A prerequisite for any treatment of the shoulder area of a patient with pain is an accurate and comprehensive understanding of the signs and symptoms that appear during the evaluation and what they have been presenting until then. Due to its many structures (most of which are in a small area) its many actions The many lesions that can occur in and out of the joints of the shoulder complex are difficult to assess. A systematic and structured approach to the shoulder history and examination ensures that key aspects of the condition are elicited and important situations are not missed. The information gathered during this process can help guide decisions about the need for special testing or investigations and ongoing management.
Note that assessment strategies based on clinical testing and diagnostic imaging have been challenged over time, and clinical testing does not appear to clearly identify pain-producing structures. The interpretation of diagnostic imaging also remains controversial. [1]
Shoulder Anatomy
The range of motion (ROM) of the arm relative to the trunk comes from more than just the glenohumeral joint. The acromioclavicular (a.c.), sternoclavicular (s.c.) and upper rib and costvertebral joints also move. Another prerequisite for normal movement is The scapula should be able to move freely relative to the dorsal chest wall.
The glenohumeral joint is a multiaxial ball-and-socket synovial joint with a relatively shallow socket: the joint cavity. Joints rely primarily on muscles and ligaments for stability and integrity. [2] The fibrocartilaginous labrum (labrum) ring surrounds and Deepens the socket of the scapula by approximately 50%. [3]
Stability is primarily provided by periarticular muscles that originate from the scapula and insert into the humeral head. This rotator cuff includes m. supraspinatus m. infraspinatus and m. subscapularis. The scapula is the dorsal bony ridge and is where the m is inserted. Trapezius and m. deltoid. The shoulder blades widen laterally, forming the acromion. The space between the acromion and the humeral head is called the subacromial space. In this space you will find the rotator tendon and the subacromial bursa (= bursa subdeltoidea). This tuberculum minus and tuberculum majus are separated by sulcus intertubercularis at the tendon of the long head m. Biceps run. This tendon continues into the joint and inserts into the top ridge of the joint cavity (labrum).
For a complete overview of shoulder anatomy, read this page on the shoulder.
Anamnesis/Medical History
A medical record is a description of a client’s past medical history. The medical history is an important part of the evaluation of patients with musculoskeletal dysfunction. Collected different memory elements, including
- Characteristics of symptoms
- Mechanisms of pain
- Patient expectations preferences and psychosocial factors (yellow flag)
These elements are weighted and incorporated into the clinical reasoning process to guide the follow-up physical examination
Patient History
- Listen carefully to the patient’s past medical history, rule out red flags, and guide shoulder examinations
- History of present illness How long did the complaint last How did it develop Was there a traumatic moment?
- Pain distribution and severity: Sleep disturbance can cause the patient to lie on the affected side, affecting daily life and daily life at work
- Self-care and other treatments the patient has tried
- Shoulder Discomfort in the Past: Course of Treatment and Treatment Results
- Complaint in relation to work situation
- Complaint in relation to sporting activity
try to understand where the complaint is
- Where arm pain radiates
- Aggravating activities, such as difficulty moving overhead Lifting objects Activities of daily living or recreational activities
- Limited pain when the upper arm is moved in one or more directions
- Feeling of instability
- Added complaints in the neck
Questions to ask to identify possible pathological conditions
- Does moving your neck change your symptoms?
- Have you ever felt unsteady with your arm movements?
- Does this make your pain level worse when you move your arms over your head?
- Is it difficult to move your arm?
- Do your arms feel heavier when you lift them over your head? [4]
Mechanism of Injury
It is critical to interrogate the mechanisms of any particular injury, especially three factors related to the time of injury: anatomical limb location and subjective experience. Take care to clarify the patient’s description of the anatomical site. Description of arm position Injured time is also precious. For example, falling on an abducted and externally rotated arm increases the risk of shoulder dislocation or subluxation. Finally, it may be useful to explore patients’ subjective experiences at the time of injury. such as crackling or cracking May be related to a broken bone or ligament; feeling something “pop” may indicate a joint dislocation or subluxation.
Physical Examination
This video provides an excellent 15-minute summary of key important procedures.
Clear the Cervical Spine
The cervical spine can transmit pain to the shoulder/scapula area. Appropriate screening of the cervical spine is imperative as it may affect the patient’s clinical presentation.
See Cervical Examination
Objective
Observation
The key principle with this phase of the shoulder examination is symmetry. The shape, position and function of each shoulder should be relatively similar. Some differences can occur due to shoulder dominance; the dominant shoulder may sit lower and may appear somewhat larger due to larger muscle mass. Also look at position of scapula and or winging and any abnormal postures of swellings/injuries.
