The shoulder is the most flexible joint in your body, and given the number of everyday activities it's involved infrom brushing your hair to reaching up into the cupboardit's easy to see why shoulder pain is something you'd want to get to the bottom of right away. The second group has a positive Jobe relocation test. Normal values of active range of motion for the shoulder joint are shown in Table 4.1 . Lateral to that is the clavicle, which distally articulates with the acromion of the scapula, forming the acromioclavicular joint. The middle layer comprises the teres major, pectoralis major, the latissimus dorsi, and the short fibers of the anterior and posterior deltoid. Kibler defined 1.5â¯cm of asymmetry as positive for ST motion abnormality. A positive test result is when the patient cannot lift the hand off the back. Tests of Rotator Cuff Strength and Integrity. 4.6A ). The difference between a shoulder with an intact rotator cuff and a torn rotator cuff is that the latter will be weak with abduction and external rotation. (See also Evaluation of the Patient With Joint Symptoms.) Is our article missing some key information? (Reproduced with permission from Perry J. Anatomy and biomechanics of the shoulder in throwing, swimming, gymnastics, and tennis. I think that the most daunting aspect of the shoulder exam is appreciating the functional anatomy of this incredibly mobile joint. Generally, glenohumeral external rotation is 90 degrees or more, and internal rotation is 0 to 30 degrees with the arm abducted 90 degrees. test deltoid and pectoralis major power and also for winging of the scapula. Shoulder Exam In examining a patient with a painful shoulder we should start with a general inspection, looking for musculoskeletal abnormalities and any associated functional deficits. The test is considered positive when pain is localized to the bicipital groove ( Video 4-9 ). The first is done with the arm abducted 90 degrees and typically supported by the examiner holding the elbow. Typically, pain occurs around 120 degrees of flexion. The teres minor is best tested with the arm abducted 90 degrees and externally rotated 90 degrees ( Fig. Itoi and others reported a sensitivity of 83%, specificity of 53%, and accuracy of 78% for the full can test in detecting partial-thickness rotator cuff tears. OSCE Checklist for Examination of the Shoulder Joint, Endovascular Abdominal Aortic Aneurysm Repair, Briefly explain to the patient what the examination involves, Ask the patient to remove their top clothing, exposing the shoulders fully, Offer the patient a chaperone, as necessary, Skin changes (e.g. Calis and associates noted the Speed’s test to have a sensitivity of 68.5% and a specificity of 55.5%. (Redrawn from McFarland EG: TK Kim, HB Park, G El Rassi, H Gill, E Keyurapan: Examination of the Shoulder: The Complete Guide, New York, Thieme, 2006, pp 162-212 Fig 2.4. The shoulder is then internally rotated and angled forward 30 degrees: the thumb should be pointing toward the floor. The primary benefit of the ball and socket arrangement is that it allows the hand to be positioned precisely in space, maximizing our ability to function. This test is positive when it elicits the pain usually experienced by the patient. Active range of motion testing is usually performed first to allow the patient to feel comfortable and avoid painful positions. The elbow is flexed to 90 degrees with the forearm pronated, and the examiner holds the patient’s wrist to resist supination and then directs that active supination be made against the resistance; pain, very definitely localized in the bicipital groove, indicates a condition of wear and tear of the long head of the biceps. Shoulder examination comprises of examining the shoulder girdle as a whole which consists of 1. Shoulder pain leads many patients to see a primary care physician. A positive test result is when the patient cannot lift the hand off of the back. The test is performed by having the patient pinch the scapulas together posteriorly in retraction. A positive test result is indicated by pain, weakness, or both. Isolating glenohumeral motion with the arm abducted 90 degrees involves externally or internally rotating the arm until scapular motion is perceived manually and visually. Second, a click or a catch in the shoulder cannot be assumed to be caused by the biceps tendon. Here, the patient’s hand is taken across their chest (horizontal adduction) and placed on top of their other shoulder. 