Shoulder Hx and Exam
Classification and natural history
| Articular classification of shoulder injuries |
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| Stabiliser classification of shoulder injuries |
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A focused history
- mechanism of injury
- anatomical site
- limb position
- subjective experiences
- pain
- Pain location:
- Pain above clavicle and posterior shoulder +/- lateral hand: consider C-spine
- Pain over deltoid +/- medial hand: likely shoulder
- Elbow pain can be either of above
- 24h nature of pain:
- Inflammatory pain usually constant, may get worse at night with difficulties going back to sleep. Can be associated with morning stiffness > 30 min.
- Mechanical pain usually intermittent, and position dependent. There may be night pain which improves when patient changes positions. Morning stiffness usually < 30min.
- ‘Aggs and Eases’
- If patient can sleep on the affected shoulder and put hand behind back: unlikely to be shoulder problem.
- In inflammatory conditions, not much (? anti-inflammatories) will make the pain better; a lot of will make it worse.
- Character:
- A sharp, shooting pain may suggest a neuropathic cause, whereas a dull deep ache may be emanating from a joint or muscle
- Aggravating and relieving factors:
- Pain relieved by gentle movement suggests an inflammatory cause.
- Pain in all directions of movement suggests joint pathology, whereas pain in one or two planes of movement may relate to muscle or tendon pathology
- Radiation:
- Shoulder pain rarely radiates below the elbow or across the midline.
- Pain radiating below the elbow may be due to nerve irritation, either the cervical spine or an unstable shoulder putting traction on adjacent nerves
- Timing:
- How long has the patient had pain and what is the natural history of this pain?
- Severity:
- A visual analogue scale gives a baseline so pain progression or resolution may be mapped. The impact on the patient’s activities of daily living should be assessed
- Pain location:
- Dysfunction
- Which movements are limited? This can help isolate the structure
- Consider the following if movements are limited by:
- pain: tendinopathy, impingement, sprain/strain, labral pathology
- mechanical block: labral pathology, frozen shoulder
- night pain (lying on affected shoulder): rotator cuff pathology, anterior shoulder instability, ACJ injury, neoplasm (particularly unremitting)
- sensation of ‘clicking or clunking’: labral pathology, unstable shoulder (either anterior or multidirectional instability)
- sensation of stiffness or instability: frozen shoulder, anterior or multidirectional instability
| Shoulder red flag conditions |
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Yellow Flags
- The Fear Avoidance Belief Questionnaire (FABQ)
- Depression Screening tools such as the Beck Depression Inventory (BDI) or the Depression Anxiety Screening Scale (DASS) are useful in screening patients for depression.
- The Pain Catastrophizing Scale, helps determine if the patient is exaggerating their pain and symptoms and the severity of the situations as a whole.
shoulder examination
- Inspection – compare both sides
- Size, shape, position, scars, lumps and bumps, colour, bruises, erythema, swelling
- Palpation
- Tenderness and altered sensation (subjective)
- local or referred
- Surface temperature, texture (objective)
- a hot tense surface may indicate infection, inflammation/synovitis, recent trauma or tumour
- Swelling?
- may indicate effusion, tumour, nodule or bone changes
- Crepitus with movement?
