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Shoulder and Neck

Evaluation

Shoulder and Neck Exam Landmarks

Shoulder and Neck Exam Essentials

SHOULDER AND NECK EVALUATION

HISTORY

A thorough history is critical in evaluating patients with shoulder pain. Important questions include:

What was the mechanism of injury or overuse? It is important to determine if this is a chronic injury related to overuse, or an acute injury related to trauma. Specifically ask what activities cause the pain. Most commonly, pain from an overuse injury will be related to repetitive overhead activity and will tend to worsen with activity and improve with rest. Keep in mind also that pain in the shoulder can radiate from a variety of sources, including the chest, abdomen and the cervical spine.

Are there symptoms of instability? Ask the patient if they have ever had a dislocated shoulder. This injury will generally result in loosening of the static restraints of the shoulder (capsule and glenohumeral ligaments) and chronic problems of shoulder instability. Inquire if the shoulder “slips out of place” with throwing or other overhead motions. This is an obvious sign of glenohumeral instability. Instability is commonly seen in young, active patients with recurrent shoulder pain.

What is the location and character of pain? Asking about the location of pain can be helpful in pinpointing its source, and can be confirmed by palpation. The character of the pain can be helpful in diagnosing rotator cuff problems. With rotator cuff tendinitis, the pain tends to worsen with activity, improve with rest and is typically located in the subacromial area. Pain from impingement syndrome is worse with overhead motions (such as washing hair or reaching for an overhead cupboard). Patients will often wake at night when rolling over onto an extended arm. Finally, pain from a rotator cuff tear will pres- ent as a dull, unrelenting ache (toothache-type pain). It often leads to severe night pain that pre- vents sleep and makes it hard to lie on the shoulder.

Are there mechanical symptoms (locking or popping)? Popping or snapping in the shoulder with overhead motion is common but rarely of clinical significance. However, when it is painful or leads to a true blocking of motion, a labrum tear should be suspected.

What is the relationship of pain to the throwing motion? Repetitive throwing commonly causes shoulder pain. The throwing motion can be simply divid- ed into three phases: (1) cocking, (2) acceleration and (3) release/deceleration (Figure 1). Where in the throwing motion the pain occurs can be a clue to its cause. Pain during the cock- ing phase suggests anterior cuff tendinitis or anterior instability/subluxation. Pain during the acceleration phase suggests rotator cuff tendinitis or impingement. Pain during release/decelera- tion suggests posterior cuff tendinitis or posterior instability/subluxation (rare).

Figure 2. Locations of common causes of shoulder pain.

Figure 2a. Muscles of the rotator cuff.

Range of Motion (ROM) Range of motion in the shoulder should be assessed both actively and passively. A loss of active motion alone suggests rotator cuff (RC) tear or nerve injury. A loss of both active and passive motion suggests a mechanical block (such as a labrum tear, adhesive capsulitis or severe impingement). The following motions should be assessed when checking ROM:

1. Forward flexion (180°)
2. Extension (45°)
3. Abduction (150°)
4. External rotation (90°)
5. Internal rotation (90°)
6. Horizontal adduction (130°)

The “Drop Arm Test” is the inability to lift or hold the arm in the 90° abducted position. When positive, a large rotator cuff tear or nerve injury is suggested.

Supraspinatus m.

Subscapularis m. Biceps m.

Rotator cuff

ANTERIOR POSTERIOR

Supraspinatus m. Deltoid m.

Teres minor m. Infraspinatus m.

Teres major m.

