Prior to clinical assessment of the shoulder, a comprehensive and accurate clinical history is helpful. Common symptoms of shoulder pathology include pain, instability, stiffness or a range of restricted movements active or passive and deformity.
Clinical examination follows the order of inspection, palpation, assessment of range of motion and special tests for the shoulder. Clinical examination of the shoulder should begin with adequate exposure of the patient and follows a basic pattern. Most clinicians follow a stepwise approach summarised as Look, Feel, Move active then passive , followed by special tests for specific pathology.
Inspection must be from all sides of both joints, with the clinician looking for bruises, swelling, deformity, erythema, asymmetry of shoulder contour and scars, either traumatic or from previous surgery. For example, in the area of the deltopectoral groove, which is a frequent approach to the shoulder [ 22 ]. The clinician must also look in the axilla, as disease here may present with shoulder symptoms, as well as non orthopaedic surgery particularly previous axillary lymph node clearance for breast cancer [ 23 ].
go here Winging of the scapula is seen in injury to the long thoracic nerve as well as the accessory nerve [ 25 ] and this can be elicited by asking the patient to press against a wall. The clinician should palpate theSC joint, clavicle, AC joint, coracoid process, acromion and the spine of scapula. The tendon of the biceps must also be palpated for tenderness. Tenderness along the joint indicates a joint pathology, most commonly osteoarthritis of the joint.
In cases of fibromyalgia, there will be concomitant tenderness over the shoulder and neck regions, as well as in other parts of the body [ 26 ]. The range of motion of the shoulder should be assessed initially actively and then passively. If active motion is limited, passive movements will help determine if the restriction is due to pain, motor disease or an obstructive pathology.
Painful active motion is seen in joint disease, while painless restriction is seen in motor nerve disease. An example of this is the scarf test for AC joint osteoarthritis. Flexion, extension, abduction and adduction can be tested, and the degree of motion can be noted compared to normal.
Adequacy of internal rotation can also be tested by asking the patient to touch the opposite shoulder, or the opposite scapula. A range of special tests exists for common conditions of the shoulder.
Although many have been described, relatively few have been evaluated and validated by quality studies. Furthermore, debate exists on the value of any single test being used alone [ 27 ]. These tests should be used together as part of a full clinical assessment. The shoulder joint is the most mobile joint in the human body and, as such, sacrifices stability to achieve this degree of mobility. There are a large amount of factors that contribute to joint stability and a deficit in any one of these can lead to recurrent instability [ 28 ].
These stabilising factors can be classified as dynamic or static. Dynamic factors include the rotator cuff, biceps tendons, negative intra-articular pressure as well as scapulothoracic and scapulohumeral motion. Static factors include the bony architecture of the joint itself as well as the glenoidlabrum and intrinsic ligaments of the glenohumeraljoint [ 28 ].
The incidence of traumatic anterior shoulder injury is reported to be 1. Dislocation of any form is most common in young and male patients [ 30 ]. The most common injury mechanism resulting in an anterior dislocation is a fall with the humerus abducted and externally rotated. In this position, the inferiorglenohumeral ligament is the primary defence against anterior translation of the humeral head on the glenoid.
A number of clinical tests have been designed to evoke the instability and allow the symptoms to present themselves, these are outlined below.
The main tests for anterior instability include the apprehension test, relocation test and surprise test. If these actions cause pain, the test is positive. A Relocation test is performed if the apprehension test is positive. It involves continuation of the external rotation force, but this time applying a posterior force to the anterior surface of the shoulder.
The relocation test is positive if theseactions relieve the pain. The surprise test involves subsequently letting go of the anterior pressure, which recreates the anxiety feeling or dislocation.
A positive apprehension test with a positive relocation test indicates anterior instability. A positive apprehension with a negative relocation indicates a possible AC joint pathology. The cross over arm test can also indicate AC joint pathology. The surprise test has the highest sensitivity The apprehension test has the highest positive likelihood ratio for anterior instability [ 27 ]. Initially, posterior instability was thought to be mostly due to capsular laxity however, recent research has showed the importance of the glenoidlabrum and the glenoid depth [ 35 ].
Again, as with most shoulder complaints, the most common presentation is pain and can be diffuse across the shoulder or localised deeply within the posterior area of the shoulder.
Athletes may present with pain particularly towards the end of their activities when muscle fatigue is high [ 35 , 36 ]. It is performed by applying posterior force on the anterior surface of an adducted and flexed shoulder.
Apprehension by the patient for this movement signifies a positive test [ 33 ]. Tears in the labrum are either restricted to the anterior labrum as with a Bankart lesion in anterior instability or extend posteriorly along the superior aspect superior labral anterior posterior - SLAP lesion. These lesions most commonly present after other injuries and conditions, such as instability and rotator cuff tears, but they can present alone and can become a significant source of shoulder problems [ 38 ].
These are, however, difficult to diagnose without radiological investigations or direct vision with arthroscopy, although there have been some clinical teststhat have been described in current literature [ 39 ]. Despite these specific tests, there are doubts regarding their efficacy including a systematic review of articles in [ 40 ] which concluded that the likelihood ratios of Speeds and Yergason's tests did not rule in or out the presence of a SLAP lesion Shoulder Impingement.
Shoulder impingement is caused by a narrowing of the subacromial space, resulting in an intrusion of the tissues within. This can be caused by a number of pathological conditions such as a bursitis, tendonitis or a partial or full thickness tendon tear [ 42 ]. The main presentation of this is pain anterolateral to the acromion, which may radiate to the lateral aspect of the humerus as far as the mid shaft area. This pain is frequently present at night and exacerbated by positioning of the affected limb overhead. Functional difficulties may also be present, such as difficulty when combing ones hair or any form of work with the arms over head [ 43 ].
If the patient reports pain in this position, then the result of the test is considered to be positive [ 44 ]. The arm is then quickly moved into internal rotation. Pain in the subacromial space denotes a positive sign [ 45 ]. The painful arc test involves observing the patient actively and slowly abducting their humerus through its entire range of movement. Rotator cuff pathology can be in the form of a tendonopathy via a partial or a complete tear and these can present as an impingement syndrome with pain on overhead activity [ 16 ].
The causes of rotator cuff tendonopathy are normally theorised into intrinsic factors, extrinsic factors or a combination of both. The intrinsic factors are as a result of chronic damage from inflammation to the tendons or the bursa by over-use or trauma to the shoulder [ 46 ].
The alternative theory is that mechanical compression of the tendons by external structures causes the chronic inflammation and subsequent degradation of the structures in the subacromial space [ 44 ]. Assessment of the shoulder by way of accurate history and clinical examination is vital for the diagnosis of shoulder pathology. Many tests exist for the assessment of the shoulder. The accuracy varies with clinician as well as patient group.
The clinician must be aware of the limitations of each test and tailor the routine of clinical exam in order to assess the shoulder appropriately. Assessment of the shoulder should be performed in the context of a detailed history and comprehensive examination, which should include a range of tests used in conjunction with each other. The authors confirm that this article content has no conflict of interest.
National Center for Biotechnology Information , U. Journal List Open Orthop J v. Open Orthop J.
Published online Sep 6.