- occurs in osteoarthritis, tendinopathy and fracture
- Tenderness and altered sensation (subjective)
Movement
- Active movement
- range of movement
- Abduction: 150 degrees
- Adduction: 30 degrees
- Forward flexion: 150-180 degrees
- Extension: 45-60 degrees
- Rotation (test with elbow flexed to 90 degrees, see Apley’s Scratch Test)
- Overhead sports (e.g. baseball, swimming) athletes have greater external rotation and restricted internal rotation
- External Rotation: 90 degrees
- Internal rotation: 70-90 degrees
- range of movement
- Painful arch
- calcification of supraspinatus tendon
- Subacromial bursitis
Passive movement
- difficult if the patient guards
- Only necessary if active movement is limited. Can help differentiate between:
- weakness, secondary to nerve of muscle
- block from mechanical cause or due to pain
- adhesive Capsulitis
- Glenohumeral Osteoarthritis
Special tests:
Rotator Cuff
Empty can test – Supraspinatus
- aka Jobe’s test
- the patient attempts to elevate the arms against resistance while the elbows are extended, the arms are abducted and the thumbs are pointing downward
- sensitivity of 18.7%
- specificity of 100%
Lift-off test – Subscapularis
- rests the dorsum of the hand on the back in the lumbar area. Inability to move the hand off the back by further internal rotation of the arm
- +ve: if pt cannot lift dorsum of hand off back
- A modified version of the lift-off test is useful in a patient who cannot place the hand behind the back. In this version, the patient places the hand of the affected arm on the abdomen and resists the examiner’s attempts to externally rotate the arm
Hornblower’s sign – Teres minor
- in scapula plane, 900 elbow flexion
- ask pt to External Rotation against resistance
- +ve: if pt cannot externally rotate → hornblower’s sign
Infraspinatus/teres minor examination
- The patient attempts to externally rotate the arms against resistance while the arms are at the sides and the elbows are flexed to 90 degrees.
Drop-arm test
- patient’s arm is abducted to at least 90 degrees, they are then asked to lower the arm slowly and control the decent.
- Inability to perform this task slowly and with control constitutes a positive test and has a positive predictive value of 100% and a sensitivity of 10%
- inability to perform the test is highly suggestive of a tear, although with a negative test the patient may still have a tear.
Provocative Testing
- Apley scratch test
- Patient touches superior and inferior aspects of opposite scapula Loss of range of motion: rotator cuff problem
- Neers Test
- for impingement of the rotator cuff tendons under the coracoacromial arch.
- The arm is fully pronated and placed in forced flexion.
- scapula should be stabilized during the maneuver to prevent scapulothoracic motion
- Hawkins’ Test
- elevating the patient’s arm forward to 90 degrees while forcibly internally rotating the shoulder
- Pain with this maneuver suggests subacromial impingement or rotator cuff tendonitis
- Adhesive Capsulitis
- pain with movement of the shoulder in any directions.
- The first range of motion to be affected is the external rotation.
- Also, there is usually an associated asymmetry in scapular movement.
- show tenderness and spasms of the trapezius muscle.
Shoulder Instability
- Patients complain of shoulder pain associated with a sensation of the shoulder “giving way,” actually representing the head of the humerus partially or completely leaving the glenoid fossa.
- can be related to a congenital hyperlaxity of the capsula and ligaments of the joint, or it may be acquired after a traumatic injury to these structures
- Sulcus Sign
- apply a downward pressure on the humerus by pulling at the level of the wrist, and at the same time observes the lateral aspect of the deltoid region.
- If a sulcus appears in this region, the test is considered to be positive for shoulder instability
- Apprehension and Relocation Test
- Apprehension test: With the patient lying supine, gently abduct and externally rotate the shoulder with one hand, and apply upwards pressure anteriorly with the other hand. A positive result is pain or fear with this guided movement, but the test is always done in combination with the Anterior Relocation test.
- Anterior Relocation test: Continuing from the apprehension test, now apply a downward pressure on the humerus. If this relieves the patient’s pain it again suggests anterior dislocation.
- Anterior Release test: Continuing from the relocation test, a positive test occurs if the patient expresses pain when the examiner’s hand is suddenly removed
- Speed Test
- to examine the proximal tendon of the long head of the biceps.
- The patient’s elbow is flexed 20 to 30 degrees with the forearm in supination and the arm in about 60 degrees of flexion.
- The examiner resists forward flexion of the arm while palpating the patient’s biceps tendon over the anterior aspect of the shoulde
systems examination as clinically indicated:
- Cervical spine, neurological assessment of upper limb, cardiovascular assessment
Spurling’s test
- for cervical root disorder
- The neck is extended and rotated toward the affected shoulder while an axial load is placed on the spine.
