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Shoulder disorders—Part 2: Examination
ARTICLE IN PRESS Journal of Bodywork and Movement Therapies (2005) 9, 283–292
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SELF-MANAGEMENT: CLINICIAN SECTION
Shoulder disorders—Part 2: Examination$ Craig Liebenson, DC 10474 Santa Monica Blvd., No. 202, Los Angeles, CA 90025, USA
The examination of the shoulder girdle complex involves a comprehensive strategy integrating assessment of serious conditions (e.g. Red Flags), orthopedic testing, and functional evaluation. Red flags of tumor or infection are uncommon, but extremely important to rule out. Orthopedic assessment aims to identify the pain generator and diagnose the condition. Functional assessment, while often ignored, is perhaps the most important step for aiding the clinician in finding the cause of biomechanical overload responsible for the patient’s symptoms. The orthopedic and functional assessments are usually combined. Shoulder stability requires proper function of the rotator cuff and surrounding muscles which attach the arm to the torso. A properly functioning shoulder allows for movement with sufficient stability when pushing, pulling, swimming, throwing, lifting, or reaching overhead. Shoulder girdle disorders are frequently related to faulty posture or motor control. Typical patterns of muscle imbalance, such as weakness of the lower scapular fixators (serratus anterior and lower trapezius), and shoulder external rotators along with tightness of the scapulae elevators (upper trapezius, levator scapulae) and shoulder internal rotators are common. Overhead activities can be particularly $
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strenuous for the shoulder and precipitate injury via repetitive strain, especially when scapular dyskinesis is present. This article will review the important features of identifying red flags, orthopedic testing, and functional evaluation.
Red flags Whereas the vast majority of shoulder problems are mechanical or inflammatory in rare instances a more serious cause is responsible. Tumor, infection, or fracture are the major causes of more serious shoulder problem.
Tumor A pancoast tumor can present as shoulder pain (Jett, 2000; Robinson et al., 2003; Spengler et al., 1973). Men over 50 with a history of cigarette smoking are at particular risk. The pain may be ‘‘nagging’’ in the shoulder and along the vertebral border of the scapula. Referred burning pain down the arm into the ulnar nerve distribution can occur. Examination may reveal wheezing with auscultation when tumor obstructs bronchus. The patient may present with Horner’s syndrome:
ptosis (drooping eyelid), constricted pupil, sweating disturbances.
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Introduction
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Infection
Table 1
Active range of motion (ROM) Passive ROM (including specific orthopedic tests
Septic Arthritis of the sternoclavicular (SC) joint can occur (Ross and Shamsuddin, 2004). The symptoms can be an insidious onset of chest pain localized in the SC joint along with a history of IV drug use, diabetes, trauma, infection (especially of central venous access). Examination may reveal tenderness of the SC joint, limited shoulder movement, swelling over SC joint, and possibly fever.
Fracture or dislocation If a patient has an observable or palpable shoulder deformity or severe shoulder motion limitation, the patient should be referred for X-ray to rule out dislocation, an undiagnosed fracture, or a rotator cuff tear (Robinson et al., 2002). As with the cervical spine, suspected fractures or severe capsule/ligament injuries of the shoulder complex often require external devices such as a shoulder sling, stabilization exercises, and neutral positioning instruction as the patient awaits the results of diagnostic imaging.
Functional orthopedic evaluation
Shoulder disorders—Part 2: Examination
Basic rules of testing During all tests it is important to identify both the movements or positions which reproduce the patients characteristic symptoms—mechanical sensitivity (MS), and the presence or absence of abnormal motor control (AMC). If a test reproduces the patients characteristic symptoms then the patient’s pain generator has been found. Once the patients MS has been identified this can be used following treatment and at the initiation of followup visits to ‘‘audit’’ the patients status and recovery. While reducing the patient’s MS with different therapies empirically demonstrates that the care program is on the right track, it is usually the AMC evaluation that guides the clinician’s decision making regarding what areas need to be mobilized or stabilized, strengthened or stretched, etc. Both the AMC and MS tests are needed to accurately make and modify the patients prescription. Table 1 summarizes the types of functional orthopedic tests performed (see Table 1). The main conditions which the functional orthopedic assessment should identify are rotator cuff tendonitis or tears, shoulder impingement syndrome (pain while reaching overhead), shoulder
Functional orthopedic tests.
such as apprehension test) Passive accessory ROM Resistance tests Functional/postural tests Palpation
instability, or severe limitation of the shoulder’s mobility (frozen shoulder or adhesive capsulitis).
Active range of motion (ROM) The shoulder physical examination begins with the patient being asked to move his/her arm in the cardinal planes of motion (flexion, extension, abduction, adduction, internal and external rotation) (see Figs. 1 and 2). During testing the patient is asked to report any symptom reproduction (e.g., pain, stiffness, crepitus). Reliability of these measurements is not 100%. Goniometric assessment of shoulder flexion and abduction has been shown to be reliable for both passive and active ROM testing in either the sitting upright or supine positions (Sabari et al., 1998). Burkhart et al. (2000) showed that shoulder patients have an average decreased shoulder internal rotation at 901 abduction on injured arm of 251. A painful arc during arm elevation (flexion, abduction, or in the scapular plane) suggests impingement is present. This occurs when there is pain during the mid-range of motion, but not at the beginning or end of the motion. A simple and practical postural screen of the patients mobility is the wall angel (Fig. 3).
Wall angel test Procedure:
The patient stands with the back against a wall with arms abducted 901, elbows bent 901, palms supinated and feet slightly forward. Both the back of the patients head and the buttock should be touching the wall. The patient should try to flatten the back. Ask the patient to nod so as to tuck their chin in. Offer passive overpressure to aid cervico-cranial flexion testing.
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Figure 1 Abduction range of motion.
