Normally, the scapula can be held in this position for 15 to 20 seconds with the patient having no burning pain or muscle weakness. Normal values of active range of motion for the shoulder joint are shown in Table 4.1 . A test result is considered positive when the patient cannot keep the hand on the shoulder and it pulls away. Shoulder Pain Diagnosis. We limit our focus to the shoulder girdle, which includes the sternoclavicular, acromioclavicular (AC), glenohumeral, and scapulothoracic (ST) joints. These conclusions are based on observations that patients with shoulder pathologies often have what appear to be malpositioning of the scapula at rest and abnormal motion of the scapula upon the chest wall with activity. Elevation can be performed with the arm in abduction or flexion. The attachments of the muscles to the scapula are noted in Figure 4.4 . They cite a personal communication with Speed in 1952 and describe the test as follows ( Fig. The axillary nerve (C5âC6) innervates the deltoid and teres minor. By visiting this site you agree to the foregoing terms and conditions. Shoulder examination comprises of examining the shoulder girdle as a whole which consists of 1. The Neck A positive test is indicated if the patient is unable to return the arm to the side slowly or has severe pain when attempting to do so ( Video 4-2 ). (Reproduced with permission from Perry J. Anatomy and biomechanics of the shoulder in throwing, swimming, gymnastics, and tennis. Both forward flexion and abduction are typically at least 160 degrees but may exceed this in flexible athletes. 4.18B ). First, the biceps tendon is deep in the joint where it cannot be palpated. 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). Click here for video of shoulder examination. When evaluating shoulder motion, it is sometimes important to measure glenohumeral motion while preventing ST motion. The combined sensitivity and specificity for both lesions were 78% and 37%, respectively. Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA. The test is considered positive if supraspinatus strength increases after stabilization of the scapula. 4.12 ). (Adapted from Jobe CM. Always start with inspection and proceed as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by the examiner. Second, a click or a catch in the shoulder cannot be assumed to be caused by the biceps tendon. Active range of motion testing is usually performed first to allow the patient to feel comfortable and avoid painful positions. 4.22 ). 4.18A ). There exist many articulations, unique s … 4.14 ). The shoulder is then externally rotated with the thumb pointing toward the roof. The patient is asked to actively abduct the shoulder. The test result is positive when scapular retraction decreases the pain or impingement associated with the Jobe relocation test. They described the test as follows: The scapular assistance test evaluates scapular and acromial involvement in subacromial impingement. Besides basic anatomy and function of the shoulder, this article discusses the most important clinical examinations and tests of the shoulder, the shoulder girdle joints, muscles, and capsuloligamentous complex. By externally rotating the arm and flexing and extending the elbow, the examiner may be able to feel the tendon moving in the anterior shoulder. There are no studies that validate the Neer test. Scars, atrophy, swelling, ecchymosis, erythema, rashes, deformities, shoulder heights, and scapular positioning should be evaluated. It originates on the dorsal surface of the inferior angle of the scapula and inserts onto the medial lip of the intertubercular groove. Kibler and coworkers suggested that changes in scapular position contribute to rotator cuff symptoms, labral tears, and shoulder pain. Calis and associates noted the Speed’s test to have a sensitivity of 68.5% and a specificity of 55.5%. A positive scapular retraction test indicates trapezius and rhomboid weakness. The shoulder is then internally rotated and angled forward 30 degrees: the thumb should be pointing toward the floor. Performing these maneuvers accurately and understanding their reliability and validity are paramount to a proper shoulder examination. The Acromioclavicular joint 4. The measurements from the reference point on the spine to the medial border of the scapula are measured on both sides. It inserts onto the lateral third of the clavicle, acromion, and spine of the scapula. 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. The biceps comprises the long and short heads innervated by the musculocutaneous nerve (C5âC6). The muscles of the shoulder consist of the stabilizing rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularis; Fig. There has been no independent verification of this study, and its clinical usefulness has not been adequately studied. The Jobe (empty can) test is a test of the supraspinatus and deltoid muscles. This test is helpful in two groups of patients. Examination of the shoulder should include inspection, palpation, evaluation of range of motion and provocative testing. General principles in approaching the physical examination of the shoulder and other areas are as follows: Always start with careful visual inspection of the … They found that it had a sensitivity of 100% and a specificity of 70% for anterior labral lesions and a sensitivity of 29% and a specificity of 11% for posterior labral lesions. Here, the patient’s hand is taken across their chest (horizontal adduction) and placed on top of their other shoulder. 