Overview
This lecture covers the steps of clinical examination for patients with shoulder pain, focusing on inspection, range of motion, targeted tests for common pathologies, and interpretation of findings.
Initial Observation and General Assessment
- Begin by inspecting the shoulder from the front, side, and back for muscle bulk and bony abnormalities.
- Assess range of motion: forward flexion, abduction, crossbody adduction, external and internal rotation, and extension.
- Always compare both shoulders for symmetry in movement and muscle bulk.
- Examine the cervical spine first to rule out referred pain from the neck.
Scapular and Rotator Cuff Assessment
- Observe scapular motion for asymmetry, indicating possible anterior shoulder pathology.
- Test supraspinatus: 90° abduction, 30° forward flexion; resist downward pressure, ask about pain.
- Empty Can Test: thumb down, resist downward pressure, check for pain and strength.
- Assess infraspinatus and teres minor via resisted external rotation.
- Test subscapularis: hand behind back, check for lag sign (hand drops), and use Gerber's Lift Off test.
- Assess serratus anterior strength: perform standing pushup, watch for scapular winging.
Pathology-Specific Tests
- Rotator cuff injuries: trauma in young, gradual onset in older patients.
- Impingement: use Neer's test (internal rotation + passive flexion), Empty Can Test, Hawkins-Kennedy Test (internal rotation + crossbody adduction).
- Palpate anterior joint line and subacromial/subdeltoid space for tenderness.
Biceps and Adhesive Capsulitis Assessment
- Biceps tendinopathy: use Speed's Test (resisted forward flexion) and Yergason's Test (resisted supination).
- Adhesive capsulitis: reduced active and passive range of motion; external rotation affected first; scapular motion asymmetry and possible trapezius muscle spasm.
Acromioclavicular Joint and Instability Tests
- AC joint pathology: localized pain, step-off deformity, crepitus, pain with Scarf Test (crossbody adduction).
- Painful arc between 150–180° abduction.
- Instability: Sulcus Sign (downward pull reveals sulcus), Apprehension and Relocation Test (pressure mimics dislocation and relief).
Labral Tears/SLAP Lesions
- Common in athletes and trauma; diagnosed with Speed's Test, O'Brien's Test (pain on downward resistance), and Crank's Test (internal/external rotation with palpation for clunk/pain).
- Acute lesions: anterior joint line fullness and loss of power on resisted movements.
Key Terms & Definitions
- Impingement — compression of rotator cuff tendons, often supraspinatus, under the acromion.
- Rotator Cuff — group of four shoulder muscles: supraspinatus, infraspinatus, teres minor, subscapularis.
- Adhesive Capsulitis — "frozen shoulder," characterized by decreased shoulder movement and pain.
- SLAP Lesion — tear of the superior labrum from anterior to posterior.
- Apprehension Test — assesses the likelihood of shoulder dislocation or instability.
- Scapular Winging — protrusion of the scapula due to serratus anterior weakness.
Action Items / Next Steps
- Review the anatomy of the shoulder and rotator cuff muscles.
- Practice the shoulder examination steps and special tests on a peer.
- Read further on clinical presentations and differentiating features of common shoulder pathologies.