Palpation
Palpation of the shoulder area can provide valuable information to the physical therapist. Physical therapists should note the presence of tissue swelling, texture and temperature. In addition, physical therapists may observe asymmetric sensory differences and pain reproduction. The main structures within reach include:
- Acromioclavicular Joint
- Sternoclavicular Joint
- Rotator Cuff Muscle Insertions
- Long Head of the Biceps Tendon
- Local or referral tenderness and sensory changes (subjective)
- Surface temperature texture (objective) – thermally stressed surfaces may indicate infection inflammation/synovitis recent trauma or tumor
- swelling – may indicate fluid-filled tumor nodules or bone changes
- Crepitus during exercise – occurs in osteoarthritis, tendinopathy and fractures [9]
Neurologic Assessment
In patients with shoulder pain as the main complaint, a comprehensive neurological examination may be required. The presence of neurological symptoms including numbness and tingling may warrant this test.
Myotomes
- C4 – Shoulder Elevation/Shrug
- C5 – Shoulder Abduction
- C6 – Elbow Flexion and Wrist Extension
- C7 – Elbow Extension Wrist Flexion
- C8 – Thumb Abduction/Extension
- T1 – Finger Abduction
Dermatomes
- C4 – Top of Shoulders
- C5 – Lateral Deltoid
- C6 – Tip of Thumb
- C7 – Distal middle Finger
- C8 – Distal 5th Finger
- T1 – Medial Forearm
Pathological Reflexes
- Hoffmann’s Reflex
- Inverted Supinator Reflex
Deep Tendon Reflexes
- Biceps Brachii – C5 Nerve Root
- Brachioradialis – C6 Nerve Root
- Triceps – C7 Nerve Root
Movement Testing
The patient performs active movements in all functional planes of the shoulder. This includes flexion, extension, abduction, adduction, and internal and external rotation. Estimate the range of motion or measure with a goniometer and compare the affected shoulder to the unaffected shoulder and to normal expected range. [9][14]
Active Range of Motion (ROM)
Dysfunction
Dysfunction – affects movement. Which actions are limited as this can help isolate the problem.
Consider the following if movement is restricted by:
- Pain: Tendinopathy Impingement Sprain/Strain Labrum Pathology
- Mechanical block: Pathological periarthritis of the labrum (see right MRI image)
- Pain at night (lying on affected shoulder): Rotator cuff lesions Anterior shoulder instability ACJ damage Tumor (especially persistent)
- “click” or “clack” feeling: labral pathological shoulder instability (anterior or multidirectional instability)
- A feeling of stiffness or instability: Freezing the front of the shoulder or multidirectional instability
Passive ROM
May include every action described in the Active ROM section. The therapist may choose to include overpressure to further stress the joint.
Muscle Length Assessment
People with shoulder pain may need to assess the flexibility of certain muscles. These muscles may include, but are not limited to:
- Latissimus Dorsi
- Pectoralis Minor/Major
- Levator Scapulae
- Upper Trapezius
- Scalenes (anterior/middle/posterior)
Muscle Strength
Resistance testing of the shoulder muscles typically includes the following exercises:
- Shoulder Flexion
- Shoulder Extension
- Shoulder Abduction
- Horizontal Abduction
- Horizontal Adduction
- Internal Rotation
- External Rotation
Resistance testing of the scapula stabilizers may include:
- Upper trapezius
- Middle trapezius
- Lower trapezius
- Serratus Anterior
- Rhomboids
- Levator Scapulae
Joint Mobility Assessment
Assessment of joint mobility may indicate insufficient intra-articular mobility and/or reappearance of symptoms.
- Glenohumeral
- Anterior
- Posterior
- Inferior
- Distraction
- Acromioclavicular
- Anterior
- Posterior
- Sternoclavicular
- Anterior
- Posterior
- Superior
- Inferior
- Scapulothoracic
- Elevation
- Depression
- Upward/downward rotation
- Protraction/Retraction
Special Tests
Some special tests exist for specific shoulder disorders. Below are links to specific pages for each pathology that describe special tests:
- Subacromial-related shoulder pain [16][17][18]
- Biceps Tendinopathy [19][20]
- Labral Tears [21][22][23]
- Laxity/Instability [24][25][26]
Outcome Measures
- Shoulder Pain and Disability Index (SPADI)
- Arm Shoulder and Hand Disability (DASH)
- Constant-Murley Shoulder Outcome Score (CMS)
- University of Pennsylvania Shoulder Score (U-Penn)
- Visual Analogue Scale
- Patient Specific Functional Scale
Special Questions
People with shoulder pain should be asked whether there are red or yellow flags. A thorough medical history and possible use of a medical screening form is the first step in the screening process. The following table highlights some of the most common red flags for patients with: Shoulder pain.