Score:
Fail if thoraco-lumbar junction does not flatten. Record where patient feels tension or pain (midback, left or right side, neck). Note if any symptoms occur when: J flattening the back, J tucking the chin, J with passive overpressure into cervico-cranial flexion.
Clinical pearl
Decreased ROM in external rotation, abduction and elevation is the signature for adhesive capsulitis.
Figure 3 Wall angel.
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Figure 2 External rotation range of motion.
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C. Liebenson Decreased ROM in internal rotation and/or elevation (abduction, scapular, or flexion) is typical of impingement syndrome and rotator cuff problems. Decreased ROM in horizontal adduction (scarf test) suggests acromio-clavicular (AC) joint dysfunction.
Shoulder disorders—Part 2: Examination
Passive ROM Following the assessment of the patient’s shoulder active ROM, passive movement should be examined. The clinician should compare shoulder internal and external rotation at 01, 451 and 901 (Godges et al., 2003; Shaffer et al., 1992; Warner et al., 1990) of shoulder abduction. Symptom reproduction with passive overpressure while the shoulder is at end range of elevation, either in flexion or adduction, suggests that the patient has a shoulder impingement syndrome where the humeral head is impinging on painsensitive tissues inferior to the acromial arch (Hawkins and Kennedy, 1980; Hawkins and Abrams, 1987; Park et al., 2005). The Neer Sign is present when there is MS with arm elevation overhead (flexion) when the arm is placed in internal rotation (Neer, 1972) (See Fig. 4). The Hawkins impingement test is positive when arm adduction and internal rotation with the arm elevated 901 reproduces the patient’s characteristic pain (see Fig. 5). The clinician should also note whether the patient has excessive range of passive motion. Excessive glenohumeral passive mobility may suggest that the patient may have an unstable glenohumeral joint. Glenohumeral instability is suspected if a patient exhibits excessive mobility (e.g., external rotation41051) and apprehension during performance of special tests. Commonly used tests in the identification of glenohumeral instability include the apprehension test (Rowe, 1988), anterior–posterior humeral glides, sulci test (Itoi et al., 1992,1999), and the hyper-abduction test (Gagey, 2001). Tyler et al. (2000) have demonstrated reliability and validity for a test of posterior capsule tightness. This test correlates with restricted shoulder internal rotation ROM at 901 abduction. If the patient has severe limited range of motion Frozen shoulder or impingement is suspected. Frozen shoulder typically has an extreme limitation in abduction, flexion (below 901) and external rotation. Impingement is limited in motions above 901 involving flexion or abduction and also has limitation of internal rotation. Excessive
Figure 4 Neer sign.
Figure 5 Hawkins impingement test.
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glenohumeral passive mobility may suggest that the patient may have an unstable glenohumeral joint. Glenohumeral instability is suspected if a patient exhibits excessive mobility (e.g., external rotation41051) and apprehension during performance of special tests. In line with Janda’s concept of the upper crossed syndrome Johnson et al. found that female dental hygienists are more likely than non dental hygienist females to develop tightness in the upper trapezius (P ¼ 0:007) and the levator scapula (P ¼ 0:01) of the non dominant upper quarter and lower fibers of the pectoralis major of the dominant upper quarter (P ¼ 0:03) (Janda, 2006; Johnson et al., 2003). Upper quadrant muscles that commonly exhibit muscle flexibility deficits are the suboccipital, sternocleidomastoid, pectoralis minor and major, teres major, subscapularis, levator scapulae, upper trapezius and latissimus dorsi (Johnson et al., 2003).
Accessory mobility/end feel The AC joint is also vulnerable to becoming hypermobile and unstable. This joint is commonly sprained during contact sports and accidents, such as a fall. Examination of the passive accessory motion of the acromioclavicular joint using anterior-to-posterior and posterior-to-anterior glides of the clavicle relative to the acromian assists in identifying acromioclavicular joint instability (Allman, 1967; Lee et al., 1997). The clinician may also assess the passive accessory motion of the SC joint, especially in patients immobilized following an upper extremity trauma or surgery as well as patients with the symptoms of thoracic outlet syndrome where entrapment of the upper limb neurovascular bundle near the costoclavicular space is suspected. The anterior slide test specifically assesses the integrity of the superior labrum. (Kibler, 1995; McFarland, 1996,2002). The anterior slide test involves the patient in a sitting position with his/ her hands held at the waist. The examiner stands behind the patient and stabilizes the scapula and clavicle with one hand. With the other hand, the examiner applies and anterosuperior force at the upper arm near the elbow. If the labrum is torn, the humeral head slides over the labrum with a pop or crack and the patient complains of anterosuperior pain (Kibler, 1995).
Resistance tests Resisted tests are very important for helping to identify tendonitis or a rotator cuff tear. Selective
287 tissue tension tests are important for distinguishing between contractile and non-contractile lesions (Cyriax, 1982; Hanchard et al., 2005). Whereas passive motions evaluate non-contactile or inert structures such as joints or ligaments, and active movements evaluate muscle length, active resisted tests evaluate muscle strength. MS with resisted tests indicates tendonitis of the muscle isolated in the test. Resisted external rotation tests the integrity of the rotator cuff with emphasis on the supraspinatus and infraspinatus contractile units. A normal patient can provide strong, painfree resistance to manually applied outside forces. If the response to resisted external rotation is weak and painful, when the resistance is applied with the glenohumeral joint positioned in its midrange, neutral position, the examiner should suspect tendonitis of the rotator cuff. If the response to resisted external rotation is weak and painfree, the examiner should suspect the presence of a neurological disorder such as an impairment of conduction of the C5 nerve or the suprascapular nerve (Cyriax, 1982). Burkhart et al. (2000) found that 72% of shoulder patients had weakness of infraspinatus or teres minor on resisted external rotation. According to Wilk et al. (1993) the external rotator muscles should be at least 65% the strength of the internal rotator muscles. The empty can test (see Fig. 6) is ideal for isolating the supraspinatus. The patients arm is elevated 901 in the scapular plane and internally rotated. Resistance is applied proximal to the wrist or elbow in a downward direction. Speed’s test (see Fig. 7) isolates the biceps muscles. The patients arm is at the side and externally rotated. Resistance is applied proximal to the wrist in extension. A recent paper demonstrated that a comprehensive functional/orthopedic examination including the combination of the Hawkins–Kennedy impingement sign, the painful arc sign, and the infraspinatus muscle test yielded the best post-test probability (95%) for impingement syndrome (Park et al., 2005).
