SHOULDER JOINT

Kanchan Sharma
INSPECTION:
We should walk around the patient and look from front, side and back, from
above
1.Look at the shoulder joint for any asymmetry.
a) Squaring of Shoulder
 Anterior Dislocation
b) Deformity of the clavicle:
old fracture of the clavicle.
c) Piano Key Phenomenon:
 Ac joint separation in which there is a superior protrusion of the clavicle.
c)Scoliotic changes in the spine.
2.Look at the skin for:
a) Redness:
 Inflammatory pathologies,
 Septic arthritis
b) Cutaneous lesions
 Neurofibromatosis,
c) Discolouration:
 Haematoma: fracture clavicle
 Venous distensions.
3.Look for post surgical scars.
 Arthroscopic repair and open surgeries of shoulder joint,
 Radial Neck Dissection,
 Lymph Node removal from the neck.
4.Look for any obvious swelling.

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  Large diffuse swelling of the shoulder joint:
Rotator Cuff Calcific Tendiniitis, Infective pathology, Inflammatory
Pathologies.
 Popeye Deformity: It is seen when there is a rupture of the long head of
the biceps tendon. There is a ball like swelling seen just proximal to the
elbow joint, which is the retracted muscle belly distally.
 Lipoma:
On the top of the shoulder (acromioclavicular joint area),scapula.
 Dislocation:
Acromioclavicular joint: distal end of clavicle osteolyisis.
 Cyst:
Acromioclavicular joint cyst.
5.Look for muscle wasting:
Deltoid atrophy:
 Seen in axillary nerve palsy
 Scaphoid sign or scallop sign is observed: where in the acromion, AC
 joint and the other another structures become more prominent as
compared to the other side.
 Muscle mass over the lateral aspect of the upper arm atrophies giving rise
to concave appearance of the upper arm.
 Supraspinatus and infraspinatous atropy:
suprascapular nerve palsy.
 Infraspinatus atrophy:
Synovial/glenolabral cyst in the spinoglenoid notch
 Pectoralis Muscle:
Poland syndrome
 Trapezius.
 spinal accessory nerve palsy
 atropy of trapezius muscle visible as scalloping of ipsilateral neck.

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6.Look whether the scapula shapes are normal and in their respective
anatomical position.
7.Look for medial or lateral scapula winging.
 Medial Scapular winging: long thoracic nerve palsy with weakness of
serratus anterior muscle, superiolateral displacement of the inferiomedial
angle and elevated medial border of the scapula.
 Lateral Scapular winging: spinal accessory nerve palsy.Inferomedial
border of the scapula is displaced superiomedially.

PALPATION:
 Feel for warmth: Infective and Inflammatory pathologies.
 Feel for tenderness: Rotator Cuff Calcific Tendiniitis, Infective
pathology, Inflammatory Pathologies
 Feel for trigger points in the muscle. Myofascial Pain Syndrome.
 Palpate if any swelling is present for: shape, size, consistency, mobility,
transluminan and pulsatile or not.
Palpate
 Sternoclavicular Joint:
 Acromioclavicular Joint,
 Bicipital Groove,
 Coracoid,
 Subscapularis.
 Subacromial area
 Shaft of humerus and head through the axilla.
 Pectoralis Muscle
 Supraspinatus Fossa
 Infraspinatus Fossa
 Trapezius
 Cervical Spine. (For Detailed Examination Refer Neck Pain Chapter)

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RANGE OF MOTION:
Range of motion is an important part of the physical examination of shoulder
joint. It is classified as:
Active Movement:As active movements are performed by the patient it is
always better to demonstrate the movement to the patient so that he can imitate
you and perform it in a precise manner.
Passive Movement: is done by the examiner.
The following are the normal range of motion of the shoulder joint:
1. Forward Flexion: elevation of the arm with elbow extended in front of
the body in sagittal plane.
2. Extension: It is the movement of the shoulder joint in which the rotation
of the humerus is beyond the scapular plane. This can be achieved with
arm by the side of the body, abducted or overhead.
3. Adduction can be tested in the following way:
a)Simple adduction: arm at the side of the body
b)Horizontal/Cross-Body adduction: arm is elevated to 90 degress
followed by the its movement across the body.
4. Abduction:
a)Coronal Plane: humerus is elevated in such a way that the upper
limb of the respective side points directly lateral.
This plane laxes posterior capsule but more stress on the anterior
capsule.
b)Scapular Plane: humerus is elevated in such a way that the upper
limb points lateral but with 20-30 degrees of forward angulation.
Laxity of both the anterior and posterior capsule is same so that
examination of the surrounding soft tissues becomes easy.
5. External Rotation: This is the movement of the humerus away from the
midline.