Red Flags
Red flags are signs and symptoms that warn physical therapists of possible non-musculoskeletal life-threatening pathological fractures, infections, tumors, and inflammatory rheumatism. Examples include: [1][27]
- Polymyalgia rheumatica. It usually presents with bilateral shoulder pain and weakness. These patients must be evaluated for temporal arteritis
- Acute compartment syndrome. It may be due to significant swelling of the limb after the injury or a bandage or cast that is too tight. The pain is disproportionate to the injury. A pulseless limb usually does not occur, or is a very late sign. This condition is a surgical emergency [9]
- Open fractures
- Fractures with nerve or blood vessel damage
- skin, especially joint infections
- Neoplasia
- Serious and life-threatening conditions with shoulder pain-like symptoms, such as referred ischemic heart pain
- Left shoulder — MI 68.7% of patients reported shoulder pain during acute myocardial infarction [28]
Yellow Flags
- Fear Avoidance Beliefs Questionnaire (FABQ)
- Depression screening tools such as the Baker Depression Inventory (BDI) or the Depression Anxiety Screening Scale (DASS) can be used to screen patients for depression.
- The Pain Catastrophization Scale helps determine whether patients are exaggerating the severity of their pain and symptoms and overall condition.
Fractures
Fractures can be caused by trauma, such as a fall on an outstretched hand. These are called FOOSH injuries. Common fractures in the shoulder area are:
- Humeral Fractures
- Clavicle Fractures[29]
- Clavicle fractures usually result from axial compression due to a direct blow to the shoulder. The middle third of the clavicle is most commonly ruptured, with an incidence of approximately 80%. The incidence of distal clavicle fractures is 10-15%, and the incidence of medial clavicle fractures is 3-5%. Significantly displaced fractures are treated surgically. Midclavicular fractures have lower nonunion rates and better functional outcomes at one year. [30] Trials of conservative management may be warranted for nondisplaced clavicle fractures.
Diagnostic radiographs of the shoulder can be used to identify cystic sclerosis of the acromioclavicular and glenohumeral joints or acromial spur osteoarthritis or calcific tendinitis. Common radiographic views may include (this may vary by medical provider):
- Supraspinatus Outlet View
- Scapular Y-View
- Axillary View
- Anterior-Posterior (AP) View
Clinical Picture
presents different shoulder lesions
- Patients with suspected glenohumeral instability or labral lesions may have a feeling of “loose or unstable”, especially in abduction and external rotation.
- Patients with suspected adhesive capsulitis may initially report severe generalized shoulder pain with progressive loss of range of motion.
- Patients with suspected subacromial or rotator cuff-related injuries may report feelings of weakness, heaviness, and/or pain.
- Osteoarthritis of the shoulder – progressive activity-related pain deep in the joint, usually in the back. Nocturnal pain becomes more common as the disease progresses
References
- Ristori D Miele S Rossettini G Monaldi E Arceri D Testa M. Building a comprehensive clinical framework for patients with shoulder pain. Archives of Physical Therapy. 2018 Dec;8(1):1-1. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5975572/ (accessed 10 September 2022)
- ↑ Hess SA: Functional stability of the glenohumeral joint. Manual Therapy 5:63-71 2000.
- ↑ Tillman B Petersen W: Clinical Anatomy. In Wulker N Mansat M Fu F ed: Shoulder Surgery: An Illustrated Textbook London 2001 Martin Dunitz.
- ↑ Flynn T et al. A basic user guide to musculoskeletal examinations for evidence-based clinicians. Motion Evidence; 2008.
