1
00:00:00,000 --> 00:00:02,500
(English captions by Andrea Matsumoto from
the University of Michigan)

2
00:00:03,100 --> 00:00:07,350
To ensure a thorough assessment it is best
to perform the musculoskeletal exam of the

3
00:00:07,350 --> 00:00:09,160
shoulder in a systematic way.

4
00:00:09,160 --> 00:00:12,930
The following is a suggested order of exam
that incorporates the common techniques for

5
00:00:12,930 --> 00:00:17,100
diagnosing shoulder injuries.

6
00:00:17,100 --> 00:00:19,630
The shoulder exam begins with inspection.

7
00:00:19,630 --> 00:00:25,380
In an anterior view assess the shoulders for
asymmetry, clavicle deformity, muscular atrophy,

8
00:00:25,380 --> 00:00:26,870
or skin changes.

9
00:00:26,870 --> 00:00:30,860
In a posterior view assess for the same.

10
00:00:30,860 --> 00:00:33,199
Next evaluate for active range of motion.

11
00:00:33,199 --> 00:00:36,790
If pain or limitation exists, repeat the motion
passively.

12
00:00:36,790 --> 00:00:41,800
To rule out cervical causes of referred shoulder
pain, evaluate neck range of motion: flexion,

13
00:00:41,800 --> 00:00:45,989
extension, lateral flexion, and rotation.

14
00:00:45,989 --> 00:00:57,239
Next evaluate active range of motion of the
shoulders: flexion, extension, abduction,

15
00:00:57,239 --> 00:01:03,460
adduction, external rotation, and internal
rotation.

16
00:01:03,460 --> 00:01:08,909
From the posterior view we can further assess
the combined adduction and external rotation

17
00:01:08,909 --> 00:01:12,020
with Apley scratch test of external rotation.

18
00:01:12,020 --> 00:01:15,130
Have the patient reach overhead and down the
spine.

19
00:01:15,130 --> 00:01:22,130
Most patients can reach past C7.

20
00:01:25,270 --> 00:01:29,659
Combine adduction and internal rotation with
the Apley scratch test of internal rotation.

21
00:01:29,659 --> 00:01:32,429
Have the patient reach behind the back and
up the spine.

22
00:01:32,429 --> 00:01:36,259
Most patients can reach to T7 or the lower
border of the scapula.

23
00:01:36,259 --> 00:01:39,130
Next assess the strength of the rotator cuff
muscles.

24
00:01:39,130 --> 00:01:42,889
The drop arm test evaluates for a supraspinatus
muscle tear.

25
00:01:42,889 --> 00:01:47,899
Passively adduct the shoulder to 90 degrees,
flex to 30 degrees, and point thumbs down.

26
00:01:47,899 --> 00:01:53,300
The test is positive if the patient is unable
to keep arms elevated after the examiner releases.

27
00:01:53,300 --> 00:01:57,189
Supraspinatus muscle strength testing can
also be done using the empty can test.

28
00:01:57,189 --> 00:02:01,099
In this same position provide resistance as
the patient lifts upward.

29
00:02:01,099 --> 00:02:04,489
Pain suggests possible tendinopathy or tear.

30
00:02:04,489 --> 00:02:08,699
Infraspinatus and teres minor muscle strength
is tested with resisted external rotation.

31
00:02:08,699 --> 00:02:11,910
Pain or weakness suggests a possibly tendinopathy
or tear.

32
00:02:11,910 --> 00:02:18,330
Subscapularis muscle strength can be tested
with resisted internal rotation.

33
00:02:18,330 --> 00:02:22,330
Subscapularis muscle strength is also tested
with the push-off test.

34
00:02:22,330 --> 00:02:26,170
Have the patient adduct the arm and internally
rotate behind their back.

35
00:02:26,170 --> 00:02:30,030
Provide resistance as the patient pushes their
arm away from the body.

36
00:02:30,030 --> 00:02:33,330
Pain or weakness suggests tendinopathy or
tear.

37
00:02:33,330 --> 00:02:36,340
Next palpate anatomic landmarks for tenderness.

38
00:02:36,340 --> 00:02:46,500
The suprasternal notch, the sternal clavicular
joint, along the clavicle, the AC joint, the

39
00:02:46,500 --> 00:02:57,040
acromion, the greater tubercle of the humerus,
the lesser tubercle of the humerus, the

40
00:02:57,040 --> 00:03:01,180
long head of the biceps which runs between
the greater and lesser trochanter, and as

41
00:03:01,180 --> 00:03:08,000
you internally and externally rotate you can
feel that, and the coracoid.

