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Common Shoulder Problems:

Common Shoulder Problems:

Clinicians find the shoulder difficult to examine for several reasons:

  • It has multiple complex parts, including the glenohumeral joint, the acromioclavicular joint, the sternoclavicular joint, and the scapulothoracic articulation.
  • Many of the pathologic processes that affect the shoulder are poorly understood. For example, although rotator cuff disease has been thought to result from impingement of the rotator cuff on the acromion, many studies now suggest that senescence of the tendon is a more important factor and that impingement against bone spurs may not play as large a role.1-3 In addition, pain elicited during a shoulder examination that once was thought to be caused by tendons hitting spurs may instead result from tendons impinging against the superior glenoid rim.1,2,4
  • Access to the affected area is restricted because of soft tissue coverage of the glenohumeral joint (by the deltoid and other muscles). Although palpation of the acromioclavicular joint is relatively easy, accurate palpation of rotator cuff tears or the biceps tendon is nearly impossible.
  • Pain patterns related to various conditions can overlap and not be specific for any one entity. For example, although pain in the deltoid or proximal humerus may result from rotator cuff problems, it also may be caused by stiffness, cervical radiculopathy, arthritis, and numerous other conditions.
  • Because many shoulder tests are sensitive for detecting abnormalities but are not specific for any one condition, they have less diagnostic value than was once thought (Table).5-7
  • A thorough evaluation often is needed to narrow the differential diagnosis and determine proper treatment, because more than one condition may be causing the patient's symptoms.

Our goal here is to help you master the shoulder examination. We review the basics of the examination, and we evaluate emerging concepts in the diagnosis of the more common shoulder conditions.

Table — Tests commonly used in the shoulder examination
Test Description Positive test result Possible diagnosis

Neer impingement test The patient's arm is elevated in flexion until pain is experienced Pain in the deltoid region Rotator cuff pathology
Stiffness

Hawkins-Kennedy test 90 forward flexion of the shoulder; internal rotation of the shoulder Pain in the deltoid region Rotator cuff pathology
Stiffness
Arthritis

O'Brien test 90 forward flexion of the shoulder and 15 horizontal adduction; with palm down, downward-directed force is applied by the examiner; the test is repeated with the palm up If pain is elicited on the top of the shoulder, there is an acromioclavicular problem; if pain is elicited in the shoulder, a SLAP lesion is present Acromioclavicular problem
SLAP lesion

Drop arm test The arm is lowered slowly after passive abduction above the shoulder level The arm cannot be held up against gravity Full-thickness rotator
cuff tear
Nerve lesion
Pain of any cause

Infraspinatus strength test With the arm at the side and the elbow flexed 90 and the arm in neutral rotation, an inward-directed force is resisted while the elbow iskept at the side The patient has weakness Torn infraspinatus
Supraspinatus injury
Suprascapular nerve palsy

Lobe test Abduction is resisted with the arm in 90 abduction in the scapular plane and maximum internal rotation; can be performed with the arm in neutral or with the thumb up ("full can" position) or thumb down ("empty can" position) The patient has weakness Rotator cuff tear
Axillary or suprascapular nerve palsy
Neurologic disorder
Cervical disk disorder

SLAP, superior labrum anterior and posterior.

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