff muscles.
The drop arm test evaluates for a supraspinatus muscle tear.
Passively adduct the shoulder to 90 degrees, flex to 30 degrees, and point thumbs down.
The test is positive if the patient is unable to keep arms elevated after the examiner releases.
Supraspinatus muscle strength testing can also be done using the empty can test.
In this same position provide resistance as the patient lifts upward.
Pain suggests possible tendinopathy or tear.
Infraspinatus and teres minor muscle strength is tested with resisted external rotation.
Pain or weakness suggests a possibly tendinopathy or tear.
Subscapularis muscle strength can be tested with resisted internal rotation.
Subscapularis muscle strength is also tested with the push-off test.
Have the patient adduct the arm and internally rotate behind their back.
Provide resistance as the patient pushes their arm away from the body.
Pain or weakness suggests tendinopathy or tear.
Next palpate anatomic landmarks for tenderness.
The suprasternal notch, the sternal clavicular joint, along the clavicle, the AC joint, the
acromion, the greater tubercle of the humerus, the lesser tubercle of the humerus, the
long head of the biceps which runs between the greater and lesser trochanter, and as
you internally and externally rotate you can feel that, and the coracoid.
Posteriorly look at acromion, the scapular spine, the supraspinatus muscle above the
spine, the infraspinatus below the spine, teres minor muscle, the trapezius muscle,
the rhomboid muscle, and look for scapular thoracic articulation, particularly looking
for winged scapula.
Specific testing of the shoulder to evaluate for injuries may include but is not limited
to the following tests.
Hawkin's test assesses for possible rotator cuff impingement.
Stabilize the scapula, passively abduct the shoulder to 90 degrees, flex the shoulder
to 30 degrees, and flex the elbow to 90 degrees, and internally rotate the shoulder.
Pain is a positive test.
Neer's test also assesses for possible rotator cuff impingement.
Stabilize the scapula and with the thumb pointing down passively flex the arm.
Pain is a positive test.
The cross arm flexion test also evaluates for acromioclavicular arthritis or subluxation.
Flex the shoulder to 90 degrees and adduct across body.
Pain at the acromioclavicular joint is a positive test.
There are several tests to evaluate for shoulder instability.
To test inferior glenohumeral stability place traction on the humerus with the arm at the
patient's side.
If a gap greater than 1cm appears between the humoral head and the undersurface of the
acromion it is considered a positive sulcus sign with inferior instability.
The load and shift test evaluates for anterior and posterior glenohumeral stability.
Provide an axial load on the humerus compressing the glenohumeral joint, then move the humeral
head anteriorly and posteriorly.
Anterior or posterior displacement is positive for instability.
The apprehension and relocation tests also evaluate for anterior glenohumeral stability.
With the patient supine, abduct shoulder to 90 degrees and externally rotate the arm to
place stress on the glenohumeral joint.
If the patient feels apprehensive that the arm may dislocate it is a positive apprehension arm.
The relocation test is performed using the examiner's hand to place a posteriorly directed
force on the glenohumeral joint.
Relief of apprehension is a positive test.
There are several tests that assess for injuries of the biceps tendon and glenohumeral labrum.
To perform a Speed's test flex the shoulder to 90 degrees with the arm supinated.
Provide downward resistance against the shoulder flexion.
Pain indicates possibly bicepital tendon or labral tear.
To perform Yergason's test flex elbow to 90 degrees, shake hands with patient and provide
resistance against supination.
Pain indicates a possible bicepital tendon or associated labral tear.
To perform O'Brien's Test point the thumb down and flex shoulder to 90 degrees.
Adduct the arm across midline, provide resistance against further shoulder flexion and evaluate
for pain.
Repeat with the thumb pointing up and again evaluate for pain.
If pain was present with the thumb down but relieved with the thumb up, it is considered
a positive test, suspicious for labral tear.
To perform the Biceps Load Test supinate the arm, abduct shoulder to 90 degrees, and flex
elbow to 90 degrees.
Externally rotate the arm until patient becomes apprehensive and provide resistance against
elbow flexion.
Pain indicates possible bicepital tendonopathy or associated labral tear.
To perform the Biceps Tension Test supinate the arm, abduct shoulder to 90 degrees, flex
elbow to 90 degrees, and externally rotate arm until patient becomes apprehensive and
pronate arm.
Pain indicates possible bicepital tendonopathy or associated labral tear.
To perform the Crank Test, fully abduct the shoulder and provide an axial load on the
humerus.
Internally and externally rotate the arm.
Pain, catching, or painful clicking is considered a positive test suggestive of a labral tear.
There are several tests to evaluate for thoracic outlet syndrome as a cause for the patient's
shoulder pain.
To perform the Costoclavicular Maneuver draw the patient's shoulders inferiorly and posteriorly.
If patient has reproduction of arm pain or numbness, consider thoracic outlet syndrome.
To perform Roos' Test abduct the shoulder to 90 degrees, flex elbow to 90 degrees, and
rapidly open and close hands for up to 3 minutes.
If the patient has reproduction of pain or numbness, consider thoracic outlet syndrome.
To perform Adson's Test locate the radial pulse.
Have the patient take a deep breath and extend neck, and rotate head towards the painful
shoulder.
If radial pulse diminishes on the affected side, it is considered a positive test suspicious
for thoracic outlet syndrome.
Spurling's Test evaluates for cervical root impingement.
With the head extended and rotated toward the painful shoulder, apply an axial load
to the cervical spine.
Reproduction of pain or paresthesias with this maneuver is a positive test.
In concluding the shoulder exam it is important to document a neurovascular exam.
Here we demonstrate a brief exam.
Resisted wrist extension tests the radial nerve.
Resisted opposition of the thumb tests the median nerve.
Resisted digit abduction tests the ulnar nerve.
Radial artery pulse and capillary refill testing.
Further neurologic or vascular exam may be indicated by history.
Acknowledgement: The Japanese translation of this video was made as part of Shizuoka-University of Michigan Advanced Residency Training, Education and Research in Family Medicine (SMARTER FM) Project supported by Shizuoka Prefecture and funded by the Community Healthcare Revival Fund.
Subtitles by the Amara.org community