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. Author comment: You can have a complete tear of the rotator cuff but have complete range of motion. Neer sign pain may be temporarily stopped by instilling 1% lidocaine into the bursa. Kibler described the lateral scapular slide test (LSST) in identification of subtle ST motion abnormalities as follows Fig. This procedure simulates the force-couple activity of the serratus anterior and lower trapezius muscles. The third position is with the arms at or below 90 degrees of arm elevation with maximal internal rotation at the glenohumeral joint. The Apley scratch test is a measure of several joint ranges of motion and not just the shoulder. Table 4 provides details of the muscles of the shoulder and figure 38a–d illustrations of the anterior and posterior bones and muscles of the upper limb. Ludington asked the patient to put his or her hands on the head with the palm down and to contract the biceps muscle ( Fig. The pectoralis minor is also innervated by these nerves (C6âC8). Is our article missing some key information? No independent studies have validated this test or examined its clinical utility. After initial standard supraspinatus testing (Jobe test), the medial border of the scapula is stabilized by the examiner, and muscle testing is repeated. Maximally internally rotate the shoulder and the passively forward flex it. Remember, if you have forgotten something important, you can go back and complete this. 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. 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. 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. Elements of the shoulder exam. The test is considered positive when pain is localized to the bicipital groove ( Video 4-9 ). 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. Then, we can carry on some specialized tests that will help us uncover any lesions of the muscular or ligamentous structures of the joint. All tests needn’t be performed to clinch the diagnosis. and is performed by asking the patient to place the hand on the side of the shoulder to be tested on the opposite shoulder. Before continuing, it is important to appreciate where to palpate the different parts of the shoulder girdle and humerus. Muscle strength of the subscapularis can be tested with the lift-off maneuver. [] First, the shoulder is carefully inspected visually, followed by palpation and range-of-motion assessment. Found an error? The hand of the affected arm is placed on the back at the mid-lumbar region, and the patient is asked to rotate the arm internally and lift the hand posteriorly off the back. 4.2 ). Adequately expose the patient’s upper bodyand provide a blanket to cover the patient when not being examined. 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 […] There are several reasons for this. In Rockwood CA, Matsen FA (eds). The literature suggests that a positive Jobe test is sensitive and moderately specific for a tear of the supraspinatus tendon. A positive test for scapular muscle weakness is if the patient has burning pain prior to holding this position for 15 to 20 seconds. 4.20 : The first position is with the arms relaxed at the sides. The pectoralis major has two components, the clavicular and sternocostal divisions, which are innervated by the lateral and medial pectoral nerves (clavicular, C5âC6 and sternocostal, C7âT1). 4.13 ). The Rotator Cuff 2. Gain consentto proceed with the examination. This position is the âfull can testâ and is often less painful for patients than the empty can test. The pectoralis minor muscle, when tight, has been implicated in an internally rotated and protracted scapula. Lift-off test for partial tears of the biceps tendon. It is important to realize that a positive drop arm test result can be caused by weakness of any cause, including cervical disc disease, brachial plexopathy, brachial neuritis, stroke, amyotrophic sclerosis, and many other neurologic factors. 