Functional tests Poor posture and/or faulty movement patterns are typical kinetic chain dysfunctions which cause biomechanical overload. Such repetitive strain irritates pain sensitive structures and can be a key perpetuating factor of pain. Movement patterns are important to assess because classic muscle tests evaluate strength, but not the quality of movement (Janda, 2006; Liebenson et al., 1998). A number of muscles participate in any movement pattern. Poor scapulohumeral
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Figure 6 Empty can test.
rhythm coordination is related to shoulder disorders (i.e. impingement) (Babyar, 1996; Yamaguchi et al., 2000). This stereotypical movement pattern screens for functional pathology during tasks involved with prehension (Kamkar et al., 1993; Kibler and McMullen, 2003). Inadequate fixation of the scapulae from below will overstress both the cervical spine and shoulder joint complex. This is evaluated during reaching and carrying tasks. Co-activation of the upper and lower scapular fixators maintain a ‘‘neutral’’ position of the scapulae during arm movements.
Score:
During the ‘‘setting phase’’, 1st 601, the shoulder should not elevate.
The lower and middle trapezius can also be assessed in the prone postion (see Figs. 9–11). In each of these tests strength, symmetry, and AMC is assessed. The chief dysfunction noted is typically the inability to maintain a depressed scapular position. Impaired muscle performance of the scapular adductors and upward rotators—serratus anterior, middle and lower trapezius—are also commonly present.
Arm abduction test Push-up test Procedure (see Fig. 8): Procedure (See Fig. 12):
Arm at side, elbow bent 901, and wrist in neutral position, slowly raise arm (abduction).
In a push-up position from toes or knees, slowly lower and then raise the trunk up.
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Figure 9 Middle trapezius.
Figure 8 Arm abduction test reproduced with permission from Liebenson CS, LeFebvre R, DeFranca C. Cervicothoracic spine: making a rehabilitation prescription. Lippincott/Williams and Wilkins, 1998.
Score:
Fail if: J scapulae retract, J scapulae wing, J shoulders shrug.
Figure 10 Scapular depression test: (a) pre-positioning to test for passive insufficiency; (b) resistance.
Burkhart et al. (2000) describe two important functional tests. The scapular assistance test (SAT) and scapular retraction test (SRT). The SAT is positive if it gives relief of impingement, clicking or rotator cuff weakness. The SAT is performed by manually stabilizing the upper medial scapula
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Figure 7 Speed’s test.
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C. Liebenson infraspinatus and teres minor muscles can be palpated with the patient prone.
Imaging
Shoulder disorders—Part 2: Examination
Figure 11 Lower trapezius.
Figure 12 Push-up test reproduced with permission from Liebenson CS, LeFebvre R, DeFranca C. Cervico-thoracic spine: making a rehabilitation prescription. Lippincott/ Williams and Wilkins, 1998.
border and rotating the inferior medial border as the arm is actively abducted and adducted by the patients. The SRT is a similar test involving retraction.
Palpation Palpation is important to provide further information about the rotator cuff, biceps tendon and/or subacromial/subdeltoid bursa. The seated position is ideal for the supraspinatus tendon. Have the patient place the hand behind their buttock. The arm can also be extended. The long head of the biceps can best be palpated either seated or supine in the bicipital groove. The subscapularis muscle is challenging to palpate. The scapula must be abducted from the rib cage. This is best performed in either supine or side lying positions. The
Imaging such as X-ray, magnetic resonance image (MRI), etc. is often indicated in trauma, the elderly, or unresponsive patients. However, not all positive imaging findings are confirmatory of symptom producing abnormalities. In fact, there is a surprisingly high rate of false positive test results in asymptomatic individuals. Ultrasound showed a complete rupture of the supraspinatus tendon in 6% of 212 patients from 56 to 83 years of age (mean: 67 years) (Schibany et al., 2004). MRI confirmed a complete rupture of the supraspinatus tendon in 90%. All patients reported no functional deficits, although strength was significantly lower in the patient group with complete supraspinatus tendon tear (Po0:01). There is a higher prevalence in older individuals of rotator cuff tendon tears that cause no pain or decrease in activities of daily living. MRI of the shoulders of 96 asymptomatic individuals were evaluated to determine the prevalence of findings consistent with a tear of the rotator cuff (Sher et al., 1995). The over-all prevalence of tears of the rotator cuff in all age-groups was 34%. There were fourteen full-thickness tears (15%) and nineteen partial-thickness tears (20%). The frequency of full-thickness and partial-thickness tears increased significantly with age (Po0:001 and 0.05, respectively). Twenty-five (54%) of the 46 individuals who were more than 60-year old had a tear of the rotator cuff: 13 (28%) had a full-thickness tear and 12 (26%) had a partial-thickness tear. Of the 25 individuals who were 40–60-year old, one (4%) had a full-thickness tear and six (24%) had a partialthickness tear. Of the 25 individuals who were 19–39-year old, none had a full-thickness tear and one (4%) had a partial-thickness tear. MRI identified a high prevalence of tears of the rotator cuff in asymptomatic individuals. These tears were increasingly frequent with advancing age and were compatible with normal, painless, functional activity. The results of the present study emphasize the potential hazards of the use of magnetic resonance imaging scans alone as a basis for the determination of operative intervention in the absence of associated clinical findings. Additionally, it is possible in symptomatic individuals that the MRI findings are merely coincidental. Fourteen completely asymptomatic patients and 32 patients with residual symptoms were
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initial outcome parameter assessments, or improvement of outcomes between the patients who had pre-evaluation MRI and those who did not.