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 6. Internal Rotation This is the movement of the humerus towards the
midline.
.

MOTOR:
INDIVIDUAL MUSCLE TESTING:
1.SUPRASPINATUS
EMPTY CAN SIGN:
How to perform the test:
Patient:
With the patient in standing position. The patient’s arm is elevated to 90 degrees
in the scapular plane with thumb pointing downwards.
Examiner:
The examiner then applies a downward force with two of his/her fingers
proximal to the elbow joint .
Analysing:
The patient is asked to resist the downward applied force maintaining the arm in
the above stated position.
When to say it is positive:
It is positive if the patient is complaining of pain and is unable to maintain the
arm in the above stated position.
Cause:
Supraspinatus weakness.
2.INFRASPINATUS AND TERES MINOR RESISTANCE STRENGTH
TESTING:
How to perform the test:
Patient:
Patient is in the standing position,
Examiner

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The examiner is standing in front of the patient.The patient arm by the side of
the body, the elbow is flexed to 90 degrees and shoulder joint is externally
rotated to 45 degrees.
Analysing :
The patient is asked to hold this position and resist the internal rotation force
applied by the examiner with two fingers on the distal forearm.
When to say it is positive:
It is positive if the patient is complaining of pain and is unable to maintain the
arm in the above stated position.
Cause:
Infraspinatus and teres minor weakness.
3.SUBSCAPULARIS:
BELLY PRESS TEST
How to perform the test:
Patient:
 Patient is in standing position.
Examiner:
 The arm at the side of the body elbow flexed at 90 degrees, wrist straight
and forearm 90 degrees to the trunk, the patient is asked to press their
hand against the belly and hold it in this position.
Analysing:
 If the patient is able to hold the hand in the above stated position, the
examiner then apply a force to lift the patients hand off their body and
the patient should resist this applied force.
When to say it is positive:
The patient will not be able to hold this position with wrist straight and elbow
forward rather the patient will try to do so by extending the shoulder
joint,dropping the elbow backwards with wrist in flexion.
Causes:

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Subscapularis Weakness.

SPECIFIC TEST: SPECIFIC CONDITIONS

PAINFUL ARC SIGN:

How to perform the test:

With the patient in standing position,the examiner asks the patient to abduct the
arm in the scapular plane to full elevation and then bring the arm back to the
same position actively.

Interpretation:

 Pain in between 60 degrees- 120 degrees

Anterolateral pain - Subacromian pain syndrome.
 Pain in between 60 degrees- 120 degrees:
Top of shoulder- Acromioclavicular joint pathologies.

DROP ARM SIGN:

How to perform the test:
Patient:
 The patient is in standing position.
Examiner:
 The examiner passively elevates the patients arm in scapular plane to
about 90 degrees .
Analysing:
 Ask the patient to maintain the arm in that position when the examiner
will let go the arm.
When to say it is positive:
 Inability to maintain the arm in that position and the arm falls back
towards the ipsilateral body
 shoulder appears to shrug.
Cause:

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Massive tear of Supraspinatus muscle.
Precaution: We should be standing near the patient to catch the arm in case
patient is unable to hold it.
2 .INFRASPINATUS AND TERES MINOR:
EXTERNAL ROTATION LAG SIGN:
How to perform the test:
Patient:
 The patient is in standing position.
Examiner:
 The examiner flexes the elbow to 90 degrees, arm at the side of the body
and then passively the shoulder joint is externally rotated to the maximum
degrees possible.
Analysing:
 Advice the patient to hold this position once the examiner let go the arm.
When to say it is positive:
Inability to maintain the arm in that position and the arm rotates internally and
is back towards the body.
Cause
Infraspinatus weakness