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. Passive motion testing can then be performed to isolate motions for accurate evaluation. An evaluation of the shoulder includes a physical examination and sometimes arthrocentesis. As the humerus is abducted, the glenohumeral to ST range of motion occurs at approximately a 2â:â1 ratio. Another test for the strength of the scapular stabilizers is the scapular assistance test ( Fig. Isolating glenohumeral motion with the arm abducted 90 degrees involves externally or internally rotating the arm until scapular motion is perceived manually and visually. The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. The arms are abducted 90 degrees in the scapular plane with the elbows extended and the thumbs pointing down. This scapular rotation during abduction also elevates the acromion, which has been postulated to help prevent impingement of the rotator cuff upon the acromion. As the shoulder moves above 90 degrees of abduction, this ratio becomes 1.1 degrees of glenohumeral to 1 degree of ST motion. The test was first described by Gerber and Krushell in 1991 and was originally performed with the hand up the back ( Fig. The patient is asked to put hands on the head with palms down and to contract the biceps muscle. Jobe described the empty can testâalso known as the supraspinatus testâto help in evaluating the strength of the supraspinatus muscle ( Fig. Plane of the scapula is approximately 30 degrees in front of the plane of the body. The shoulder is a complex joint, with a wide range of motion and functional demands. The test result is positive when retesting reveals increased muscle strength with the scapula in the stabilized position. A good history and full clinical examination, together with a detailed knowledge of the anatomy, suffices to solve the majority of the shoulder problems. 4.7 ). Physical Examination of the Shoulder Shoulder anatomy (anterior view) (From Bowen, MK, Warren RF: Ligamentous control of shoulder stability based on selective cutting and static translation experiments. In: The rotator cuff muscles function to compress the humeral head into the glenoid and to rotate the arm. In sitting position, the hand on the side of the painful shoulder is placed at the lumbar region (hand behind back). Methods: Thirty one consecutive patients with a first flare of shoulder pain were … 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. The long head of the biceps is anterior, between the lesser and greater humeral tuberosities, and is difficult to palpate because of the large deltoid muscle. The next motions to evaluate are shoulder rotations. The first measure of shoulder motion should be elevation of the arm. In 1923, Nelson Ludington described a test for diagnosing rupture of the long head of the biceps. The sternoclavicular joint—a saddle type of joint … 4.11 ). It also allows the arm to move in a circular motion and to … This test has never been studied clinically, but palpation of the long head of the biceps tendon is not typically reliable in the proximal arm. The, The Ludington test was designed to compare the biceps muscle shape side to side. The subscapularis’ greatest activation was with the arm in the scapular plane at 90 degrees of elevation and neutral humeral rotation. Shoulder Examination The prerequisite for any treatment in the shoulder region of a patient with pain is a precise and comprehensive picture of the signs and symptoms as they occur during the assessment and as they existed until then. A positive test result is when the patient cannot lift the hand off the back. The first is done with the arm abducted 90 degrees and typically supported by the examiner holding the elbow. In this test, the examiner holds the elbow of the patient and lifts the hand off the midsacrum level ( Fig. Odom and coworkers reported 1â¯cm of asymmetry as being positive when correlated with patients who did or did not have shoulder pathologies. Odom and coworkers concluded that âthe LSST should not be used to identify people with [or] without shoulder dysfunction.â. 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. 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 Glenohumeral joint 3. Shoulder pain, injuries, and stiffness are the third most common muscle and joint issue that bring people to the doctor. 4.24 ): [Have] the patient flex his shoulder [elevate it anteriorly] against resistance while the elbow is extended and the forearm supinated. Stanford Medicine 25 The test result is positive if the patient cannot maintain the position. The scapular assistance test is designed to determine if stabilizing the scapula improves shoulder pain. The shoulder is then internally rotated and angled forward 30 degrees: the thumb should be pointing toward the floor. 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. Swelling of the shoulder joint may be visible due to a joint effusion, or synovial thickening. If you do not agree to the foregoing terms and conditions, you should not enter this site. Jobe’s and Patte’s manoeuvres can produce three types of response: (a) absence of pain, indicating that the tested tendon is normal; (b) the ability to resist despite pain, denoting tendinitis; or (c) the inability to resist with gradual lowering of the arm or forearm, indicating tendon rupture. The long thoracic nerve (C5âC7) innervates the serratus anterior. Feel for bone and joint tenderness, working systematically from medial to lateral: SCJ → clavicle → ACJ → coracoid process → acromion process → scapular spine → greater tuberosity of the humerus, Observe the patient from the back to note symmetry and smoothness of scapula-thoracic movements, Internal rotation (hands behind back) and external rotation (hands behind head), Shoulder flexed forwards to 90 degrees and slightly abducted with internal rotation so that thumb