Summary Thorough evaluation of patients with shoulder problems should classify patients into discreet diagnostic groups—red flags, impingement syndrome, adhesive capsulitis, shoulder instability. Most rotator cuff tendonitis patients fall into the impingement category. The most important aspect of the initial evaluation is to rule out red flags suggestive of tumor, infection or fracture. If present such patients always require additional testing and often referral. A patient will be classified into the impingement category if there is (a) pain with active shoulder motions (i.e., painful arc), (b) pain with overpressure of passive shoulder elevation (i.e., a positive Neer’s test) or horizontal shoulder adduction/internal rotation (Hawkins test), and (c) painfully weak resisted shoulder motions. Impingement syndrome patients should also be evaluated for partial or full-thickness rotator cuff tears, especially if the response to 4–6 weeks of rehabilitation is unsatisfactory. Patients with adhesive capsulitis have severe ROM loss. The most restricted ROMs are with shoulder abduction, external rotation, and flexion. In contrast, patients with shoulder instability are hypermobile. A history of recurrent dislocations is often present. An apprehension sign may be present. SLAP II-IV lesions are common in this patient group and the labrum can be seen to be stretched anterior during many of the functional tests.
References Allman Jr., F.L., 1967. Fractures and ligamentous injuries of the clavicle and its articulation. Journal of Bone and Joint Surgery—American 49, 774–784. Babyar, S.R., 1996. Excessive scapular motion in individuals recovering from painful and stiff shoulders: causes and treatment strategies. Physical Therapy 76, 226–238. Bradley, M.P., Tung, G., Green, A., 2005. Overutilization of shoulder magnetic resonance imaging as a diagnostic screening tool in patients with chronic shoulder pain. Journal of Shoulder and Elbow Surgery 14 (3), 233–237. Burkhart, S.S., Morgan, C.D., Kibler, W.B., 2000. Shoulder injuries in overhead athletes. The ‘‘Dead Arm’’ Revisited. Clinics in Sports Medicine 19, 125–158. Connor, P.M., Banks, D.M., Tyson, A.B., Coumas, J.S., D’Alessandro, D.F., 2003. Magnetic resonance imaging of the
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investigated with MRI 27–53 months (mean 39 months) after open transosseous reinsertion of the rotator cuff (Zanetti et al., 2000). Residual defects or retears were detected in three (21%) and bursitis-like abnormalities in 14 (100%) of the 14 asymptomatic patients. Fifteen (47%) residual defects or retears and 31 (97%) bursitis-like abnormalities were diagnosed in the 32 patients with residual symptoms. The size of the residual defects/retears was significantly smaller in the asymptomatic group (mean 8 mm, range 6–11 mm) than in the symptomatic group (mean 32 mm, range 7–50 mm) (t-test, P ¼ 0:001). The extent of the bursitis-like subacromial abnormalities did not significantly differ (t-test, P40:05) between asymptomatic (mean 28 3 mm) and symptomatic patients (mean 32 3 mm). Thus, small residual defects or re-tears (o 1 cm) of the rotator cuff are not necessarily associated with clinical symptoms. Subacromial bursitis-like MR abnormalities are almost always seen after rotator cuff repair even in patients without residual complaints. They may persist for several years after rotator cuff repair and appear to be clinically irrelevant. Detailed MRI scans of asymptomatic dominant and nondominant shoulders of elite overhead athletes were obtained (Connor et al., 2003). Images from a surgical control group were intermixed to assess accuracy and control for observer bias. A 5-year follow-up interview was performed to determine whether MRI abnormalities found in the initial stage of the study represented truly clinical false-positive findings or symptomatic shoulders in evolution. Eight of 20 (40%) dominant shoulders had findings consistent with partial- or full-thickness tears of the rotator cuff as compared with none (0%) of the nondominant shoulders. Five of 20 (25%) dominant shoulders had MRI evidence of Bennett’s lesions compared with none (0%) of the nondominant shoulders. None of the athletes interviewed 5 years later had any subjective symptoms or had required any evaluation or treatment for shoulder-related problems during the study period. Thus, MRI alone should not be used as a basis for operative intervention in this patient population. For chronic shoulder pain of non-traumatic origin it does not appear MRI is a front line diagnostic test (Bradley et al., 2005). In total, 41% of 101 consecutive patients had a shoulder MRI prior to specialist evaluation by an orthopedic fellowshiptrained shoulder specialist. There were no statistically significant differences in age, sex, affected shoulder, insurance status, mechanism of injury, comorbid conditions, range of motion, treatment,
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C. Liebenson Neer II, C.S., 1972. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. Journal of Bone and Joint Surgery 54, 41–50. Park, H.B., Yokota, A., Gill, H.S., El Rassi, G., McFarland, E.G., 2005. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. Journal of Bone and Joint Surgery—American 87 (7), 1446–1455. Robinson, C.M., Kelly, M., Wakefield, A.E., 2002. Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: risk factors and results of treatment. Journal of Bone and Joint Surgery—American A-84 (9), 1552–1559. Robinson, D., Halperin, N., Agar, G., et al., 2003. Shoulder girdle neoplasms mimicking frozen shoulder syndrome. Journal of Shoulder and Elbow Surgery 12, 451–455. Ross, J.J., Shamsuddin, H., 2004. Sternoclavicular septic arthritis: review of 180 cases. Medicine 83, 139–148. Rowe, C.R., 1988. Recurrent anterior transient subluxation of the shoulder. The ‘‘dead arm’’ syndrome. Orthopedic Clinics of North America 19 (4), 767–772. Sabari, J.S., Matzev, I., Lubarsky, D., Liskay, E., Homel, P., 1998. Goniometric assessment of shoulder range of motion: comparison of testing in supine and sitting positions. Archives of Physical Medicine and Rehabilitation 79, 647–651. Schibany, N., Zehetgruber, H., Kainberger, F., Wurnig, C., BaSsalamah, A., Herneth, A.M., Lang, T., Gruber, D., Breitenseher, M.J., 2004. