Non-traumatic shoulder pain: physical examination tests

NPS MedicineWise Non-traumatic shoulder pain:
physical examination tests By Dr Michael Yelland
General practicioner A targeted examination is an essential component of the assessment of shoulder complaints. The clinician should always consider whether
the findings are consistent with the history. If they are, diagnostic confidence is increased
and imaging may not be required. If inconsistencies are noted, other causes
of pain including non-musculoskeletal causes should be considered by revisiting the history
and ordering appropriate investigations. This video focusses on the most clinically
useful examination tests for patients in general practice presenting with
non-traumatic shoulder pain. I will demonstrate them in the conventional
order of inspection, palpation and movement testing, although doing palpation after
movement testing is a reasonable alternative. For inspection, the patient should be
appropriately undressed and inspected from the front, side and back to look
for asymmetry, which may indicate scoliosis, arthritis or trauma. Look for scars that indicate
any previous surgery/injury. Check the shoulder for any swelling as this
can indicate inflammatory joint disease, effusion and anterior dislocation. The presence of redness may also indicate
inflammation and conditions such as early shingles. Next move to palpation of the
joints and soft tissues to help localise the source of the pain. Throughout palpation feel for
several things concurrently. First, the skin and subcutaneous tissues
for warmth and bogginess, and for the sensation of an effusion
as signs of inflammation or infection. Checking for tenderness over the joints and
soft tissues is particularly important as local tenderness strongly
suggests the site of pathology. Finally, assessing the relationship of bones
to each other detects signs of subluxation. An orderly system of joint palpation
starts with the sternoclavicular joint, moving out to the acromioclavicular joint
and then around the glenohumeral joint. Note that the best landmark for the glenohumeral
joint line is the posterolateral corner of the acromion. Most of the soft tissue structures of interest
are at or just below this level. At the front there are the ligaments
of the joint capsule, which are tender in inflammatory conditions such as capsulitis. There may be a palpable effusion
in inflammatory arthritis. Also, the biceps tendon, in its groove,
can be rolled under the fingers. Anterolaterally is the subdeltoid bursa,
often called the subacromial bursa. This is tender in bursitis, but the alternative
interpretation of this is tenderness of the insertion of the supraspinatus tendon
indicating tendinopathy or tendon tears. More laterally is the attachment of the
infraspinatus that may be similarly affected. Next, move posteriorly to palpate the body
of these muscles for tenderness and wasting. Locate the spine of the scapula
and palpate above it for the supraspinatus and below it
for the infraspinatus. These are most commonly
tender in their midportions. These tender points can be a source of
pain that often goes unrecognised. Also look for wasting of supraspinatus and
infraspinatus, which may occur with complete tendon tears or neurological disorders. Finally, anteriorly there may be tenderness
in the mid-portion of pectoralis major. The assessment of range of movement is valuable in establishing a baseline from which
future examinations can be measured. It begins with active movements in all
functional planes for the shoulder. The expected range of movement
varies with age, gender and other factors, so comparison of sides is very helpful
in detecting abnormalities. Assess flexion by asking the patient to raise
their arms forward until they point upwards. Assess extension by asking the patient
to move them behind them. Next assess abduction.
This is done 30 degrees forward of the coronal plane in
the plane of the scapula. Ask the patient to lift their arms
away from their sides as far as possible. You should look for a painful arc of abduction
from 60 to 120 degrees suggestive of subacromial bursitis, rotator cuff
tendinopathy and tears. Assess adduction by asking
the patient to bring their arms across their trunk to the opposite sides. Assess external rotation
by asking the patient to hold their elbows to their body
flexed at 90 degrees. Then ask them to move their forearms
in an arc-like motion outwards. This is one of the first movements
affected by the contraction of the shoulder capsule in capsulitis. Assess internal rotation by asking the patient
to place their hand behind their back and reach as far up the spine
as they are able to. This is also often painful and
restricted in subacromial bursitis, rotator cuff tendinopathy and tears.
Alternatively, external and internal rotation may be tested with the shoulder abducted
to 90 degrees, like this. Assessment of passive movement is only
necessary where active movement is limited. It can efficiently be integrated
with active movement testing by gently assisting the patient
at the end of their active range. This can help differentiate between: weakness,
secondary to a tendon tear or neurological disorder; capsular tightness as in capsulitis;
joint degeneration as in osteoarthritis; or simply pain, as in tendinopathy or bursitis. So, for example, with testing passive abduction
in a patient whose active abduction is restricted to 90 degrees, with a full thickness tear
of supraspinatus, the passive range is greater than the active range, but in capsulitis or
osteoarthritis, passive and active ranges should be similarly restricted. There are many tests for testing impingement,
but their common aim is to check for pain with compression of the structures lying between
the acromion and the head of the humerus, namely the bursa and the rotator cuff tendons. A commonly used impingement test is the
Hawken-Kennedy test, in which you face The patient and raise their arm to 90 degrees
in front of them with the elbow bent. Put your arm on that side under their elbow,
and place your hand on their shoulder to stop it rising up as you passively internally rotate
their shoulder with your other hand. Shoulder pain occurs in a positive test. Then test the other side for comparison. Make sure the patient does not turn away
from you in an effort to minimise any pain. This is a test of resisted abduction used
to detect rotator cuff tendon tears. The patient is instructed to abduct both shoulders
to 90 degrees in the plane of the scapula and to hold them with the thumbs down,
as if emptying a can, while the examiner pushes
firmly down on them. A positive test is noted when there is giving
way on one side, suggesting rotator cuff weakness. When assessing patients
with non-traumatic shoulder pain, the possibility of referred pain from the
cervical spine should be entertained, particularly when the pain is in the posterior
part of the shoulder, the usual site of referral from the lower cervical spine. A simple screening test for this
is the cervical compression test. With this the patient is seated and
by directing the head, the neck is moved into the posterior quadrant on the
side of the affected shoulder by introducing side bending,
rotation and extension. Then up to 7 kg of axial compression is applied,
ceasing compression if pain is produced as the pressure on the facet joints, discs
and nerves on that side increases. Neck or shoulder pain on the side
being compressed suggests cervical discs or facet joints as the source, whereas reproduction
of arm pain or paraesthesia on that side is positive for cervical nerve root compression,
where the test is also called ‘Spurling’s test’. For more information about assessing
non-traumatic shoulder pain in general practice, go to NPS MedicineWise
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