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The clinical examination of the shoulder

Examination of the painful shoulder must be rigorous

Like any joint, the shoulder must be explored using a systematic clinical examination. This examination naturally follows an interrogation during which the medical history, the circumstances of occurrence, the duration of evolution, the location and the nature of the pain will be recorded. Particularly important is the terrain on which shoulder pathology occurs. In young subjects under the age of 25, we will first think of a pathology of instability, in middle-aged female subjects, capsulitis and calcifications of the shoulder will be particularly considered. In subjects over 50 years old, it is the pathology of the rotator cuff which will be by far in the first place. The socio-professional context is important. it is necessary to identify the arduousness of the patient's work, but also the notion of sinistrosis which can settle around a pathology of the shoulder...

Anatomical Reminder

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inspection

palpation

Joint amplitudes

Muscle Strength / Testing

Specific maneuvers

Unstable shoulder examination

The main thing to REMEMBER

Shoulder inspection

1. Patient attitude

We are looking for an asymmetry of the shoulders which can immediately suggest a neurological pathology. Peracute pain in the shoulder readily leads to a particular attitude, known as upper limb trauma, the opposite arm supporting the affected arm in an abduction position, the arm resting on the abdomen. Apart from a traumatic context, this attitude should evoke a hyperalgesic crisis by rupture of a tendon calcification in the subacromial bursa.

2. Muscle changes

Atrophy of the supraspinatus and infraspinatus muscles is particularly sought, comparing to the opposite side. Minor atrophies can be detected by examining up-to-date muscles. Atrophy of the supraspinous and/or infraspinous masses can reflect a massive rupture of the rotator cuff in the subject of advanced age; it can reflect a neurological pathology by damage to the suprascapular nerve in younger athletes. In this case the atrophy of one or both pits makes it possible to specify the seat of the compression of the suprascapular nerve.

3. Deformations

The acromioclavicular joint may be the site of an upward protrusion which may reflect a disjunction. Swelling of the joint may reflect arthropathy. The protrusion of the scapula which detaches from the costal grill can reflect paralysis of the serratus anterior nerve. When this does not appear clearly and is suspected, "pump" movements against a wall can unmask this detachment. The deformation of the muscular relief of the biceps brachii can reflect the spontaneous rupture of its long head. This deformation appears particularly when this biceps is made to contract by a maneuver of bending the elbow upset. A fall of the shoulder stump or unilateral deltoid atrophy should suggest neurological damage.

4. Swelling

The effusion of the shoulder and/or the subacromial-deltoid bursa leads to an increase in volume of the shoulder. This deformity appears particularly in front because of the anterior extension of this bursa. This effusion is particularly common in massive rotator cuff tears. The effusion can be citrine, or hemorrhagic (hemorrhagic senile shoulder). The puncture in the anterior part of the articulation can make it possible to affirm the nature of this effusion.

5. Color Changes

A reddish discoloration of the shoulder suggests an inflammatory or infectious process. A hematoma in the anterior region of the shoulder often overflowing onto the thorax suggests a recent rupture of the long head of the biceps muscle.

Inspection

Palpation

Palpation should involve the sternoclavicular and acromioclavicular joints, looking for pain. Palpation of the anterior region of the shoulder, and particularly of the coracoid region, is of little interest: this area is spontaneously painful in normal subjects. Pain in this region is also very nonspecific, because all causes of inflammation of the subacromial bursa, which is very extensive in front, lead to pain on palpation of this region. Palpation of the acromioclavicular joint looks for pain, but also abnormal mobility in "piano key" suggesting a disjunction.

Palpation of the various tendinous insertions of the rotator cuff on the humeral head can be achieved by certain maneuvers: the supraspinatus is palpated on the anterior surface of the acromion, the arm being placed in internal rotation, the arm in the back ; the infraspinatus can be palpated on the posterior surface of the acromion, after having placed the arm in adduction-external rotation, so as to release the insertion of the acromial vault. These palpations, widely used by physiotherapists for deep transverse massages, are in fact of little diagnostic value.

