[Music] Hello my name is Dr. Brenda Christopher. I'm a Sports and Exercise Medicine physician. Today, I'll be talking to you about the clinical examination of a patient who presents with shoulder pain. The clinical examination starts with the patient taking their shirt off because here I can assess for a limitation of range of movement or any functional abnormalities. I start with a general inspection of the front, the side, and the back. And here I'm looking at muscle bulk, any bony abnormalities which are asymmetrical. Before I conduct a shoulder examination, it's best practice to do an examination of the cervical spine to ensure that no pathology is originating from there, and it's purely shoulder. So we assess range of movement by forward flexion, abduction all the way up to the top, crossbody adduction, external rotation, and then if I can position you side on for extension, and then turn around to the back for internal rotation. And I compare right to left. It's good practice to get the patient to repeat the full range of motion whilst you observe the scapula, and you look for any asymmetries in scapular motion. So an abnormality or an asymmetry in scapular rhythm can often mean that there's a pathology in the front of the shoulder. So next, I'm going to show you targeted clinical examinations of the shoulder joint. for the most common pathologies. I will start with the rotator cuff as it is the most common diagnosis. We will test the four rotator cuff tendons: supraspinatus, infraspinatus, teres minor, and subscapularis, so it's useful to know the anatomy of the scapula with the spine dividing the supraspinatus fossa and the infraspinatus fossa. The supraspinatus tendon and muscle bellies originate in the fossa here and then work their way around to the anterior aspect of the shoulder, and the inferior infraspinatus muscle belly lies here. To test supraspinatus, I get them in ninety degrees of abduction and thirty degrees of forward flexion, and this is in the scapular plane. Here, I test for power of supraspinatus by pushing down, and I make sure the right side is equal to the left. And I'm also asking the patient for any pain. Then, I get the patient to simulate emptying a can by bringing their thumb to the floor and I can assess power again and ask for pain. And can you place your hands like this and then externally rotate? So next, I test the integrity of infraspinatus and teres minor by resisting external rotation. And I ask for pain or a noted loss of power or any asymmetry. This is a test for subscapularis where you place the hand in this position, and if the patient can maintain this position, that's normal. If there's a internal rotation lag sign, the patient's hand will drop towards the back. I can also assess for power with Gerber's Lift Off where I ask the patient to resist my downward motion. Even though serratus anterior is not strictly a rotator cuff tendon, I assess the strength of this by asking the patient to do a standing pushup. And if you can visualize any winging of the scapula, serratus anterior weakness is present. Younger patients will complain of an associated trauma with their rotator cuff pathologies. And this is in contrast to the older patient, where there'll be a gradual onset of shoulder pain and no associated trauma. The next pathology is impingement, and this represents a pinching of supraspinatus. There are three specialist tests for impingement. The first one is Neer's where I ask the patient to fully internally rotate the arm and passively flex the shoulder joint. This should decrease the space and impinge on the supraspinatus, and it should replicate any symptoms, such as pain. The second test is a test that we've already carried out for rotator cuff pathology. It's Empty Can's Test, and that is again reducing the space here. And if this elicits pain, it's consistent with signs of impingement. So the final test is the Hawkins Kennedy Test where there's an element of internal rotation and cross body adduction. And it's here that I'm trying to pinch the supraspinatus and cause pain. Palpation over the anterior joint line is useful if it's tender. And then also to reveal the subacromial subdeltoid space, you can ask the patient to bring their hand in this position, and then feel over the anterior joint line again. So patients who have impingement can also have scapula movement asymmetries. There are two specialist tests: Yergason's and Speed's, for biceps tendinopathy. Speed's is resisted forward flexion and note that I'm palpating the biceps tendon. As I do this, I'm asking for any pain. Yergason's is resisted supination. I ask the patient to hold my hand or shake my hand, and again I palpate over the origin and the insertion of the biceps tendon. Adhesive capsulitis usually is shown by a reduction in range of movement both actively and passively. External rotation is usually the first range of movement to be affected. With adhesive capsulitis, you often notice an asymmetry of scapula motion secondary to the limitation of the range of movement in the glenohumeral joint. It's useful to note that many patients might have muscle spasms or trigger points within the trapezius in adhesive capsulitis. In the initial stages of adhesive capsulitis, there's a painful range of movement. Later on in the disease, there's a restricted range of movement. Acromioclavicular pathology is probably the easiest diagnosis to make when examining the shoulder joint. Those often localize pain over the AC joint and the patient will point directly to this. The patient can complain of night pain when they roll over to the affected shoulder because this loads the ACJ. Locate the AC joint and feel for a step-off deformity. Also, assess for any crepitus or pain. The Scarf Test is a specialist test which compresses the space where I force crossbody adduction whilst palpating the joint. A positive test is pain or crepitus. There will also be a painful arc in adduction in the 150 to 180 degrees of abduction, so the last 30 degrees of motion. Signs of chronic shoulder instability, which represents subluxation or hyperlaxity of the shoulder joint, can be assessed with the Sulcus Sign. And here I'm applying a downward force of the humerus, and I'm looking for a sulcus that will appear over the lateral deltoid region. Another way to assess shoulder instability is by the Apprehension and Relocation test. Assimilating a dislocation, I apply a downward pressure with a fulcrum with my fist under the posterior aspect of the shoulder. If this causes any pain or discomfort, I then apply a downward pressure, which should hopefully reach all the patients and the pain goes away. Labral tears or SLAP lesions are commonly seen in athletes, may be a consequence of dislocations, or are often seen in motor vehicle accidents when the arm is in the overhead position. So the first test of the SLAP lesion is the Speed's Test, which is the same test that we did for the biceps tendinopathy. This is because the biceps insert at the superior edge of the labrum. O'Brien's test is resistance to me when I press down. And if that's positive, it should cause pain. And the final test is Crank's Test where I'm internally and externally rotating the shoulder trying to cause pain whilst also palpating for clunks. Acute lesions usually present with an anterior joint line fullness, and you can also see a loss of power on resisted movements. Thank you, Chad, for being the patient today. Thank you for watching the Stanford 25 examination of the shoulder joint. Please visit our website and subscribe to further videos. The preceding program is copyrighted by the Board of Trustees of the Leland Stanford Junior University. Please visit us at med.stanford.edu. [Music] [Music]