The Five-Minute Shoulder Exam

by Mario R. Taillon, MD, FRCSC

The essential first step to the shoulder exam is to be able to see clearly the front and back of the shoulder. A tank top, or an examination gown tied under the axillae permits this examination in women patients.

The neck is examined first, assessing range of motion in flexion, extension, rotation, lateral flexion.

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INSPECTION

• With the patient sitting, look for atrophy in three sites; the supraspinatus fossa, the infraspinatus fossa and the deltoid. This demonstrates weakness due either to a rotator cuff tear, or a neurological deficit.

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• Examination of the shoulder blades: scapular winging and thoraco-scapular dysfunction are almost universal in shoulder instability. Classically this can be due to paralysis of the long thoracic nerve either from trauma or possible tumor, but is much more common in shoulder instability. It is assessed by having the patient perform push-ups against a wall and observing the lower pole of the scapula, which will push outwards.

PALPATION

• Assess the clavicle and the posterior joint line.
• To palpate the acromio-clavicular joint, find the "soft spot" at the back of the clavicle, anterior to that is the A-C joint.
• To palpate the rotator cuff bursa, extend the patient's arm backwards and internally rotate it. This brings the bursa anteriorly where it can be palpated by the index finger when the hand is placed across the upper aspect of the shoulder with the thumb posteriorly and the index finger anteriorly.

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RANGE OF MOTION

Assess:

• Forward elevation. The motion involved in reaching forward and up to a cupboard above the head. This is measured from zero (lowest) to 180 degrees. Always supplement active motion with passive movement to obtain the patient's full range.
• Internal rotation. Ask the patient to rotate his arm across his back and walk the fingers as far up the back as possible, recording this by vertebral level. If the patient is very stiff this may only be a sacral level. As a guide the inferior border of the scapula is located at about T7. Compare the internal rotation of the injured side with the normal side.
• External rotation. Ask the patient to keep the upper arms flat against his/her sides and rotate the forearms outward. The range is from zero (straight ahead) to 90 degrees.
• The lift-off test. This tests the subscapularis. With the arm behind the back ask the patient to lift his hand off his back.

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SPECIAL TESTS FOR SPECIFIC CONDITIONS

1. Impingement

• Jobe's Test. The arm is held in the scapular plane, not directly in front or out to the side, but at a comfortable angle, as if pouring out a can of pop (about 30 degrees from full extension). If holding the pouring position is painful it is because the greater tuberosity is being driven up against the acromion, a positive Jobe's test for impingement. At the same time, since this is a position of strength, push down on the arm to test for any weakness.
• Hawkin's Test. With the arm in the throwing position and flexed forward about 30 degrees, forcibly internally rotate the humerus. Pain suggests impingement of the supraspinatus tendon against the coraco-acromial ligament. Crepitus can also often be detected at the subacromial bursa.
• Infraspinatus Strength. Ninety percent of external rotation depends on infraspinatus strength, and loss of strength in the infraspinatus correlates closely with the size of a rotator cuff tear.
• Supraspinatus Strength. The arms are held in the scapular plane as if pouring out a can of pop ask the patient to forward elevate and assess weakness, test resisted external rotation with the arm by the side.
• Subscapularis Strength. With the supraspinatus and infraspinatus tendons, the subscapularis is part of the rotator cuff. The strength of this is tested by the lift-off test. The patient is asked to hold his hand behind his back at waist level, palm facing out, and move the arm away from the body against pressure from the examiner.
• Acromio-Clavicular Joint Tests. For osteoarthritis or osteolysis, often seen in athletes who bench press weights will have tenderness over the AC joint, pain on internal rotation and on cross body adduction of the arm, and a positive O'Brion's test.
• O'Brion's Test is performed by adducting the arm across the chest, pronating the hand as if pouring out a can of pop, and then performing resisted forward elevation. A positive O'Brion's test is demonstrated by pain reported at the top of the AC joint with this maneuver, but not if the hand is supinated.

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2. Instability

There is considerable overlap between instability and impingement, and instability can be difficult to assess.

• Sulcus Sign. The patient's arm is held at his side in a position of rest. The arm is gently pulled downwards while the examiner looks and palpates for a depression below the shoulder.
• Load and Shift Testing. The humeral head is grasped between the thumb and fingers and with the patient supine, the degree of mobility is assessed.
• Apprehension Sign. With the patient seated or supine, externally rotate the shoulder. The patient demonstrates apprehension that the shoulder will dislocate, and will often resist the activity, informing the examiner that the shoulder will 'go out'. To take the test one step further, apply pressure over the humeral head to prevent dislocation, extend the arm further back, and then release the joint. The patient will jump and internally rotate the shoulder – a positive relocation sign.

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Video: Instability (above)

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Video: Full Exam (above)