4.2 ). It also allows the arm to move in a circular motion and to … 51. Bennett found Speed’s test to have a specificity of 13.8% and a sensitivity of 90% for biceps tendon disorders. Although the muscles are the dynamic stabilizers, the static stabilizers of the ligaments and joint capsule should not be forgotten ( Fig. The examiner then asks the patient to try to keep the hand on the shoulder while the examiner attempts to pull it off the opposite shoulder. It originates on the dorsal surface of the inferior angle of the scapula and inserts onto the medial lip of the intertubercular groove. The triceps has three heads, the long, lateral, and medial, which are supplied by the radial nerve (C6âC8). The test was first described by Gerber and Krushell in 1991 and was originally performed with the hand up the back ( Fig. 4.7 ). The arms are abducted 90 degrees in the scapular plane with the elbows extended and the thumbs pointing down. Abduction of the arm can be performed in the plane of the body but is best performed in the âscapular plane,â which is approximately 30 degrees in front of the plane of the body ( Fig. The superficial structures that should be evaluated are the sternal notch, sternoclavicular joint, clavicle, AC joint, long head of the biceps tendon, subacromial bursae, greater and lesser tuberosities of the humerus, coracoid process, supraclavicular fossa, and spine of the scapula with its borders ( Fig. The active and passive range of motion of both sides should be compared. 1 Introduction2 Inspection3 Palpate4 Movement5 Special Tests6 Complete the Examination Introduction Introduce yourself to the patient Wash your hands Briefly explain to the patient what the examination involves Ask the patient to remove their top clothing, exposing the shoulders fully Offer the patient a chaperone, as necessary Always start with inspection and proceed as below […] Remember, if you have forgotten something important, you can go back and complete this. In this test, the examiner holds the elbow of the patient and lifts the hand off the midsacrum level ( Fig. After initial standard supraspinatus testing (Jobe test), the medial border of the scapula is stabilized by the examiner, and muscle testing is repeated. Next, external rotation with the arm at the side should be compared with that of the opposite extremity. They found the drop arm test to have a 100% PPV (ie, if present, the patient has a tear) and 10% sensitivity (ie, if negative, the patient could still have a tear). The rhomboids include the major and minor divisions and are innervated by the dorsal scapular nerve (C5). A test result is considered positive when the patient cannot keep the hand on the shoulder and it pulls away. Once you've finished editing, click 'Submit for Review', and your changes will be reviewed by our team before publishing on the site. Muscle strength of the subscapularis can be tested with the lift-off maneuver. The Apley scratch test is a measure of several joint ranges of motion and not just the shoulder. The sternoclavicular joint—a saddle type of joint … Internal and external rotation from this position can vary greatly, particularly in overhead athletes. The minor originates from ribs 3 to 5 and inserts onto the medial coracoid. The Acromioclavicular joint 4. The upper limb. 4.18B ). This has since been disproven, and although scapular dyskinesia can be associated with a variety of shoulder conditions, it cannot be used reliably as a diagnostic tool for specific shoulder conditions. The subscapularis is innervated by the nerve to the subscapularis (upper and lower), composed of the cervical 5, 6, and 7 roots. A number of physical examination maneuvers have been developed to assist examiners in diagnosing shoulder problems. The supraspinatus test is first performed by assessing the deltoid with the arm at 90 degrees of abduction and neutral rotation. If you do not agree to the foregoing terms and conditions, you should not enter this site. This information is intended for medical education, and does not create any doctor-patient relationship, and should not be used as a substitute for professional diagnosis and treatment. The sensitivities and specificities of this test for pathologic conditions were low regardless of the position measured. The long head originates from the infraglenoid tubercle of the scapula, and the lateral and medial heads originate from the posterior surface of the humerus superior and inferior to the spiral groove, respectively. Naredo and coworkers reported a test described by Patte in 1995 for assessing tears of the infraspinatus and teres minor (see Fig. Doing the basic aspects of a musculoskeletal examination is especially important in the shoulder: The key to performing a good shoulder examination is to develop a system in which the patient is prepped so you can (1) see the shoulders; (2) compare both sides; (3) do a neurovascular examination; and (4) consider the joint above, which in this case is the cervical spine. Your doctor will start with a physical exam to check for any structural problems and rule out anything that might involve your spine or neck. We limit our focus to the shoulder girdle, which includes the sternoclavicular, acromioclavicular (AC), glenohumeral, and scapulothoracic (ST) joints. Shoulder Exam; Hand Exam; Elbow Exam; Hip Exam; Lower Back Exam; Detailed examination of the joints is usually not included in the routine medical examination. No independent studies have validated this test or examined its clinical utility. The examiner abducts the arm at 90 degrees of abduction and neutral rotation. A positive test for scapular muscle weakness is if the patient has burning pain prior to holding this position for 15 to 20 seconds. Patte test for testing teres minor and infraspinatus. In Rockwood CA, Matsen FA (eds). THE SHOULDER JOINT MAJ VM PHILIP JUNIOR RESIDENT ORTHOPAEDICS 2. In: The rotator cuff muscles function to compress the humeral head into the glenoid and to rotate the arm. Examination of the Shoulder Joint. The teres minor originates from the superior lateral portion of the scapula and inserts onto the inferior aspect of the greater tuberosity. For diagnosis of subacromial impingement (not evaluating the biceps tendon) using MRI and Neer injection test as the gold standards: Physical examination tests of the biceps tendon present challenges to the clinician. The many possibilities are owed to the anatomy involved in allowing your shoul… Lift-off test for partial tears of the biceps tendon. With the arm in this position and the thumb in internal rotation, this test is known as the âJobe test.â However, subsequent study has found that the test has equal validity whether the thumb is pointing down, neutral, or up. We have found no reports assessing the sensitivity, specificity, PPV, or NPV of this test. 4.15 and 4.16 ). They originate from the ligamentum nuchae and spinous processes from C7 to T5 and insert onto the medial border of the scapula from the scapular spine to the inferior angle. The test result is positive, indicating lower trapezius weakness as part of the injury, when it gives relief of symptoms of impingement, clicking, or rotator cuff weakness. An understanding of the intricate network of bony, ligamentous, muscular, and neurovascular anatomy is required in order to properly identify and diagnose shoulder pathology. Scapular muscle weakness can be noted as a burning pain in less than 15 seconds. The test result was positive if there was a visible deformity of the biceps (Popeye deformity) or if the biceps tendon could not be felt proximally in the arm. Plane of the scapula is approximately 30 degrees in front of the plane of the body. 4.5 ). It has a vast origin from the occipital protuberance and superior nuchal line superiorly to the 12th thoracic vertebra inferiorly. Proper positioning of the scapula throughout motion allows the muscles associated with the scapula to have the appropriate lengthâtension relationships for the greatest efficiency of limb positioning. The third position is with the arms at or below 90 degrees of arm elevation with maximal internal rotation at the glenohumeral joint. When Neer and Hawkins tests were both positive for detecting bursitis: If only one of the two tests was positive, for detecting bursitis: Yocum’s test in combination with Hawkins’ and Neer’s test: It is helpful to dress the patient so that both shoulders can be seen completely, allowing side-to-side comparison. However, the strength of the infraspinatus can best be tested with resisted external rotation with the arm at the side (see Fig. The latissimus dorsi forms the posterior border and may occasionally be torn, especially in baseball pitchers. The combined sensitivity and specificity for both lesions were 78% and 37%, respectively. The first group has decreased retraction and apparent muscle weakness. 4.17 ). 4.6B ) and internal rotation ( Fig. For example, Kibler and associates proposed that there were four patterns of scapular dyskinesia. 4.18A ). The infraspinatus is best assessed by testing external rotation with the arms at the side. Naredo and associates compared the Patte test with findings on ultrasonography and showed the test to have a sensitivity of 70.5%, specificity of 90%, PPV of 85.7%, and NPV of 70.5% for detecting infraspinatus lesions; a sensitivity of 57.1%, specificity of 70.8%, PPV of 36.3%, and NPV of 85% for detecting infraspinatus tendonitis; and a sensitivity of 36.3%, specificity of 95%, PPV of 80%, and NPV of 73% for detecting infraspinatus tears. One study found that only 5% of patients with superior labral tears have a click, but 5% of a control group also had a click. The Jobe (empty can) test is a test of the supraspinatus and deltoid muscles. They insert onto the proximal ulna (olecranon). Gain consentto proceed with the examination. The supraspinatus could not be effectively isolated from the deltoid muscle when resisting abduction of the arm, but it is typically tested with the arm elevated 90 degrees with the thumb in internal, neutral, or external rotation. Although the original description of the drop arm test remains obscure, it has been ascribed to Codman and described by Magee as follows: The examiner abducts the patient’s shoulder to 90 degrees and then asks the patient to slowly lower the arm to the side in the same arc of movement. Have the patient flex the shoulder (elevate it anteriorly) against resistance while the elbow is extended and the forearm supinated. Dynamic stability of the glenohumeral joint is provided by contraction of the rotator cuff and, to a lesser degree, the long head of the biceps. 