- Wasting at the side – likely to be deltoid. This could cause the shoulder to become flattened. Often secondary to nerve lesion.
- Wasting at the back – likely to be trapezius
- Deformity over the clavicle – suggests previous fracture
- Generalised swelling – probably caused by effusion
- Flex the arm at the elbow – look for ruptured biceps tendon. You will see a large mass of muscle, that can either be near the elbow joint, or anywhere further up the humerus.
- ‘Winged scapula’ – asking the patient to push against a wall can exaggerate this. It is where the scapula is abnormally laterally rotated. It is the result of a lesion of the long thoracic nerve, or of the muscle this nerve supplies – serratus anterior.
- Acromio-clavicular joint – common site of arthritis. To find this part of the joint, move laterally along the clavicle.
- Greater tuberosity – the insertion point of the rotator cuff muscles
- General Palpation – feel (and sometimes you can also hear it!) for any creptius. This is a crunching, grating feeling inside the joint, indicative of degeneration.
- The subacrominal space – specific tenderness hear can help localise an impingement pathology
- Swelling – feel for any generalised swelling. This can be caused by:
- Previous fractures
- Palpation of the dorsal spine and interscapular area – this area is sometimes called a trigger point for fibromyalgia. Palpating this area in individuals with this condition can elicit pain.
- Abduction – Should be done against resistance, and remember that supraspinatus (which is the muscle your are mainly testing!) is only responsible for the first 15’ of abduction.
- Internal rotation – Ask patient to put the palms of their hands on the back of their necks
- External rotation – Ask patient to put the backs of their hands on their bottom. How high up their back can they reach? Normal is about L4. If they cant get up very high, external rotation may be reduced. External rotation is particularly badly affected in frozen shoulder (adhesive capsulitis), although this condition limits all movements.
Assessing individual muscles
- Initiated by the deltoid muscle, for the first 15 degrees. Then supraspinatus typically takes over most of the work
- Suprapsinatus is a common cause of restricted abduction
- Internal rotation
- External rotation
- Flexion (anterior elevation) – to 180 degrees
- Extension (posterior elevation) – to 50 degrees
- Restriction of active movements only – suggests pathology of the muscles and tendons of the rotator cuff. In this case, active movement is also often painful.
- Restriction of both active and passive movements – suggests pathology of the shoulder joint itself. In these cases, limitation can be due to pain, inflammation or mechanical problems, and often a combination of these factors.
- Capsulitis is an exception to the above. In this condition, there is inflammation of the joint capsule, restricting both active and passive movement, but the joint itself is normal. Signs of capsulitis include:
- Positive scarf test
- Loss of external rotation
Movements against resistance (isometric contractions)
- Supraspinatus (abduction) – Arms flexed at 30’, with palms pointing laterally, and thumbs pointing downwards. Patient tries to flex arms further against resistant.
- Infraspinatus / teres minor (external rotation) – Elbow tucked into chest well, flexed at 90’. Patient tries to move palms apart (external rotation) against resistance
- Subscapularis (internal rotation) – Elbow tucked into chest well, flexed at 90’. Patient tries to move palms together (internal rotation) against resistance
Test for shoulder impingement – which is essentially inflammation of the tendons of the rotator cuff. Ask the patient to flex their arm to 90’. Then flex the elbow to 90’ so that this forearm is parallel to the floor. Now, press down on the patient’s wrist and at the same time try to forcibly inwardly rotate the shoulder joint. This is a passive movement, so the patient should be relaxed. This basically presses the tendons of the shoulder cuff against the coraco-humeral ligament. you may also want to repeat the test with external rotation to check the tendon of subscapularis.
- Positive test – pain is elicited. Particularly if the pain is greater, the greater the degree of internal rotation
- Negative test – no pain
- You can double-check your findings. If you repeat the test, but instead, push the patient’s arm backwards, this should releive/not elicit any pain. This is known as the relocation manouvre.
- This tests for shoulder instability / anterior dislocation of the shoulder