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. European Journal of Radiology 51 (3), 263–268. Shaffer, B., Tibone, J.E., Kerlan, R.K., 1992. Frozen shoulder. A long-term follow-up. Journal of Bone and Joint Surgery—American 74, 738–746. Sher, J.S., Uribe, J.W., Posada, A., Murphy, B.J., Zlatkin, M.B., 1995. Abnormal findings on magnetic resonance images of asymptomatic shoulders. Journal of Bone and Joint Surgery—American 77 (1), 10–15. Spengler, D., Kirsh, M., Kaufer, H., 1973. Orthopaedic aspects and early diagnosis of superior sulcus lung tumor. Journal of Bone and Joint Surgery 55, 1645–1650. Tyler, T.F., Nicholas, S.J., Roy, T., Gleim, G.W., 2000. Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. American Journal of Sports Medicine 28 (5), 668–673. Warner, J.J., Micheli, L.J., Arslanian, L.E., Kennedy, J., Kennedy, R., 1990. Patterns of flexibility, laxity, and strength in normal shoulders and shoulders with instability and impingement. American Journal of Sports Medicine 18 (4), 366–375. Wilk, K.E., Andrews, J.R., Arrigo, C.A., et al., 1993. The strength characteristics of internal and external rotator muscles in professional baseball pitchers. American Journal of Sports Medicine 21, 61–66. Yamaguchi, K., Sher, J.S., Andersen, W.K., Garretson, R., Uribe, J.W., Hechtman, K., Neviaser, R.J., 2000. Glenohumeral motion in patients with rotator cuff tears: a comparison of asymptomatic and symptomatic shoulders. Journal of Shoulder and Elbow Surgery 9, 6–11. Zanetti, M., Jost, B., Hodler, J., Gerber, C., 2000. MR imaging after rotator cuff repair: full-thickness defects and bursitislike subacromial abnormalities in asymptomatic subjects. Skeletal Radiology 29 (6), 314–319.
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SELF-MANAGEMENT: CLINICIAN SECTION
Shoulder disorders—Part 2: Examination$ Craig Liebenson, DC 10474 Santa Monica Blvd., No. 202, Los Angeles, CA 90025, USA
The examination of the shoulder girdle complex involves a comprehensive strategy integrating assessment of serious conditions (e.g. Red Flags), orthopedic testing, and functional evaluation. Red flags of tumor or infection are uncommon, but extremely important to rule out. Orthopedic assessment aims to identify the pain generator and diagnose the condition. Functional assessment, while often ignored, is perhaps the most important step for aiding the clinician in finding the cause of biomechanical overload responsible for the patient’s symptoms. The orthopedic and functional assessments are usually combined. Shoulder stability requires proper function of the rotator cuff and surrounding muscles which attach the arm to the torso. A properly functioning shoulder allows for movement with sufficient stability when pushing, pulling, swimming, throwing, lifting, or reaching overhead. Shoulder girdle disorders are frequently related to faulty posture or motor control. Typical patterns of muscle imbalance, such as weakness of the lower scapular fixators (serratus anterior and lower trapezius), and shoulder external rotators along with tightness of the scapulae elevators (upper trapezius, levator scapulae) and shoulder internal rotators are common. Overhead activities can be particularly $
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strenuous for the shoulder and precipitate injury via repetitive strain, especially when scapular dyskinesis is present. This article will review the important features of identifying red flags, orthopedic testing, and functional evaluation.
Red flags Whereas the vast majority of shoulder problems are mechanical or inflammatory in rare instances a more serious cause is responsible. Tumor, infection, or fracture are the major causes of more serious shoulder problem.
Tumor A pancoast tumor can present as shoulder pain (Jett, 2000; Robinson et al., 2003; Spengler et al., 1973). Men over 50 with a history of cigarette smoking are at particular risk. The pain may be ‘‘nagging’’ in the shoulder and along the vertebral border of the scapula. Referred burning pain down the arm into the ulnar nerve distribution can occur. Examination may reveal wheezing with auscultation when tumor obstructs bronchus. The patient may present with Horner’s syndrome:
ptosis (drooping eyelid), constricted pupil, sweating disturbances.
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Infection
Table 1
Active range of motion (ROM) Passive ROM (including specific orthopedic tests
Septic Arthritis of the sternoclavicular (SC) joint can occur (Ross and Shamsuddin, 2004). The symptoms can be an insidious onset of chest pain localized in the SC joint along with a history of IV drug use, diabetes, trauma, infection (especially of central venous access). Examination may reveal tenderness of the SC joint, limited shoulder movement, swelling over SC joint, and possibly fever.
Fracture or dislocation If a patient has an observable or palpable shoulder deformity or severe shoulder motion limitation, the patient should be referred for X-ray to rule out dislocation, an undiagnosed fracture, or a rotator cuff tear (Robinson et al., 2002). As with the cervical spine, suspected fractures or severe capsule/ligament injuries of the shoulder complex often require external devices such as a shoulder sling, stabilization exercises, and neutral positioning instruction as the patient awaits the results of diagnostic imaging.