4.15 ). The hand of the affected arm is placed on the back at the midlumbar region, and the patient is asked to rotate the arm internally and lift the hand posteriorly off the back. The upper trapezius, levator scapula, and superior serratus anterior elevate the scapula; the pectoralis minor and major and latissimus dorsi depress the scapula; the serratus anterior, pectoralis minor, and levator scapula protract the scapula; the trapezius, rhomboids, and latissimus dorsi retract the scapula; the superior and inferior portions of the trapezius and inferior portion of the serratus anterior cause lateral scapular rotation; and the levator scapula, rhomboids, pectoralis minor, and major and latissimus dorsi cause medial scapular rotation. The pain is typically into the deltoid area and sometimes worsens when bringing the arm down from an elevated position. In the initial portion of abduction, glenohumeral motion predominates, and the ratio has been found to be 4.4 degrees of glenohumeral motion for every degree of ST motion. The patient is asked to actively abduct the shoulder. Also, even the extra-articular part of the tendon in the bicipital groove is difficult to palpate because other structures (namely the rotator cuff tendons) attach near the bicipital groove. The Clavicle 5. Stiffness 3. The shoulder girdle allows for a large degree of motion in multiple planes, with the glenohumeral joint being the most mobile joint in the body. The test result was positive when the patient reported pain or demonstrated weakness with the arm in this position. Internal rotation of the shoulder can be performed by asking the patient to place the arms up the back with the thumbs up ( Fig. The patient is asked to place the hand on his or her other shoulder and to raise the elbow without elevating the shoulder. In a patient with impingement symptoms with forward elevation or abduction, assistance for scapular elevation is provided by manually stabilizing the scapula and rotating the inferior border of the scapula as the arm moves. (From Bowen, MK, Warren RF: Ligamentous control of shoulder stability based on selective cutting and static translation experiments. The planes of shoulder girdle motion include forward flexion, extension, internal/external rotation, abduction/adduction, and a combination called circumduction . Muscle testing against the resistance is then performed. Elements of the shoulder exam. The bear hug test was described by Barth and associates and is performed by asking the patient to place the hand on the side of the shoulder to be tested on the opposite shoulder ( Fig. A good history and full clinical examination, together with a detailed knowledge of the anatomy, suffices to solve the majority of the shoulder problems. Shoulder pain, injuries, and stiffness are the third most common muscle and joint issue that bring people to the doctor. The second is with the hands on the hips with the fingers anterior and the thumb posterior with approximately 10 degrees of shoulder extension. 4.8 ). The first step of shoulder examination is to have the patient undress so that both shoulders can be examined and compared. It originates from the anterior portion of the scapula (subscapularis fossa) and inserts onto the lesser tuberosity of the humerus. and is performed by asking the patient to place the hand on the side of the shoulder to be tested on the opposite shoulder. Jobe and Patte maneuvers can produce three types of responses: (1) absence of pain, indicating that the tested tendon is normal; (2) the ability to resist despite pain, denoting tendonitis; or (3) the inability to resist with gradual lowering of the arm or forearm, indicating tendon rupture. Deformity of the joint and fractures and dislocations are usually obvious (figure 37a,b). The pectoralis minor is also innervated by these nerves (C6âC8). Acromioclavicular Joint Examination. Most of the shoulder girdle is supplied by the fifth and sixth cervical roots through the upper trunk of the brachial plexus. Elevation can be performed with the arm in abduction or flexion. The rotator cuff muscles (supraspinatus, infraspinatus, subscapularis, and teres minor) are the inner layer; these muscles serve first to provide compressive force of the humeral head into the glenoid and secondly to provide rotation of the arm.