1. Shoulder Pain and the Shoulder Exam
CHA Ambulatory Didactics
Kate Lupton, MD

2. Shoulder Overview Very complex structure with tremendous ROM
4 joints – sternoclavicular, acromioclavicular, glenohumeral, scapulothoracic
Glenohumeral – ball and socket joint (golf ball on a tee), glenoid only covers 25% of humeral head

3. Anatomy

4. Shoulder Activity/ROM
Static glenohumeral stability – joint surfaces, capsule and labrum
Dynamic stability – RC & scapular rotators (trapezius, serratus anterior, rhomboids, levator scapulae)
Rotator cuff – depress humeral head against glenoid
Internal rotation - Subscapularis
External rotation - Infraspinatus, teres minor
Abduction - supraspinatous
Scapular stability – trapezius, serratus anterior, rhomboids
Upward scapular rotation – trapezius & serratus anterior
Scapular retraction – trapezius & rhomboids

5. History Background – Handedness, occupation, recreational activities
CC: Pain vs instability vs decreased movement
Characterize CC: “loose” arm, “dead” arm
Injury? -> Mechanism
Associated Sx – neurovascular, stiffness, crepitus
Function – putting on jacket, overhead activities, sleeping

6. Principles of the MSK Exam
Good exposure (clothing removed, in gown)
LOOK
FEEL
MOVE
SPECIAL TESTS

7. Look/Feel - Surface Anatomy

8. Look SEADS – swelling, erythema, atrophy, deformity, scars
Dominant shoulder usually slightly lower than non-dominant side
Head forward posture, shoulders rolled forward, scapula protracted
Squaring of shoulder – r/o dislocation
SC joints, clavicle deformity - ?fracture
AC joints – step deformity - ?separation
Atrophy – trapezius, infraspinatus, teres minor

9. Feel
Palpate joints – SC joint, along clavicle, AC joint, coracoid process, along scapula
Palpate muscles and tendons – trapezius, posterior shoulder, biceps tendon, supraspinatus insertion
Feel for crepitus while rotating the arm

10. Move – Active Range of Motion
Flexion/Extension
Trace arc while reaching forward with elbow straight
Normal flexion to 160°-180°, extension to -60°
Abduction/Adduction
Trace arc reaching to side with straight arm
Normal range is 0°-180°

11. Move – Active Range of Motion
Abduction & internal rotation
Should be able to reach to ~C-7 level (prominent bump on C-spine)
Adduction & external rotation
Should be able to reach lower border of scapula (~T7 level)

12. Move – Passive ROM
If pain or limitation w/ active ROM, assess with passive ROM testing
Grasp humerus, move through flexion/extension, abduction, adduction
Feel for crepitus with hand on shoulder
Note movements that precipitate pain – pain/limitation on active but not passive ROM suggests muscle/tendon problem
Note limitations in movement – where in arc does it occur? Due to pain or weakness? Symmetric or asymmetric?

13. Move
Painful arc on abduction? Glenohumeral joint from °, AC joint °
Watch scapular motion – look for asymmetry, jerky motion
Wall push-up for scapular winging

14. Rotator Cuff Anatomy and Function
4 Major Muscles
Depress humeral head, keep it in contact with glenoid throughout wide ROM
Supraspinatus – abducts shoulder (to ~80°)
Infraspinatus – external rotation
Teres minor – external rotation
Subscapularis – internal rotation

15. Special Tests - Supraspinatus
Empty/Full Can Test
Hold arms at 1:00 and 11:00, abducted 30 °
Internally rotate so thumbs point down (“empty can”), pt lifts up against resistance. Repeat with thumbs pointed up
Note pain (tendinopathy, partial tear), weakness (tear)
Deltoid is responsible for abduction beyond °

16. Special Tests – Infraspinatus
External Rotation
Fully adduct arm, flex elbow to 90 °, medially rotate humerus 45 ° (hand at 12:00)
Have pt try to externally rotate while you resist against their forearms

17. Special Tests - Subscapularis
Posterior (Gerber’s)Lift Off
Pt places hand behind back, palm facing out
Pt lifts hand away from the back
Note pain, weakness
Belly Press
Place hands on abdomen, elbows out
Press in on abdomen or keep elbows out while posteriorly directed force is applied to elbows
Positive test if unable to keep elbows out

18. Shoulder Impingement/Bursitis
4 tendons of the RC pass under the acromion and coracoacromial ligament and insert in the humeral head
Space between arcromion, coracoacromial ligament and tendons can narrow, causing impingement of tendons (esp supraspinatus)
Resulting friction inflames tendons and subacromial bursa
Causes shoulder pain, esp with reaching overhead

19. Special Tests - Impingement
Neer’s Test
Place hand on pt’s scapula, other on forearm
Pt fully internally rotates (thumb pointed down)
Passively forward flex arm through full range of motion
Pain = impingement

20. Special Tests - Impingement
Hawkins-Kennedy Test
Flex arm to 90°
Stabilize shoulder with one hand
Forcibly internally rotate shoulder, thumb pointed down
Pain = impingement

21. Special Tests - Bursitis
Subacromial Palpation
Identify acromion by following scapular spine to distal end
Palpate in subacromial space
Pain = inflamed bursa and/or tendons

22. Biceps Tendon
Long head of biceps tendon runs in the bicipital groove of humerus, inserts at superior glenoid
Biceps flexes and supinates forearm
Subject to similar stresses as RC tendons
Inflammation causes pain in top and anterior shoulder, especially with flexion/supination

23. Special Tests – Biceps Tendon
Palpation
Palpate along biceps tendon/bicipital groove
Confirm location by having pt supinate while palpating
Yergason’s Test
Flex elbow to 90°with arm adducted (elbow against side)
Grasp pt’s hand, resist while they supinate
Pain = tendinopathy

24. Special Tests – AC Joint
Palpation
Palpate point at which distal clavicle articulates with acromion
O’Brien
Flex shoulder to 90° while internally rotated (thumb down)
Adduct arm 10-15° from 12:00
Apply downward force to arm while pt resists
Repeat with thumb pointed up
If there is pain with first maneuver and not second, indicates labral or AC joint pathology
Cross Arm /Forced Flexion
Flex shoulder to 90°, flex elbow, then actively adduct

25. Special Tests – Shoulder Instability
Apprehension/Relocation
With patient supine, abduct shoulder 90°, flex elbow 90°
Externally rotate shoulder by moving forearm from perpendicular to parallel with body
Pain or sense of instability with further external rotation is a positive test, indicating anterior shoulder instability
If sx are relieved with posterior force applied to proximal humerus, that is a positive relocation test and further supports dx
Sulcus Sign
Arm hangs relaxed at the side
Pull arm straight down, look for step-off under lateral acromion
Indicates inferior instability

26. Many Thanks
Anthony Luke, MD – UCSF
Charlie Goldberg, MD - UCSD