Palpation of the tendon of the long head of the biceps at the anterior part of the shoulder is practically impossible except in particularly thin subjects. It should be remembered that the tendon is in a perfectly anterior position when the arm is placed at 10° of internal rotation. When you believe you are palpating the biceps tendon, it is generally the anterior edge of the deltoid that you are actually palpating.

Palpation of the paravertebral muscles looks for contracted areas. It should be noted that all shoulder pathologies that lead to dysfunction of the scapulothoracic joint (external bell of the scapula in particular) lead to pain and contractures of the paravertebral muscles and trapezius muscles, explaining the frequent irradiation of cervical spine pain.

Palpation will finally look for abnormal elasticity of the skin which can be interesting in the context of multi-directional instabilities of the shoulder.

Palpation

Joint amplitudes

Examination of the mobility of the shoulder is interested not only in the articular amplitudes, but also in a possible dysfunction during the movement. It is also crucial to know whether or not any reductions in amplitude are related to pain. The patient should be examined in a standing position and in a supine position. Abduction and internal rotation movements are best examined in the standing position, while external rotations and passive shoulder elevation are best examined in the supine position. The movements which must be sought are the anterior elevation in flexion, the abduction in the axis of the scapula (about 20°C of antepulsion), the external rotation measured in three positions:

1. arms along the body, elbow bent at 90°C (RE1)

2. arm abducted at 90°C, elbow flexed at 90°C (RE2)

3. arm in anterior elevation at 90°C, elbow flexed at 90°C (RE3).

Internal rotation is measured by carrying the arm behind the back; the level reached: buttocks, sacrum, vertebral level is mentioned. All these measures must be bilateral and comparative. A particular joint limitation is achieved in adhesive capsulitis of the shoulder: in this case all movements are affected, the loss of amplitude (measured by goniometer) being greater for flexion and external rotation than for abduction and internal rotation; the examiner also feels a very characteristic sensation of an elastic stop at the end of amplitude.

Amplitudes

Muscle Strength / Testing

At the shoulder, the difficulty of muscle testing comes from the fact that each movement actually tests a large number of structures, and it is difficult to specifically test a given muscle. Resistance forward flexion tests both the anterior part of the deltoid muscle, part of the pectoralis major, the coraco-biceps, the long head of the biceps. Abduction against resistance tests the middle part of the deltoid, the supraspinatus, the long head of the biceps. Internal rotation of the forearm makes it possible to test the supraspinatus more specifically (Jobe's maneuver). This maneuver is performed with the arms at 90° abduction and 30° anterior flexion (plane of the scapula) with the thumbs pointing downwards in order to perform a median rotation. The examiner, in front of the patient, tries to lower his arms against resistance. This test can be carried out in a numerical way using a dynamometer applied around the patient's wrist. This objective measurement is essential for completing the forms recommended by the various learned societies interested in the shoulder. External rotation against resistance essentially tests the infraspinatus and the teres minor (teres minor). The posterior part of the deltoid only plays an accessory role.

Internal rotation against resistance is achieved by the Gerber maneuver. This consists of placing the hand behind the back at the height of the lumbar hinge; the examiner raises the hand 10 cm, maintains the flexion of the elbow, and asks the patient to maintain this position. The test is positive if the patient's hand passively hits his back like a spring. The positivity of this test would confirm the rupture of the subscapularis.

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job test

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Patte test

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GERBER test

Palm Up Test

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Force et test

Specific maneuvers

1. The classic signs

Looking for a drawer:

This maneuver is performed by palming the upper face of the shoulder with one hand in order to stabilize the scapula, the other hand prints between thumb and index finger antero-posterior movements which will be compared to the opposite side. It should be ensured that the shoulder is not spontaneously in an abnormal position in the glenoid, which can be seen in multi-directional instabilities. We should not take for a posterior drawer the simple repositioning in neutral position of a shoulder spontaneously sub-dislocated forward (we find here a problem identical to the posterior sub-luxations of the knee by rupture of the posterior cruciate which can be confused with a front drawer).