42
00:03:08,000 --> 00:03:15,790
Posteriorly look at acromion, the scapular
spine, the supraspinatus muscle above the

43
00:03:15,790 --> 00:03:28,520
spine, the infraspinatus below the spine,
teres minor muscle, the trapezius muscle,

44
00:03:28,520 --> 00:03:34,950
the rhomboid muscle, and look for scapular
thoracic articulation, particularly looking

45
00:03:34,950 --> 00:03:37,490
for winged scapula.

46
00:03:37,490 --> 00:03:42,130
Specific testing of the shoulder to evaluate
for injuries may include but is not limited

47
00:03:42,130 --> 00:03:43,930
to the following tests.

48
00:03:43,930 --> 00:03:47,600
Hawkin's test assesses for possible rotator
cuff impingement.

49
00:03:47,600 --> 00:03:53,480
Stabilize the scapula, passively abduct the
shoulder to 90 degrees, flex the shoulder

50
00:03:53,480 --> 00:03:58,790
to 30 degrees, and flex the elbow to 90 degrees,
and internally rotate the shoulder.

51
00:03:58,790 --> 00:03:59,459
Pain is a positive test.

52
00:03:59,459 --> 00:04:05,170
Neer's test also assesses for possible rotator
cuff impingement.

53
00:04:05,170 --> 00:04:09,770
Stabilize the scapula and with the thumb pointing
down passively flex the arm.

54
00:04:09,770 --> 00:04:11,560
Pain is a positive test.

55
00:04:11,560 --> 00:04:17,310
The cross arm flexion test also evaluates
for acromioclavicular arthritis or subluxation.

56
00:04:17,310 --> 00:04:20,849
Flex the shoulder to 90 degrees and adduct
across body.

57
00:04:20,849 --> 00:04:25,129
Pain at the acromioclavicular joint is a positive
test.

58
00:04:25,129 --> 00:04:29,210
There are several tests to evaluate for shoulder
instability.

59
00:04:29,210 --> 00:04:33,800
To test inferior glenohumeral stability place
traction on the humerus with the arm at the

60
00:04:33,800 --> 00:04:34,639
patient's side.

61
00:04:34,639 --> 00:04:39,360
If a gap greater than 1cm appears between
the humoral head and the undersurface of the

62
00:04:39,360 --> 00:04:45,449
acromion it is considered a positive sulcus
sign with inferior instability.

63
00:04:45,449 --> 00:04:50,430
The load and shift test evaluates for anterior
and posterior glenohumeral stability.

64
00:04:50,430 --> 00:04:54,999
Provide an axial load on the humerus compressing
the glenohumeral joint, then move the humeral

65
00:04:54,999 --> 00:04:58,110
head anteriorly and posteriorly.

66
00:04:58,110 --> 00:05:02,610
Anterior or posterior displacement is positive
for instability.

67
00:05:02,610 --> 00:05:07,229
The apprehension and relocation tests also
evaluate for anterior glenohumeral stability.

68
00:05:07,229 --> 00:05:12,860
With the patient supine, abduct shoulder to
90 degrees and externally rotate the arm to

69
00:05:12,860 --> 00:05:15,389
place stress on the glenohumeral joint.

70
00:05:15,389 --> 00:05:20,870
If the patient feels apprehensive that the arm
may dislocate it is a positive apprehension arm.

71
00:05:20,870 --> 00:05:25,569
The relocation test is performed using the
examiner's hand to place a posteriorly directed

72
00:05:25,569 --> 00:05:27,729
force on the glenohumeral joint.

73
00:05:27,729 --> 00:05:30,620
Relief of apprehension is a positive test.

74
00:05:30,620 --> 00:05:35,659
There are several tests that assess for injuries
of the biceps tendon and glenohumeral labrum.

75
00:05:35,659 --> 00:05:40,610
To perform a Speed's test flex the shoulder
to 90 degrees with the arm supinated.

76
00:05:40,610 --> 00:05:43,620
Provide downward resistance against the shoulder
flexion.

77
00:05:43,620 --> 00:05:50,240
Pain indicates possibly bicepital tendon
or labral tear.

78
00:05:50,240 --> 00:05:54,999
To perform Yergason's test flex elbow to
90 degrees, shake hands with patient and provide

79
00:05:54,999 --> 00:05:57,449
resistance against supination.

80
00:05:57,449 --> 00:06:02,830
Pain indicates a possible bicepital tendon
or associated labral tear.

81
00:06:02,830 --> 00:06:07,229
To perform O'Brien's Test point the thumb
down and flex shoulder to 90 degrees.

82
00:06:07,229 --> 00:06:12,919
Adduct the arm across midline, provide resistance
against further shoulder flexion and evaluate

83
00:06:12,919 --> 00:06:14,770
for pain.