- ↑ Lifting with Christi Joint Musculoskeletal Physical Exam: Shoulder and Neck Available at: https://www.youtube.com/watch?v=f9kYF8K0HSs&app=desktop (last accessed 23 November 2019)
- ↑ BJSM video. Shoulder Exam (3 of 9): Range of motion. Available at: http://www.youtube.com/watch?v=d7HfaAlgaro [last accessed 25/01/14]
- ↑ BJSM video. Shoulder exam (4 of 9): Scapular control (is there any scapular dyskinesia?). Available at: http://www.youtube.com/watch?v=pEY93k5XXL0 [Last accessed 25/01/14]
- ↑ BJSM video. Shoulder Exam (5 of 9): AC Combined Exam. Available at: http://www.youtube.com/watch?v=-y_NUVmHe-E [last accessed 25/01/14]
- ↑ Jump up to: 9.0 9.1 9.2 AFP Initial Assessment of the Injured Shoulder Volume 41 Issue 4 April 2012 Pages 217-220 Available from: https://www.racgp.org.au/afp/2012/april/initial -assessment -of-the-injured-soulder/ (last accessed 11/23/2019)
- ↑ BJSM video. Shoulder examination (6 out of 9): rule out SLAP tears (Kuhn test). Available at: http://www.youtube.com/watch?v=YMPZi2_Jy9o [Last accessed 25/01/14]
- ↑ BJSM video. Shoulder Exam (7 of 9): Check for SLAAP tears. Available at: http://www.youtube.com/watch?v=beVd-cX_TX8 [last accessed 25/01/14]
- ↑ BJSM video. Shoulder Exam (8 of 9): Check for impingement (rotator cuff). Available at: http://www.youtube.com/watch?v=r8Rl0_KE3OA [last accessed 25/01/14]|}
- ↑ BJSM video. Shoulder Exam (9 of 9): Test for instability. Available at: http://www.youtube.com/watch?v=Fz2g5gI3RGg [last accessed 25/01/14]
- ↑ Hislop HJ Montgomery J. Daniels and Worthingham’s Muscle Testing: Manual Examination Techniques. Sanders 8th Edition 2007
- ↑ Magee David J. Orthopedic Physical Assessment – eBook. Elsevier Health Sciences 2014.
- ↑ Callis M et al. Diagnostic value of clinical diagnostic tests for subacromial impingement syndrome. Arimdis 2000 59 44-47.
- ↑ Murphy D, Hurwitz R. A theoretical model developed for diagnosis-based clinical decision rules for the management of patients with spinal pain. 2007;8:175
- ↑ Song L Yan HB Yang JG Sun YH Hu DY. The effect of patient symptom interpretation on medical treatment behavior of patients with acute myocardial infarction [J]. Chinese Medical Journal (English). 2010 Jul;123(14):1840-5
- ↑ Flynn T et al. A basic user guide to musculoskeletal examinations for evidence-based clinicians. Motion Evidence; 2008
- ↑ Rutkow IM. Spleen rupture in infectious mononucleosis: a critical review. Arch Surgery. 1978 Jun;113(6):718-20
- ↑ Tamura M Hoda MA Klepetko W. Current treatment modalities for superior sulcus tumors. Eur J Journal of Cardiothoracic Surgery. 2009 Oct;36(4):747-53. Electronic version 20 August 2009
- ↑ Strauss E. Flanagin BA Mitchell MT Thistlethwaite WA Alverdy JC. The role of liver biopsy in chronic hepatitis C. Ann Hepatol 2010; 9 Supplement: 39-42.
- ↑ Diagnosis and management of atypical manifestations of hiatal hernia after bariatric surgery. Journal of Obesity Surgery. 2010 Mar;20(3):386-92. Electronic version October 24, 2009.
- ↑ McKee, MD. Clavicle fractures 2010: sling/bandaging or open reduction and internal fixation? Orthop Clin North AM. 2010 Apr;41(2):225-31
- ↑ Altamimi SA McKee, MD. Nonoperative management of displaced midclavicular fractures compared with plate fixation. J Osteoarthritis Am. 2008 Mar;90 Supplement 2 Pt 1:1-8
- ↑ BJSM video. Shoulder Exam (2 of 9): Examination and palpation. Available at: http://www.youtube.com/watch?v=Xf52jbNA7wg [last accessed 25/01/14]
- ↑ Murphy D, Hurwitz R. A theoretical model developed for diagnosis-based clinical decision rules for the management of patients with spinal pain. 2007;8:175.
- ↑ Ottoman A et al. The Pain Classification Scale: Further Psychometric Evaluation of an Adult Sample. Journal of Behavioral Medicine. 2000; Vol 23(4): 351-365.
- ↑ McKee, MD. Clavicle fractures 2010: sling/bandaging or open reduction and internal fixation? Orthop Clin North AM. 2010 Apr;41(2):225-31
- ↑ Altamimi SA McKee, MD. Nonoperative management of displaced midclavicular fractures compared with plate fixation. J Osteoarthritis Am. 2008 Mar;90 Supplement 2 Pt 1:1-8
