Soft Tissue Shoulder Disorders Care Pathway

7. Physical Examination

 

A comprehensive clinical examination should consider the biopsychosocial aspects of the patient’s condition, cultural considerations, and the necessity of obtaining informed consent. This approach is crucial for both new and existing patients, especially when they present with new complaints. Obtaining informed consent involves explicitly addressing the purpose and process of the examination, ensuring the patient understands and agrees to the procedures. Special care should be taken when contact is made in sensitive areas, prioritizing the patient’s comfort and understanding throughout the examination. Additionally, cultural awareness is essential in healthcare, as a patient's cultural background can significantly influence their perception and response to treatment. Practitioners should adapt their examination techniques and interactions to be respectful and sensitive to cultural differences, tailoring their approach to meet the specific needs and considerations of each patient.

 

Observation:

Abnormalities, asymmetries, posture, gait, movements, facial expression.

 

Range of Motion:

Active, passive, resisted ROM in all planes (flexion, extension, abduction, adduction, internal and external rotation). Consider hypomobility, hypermobility and aberrant movement patterns.

 

Motor Strength:

• Assess for asymmetry or weakness, which may indicate muscle involvement, suspected tears, or peripheral nerve injury:

  • Shoulder flexion: Anterior deltoid, coracobrachialis, biceps brachii.

  • Shoulder extension: Posterior deltoid, latissimus dorsi, teres major, triceps brachii.

  • Shoulder abduction: Middle deltoid, supraspinatus.

  • Shoulder adduction: Pectoralis major, latissimus dorsi, teres major.

  • Shoulder internal rotation: Subscapularis, pectoralis major, latissimus dorsi, teres major.

  • Shoulder external rotation: Infraspinatus, teres minor.

  • Shoulder horizontal abduction: Posterior deltoid.

  • Shoulder horizontal adduction: Pectoralis major, anterior deltoid.

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Palpation:

Identify areas of tenderness in the shoulder and surrounding musculature.

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Neurological Examination:

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Motor Strength (Specific to Nerve Roots): 

• C5: Shoulder abduction

• Record the clinical findings: E.g., C5: Shoulder abduction strength:  L 3/5, R 5/5

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Reflexes: 

• C5: Biceps brachii

• Record the clinical findings: E.g., C5: R 2/4, L 3+/4

 

Sensory Examination: 

• C4: Anterior shoulder

• C5: Lateral shoulder

• T1: Medial side of the forearm and upper arm

• T2: Medial aspect of the upper arm

• Record the clinical findings for each, examples:

   

  • "Patient reports that they perceive the same for sharp, light, and vibration for C4, C5, T1, and T2."

  • "Patient reports a loss of perception of sharp and light touch for C5 on the right with all other sensations intact."

 

Lower Motor Neuron Signs:

• Key Observations: Muscle weakness, muscle atrophy, fasciculations, reduced muscle tone, flaccidity, diminished reflexes. May indicate neurological conditions (e.g., nerve compression, radiculopathy, trauma, peripheral neuropathy, ALS).

• Record as: E.g., "LMN signs: Atrophy (yes/no), Fasciculations (yes/no), Muscle tone (reduced/normal), Function loss (symmetrical/asymmetrical)"

 

Upper Motor Neuron Signs:

• Key Observations: Increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus), pyramidal weakness. May indicate conditions affecting the central nervous system (e.g., cervical spondylotic myelopathy, multiple sclerosis, stroke, spinal cord injuries, ALS, traumatic brain injury).

• Record as: E.g., "UMN signs: Muscle tone (increased/normal), Hyperreflexia (yes/no), Babinski sign (positive/negative), Clonus (yes/no)"

 

Special/Orthopedic Tests:

Select tests to use alongside a comprehensive clinical examination; the validity and reliability of these tests vary. Record: For all tests, note the shoulder tested, whether the test is positive or negative, and include an observational note for the responses to the test to also inform the clinical picture. E.g., left shoulder Hawkins-Kennedy test (+) patient reports pain in the anterior or lateral aspect of the shoulder. Tests include:

 

Tests for Rotator Cuff Conditions, Impingement Syndrome, Calcific Tendinitis, and Bursitis:

1. Neer’s Test: Positive sign: Pain in the anterior or lateral aspect of the shoulder.

2. Hawkins-Kennedy Test: Positive Sign: Pain in the shoulder during internal rotation of the arm.

3. Empty can (Jobe) Test: Positive Sign: Pain or weakness when resisting downward pressure.

4. Drop Arm Test: Positive Sign: Inability to slowly lower the arm or sudden dropping of the arm.

5. Infraspinatus Test: Positive Sign: Pain or weakness during resisted external rotation with the arm at the side.

6. Hornblower’s Test: Positive Sign: Inability to maintain the arm in external rotation at 90 degrees of abduction, indicating teres minor or infraspinatus weakness.

7. Lift-Off Test: Positive Sign: Inability to lift the hand away from the back or weakness in doing so.
8. Painful Arc Test: Positive Sign: Pain during shoulder abduction, particularly between 60° and 120°, which is indicative of subacromial impingement, calcific tendinitis, or bursitis.
9. Belly Press Test: Positive Sign: Unable to maintain the elbow forward or compensate by flexing the wrist (bringing the wrist behind the elbow), this indicates weakness or injury of the subscapularis muscle.

 

Tests for Biceps Tendon Pathology:

1. Speed’s Test: Positive Sign: Pain in the bicipital groove.

2. Yergason’s Test: Positive Sign: Pain or a snapping sensation in the bicipital groove.

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Tests for Shoulder Instability:

1. Apprehension Test: Positive Sign: Apprehension/pain, indicating fear of shoulder dislocation.

2. Relocation Test: Positive Sign: Relief of apprehension/pain with posterior pressure on the humeral head.

3. Sulcus Sign: Positive Sign: A visible sulcus or indentation below the acromion when downward traction is applied to the arm.

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Tests for Labral Tears and SLAP Lesions:

1. O’Brien Test: Positive Sign: Pain or clicking in the shoulder with the arm in internal rotation that is relieved with external rotation.

2. Crank Test: Positive Sign: Pain or a clicking sound.

 

Tests for Acromioclavicular (AC) Joint Pathology:

1. Cross-Body Adduction Test: Positive Sign: Pain in the acromioclavicular (AC) joint during adduction of the arm across the body.

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Tests for Adhesive Capsulitis:

1. Apley Scratch Test: Positive Sign: Limited range of motion compared to the unaffected side.

2. External Rotation Lag Sign: Positive Sign: Inability to maintain external rotation when the arm is placed in an externally rotated position.

3. Shoulder Shrug Sign: Positive Sign: Patient uses shoulder shrugging as a compensatory mechanism for restricted glenohumeral joint movement.

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Advanced Diagnostics:

Imaging: Generally not recommended within the first six weeks unless red flags are present, to avoid unnecessary radiation exposure, overdiagnosis, and costs. Consider ultrasound or MRI if there is non-response to treatment (e.g., to differentiate between full- and partial-thickness rotator cuff tears).