84
00:06:14,770 --> 00:06:18,889
Repeat with the thumb pointing up and again
evaluate for pain.

85
00:06:18,889 --> 00:06:22,939
If pain was present with the thumb down but
relieved with the thumb up, it is considered

86
00:06:22,939 --> 00:06:27,169
a positive test, suspicious for labral tear.

87
00:06:27,169 --> 00:06:33,860
To perform the Biceps Load Test supinate the
arm, abduct shoulder to 90 degrees, and flex

88
00:06:33,860 --> 00:06:35,759
elbow to 90 degrees.

89
00:06:35,759 --> 00:06:41,710
Externally rotate the arm until patient becomes
apprehensive and provide resistance against

90
00:06:41,710 --> 00:06:44,089
elbow flexion.

91
00:06:44,089 --> 00:06:50,439
Pain indicates possible bicepital tendonopathy
or associated labral tear.

92
00:06:50,439 --> 00:06:56,800
To perform the Biceps Tension Test supinate
the arm, abduct shoulder to 90 degrees, flex

93
00:06:56,800 --> 00:07:02,789
elbow to 90 degrees, and externally rotate
arm until patient becomes apprehensive and

94
00:07:02,789 --> 00:07:04,809
pronate arm.

95
00:07:04,809 --> 00:07:10,589
Pain indicates possible bicepital tendonopathy
or associated labral tear.

96
00:07:10,589 --> 00:07:14,409
To perform the Crank Test, fully abduct the
shoulder and provide an axial load on the

97
00:07:14,409 --> 00:07:15,939
humerus.

98
00:07:15,939 --> 00:07:17,509
Internally and externally rotate the arm.

99
00:07:17,509 --> 00:07:25,159
Pain, catching, or painful clicking is considered
a positive test suggestive of a labral tear.

100
00:07:27,800 --> 00:07:32,219
There are several tests to evaluate for thoracic
outlet syndrome as a cause for the patient's

101
00:07:32,219 --> 00:07:34,300
shoulder pain.

102
00:07:34,300 --> 00:07:39,460
To perform the Costoclavicular Maneuver draw
the patient's shoulders inferiorly and posteriorly.

103
00:07:39,460 --> 00:07:45,309
If patient has reproduction of arm pain or
numbness, consider thoracic outlet syndrome.

104
00:07:45,309 --> 00:07:50,439
To perform Roos' Test abduct the shoulder
to 90 degrees, flex elbow to 90 degrees, and

105
00:07:50,439 --> 00:07:53,669
rapidly open and close hands for up to 3 minutes.

106
00:07:53,669 --> 00:07:59,520
If the patient has reproduction of pain or
numbness, consider thoracic outlet syndrome.

107
00:07:59,520 --> 00:08:02,629
To perform Adson's Test locate the radial
pulse.

108
00:08:02,629 --> 00:08:07,199
Have the patient take a deep breath and extend
neck, and rotate head towards the painful

109
00:08:07,199 --> 00:08:07,969
shoulder.

110
00:08:07,969 --> 00:08:12,439
If radial pulse diminishes on the affected
side, it is considered a positive test suspicious

111
00:08:12,439 --> 00:08:15,909
for thoracic outlet syndrome.

112
00:08:15,909 --> 00:08:20,789
Spurling's Test evaluates for cervical root
impingement.

113
00:08:20,789 --> 00:08:25,080
With the head extended and rotated toward
the painful shoulder, apply an axial load

114
00:08:25,080 --> 00:08:27,330
to the cervical spine.

115
00:08:27,330 --> 00:08:32,330
Reproduction of pain or paresthesias with
this maneuver is a positive test.

116
00:08:35,970 --> 00:08:39,659
In concluding the shoulder exam it is important
to document a neurovascular exam.

117
00:08:39,659 --> 00:08:42,120
Here we demonstrate a brief exam.

118
00:08:42,120 --> 00:08:47,390
Resisted wrist extension tests the radial
nerve.

119
00:08:47,390 --> 00:08:52,830
Resisted opposition of the thumb tests the
median nerve.

120
00:08:52,830 --> 00:08:58,560
Resisted digit abduction tests the ulnar nerve.

121
00:08:58,560 --> 00:09:03,210
Radial artery pulse and capillary refill testing.

122
00:09:03,210 --> 00:09:05,700
Further neurologic or vascular exam may be
indicated by history.

123
00:09:05,700 --> 00:09:06,990
Acknowledgement: The Japanese translation of this video was made as part of Shizuoka-University of Michigan Advanced Residency Training, Education and Research in Family Medicine (SMARTER FM) Project supported by Shizuoka Prefecture and funded by the Community Healthcare Revival Fund.