The sulcus test:

The maneuver consists of palming the patient's elbow, and performing a traction in the axis of the upper limb: the appearance of an ax blow on the external face of the deltoid, just below the acromial rim reflects a subluxation lower humeral head, reflecting abnormal lower laxity.

The apprehension test:

This test can be performed on the patient in a standing or sitting position. It consists of placing the arm in abduction at 90°, external rotation. The examiner applies, with his thumb, a force directed forwards, while his other fingers are placed at the anterior part of the articulation in order to detect a possible jump. This maneuver is positive if the patient dodges the posterior pressure, and if he fears the reproduction of the phenomena of subluxation that he knows. On the other hand, the mere presence of pain on palpation has no value.

The repositioning test:

The patient is placed in a supine position on the examination table, the shoulder being placed on the side edge of the table which acts as a lever. The arm is then positioned in abduction at 90° and in external rotation. At a certain degree of external rotation, the feeling of apprehension appears, the support on the edge of the table being identical to the posterior pressure used in the sign of apprehension. The examiner then presses the patient's arm, which has the effect of pushing back the humeral head and eliminating the feeling of apprehension.

Conflict tests:

1. The impingement sign was popularized by Neer and Welsch. The examiner stands behind the patient. Rotation of the scapula is prevented by one hand while the other passively raises the patient's arm in anterior flexion and abduction. The sign is positive if pain appears. This sign, which aims to compress the anterior part of the cuff against the acromion, is positive in the pathology of the cuff. The impingement test consists of injecting 10 ml of Xylocaine at 1 p. cent in the subacromial bursa. The disappearance of the pain by renewing the impingement maneuver confirms the subacromial origin of the pathology.

NEER TEST

2. The search for a painful arc: This test consists of looking for pain in the abduction in the coronal plane. This pain appears more readily when lowering the arm than when raising it. It can be improved by applying a slight counter-resistance during the manoeuvre.

3. The Yocum test: The patient places his hand on the opposite shoulder and performs an elbow raise without lifting his shoulder. This maneuver can also be sensitized by applying a slight force against resistance. The occurrence of pain during this maneuver is a sign of lesion of the subacromial space. In some cases, patients are unable to place their hand on the opposite shoulder, usually indicative of intense subacromial bursitis. Beware of possible confusion with an acromioclavicular pathology reproduced by forced horizontal abduction.

YOCUM

4. The Hawkins manoeuvre: The upper limb is placed in the RE3 position: anterior elevation of the arm, elbow flexion at 90°. The examiner then applies a medial (internal) rotation by lowering the forearm, which triggers pain in the event of a subacromial impingement.

HAWKINS

2. Maneuvers testing the long head of the biceps

Yergason's test

The elbow is flexed at 90°, the forearm in pronation, the examiner resists the patient who performs a supination against resistance. The appearance of pain in the region of the bicipital gutter suggests a pathology of the long biceps.

The Gilcherreest palm-up test

With the elbow extended and the forearm supinated, the examiner resists anterior elevation of the arm to approximately 60° elevation. The test is positive if pain (and not a deficit) appears in the region of the bicipital region.

Ludington's test

Both hands are placed on the head, the fingers being crossed, the patient performs contraction-relaxation maneuvers of the biceps. The test is positive if pain appears during this maneuver. The deformation of the muscle obviously reflects its rupture.

3. Tests by anesthetic injection

We have already mentioned Neer's test. When the diagnosis is difficult, between a glenohumeral pathology and a pathology of the subacromial space, the glenohumeral injection of Xylocaine can be a valuable element. Test injection of the acromioclavicular joint may also be of great interest. In case of difficulty, these injections are best performed under radiographic control by injecting a small amount of contrast product.

Finally, mention should be made of the useful maneuvers in the event of a clinically stiff shoulder: it is sometimes difficult to rule out the origin of this stiffness, and in particular to know whether it is a purely analgesic stiffness. Injection of anesthetic into the subacromial space is particularly useful. The reappearance of normal amplitudes affirms the purely analgesic character of the stiffness.