Functional orthopedic evaluation
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Basic rules of testing During all tests it is important to identify both the movements or positions which reproduce the patients characteristic symptoms—mechanical sensitivity (MS), and the presence or absence of abnormal motor control (AMC). If a test reproduces the patients characteristic symptoms then the patient’s pain generator has been found. Once the patients MS has been identified this can be used following treatment and at the initiation of followup visits to ‘‘audit’’ the patients status and recovery. While reducing the patient’s MS with different therapies empirically demonstrates that the care program is on the right track, it is usually the AMC evaluation that guides the clinician’s decision making regarding what areas need to be mobilized or stabilized, strengthened or stretched, etc. Both the AMC and MS tests are needed to accurately make and modify the patients prescription. Table 1 summarizes the types of functional orthopedic tests performed (see Table 1). The main conditions which the functional orthopedic assessment should identify are rotator cuff tendonitis or tears, shoulder impingement syndrome (pain while reaching overhead), shoulder
Functional orthopedic tests.
such as apprehension test) Passive accessory ROM Resistance tests Functional/postural tests Palpation
instability, or severe limitation of the shoulder’s mobility (frozen shoulder or adhesive capsulitis).
Active range of motion (ROM) The shoulder physical examination begins with the patient being asked to move his/her arm in the cardinal planes of motion (flexion, extension, abduction, adduction, internal and external rotation) (see Figs. 1 and 2). During testing the patient is asked to report any symptom reproduction (e.g., pain, stiffness, crepitus). Reliability of these measurements is not 100%. Goniometric assessment of shoulder flexion and abduction has been shown to be reliable for both passive and active ROM testing in either the sitting upright or supine positions (Sabari et al., 1998). Burkhart et al. (2000) showed that shoulder patients have an average decreased shoulder internal rotation at 901 abduction on injured arm of 251. A painful arc during arm elevation (flexion, abduction, or in the scapular plane) suggests impingement is present. This occurs when there is pain during the mid-range of motion, but not at the beginning or end of the motion. A simple and practical postural screen of the patients mobility is the wall angel (Fig. 3).
Wall angel test Procedure:
The patient stands with the back against a wall with arms abducted 901, elbows bent 901, palms supinated and feet slightly forward. Both the back of the patients head and the buttock should be touching the wall. The patient should try to flatten the back. Ask the patient to nod so as to tuck their chin in. Offer passive overpressure to aid cervico-cranial flexion testing.
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Figure 1 Abduction range of motion.
Score:
Fail if thoraco-lumbar junction does not flatten. Record where patient feels tension or pain (midback, left or right side, neck). Note if any symptoms occur when: J flattening the back, J tucking the chin, J with passive overpressure into cervico-cranial flexion.
Clinical pearl
Decreased ROM in external rotation, abduction and elevation is the signature for adhesive capsulitis.
Figure 3 Wall angel.
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Figure 2 External rotation range of motion.
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C. Liebenson Decreased ROM in internal rotation and/or elevation (abduction, scapular, or flexion) is typical of impingement syndrome and rotator cuff problems. Decreased ROM in horizontal adduction (scarf test) suggests acromio-clavicular (AC) joint dysfunction.
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Passive ROM Following the assessment of the patient’s shoulder active ROM, passive movement should be examined. The clinician should compare shoulder internal and external rotation at 01, 451 and 901 (Godges et al., 2003; Shaffer et al., 1992; Warner et al., 1990) of shoulder abduction. Symptom reproduction with passive overpressure while the shoulder is at end range of elevation, either in flexion or adduction, suggests that the patient has a shoulder impingement syndrome where the humeral head is impinging on painsensitive tissues inferior to the acromial arch (Hawkins and Kennedy, 1980; Hawkins and Abrams, 1987; Park et al., 2005). The Neer Sign is present when there is MS with arm elevation overhead (flexion) when the arm is placed in internal rotation (Neer, 1972) (See Fig. 4). The Hawkins impingement test is positive when arm adduction and internal rotation with the arm elevated 901 reproduces the patient’s characteristic pain (see Fig. 5). The clinician should also note whether the patient has excessive range of passive motion. Excessive glenohumeral passive mobility may suggest that the patient may have an unstable glenohumeral joint. Glenohumeral instability is suspected if a patient exhibits excessive mobility (e.g., external rotation41051) and apprehension during performance of special tests. Commonly used tests in the identification of glenohumeral instability include the apprehension test (Rowe, 1988), anterior–posterior humeral glides, sulci test (Itoi et al., 1992,1999), and the hyper-abduction test (Gagey, 2001). Tyler et al. (2000) have demonstrated reliability and validity for a test of posterior capsule tightness. This test correlates with restricted shoulder internal rotation ROM at 901 abduction. If the patient has severe limited range of motion Frozen shoulder or impingement is suspected. Frozen shoulder typically has an extreme limitation in abduction, flexion (below 901) and external rotation. Impingement is limited in motions above 901 involving flexion or abduction and also has limitation of internal rotation. Excessive
Figure 4 Neer sign.
Figure 5 Hawkins impingement test.
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glenohumeral passive mobility may suggest that the patient may have an unstable glenohumeral joint. Glenohumeral instability is suspected if a patient exhibits excessive mobility (e.g., external rotation41051) and apprehension during performance of special tests. In line with Janda’s concept of the upper crossed syndrome Johnson et al. found that female dental hygienists are more likely than non dental hygienist females to develop tightness in the upper trapezius (P ¼ 0:007) and the levator scapula (P ¼ 0:01) of the non dominant upper quarter and lower fibers of the pectoralis major of the dominant upper quarter (P ¼ 0:03) (Janda, 2006; Johnson et al., 2003). Upper quadrant muscles that commonly exhibit muscle flexibility deficits are the suboccipital, sternocleidomastoid, pectoralis minor and major, teres major, subscapularis, levator scapulae, upper trapezius and latissimus dorsi (Johnson et al., 2003).
