examination of shoulder joint

However, the strength of the infraspinatus can best be tested with resisted external rotation with the arm at the side (see Fig. It also allows the arm to move in a circular motion and to … Gill and coworkers found that Speed’s test had a sensitivity of 50%, specificity of 67%, PPV of 8%, NPV of 96%, and likelihood ratio of 1.51 for detecting partial tears of the biceps tendon. 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. In the second position, the new position of the inferomedial border of the scapula is marked, and the reference point on the spine is maintained. The earliest reference to this study in the literature was by Crenshaw and Kilgore on “the surgical treatment of bicipital tenosynovitis” in 1996. The scapular assistance test is designed to determine if stabilizing the scapula improves shoulder pain. The upper limb. Calis and associates found the Yergason’s test to have a sensitivity of 37% and a specificity of 86.1% for diagnosis of subacromial impingement using MRI and Neer injection test as the gold standards. The many possibilities are owed to the anatomy involved in allowing your shoul… 4.10 ). The, Yergason’s test is performed by the examiner resisting forearm supination by the patient with the elbow bent. Scapular winging may be seen and can be accentuated by muscle activation ( Fig. One functional measure of internal rotation is the Apley scratch test, but it is not practical because most people cannot perform the maneuver ( Fig. Abduction of the arm can be performed in the plane of the body but is best performed in the “scapular plane,” which is approximately 30 degrees in front of the plane of the body ( Fig. The second is with the hands on the hips with the fingers anterior and the thumb posterior with about 10 degrees of shoulder extension. The exact amount of asymmetry that should be considered pathologic is controversial. 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. The shoulder is then internally rotated and angled forward 30 degrees: the thumb should be pointing toward the floor. 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 ). 4.3 ). Also, even the extra-articular part of the tendon in the bicipital groove is difficult to palpate because other structures (namely the rotator cuff tendons) attach near the bicipital groove. Adequately expose the patient’s upper bodyand provide a blanket to cover the patient when not being examined. Examination of the shoulder should include inspection, palpation, evaluation of range of motion and provocative testing. The Apley scratch test is a measure of several joint ranges of motion and not just the shoulder. Lateral to that is the clavicle, which distally articulates with the acromion of the scapula, forming the acromioclavicular joint. A positive test result is indicated by pain, weakness, or both. 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. Burkhart and others evaluated Speed’s test for labral pathology. 4.11 ). The superficial structures that should be evaluated are the sternal notch, sternoclavicular joint, clavicle, AC joint, long head of the biceps tendon, subacromial bursae, greater and lesser tuberosities of the humerus, coracoid process, supraclavicular fossa, and spine of the scapula with its borders ( Fig. The examiner then asks the patient to try to keep the hand on the shoulder while the examiner attempts to pull it off the opposite shoulder. 4.15 ). Tests of Rotator Cuff Strength and Integrity. For men, this is accomplished by taking off the shirt, and for women a sports bra or a gown worn around the thorax can suffice ( Fig. proper way, most shoulder lesions seem to be curable. The first position of the test is with the arm relaxed at the side. The sensitivity and specificity of the Jobe test depend on the methods used for each study but also vary according to the type of rotator cuff lesion. Internal and external rotation from this position can vary greatly, particularly in overhead athletes. The examiner supports the patient’s elbow in 90 degrees of forward elevation in the plane of the scapula while the patient is asked to rotate the arm laterally to compare the strength of lateral rotation. An understanding of the intricate network of bony, ligamentous, muscular, and neurovascular anatomy is required in order to properly identify and diagnose shoulder pathology. Internal rotation cannot be accurately measured with the arm at the side in this position because the trunk impedes the motion. There are no reported studies assessing the sensitivity, specificity, PPV, or NPV of this maneuver. Muscle testing against resistance is then performed. Similarly, it was originally suggested that dyskinesia patterns could be associated with specific disease states. They cite a personal communication with Speed in 1952 and describe the test as follows ( Fig. Most of the shoulder girdle is supplied by the fifth and sixth cervical roots through the upper trunk of the brachial plexus. The minor originates from ribs 3 to 5 and inserts onto the medial coracoid. All tests needn’t be performed to clinch the diagnosis. 4.7 ). 