In cases of particularly difficult diagnosis between capsular retraction and analgesic stiffness, the realization by an anesthetist of an inter-scalene block allows the differential diagnosis by the immediate disappearance of antalgic stiffness.

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manoeuvres spécifiques

How to examine an unstable shoulder?

In the case of typical and documented recurrent dislocation (x-rays in the dislocated position), the problem is relatively simple, the only pitfall is not recognizing an associated hyperlaxity. The development of intense sports practice leads to seeing in consultation many cases where the gene is less well characterized. It is here above all that the systematic examination will be essential.

The interrogation

Inaugural trauma is often spontaneously reported by the patient. It should always be researched carefully. Sometimes the first episode of dislocation seemed to be of non-traumatic origin, but the interrogation may find relatively significant shoulder trauma in the history, which must be taken into account. There are indeed situations where trauma can create most of the lesions necessary for dislocation without the latter occurring. In other cases, the notion of intensive sports practice with abduction movements and forced external rotation is useful to research.

Conversely, the existence of an inaugural trauma does not dispense with looking for any associated signs of multidirectional hyperlaxity. The type of trauma is often difficult to characterize with precision. The only important concept is that of direct trauma to the shoulder stump (from back to front) or indirect trauma (to the elbow or the forearm) which is by far the most common. We see that the analysis of this first parameter is therefore far from unambiguous. The description of instability accidents is important. The number of episodes of instability and the ease of occurrence should be analyzed. Many episodes of instability occurring for a minimal trauma will obviously plead in favor of an intervention. But it is clear that a first recurrence of dislocation occurring in a scuba diver may also lead to discussion of the intervention given the specific risk incurred...

physical examination

The physical examination will take place in three stages and it is necessary to differentiate between three main categories of clinical signs: the signs of apprehension correspond to dynamic maneuvers whose objective is to unmask the instability, the signs of laxity on the analysis of which we will come back and, finally, the elements in favor of an associated multidirectional hyperlaxity.

Fig 5 of the arm. It aims to put the shoulder in the position of maximum instability,

ie in abduction and forced external rotation.

The test is positive when the patient describes pain and a feeling of insecurity.

Apprehension maneuvers:

Their common objective is to put the humeral head in a situation of imminent instability, which triggers in the patient a keen apprehension and recognition of the spontaneous functional gene.

arm arm test

It aims to reproduce the situation of instability, it is the most classic test. It consists of provoking abduction associated with maximum external rotation which in some cases triggers the feeling of apprehension (Fig 5). This is the most frequently used test. Its presence is very specific for an instability. The fact that this test is negative does not rule out the hypothesis of shoulder instability. This test can be performed either standing or seated.

The relocation test

This is a more sensitive variant of the previous test. It is performed on a patient in the supine position. At first we practice the conventional test of arming it by pushing the humeral head forward which triggers apprehension. Secondly, this test is performed by pressing on the anterior face of the humeral head. This direct pressure on the head will prevent anterior subluxation of the head and cause the test to be negative (fig 6a, 6b).

Fig 6: Relocation test, It is performed in a lying position.

a: Pressure from back to front on the head sensitizes the triggering of insecurity, conversely

b: pressure from front to back on the head prevents the latter from subluxing forward and prevents the onset of pain.

The lower apprehension test

It was initially described by Feagin and clarified secondarily by Itoi (16) who suggested calling it ABIS (Abduction inferior stability). On an abducted upper limb, the patient's forearm rests on the shoulder of the examiner who exerts pressure directed downwards at the level of the neck of the humerus. The presence of shoulder instability causes the head to descend with the appearance of a furrow with, sometimes, a feeling of apprehension (fig 7).

Fig 7: Abduction Inferior Stability (ABIS) Test

The arm is abducted, the forearm resting on the examiner's shoulder,

progressive pressure on the arm pushes the humeral head down.

The test is positive if there is head-down migration or a feeling of apprehension.

Global laxity tests:

These tests aim to highlight abnormal movements of the humeral head. Since no joint ligament is stretched in the position where these tests are performed, they should not be interpreted as tests of ligament laxity. They provide difficult-to-interpret global information about joint laxity that takes into account not only the laxity of the whole capsulo-ligamentous apparatus but also the control of muscle tone. They should be interpreted as hyperlaxity tests.