Accessory mobility/end feel The AC joint is also vulnerable to becoming hypermobile and unstable. This joint is commonly sprained during contact sports and accidents, such as a fall. Examination of the passive accessory motion of the acromioclavicular joint using anterior-to-posterior and posterior-to-anterior glides of the clavicle relative to the acromian assists in identifying acromioclavicular joint instability (Allman, 1967; Lee et al., 1997). The clinician may also assess the passive accessory motion of the SC joint, especially in patients immobilized following an upper extremity trauma or surgery as well as patients with the symptoms of thoracic outlet syndrome where entrapment of the upper limb neurovascular bundle near the costoclavicular space is suspected. The anterior slide test specifically assesses the integrity of the superior labrum. (Kibler, 1995; McFarland, 1996,2002). The anterior slide test involves the patient in a sitting position with his/ her hands held at the waist. The examiner stands behind the patient and stabilizes the scapula and clavicle with one hand. With the other hand, the examiner applies and anterosuperior force at the upper arm near the elbow. If the labrum is torn, the humeral head slides over the labrum with a pop or crack and the patient complains of anterosuperior pain (Kibler, 1995).
Resistance tests Resisted tests are very important for helping to identify tendonitis or a rotator cuff tear. Selective
287 tissue tension tests are important for distinguishing between contractile and non-contractile lesions (Cyriax, 1982; Hanchard et al., 2005). Whereas passive motions evaluate non-contactile or inert structures such as joints or ligaments, and active movements evaluate muscle length, active resisted tests evaluate muscle strength. MS with resisted tests indicates tendonitis of the muscle isolated in the test. Resisted external rotation tests the integrity of the rotator cuff with emphasis on the supraspinatus and infraspinatus contractile units. A normal patient can provide strong, painfree resistance to manually applied outside forces. If the response to resisted external rotation is weak and painful, when the resistance is applied with the glenohumeral joint positioned in its midrange, neutral position, the examiner should suspect tendonitis of the rotator cuff. If the response to resisted external rotation is weak and painfree, the examiner should suspect the presence of a neurological disorder such as an impairment of conduction of the C5 nerve or the suprascapular nerve (Cyriax, 1982). Burkhart et al. (2000) found that 72% of shoulder patients had weakness of infraspinatus or teres minor on resisted external rotation. According to Wilk et al. (1993) the external rotator muscles should be at least 65% the strength of the internal rotator muscles. The empty can test (see Fig. 6) is ideal for isolating the supraspinatus. The patients arm is elevated 901 in the scapular plane and internally rotated. Resistance is applied proximal to the wrist or elbow in a downward direction. Speed’s test (see Fig. 7) isolates the biceps muscles. The patients arm is at the side and externally rotated. Resistance is applied proximal to the wrist in extension. A recent paper demonstrated that a comprehensive functional/orthopedic examination including the combination of the Hawkins–Kennedy impingement sign, the painful arc sign, and the infraspinatus muscle test yielded the best post-test probability (95%) for impingement syndrome (Park et al., 2005).
Functional tests Poor posture and/or faulty movement patterns are typical kinetic chain dysfunctions which cause biomechanical overload. Such repetitive strain irritates pain sensitive structures and can be a key perpetuating factor of pain. Movement patterns are important to assess because classic muscle tests evaluate strength, but not the quality of movement (Janda, 2006; Liebenson et al., 1998). A number of muscles participate in any movement pattern. Poor scapulohumeral
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Figure 6 Empty can test.
rhythm coordination is related to shoulder disorders (i.e. impingement) (Babyar, 1996; Yamaguchi et al., 2000). This stereotypical movement pattern screens for functional pathology during tasks involved with prehension (Kamkar et al., 1993; Kibler and McMullen, 2003). Inadequate fixation of the scapulae from below will overstress both the cervical spine and shoulder joint complex. This is evaluated during reaching and carrying tasks. Co-activation of the upper and lower scapular fixators maintain a ‘‘neutral’’ position of the scapulae during arm movements.
Score:
During the ‘‘setting phase’’, 1st 601, the shoulder should not elevate.
The lower and middle trapezius can also be assessed in the prone postion (see Figs. 9–11). In each of these tests strength, symmetry, and AMC is assessed. The chief dysfunction noted is typically the inability to maintain a depressed scapular position. Impaired muscle performance of the scapular adductors and upward rotators—serratus anterior, middle and lower trapezius—are also commonly present.
Arm abduction test Push-up test Procedure (see Fig. 8): Procedure (See Fig. 12):
Arm at side, elbow bent 901, and wrist in neutral position, slowly raise arm (abduction).
In a push-up position from toes or knees, slowly lower and then raise the trunk up.
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Figure 9 Middle trapezius.
Figure 8 Arm abduction test reproduced with permission from Liebenson CS, LeFebvre R, DeFranca C. Cervicothoracic spine: making a rehabilitation prescription. Lippincott/Williams and Wilkins, 1998.
Score:
Fail if: J scapulae retract, J scapulae wing, J shoulders shrug.
Figure 10 Scapular depression test: (a) pre-positioning to test for passive insufficiency; (b) resistance.
Burkhart et al. (2000) describe two important functional tests. The scapular assistance test (SAT) and scapular retraction test (SRT). The SAT is positive if it gives relief of impingement, clicking or rotator cuff weakness. The SAT is performed by manually stabilizing the upper medial scapula
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Figure 7 Speed’s test.
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C. Liebenson infraspinatus and teres minor muscles can be palpated with the patient prone.
Imaging
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Figure 11 Lower trapezius.
Figure 12 Push-up test reproduced with permission from Liebenson CS, LeFebvre R, DeFranca C. Cervico-thoracic spine: making a rehabilitation prescription. Lippincott/ Williams and Wilkins, 1998.
border and rotating the inferior medial border as the arm is actively abducted and adducted by the patients. The SRT is a similar test involving retraction.