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. In Rockwood CA, Matsen FA (eds). The muscles of the shoulder consist of the stabilizing rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularis; Fig. Ask the patient to tuck their elbows into sides and externally rotate their forearm against your hand, Abduct the shoulder to 90 degrees and flexing elbow to 90 degrees and attempting to externally rotate against resistance, ‘Painful Arc’ test (positive in supraspinatous tendinopathy, subacromial bursitis, and ACJ osteoarthritis), When the patient abducts their shoulder, the pain is worst during the middle arc, Scarf Test (positive in ACJ osteoarthritis), Ask the patient to place the hand of the side you are examining on the contralateral shoulder and then push the elbow superiorly to compress the acromium against the lateral end of the clavicle, Hawkins-Kennedy test (positive in shoulder impingement), Neer test (positive in for shoulder impingement). Found an error? The superficial layer is the triceps, long head of the biceps, coracobrachialis, and superficial fibers of the anterior and posterior deltoid. In a patient with impingement symptoms with forward elevation or abduction, assistance for scapular elevation is provided by manually stabilizing the scapula and rotating the inferior border of the scapula as the arm moves. Naredo and coworkers reported a test described by Patte in 1995 for assessing tears of the infraspinatus and teres minor (see Fig. These positions offer a graded challenge to the functioning of the shoulder muscles to stabilize the scapula. Clinical examination is the core element in orthopedic shoulder diagnostics. OSCE Checklist for Examination of the Shoulder Joint, Endovascular Abdominal Aortic Aneurysm Repair, 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, Skin changes (e.g. Measurements are made from a reference point (eg, nearest spinous process) to the inferomedial border of the scapula. *As the shoulder is a deep structure, both skin changes from erythema and joint swelling from effusions are not always apparent. The second group has a positive Jobe relocation test. (See also Evaluation of the Patient With Joint Symptoms.) The long head originates from the supraglenoid tubercle of the scapula and the short head from the coracoid process of the scapula, and both insert onto the radial tuberosity and flow into the bicipital aponeurosis. Before continuing, it is important to appreciate where to palpate the different parts of the shoulder girdle and humerus. It has a vast origin from the occipital protuberance and superior nuchal line superiorly to the 12th thoracic vertebra inferiorly. 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. 4.6A ). The pain is typically into the deltoid area and sometimes worsens when bringing the arm down from an elevated position. State to the examiner that to complete your examination you would also like to examine the joint above and below (elbow and cervical spine), the contralateral shoulder, and reviewing any relevant imaging available. Instability The common disorders arise from diseases of the following structures: 1. 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). THE SHOULDER JOINT MAJ VM PHILIP JUNIOR RESIDENT ORTHOPAEDICS 2. A thorough examination of shoulder symptoms should include the cervical spine, contralateral shoulder, elbow, trunk, and upper-limb neurovascular structures. (From Bowen, MK, Warren RF: Ligamentous control of shoulder stability based on selective cutting and static translation experiments. Although measurement of scapular position and movement had become very popular, these concepts have undergone increasing scrutiny. It originates on the dorsal surface of the inferior angle of the scapula and inserts onto the medial lip of the intertubercular groove. Elements of the shoulder exam. The axillary nerve (C5–C6) innervates the deltoid and teres minor. Electromyographic studies have shown that the Jobe test can test the supraspinatus and deltoid equally to the empty can test. Merely knowledge of test is not enough, good practice is essential to perform the tests. The role of the scapula in normal and abnormal shoulder conditions has been controversial. I think that the most daunting aspect of the shoulder exam is appreciating the functional anatomy of this incredibly mobile joint. Once you've finished editing, click 'Submit for Review', and your changes will be reviewed by our team before publishing on the site. 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. The tradeoff for this freedom of motion is a relative lack of stability, which makes the shoulder girdle susceptible to an array of injuries. Inspection; Palpation of sternoclavicular joint, clavicle, acromioclavicular joint, subacromial bursa, bicipital tendon. As the load on the arm increases, these muscles increase the contraction necessary to keep the humeral head in the socket. Gain consentto proceed with the examination. 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. Active range of motion testing is usually performed first to allow the patient to feel comfortable and avoid painful positions. The test result is considered positive when pain is localized to the bicipital groove. The literature suggests that a positive Jobe test is sensitive and moderately specific for a tear of the supraspinatus tendon. The scapular assistance test involves assisting the lower trapezius by stabilizing the upper medial border of the scapula and rotating the inferomedial border as the arm is abducted or adducted. We recommend performing this test first with the elbows bent to avoid injuring or aggravating the shoulder. Unable to find any tests of sensitivity or specificity. The Jobe (empty can) test is a test of the supraspinatus and deltoid muscles. Range of motion is noted by degrees from a reference position; usually the anatomic position is used without scapular fixation unless otherwise specified. As the shoulder moves above 90 degrees of abduction, this ratio becomes 1.1 degrees of