3.SUBSCAPULARIS
INTERNAL ROTATION LAG SIGN:
How to perform the test:
Patient:
The patient is in standing position. The patient is asked to touch the lower
back(lumbar region) with the back side of their hand.
Examiner
The examiner passively lifts the hand away from the body .
Analysing:

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The patient t is asked to maintain the arm in that position.
When to say it is positive:
It is positive if the patient is not able to hold this position and the hand drops
back.
Causes:
Subscapularis tear
IMPINGEMENT SYNDROMES
NEERS IMPINGEMENT SIGN
How to perform the test:

The patient is in standing position and the arm is in the scapular plane and
thumb facing downwards. The examiner is standing at the back of patient ,
stablising the scapula by placing one hand over the top of the shoulder. With the
other hand placed just above the elbow lifts the arm until full elevation is
achieved or until the patient complains of new pain or worsening of the existing
shoulder pain.

Interpretation:

60-120 degrees of elevation – pain in the anterolateral aspect of the arm.-

subacromial impingement

HAWKINS-KENNEDY IMPINGEMENT TEST

How to perform the test:

With the patient in standing position and examiner standing at the side of the
patient passively elevates the arm forwards to 90 degrees with elbow flexed at
90 degrees .

The examiner can repeat the tests in different directions of the arm ranging from
90 degrees of abduction to 90 degrees of forward elevation.

Interpretation of the test:

The patient complains of pain if there is subacromial impingement.

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AC JOINT PATHOLOGY

How to perform the test:

CROSS BODY ADDUCTION TEST:

With the patient in standing position and examiner standing at the side of the
patient

passively elevates the arm to 90 degrees and rotates it internally such that the
forearm is parallel to the floor .The arm is then adducted passively across the
patient body.

Interpretation of the test:

It is positive if the patient will complain of pain over the top of the shoulder
joint.

Cause

Acromioclavicular Joint Pathologies.

SPEED TEST:

How to perform the test:

With the patient in standing position and arm elevated to 90 degrees ,elbow
fully extended and palm facing upwards. The examiner standing on the side of
the patient applies a downward force with two fingers on the distal foearm.The
patient is asked to resist this downward force.

Interpretation of the test:

If the patient complains of pain in the bicipital groove it is suggestive of long

head of biceps tendiniitis.

YERGASONS TEST

How to perform the test:

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With the patient in standing postion and arm by the side of the body elbow
flexed to 90 degrees and forearm in supination.The examiner standing at the
side of the patient applies a pronating force and patient is asked to resist this
pronating force.

Interpretation of the test:

If the patient complains of pain in the bicipital groove it is suggestive of long
head of biceps tendiniitis

REFERENCES:

1. Charalambous PC. Clinical History for Shoulder Conditions:The

Shoulder Made Easy.UK:Springer,2019:( 69-75)

2. Charalambous PC. Clinical Examination for Shoulder:The Shoulder

Made Easy.UK:Springer,2019:(77-115)

3. Warth JR and Millet JP. Range of motion: Physical Examination of the

Shoulder An Evidence-Based Approach. USA:Springer,2015 : (5-34)

4. Warth JR and Millet JP. StrengthTesting :Physical Examination of the

Shoulder An Evidence-Based Approach.USA:Springer,2015 : (39-70)

5. Castro MHW,Terosch J &Grossman WT.Shoulder.Examination

&Diagnosis of Musculoskeletal Disorders.Clinical Examination.Imaging

Modalities.NewYork:Thieme Stuttgart,.2001: (1-24)Enke F 1995&1996

Orthopädisch-trauma- tologische Gelenkdiagnostik and Orthopädisch-

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 trau- matologische Wirbelsäulen- und Beckendiagnostik.Translated by

Grossman J, Verlag, Stuttgart, Germany:Thieme,2001

6. Hoppenfeld S. Physical Examination of the Shoulder In Physical

Examination of the Spine &Extremities.East Norwalk:APPLETON-

CENTURY-CROFTS,1976:( 1-34)

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