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Kathleen Carr: As with all joint exams, it
is important to follow a standard routine including
inspection, palpation, range of motion, strength
testing, and special tests. Both of the patients
shoulders must be exposed for the examination, and it
is always important to compare the effected shoulder
to the unaffected shoulder. With the patient sitting,
begin by inspecting the shoulders for evidence of
gross abnormalities or deformities including evidence
of trauma, swelling of the AC joint, erythema, warmth,
asymmetry between the two sides, and muscle atrophy
especially of the supraspinatus, infraspinatus and
deltoid muscles. To palpate the shoulder begin
medially at the sternoclavicular joint noting any
pain. Palpate the clavicle, laterally, to the
acromioclavicular joint which is a soft spot just
posterior to the distal end of the clavicle. Move
your finger forward over the acromion to palpate the
subacromial bursa. Then move anteriorly and laterally
to the bicipital groove. If you have difficulty
locating it, you can externally rotate the humerus,
palpating the anterior superior portion of the humoral
head and feel the tendon moving in the groove. Medial
to the bicipital groove is the lesser tuberosity.
Next, move laterally and superiorly to the greater
tuberosity which is just interior to the lateral
boarder of the acromion. Finally, palpate the spine
of the scapula and the supraspinatus, and
infraspinatus muscles. When evaluating range of
motion, ask the patient to move both of her arms so
that you can compare the movements. If her movements
are limited by pain, weakness, or tightness, passively
assist the movement. You may find it helpful to ask
the patient to mimic your own movements. First, have
the patient perform forward flexion to 180 degrees.
Next, ask her to extend her arms behind her back.
Normal extension is to about 40 degrees. With the
arms slightly supinated, have the patient abduct her
arms. She should be able to lift her arms in a
smooth, painless arc from 0 to 180 degrees. Next, the
patient lowers her arms to her side, which is
abduction to zero degrees. External rotation can be
tested with the arms at the side and the elbows flexed
to 90 degrees. Ask the patient to externally rotate
her arms. Normal external rotation is to about 45
degrees. You can test internal rotation by asking the
patient to bring her hands together from this
position. Normal internal rotation is to 55 degrees.
External rotation and internal rotation can also be
tested with the apley scratch tests. For external
rotation, have the patient reach behind her head, note
that this motion also involves abduction. The patient
should be able to reach the superior medial aspect of
the opposite scapula or you can note the vertebral
level that she can reach with her index finger. For
internal rotation, ask the patient to reach with both
hands up her back as far as she can go. She should be
able to reach the inferior angle of the opposite
scapula or again you can note the vertebral level that
the patient can reach. For reference, the inferior
border of the scapula is at about T7. After range of
motion testing, test the patient's strength. Place
one hand on the superior aspect of the her shoulder,
and grasp her arm with your other hand. Ask her to
bend her elbow and bring her arm forward to test her
strength of flexion. Next, have her push back against
you to test her strength in extension. All muscle
testing should be greater than the 5 point scale and
compared to the other side. Return to the position of
elbow flexion with arms at the side. To test for
external rotation strength, ask the patient to rotate
her arms out against your resistance. This mainly
tests infraspinatus but also teres minor. To gain
mechanical advantage, switch the positions of your
hands and ask the patient to bring her hands together
to the midline, this tests subscapularis. To test the
supraspinatus perform the empty can test or jobe's
test. Bring the patient's arms to 90 degrees of
abduction, and then into the scapular plain by moving
forward about 30 degrees. Point her thumbs down to
the floor as if she's dumping out the contents of some
cans, then ask the patient to push up against your
hands. Finally, test the subscapularis with the lift
off test. Move the patient's arm behind her back to
waist level with the palm out. Ask her to push her
hand away from her body. Special tests of the
shoulder are performed last to test the integrity of
the rotator cuff, impingement problem, problems of the
biceps tendon, labral tears and shoulder instability.
With the patient standing, perform the drop arm test
for a rotator cuff tear, specifically a supraspinatus
tear. Ask the patient to raise her harm to the side
as high as possible and slowly lower to 90 degrees.
When there is a rotator cuff tear, the patient will
not be able to hold here arm at 90 degrees and it will
drop to her side. Impingement tests evaluate the area
under the acromioclavicular joint that the rotator
cuff muscles traverse through. For nearest sign,
stabilize the patient's scapula with one hand and then
pronate the effected arm and then passively forward
flex her arm as high as possible. This pinches the
rotator cuff muscles under the coracoacromial arch. A
positive test is any pain reported by the patient.
The Hawkin's test is performed by forward flexing the
patient's arm to 90 degrees, bending the elbow, and
forcibly internally rotating the humerus. This drives
the greater tuberosity under the coracoacromial arch
impinging the supraspinatus tendon. Speed's test is
performed by having the patient forward flex her arm
against your resistance with the arm supinated. Pain
indicates biceps tendon offer labral pathology. A
more sensitive test for labral tears is O'Brien's
test. Forward flex the patient's arm to 90 degrees,
abduct it about 20 degrees, and internally rotate it
so that her thumb is down. Ask the patient to resist
your downward pressure. Next, externally rotate her
arm so that her thumb is up, and again ask her to
resist your downward pressure. A positive test is
pain or painful clicking that the patient experiences
when the thumb is down which is reduced or eliminated
when the thumb is up. Next perform the crank test for
labral pathology by abducting the patient's arm in the
scapular plain, flexing the elbow, and applying a
gentle axial load through the glenohumeral joint while
internally and externally rotating the humerus. A
positive test is pain, catching, or painful clicking.
The last special test for the shoulder test for
glenohumeral joint stability. The apprehension test
can be done with the patient standing or sitting.
With one hand stabilizing the patient's scapula, move
her arm into 90 degrees of abduction, and externally
rotate the humerus. A positive test is a look of
apprehension on the patient's face. The apprehension
test can also be performed with a patient in the
supine position and her arm abducted to 90 degrees.
Externally rotate the humerus and monitor for facial
expression of apprehension. The relocation test is
performed after a positive apprehension test by
applying posterior pressure on the proximal humerus
and noting the patient's sense of relief. The
anterior release test for anterior shoulder
instability can be performed with a patient in the
same position as for the relocation test. A positive
test is the patient's report of pain or feeling of
instability upon release of pressure from the proximal
humerus.