Shoulder

Conditions

• Rotator Cuff & Impingement
• Instability
• Thoracic Outlet Syndrome
• LHB Rupture
• Frozen Shoulder
• ACJ Arthritis
• ACJ Dislocation
• GHJ Arthritis
• Fused Shoulder
• Brachial Neuritis/Parsonage Turner Syndrome
• Pec Major or Lat Dorsi Rupture
• Klippel Feil & Sprengel Shoulder
• Pseudoarthrosis of Clavicle
• Congenital Absence of Clavicles (Cleidocranial Dysplasia)
• Facioscapulohumeral Dystrophy

Rotator Cuff, Impingement & ACJ Arthritis

Look

• Asymmetry – clavicles, ACJ, deltoid contour, scapula, scars
• Wasting – deltoid, supraspinatus & infraspinatus fossae

Feel

• SCJ, clavicle, ACJ, acromion, LHB, scapula spine, trapezius, neck
• Deltoid (axillary nerve) sensation

Move

• Neck ROM
• Shoulder ROM:
  • FF, ABD, ER, IR
  • Comment on pain, impingement arc, hitching of shoulder
  • Active, assisted, and passive ROM
  • GHJ motion from the back passively
    • Comment and test for scapula winging if present
  • GHJ motion with scapula stabilized passively
• Cuff Power and Impingement Tests:
  • Hawkins Impingement Test
  • Teres Minor
  • Hornblower Sign if weak teres minor
  • Cross Arm Adduction Test for ACJ – note exact location of pain
  • Jobe’s Test
  • Infraspinatus
  • Infraspinatus Lag Sign if weak
  • Subscapularis – Belly Press and Bear Hug Tests
  • Gerber Lag Sign if weak subscapularis

Other Tests

• If cuff and impingement equivocal or other pathology suspected:
  • ACJ
  • Biceps
  • SLAP

Shoulder Instability

Look

• Asymmetry, wasting, scars from arthroscopy, features of hyperlaxity

Feel

• Normal pattern
• Important to feel for axillary nerve function

Move

• Beighton’s Score
• Active ROM screen
• Abduction from behind – check for winging

Special Tests

• Sit Down:
  • Sulcus Sign
  • Anterior and Posterior Load Shift Test
• Lie Down:
  • Anterior Apprehension Test
  • Posterior Apprehension Test
• Test LHB if other tests negative or patient has LHB pain on palpation:
  • Speed’s Test
  • Yergason’s Test
  • O’Brien’s Test

Other Tests

• Check Cuff
• Check ACJ
• Pulses
• Neurology
• C-Spine

Thoracic Outlet Syndrome

Look

• Scars around clavicle, posterior triangle, or neck
• Muscular man, thin lady

Feel

• Neurologic examination
• Pulse

Move

• C-spine ROM and exacerbation
• Shoulder active ROM and exacerbation of symptoms

Special Tests

• If patient describes tingling in arm or history indicates TOS:
  • Roo’s Test:
    • For neurologic component
    • Brace shoulders back
    • Flex elbows to 90 degrees
    • Open and close hand rapidly
    • Reproduction of neurologic symptoms is a positive result
  • Adson’s Test:
    • For vascular component
    • Extend and turn neck to ipsilateral side
    • Abduct arm to 30 degrees
    • Palpate pulse
    • Ask to take a deep breath and hold
    • If pulse disappears or is dramatically less, test is positive

ACJ Dislocation

Examination

• Describe features on inspection
• Check ROM – is abduction full or abnormal
• Turn patient and ask to abduct again

Palpation

• Identify if superior or posterior dislocation
• Assess reducibility by elevating arm and pushing down on clavicle
  • Ask to abduct in reduced position and comment if improved

Frozen Shoulder

Examination

• Asymmetry
• ROM:
  • Check ER in adduction actively and passively
  • Quantify FF – inferior capsule tightness
  • Assess ER in abduction for rotator interval contracture

LHB Rupture

Examination

• Describe typical features
• Accentuate deformity by flexing elbow passively and against resistance
• Speed’s and Yergason’s Test
• Assess Rotator Cuff:
  • Often associated with cuff pathology in elderly men

Facioscapulohumeral Dystrophy

Inspection

• Syndromic appearance
• Unusual appearance of chest and pectoral girdle

Examination

• ROM limited – may be painful
• Assess ROM from behind
• Reproduce winging
• Ask patient to whistle – will not be able to