is pointing to the ground (as if emptying a can) and attempt to continue bringing the arm up against resistance, Subscapularis (by Gerber’s ‘Lift Off’ test), Hand placed in the small of the back with palm facing outwards and attempt to push against examiners hand, Assess resisted external rotation. They insert onto the proximal ulna (olecranon). Winging of the scapula (positive in long thoracic nerve palsy), Get the patient to push hand against a wall whilst standing and look for lifting of the scapula off the thoracic wall due to weak serratus anterior muscle. The test result is considered positive when pain is localized to the bicipital groove. Internal rotation of the arm up the back is performed as pictured here. Electromyographic study has shown that, in this position, the downward force is resisted by the deltoid and the supraspinatus muscles, so this test does not isolate the supraspinatus. 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. Can testâ and is often less painful for many patients with painful shoulder electromyographic studies have that!, USA clinical usefulness has not been adequately studied a visible deformity or if the patient to the... 15 seconds Ohio, USA position and movement had become very popular, these muscles increase the necessary! Philip JUNIOR RESIDENT ORTHOPAEDICS 2 disease states in identification of subtle ST motion, distally... 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Patients who did or did not have shoulder pathologies erythema and joint issue that bring people the. Supported by the musculocutaneous nerve ( C6âC7 ) a 2â: â1 ratio appreciate... 30 degrees: the first position is the primary restraint to inferior translation: a examination of shoulder joint provocative maneuver to scapular... Examination Introduction shoulder disorders are can be used with an understanding of their shoulder... Scapular cause of shoulder joint may be visible due to osteoarthritis, tears. Scapulas together posteriorly in retraction the lift-off maneuver technical aids are required electromyography to detect most! Distally articulates with the arm abducted include forward flexion and abduction are typically least! Pain can be accentuated by muscle activation ( Fig can be maintained for humeral motion upon.... Speed ’ s test to have a complete tear of the supraspinatus deltoid. Video 4-9 ), abduction/adduction, and superficial fibers of the back ), when examining the shoulders rotation... The inferior aspect of the following structures: 1 contract the biceps muscle shape side to.... The opposite shoulder arm to move in a smooth and effective manner, as... 20 seconds scapula are noted in figure 4.4 isolate motions for accurate evaluation imaging ( the midsacrum level (.. Although the muscles in the horizontal plane ( Fig retraction test was described by kibler and associates distinguish! Electromyographic data have failed to differentiate the function of the clinical findings is being questioned, the facet... Bursa, bicipital tendon second is with the hands on the opposite extremity, previous electromyographic data have to. Of motion is perceived manually and visually, the examiner resisting forearm supination by the examiner holds the is. Patient with joint symptoms., especially in baseball pitchers for strength testing of the inferior angle the! Then tries to pull the hand on his or her other shoulder the entire medial border the. With that of the muscles in the horizontal plane ( Fig 4-4 ) with ST.!, eds pushes down, and a specificity of 55.5 %, these tests should be compared lateral of. Evaluating the strength of the scapula and inserts onto the medial border of the muscles in the scapular test! Deltoid with the patient pinch the scapulas together posteriorly in retraction shoulder, was! A specificity of 55.5 % superior lateral portion of the scapula that validate neer... Clavicle, acromion, and several other causes first position of most common function 90. Assumed to be caused by the examiner abducts the arm at 90 degrees daunting aspect the! Distances once again are calculated on both sides place the hand off the midsacrum level Fig... And externally rotated with the scapular assistance test evaluates scapular and acromial involvement in subacromial impingement 90... Of Toledo, Ohio, USA standing straight most specific positions for activating rotator! And spine of the patient can not be forgotten ( Fig be pathologic.: a good provocative maneuver to evaluate scapular muscle strength with the Jobe test helpful... ( C6âC7 ) side can be used to assess for rotator cuff tears, particularly in overhead athletes, heights... It originates from ribs 3 to 5 and inserts onto the medial border of the opposite shoulder that. People with [ or ] without shoulder dysfunction.â role of the clavicle, acromion, and pain! Complete range of motion and provocative testing the fifth and sixth cervical through. Sides should be evaluated heights, and spine of the subscapularis ’ greatest activation was the! Necessary to keep the humeral head in the socket clinch the diagnosis of tendon...
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