The test sulcus

On a very relaxed patient, the test consists of gently pulling the lower limb downwards (fig 8). The test is positive when the traction causes the humeral head to descend, which is demonstrated by the appearance of a furrow below the external edge of the acromion (20). It is possible to quantify the amount of inferior displacement of the humeral head.

Fig 8: Sulcus test

In a relaxed patient the examiner gently pulls the humerus down.

The test is positive if the head descends, revealing a groove under the outer edge of the acromion.

The importance of the furrow can be measured. This test has indicative value in favor of hyperlaxity.

Drawer tests

Again, the patient must be relaxed. He is asked to lean slightly forward and let both upper limbs hang down. One hand of the examiner maintains the shoulder girdle, the other grasps the humeral head and tries to cause an anterior then posterior drawer in search of an abnormal translation of the humeral head (Fig 9). This test can also be performed on a patient seated or even lying on their back.

Fig 9: Drawer test

In a patient who is relaxed and leaning slightly forward,

the examiner grasps the humeral head between thumb and forefinger and attempts to induce an anterior or posterior glide.

This test indicates global hyperlaxity (is not specific to a given ligament) and can provide information on the direction of instability.

Is a specific laxity test possible?

Insofar as there is a constant value of passive abduction and that the amplitude of this movement is controlled by the LGHI, we made the hypothesis that a laxity of the LGHI must be accompanied by an increase in amplitude of active abduction. The passive abduction test was performed in patients suffering from post-traumatic shoulder instability without signs of associated hyperlaxity. In 85 percent of cases, the passive abduction amplitude was at least 105°, whereas on the healthy side it was limited to 90°. In fifteen percent of the cases the test provoked a very strong sensation of apprehension, which makes the measurement of passive abduction impossible. In these cases, the test has the value of an apprehension test and joins the test initially described by Feagin and proposed by Itoi (16) under the name of ABIF test. The test was performed under general anesthesia just before the operation, in all cases the passive abduction was at least 105° while the contralateral side did not rise above 90°.

Provided that this test is carried out very strictly in the frontal plane, we therefore have a means of objectifying the elongation of the inferior glenohumeral ligament and of directly demonstrating the laxity of this ligament. This passive hyperabduction test is therefore positive if the amplitude on the affected side is greater than 105° (Fig 10). This is the first test allowing the direct assessment of shoulder ligament laxity, but it deserves to be validated by prospective work measuring its specificity and sensitivity.

Fig 10: Positive hyperabduction test. Amplitude asymmetry is evident between the two sides

and establishes the existence of laxity of the ligament complex.

The neurological examination should not be forgotten because nearly 15% of chronic instabilities of the shoulder give rise to damage to the circumflex nerve.

The search for signs of constitutional hyperlaxity

The existence of multidirectional hyperlaxity indeed modifies the prognosis of the treatment of the instability. The examination will find at the level of the upper limb a test of the furrow (sulcus test) greater than 2 cm as well as very important anterior and posterior drawers. External rotation of the upper limb greater than 90° is also considered a sign of hyperlaxity. We will look for laxity at the level of the wrists, the existence of an exaggerated hyperextension at the level of the elbows, a significant genu recurvatum or the possibility of significant flexion of the trunk forwards (possibility of putting the hands flat on the ground ). The passive hyperabduction test will be positive on both sides. If such signs are present, the diagnosis of instability associated with multidirectional hyperlaxity will be made. Arguments in favor of genuine multidirectional instability will have to be carefully sought. The most important element is the existence of episodes of posterior instability which occur in anterior elevation and in internal rotation. The questioning seeks the notion of episode of posterior instability of the shoulder. In this context, it will be necessary to look for the notion of a history of voluntary dislocation of the shoulder.

In some difficult cases, especially when there is doubt about genuine multidirectional instability, CT arthrography may not be helpful. An indication for arthroscopy may be discussed in search of objective laxity criteria as described by Detrisac.