Palpation Palpation is important to provide further information about the rotator cuff, biceps tendon and/or subacromial/subdeltoid bursa. The seated position is ideal for the supraspinatus tendon. Have the patient place the hand behind their buttock. The arm can also be extended. The long head of the biceps can best be palpated either seated or supine in the bicipital groove. The subscapularis muscle is challenging to palpate. The scapula must be abducted from the rib cage. This is best performed in either supine or side lying positions. The
Imaging such as X-ray, magnetic resonance image (MRI), etc. is often indicated in trauma, the elderly, or unresponsive patients. However, not all positive imaging findings are confirmatory of symptom producing abnormalities. In fact, there is a surprisingly high rate of false positive test results in asymptomatic individuals. Ultrasound showed a complete rupture of the supraspinatus tendon in 6% of 212 patients from 56 to 83 years of age (mean: 67 years) (Schibany et al., 2004). MRI confirmed a complete rupture of the supraspinatus tendon in 90%. All patients reported no functional deficits, although strength was significantly lower in the patient group with complete supraspinatus tendon tear (Po0:01). There is a higher prevalence in older individuals of rotator cuff tendon tears that cause no pain or decrease in activities of daily living. MRI of the shoulders of 96 asymptomatic individuals were evaluated to determine the prevalence of findings consistent with a tear of the rotator cuff (Sher et al., 1995). The over-all prevalence of tears of the rotator cuff in all age-groups was 34%. There were fourteen full-thickness tears (15%) and nineteen partial-thickness tears (20%). The frequency of full-thickness and partial-thickness tears increased significantly with age (Po0:001 and 0.05, respectively). Twenty-five (54%) of the 46 individuals who were more than 60-year old had a tear of the rotator cuff: 13 (28%) had a full-thickness tear and 12 (26%) had a partial-thickness tear. Of the 25 individuals who were 40–60-year old, one (4%) had a full-thickness tear and six (24%) had a partialthickness tear. Of the 25 individuals who were 19–39-year old, none had a full-thickness tear and one (4%) had a partial-thickness tear. MRI identified a high prevalence of tears of the rotator cuff in asymptomatic individuals. These tears were increasingly frequent with advancing age and were compatible with normal, painless, functional activity. The results of the present study emphasize the potential hazards of the use of magnetic resonance imaging scans alone as a basis for the determination of operative intervention in the absence of associated clinical findings. Additionally, it is possible in symptomatic individuals that the MRI findings are merely coincidental. Fourteen completely asymptomatic patients and 32 patients with residual symptoms were
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initial outcome parameter assessments, or improvement of outcomes between the patients who had pre-evaluation MRI and those who did not.
Summary Thorough evaluation of patients with shoulder problems should classify patients into discreet diagnostic groups—red flags, impingement syndrome, adhesive capsulitis, shoulder instability. Most rotator cuff tendonitis patients fall into the impingement category. The most important aspect of the initial evaluation is to rule out red flags suggestive of tumor, infection or fracture. If present such patients always require additional testing and often referral. A patient will be classified into the impingement category if there is (a) pain with active shoulder motions (i.e., painful arc), (b) pain with overpressure of passive shoulder elevation (i.e., a positive Neer’s test) or horizontal shoulder adduction/internal rotation (Hawkins test), and (c) painfully weak resisted shoulder motions. Impingement syndrome patients should also be evaluated for partial or full-thickness rotator cuff tears, especially if the response to 4–6 weeks of rehabilitation is unsatisfactory. Patients with adhesive capsulitis have severe ROM loss. The most restricted ROMs are with shoulder abduction, external rotation, and flexion. In contrast, patients with shoulder instability are hypermobile. A history of recurrent dislocations is often present. An apprehension sign may be present. SLAP II-IV lesions are common in this patient group and the labrum can be seen to be stretched anterior during many of the functional tests.
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investigated with MRI 27–53 months (mean 39 months) after open transosseous reinsertion of the rotator cuff (Zanetti et al., 2000). Residual defects or retears were detected in three (21%) and bursitis-like abnormalities in 14 (100%) of the 14 asymptomatic patients. Fifteen (47%) residual defects or retears and 31 (97%) bursitis-like abnormalities were diagnosed in the 32 patients with residual symptoms. The size of the residual defects/retears was significantly smaller in the asymptomatic group (mean 8 mm, range 6–11 mm) than in the symptomatic group (mean 32 mm, range 7–50 mm) (t-test, P ¼ 0:001). The extent of the bursitis-like subacromial abnormalities did not significantly differ (t-test, P40:05) between asymptomatic (mean 28 3 mm) and symptomatic patients (mean 32 3 mm). Thus, small residual defects or re-tears (o 1 cm) of the rotator cuff are not necessarily associated with clinical symptoms. Subacromial bursitis-like MR abnormalities are almost always seen after rotator cuff repair even in patients without residual complaints. They may persist for several years after rotator cuff repair and appear to be clinically irrelevant. Detailed MRI scans of asymptomatic dominant and nondominant shoulders of elite overhead athletes were obtained (Connor et al., 2003). Images from a surgical control group were intermixed to assess accuracy and control for observer bias. A 5-year follow-up interview was performed to determine whether MRI abnormalities found in the initial stage of the study represented truly clinical false-positive findings or symptomatic shoulders in evolution. Eight of 20 (40%) dominant shoulders had findings consistent with partial- or full-thickness tears of the rotator cuff as compared with none (0%) of the nondominant shoulders. Five of 20 (25%) dominant shoulders had MRI evidence of Bennett’s lesions compared with none (0%) of the nondominant shoulders. None of the athletes interviewed 5 years later had any subjective symptoms or had required any evaluation or treatment for shoulder-related problems during the study period. Thus, MRI alone should not be used as a basis for operative intervention in this patient population. For chronic shoulder pain of non-traumatic origin it does not appear MRI is a front line diagnostic test (Bradley et al., 2005). In total, 41% of 101 consecutive patients had a shoulder MRI prior to specialist evaluation by an orthopedic fellowshiptrained shoulder specialist. There were no statistically significant differences in age, sex, affected shoulder, insurance status, mechanism of injury, comorbid conditions, range of motion, treatment,
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