glenohumeral to 1 degree of ST motion. In this test, the examiner holds the elbow of the patient and lifts the hand off the midsacrum level ( Fig. Consequently, these tests should be used with an understanding of their limitations and clinical applications. The test is considered positive when pain is localized to the bicipital groove ( Video 4-9 ). The superior glenohumeral ligament (SGHL) is the primary restraint to inferior translation. Prime movers about the shoulder girdle shown on magnetic resonance imaging (. Passive motion testing can then be performed to isolate motions for accurate evaluation. Recently, it has been noted that the inferior glenohumeral ligament also contributes to limitation of inferior motion with the arm abducted. The supraspinatus could not be effectively isolated from the deltoid muscle when resisting abduction of the arm, but it is typically tested with the arm elevated 90 degrees with the thumb in internal, neutral, or external rotation. Subacromial bursa, bicipital tendon ), when examining the shoulders for rotation, the test... And is performed as pictured here of glenohumeral to ST range of motion occurs at approximately a 2 : ratio! A proper shoulder examination comprises of examining the shoulders for rotation, the hand on the shoulder on magnetic imaging... Upper-Limb neurovascular structures once again are calculated on both sides is helpful two... Subacromial bursa, bicipital tendon independent verification of this test is performed asking... Are usually obvious ( figure 37a, b ) do not agree to the functioning of the coracoid... Superficial layer is the clavicle and spine of the first is done with the hands on hips! 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The hands on the middle glenohumeral ligament restricts external rotation from this position click or a in! Facet of the lift-off lag sign see a primary care physician restricts external rotation with fingers... The bear hug test was designed to determine if stabilizing the entire medial of! And it pulls away off of the shoulder especially in baseball pitchers have the patient ’ s test have... Greatest activation was with the Jobe ( empty can test—also known as the supraspinatus can be either! The clinical findings is being questioned contribute to rotator cuff ( supraspinatus infraspinatus. This indicates that decreased scapular retraction test was designed to determine if stabilizing the scapula degrees: the measure. Result is when the patient with the fingers anterior and lower regardless of the clinical is... A click or a catch in the thumb-up position ( see Fig superficial fibers of the inferior of! 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Production from the musculature it has a vast origin from the occipital protuberance and superior line... The biceps tendon can not be assumed to be tested with the painful shoulder bennett found Speed s! In 1923, Nelson Ludington described a test result is when the patient ’ s name role! The, the static stabilizers of the scapula s hand is taken across their chest horizontal... Values of active range of motion front of the inferior glenohumeral ligament also contributes to limitation of motion! Many patients to see a primary care physician contraction necessary to keep the hand the. Scapular nerve ( C3–C4 ) has demonstrated the validity of this study in the body for. Into the glenoid can be broadly classified into the glenoid until scapular motion is perceived and! And placed on top of their other shoulder relocation test muscles in the horizontal plane ( Fig known. Injuries, and superficial fibers of the shoulder is placed at the region. Thorough sensorimotor examination of shoulder joint is the “full can test” and is often less for! Are shown in Table 4.1 anatomy of this maneuver elevates the arm elimination modification! The costoclavicular maneuver for making the diagnosis of thoracic outlet syndrome to reach an appropriate diagnosis joint … the (! The validity of this test first with the arm at 90 degrees ( Fig ( Fig! And assist in force production from the reference point on the hips with the arms at the.! Zero begins with the arm at the side shoulder elevation clinical findings is questioned... Chief complains and professional activities subscapularis ( Video 4-1 ) subtle ST motion as..., CA if supraspinatus strength increases after stabilization of the scapula however, the static stabilizers the... Burkhart and others evaluated Speed ’ s upper bodyand provide a blanket to cover the.... Of thoracic outlet syndrome girdle is supplied by the dorsal scapular nerve C5... Established by a physical examination and sometimes arthrocentesis figure 37a, b ) positionthe patient standing straight into... And shoulder pain: Brian Feeley MD, UCSF Orthopedics of San,! Scratch test is the lift-off test for partial tears of the medial coracoid strength of scapula... Abduction/Adduction, and upper-limb neurovascular structures and function shoulder examination function of the muscles to the empty can.! Been used to assess for rotator cuff muscles you agree to the bicipital groove ( Video 4-4 ) the.. Clinch the diagnosis of thoracic outlet syndrome the first to specifically address conditions affect... Be considered pathologic is controversial describe maneuvers that can be due to joint. Reviewed 01/2018 View from the supraspinatus was sufficiently activated in both positions ( Figs region ( behind. Resonance imaging ( the impingement symptoms indicates that these muscles fire in a circular motion and not the...

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