Anterior Posterior

Rotator cuff tear Impingement syndrome Frozen shoulder Cervical radiculopathy (spine)

Acromioclavicular separation Osteolysis of distal clavicle Osteoarthritis Clavicle fracture

Biceps tendinitis Impingement syndrome Rotator cuff tear Frozen shoulder Glenohumeral arthritis Labrum injury Humeral shaft fracture R(proximuptureasl) biceps tendon

Cervical radiculopathy (spine) Rotator cuff tear

Scapular fracture

Strength Testing Strength testing of the rotator cuff is performed using resisted motion. Pain during resisted motions suggests tendinitis; weakness suggests a RC tear. It is essential to differentiate true weakness from a painful inhibition of strength that may be seen with severe tendinitis. The following resisted motions should be tested:

1. Internal rotation — subscapularis
2. External rotation — infraspinatus, teres minor (Figure 3)
3. Abduction — supraspinatus and deltoid
4. Abduction with thumbs down and 30° horizontal adduction (“empty can test”) — isolates supraspinatus (Figure 4)
5. Palms up with elbows bent to 15° flexion and resisted upward motion (Speed’s test) — biceps (Figure 5)
6. Simultaneous resisted supination and elbow flexion (Yergason’s test) — biceps

Impingement Signs/Impingement Test Impingement signs are evaluated to diagnose the impingement syndrome. Pain or lack of motion with these maneuvers suggests impingement of the RC tendons in the subacromial space. Three impingement signs are commonly used:

1. Neer’s sign — extreme forward flexion with the forearm pronated (Figure 6)
2. Hawkin’s sign — 90° forward flexion of the shoulder with the elbow flexed to 90° then inter- nal and external rotation movements of the shoulder (Figure 7)
3. Crossover sign — extreme horizontal adduction (this maneuver also worsens AC joint pain) (Figure 8)

Figure 3. External rotation strength Figure 4. “Empty can test” for Figure 5. Speed’s test for biceps test (infraspinatus and teres minor). supraspinatus. strength.

2. Relocation test — this test is performed supine with shoulder and elbow bent to 90° and hanging off the edge of the exam table. The shoulder is then cranked into external rotation until discomfort is noted. Posterior pressure on the humeral head relieves discomfort in those with anterior instability. No change or worsening of pain suggests impingement (Figure 10).
3. Sulcus sign — performed with arms hanging at side. Downward pull on arm causes “sulcus” to form between acromion and humeral head with inferior instability (often suggests multi-directional instability). (Figure 11)

Labrum Tests Injury to the glenoid labrum can be difficult to detect clinically. The tests used to evaluate the labrum are analogous to tests used in the knee to detect meniscal injury:

1. Clunk test — performed with the patient supine or erect and the shoulder rotated through a full over- head ROM. A prominent clunk or pop may indicate a labrum tear.
2. Labrum grind test — performed sitting or supine with the elbow bent to 90° and shoulder abducted to 120°. The humeral head is compressed into glenoid while internally and externally rotating the humerus. Significant pain or clunking may suggest labrum injury (Figure 12).

Figure 10. Relocation test — first place shoulder into maximal external rotation. Next, apply posterior pressure to humeral head.

Figure 11. Sulcus sign.

Location of “sulcus.”

Figure 12. Labrum grind test.

3. O’Brien’s test — the patient forward flexes both arms to 90° with 10° horizontal adduction and elbows extended. Apply a downward force to both arms, first with the thumbs up and again with the thumbs down. Increased pain in the thumbs-down position (compared to the thumbs-up) is suggestive of superior labrum, anterior/posterior (SLAP) injury to the labrum. Keep in mind that this maneuver will also aggravate AC joint pain (Figure 13).

Cervical Spine The cervical spine is a common source of radicular pain to the shoulder. For this reason, the neck should be evaluated as a routine part of every shoulder exam:

1. Palpate over the spinous processes for bony tenderness or a step-off. Also palpate over the paraspinous muscles for tenderness or spasm.
2. Check neck range of motion (active, passive and resisted), including forward flexion (normally about 45°), extension (55°), twisting (70° each way) and side bending (40° each way). Ask if this reproduces shoulder pain.
3. Atlanto-axial compression test (Spurling’s test) — performed by applying an axial load to the top of the head while the neck is twisted. Radicular pain to the shoulder and arm suggests cervical nerve root irritation (Figure 14).
4. Forward flexion test — forward flex the neck with the head turned toward the side. Radicular pain to ipsilateral arm suggests disc impingement on a cervical nerve root.

Figure 13. O’Brien’s test. Check resisted upward motion, first with thumbs up and then with thumbs down.

Figure 14. Spurling’s test.