![]() ![]() Neer’s impingement sign is elicited when the patient’s rotator cuff tendons are pinched under the coracoacromial arch. ![]() Rotation of loaded shoulder from extension to forward flexion Posterior force on humerus while externally rotating the armĮlbow flexed to 90 degrees with forearm pronatedĮlbow flexed 20 to 30 degrees and forearm supinated Spine extended with head rotated to affected shoulder while axially loadedĪnterior pressure on the humerus with external rotation Loss of range of motion: rotator cuff problemįorward flexion of the shoulder to 90 degrees and internal rotationįorward elevation to 90 degrees and active adduction Patient touches superior and inferior aspects of opposite scapula TABLE 2 Tests Used in Shoulder Evaluation and Significance of Positive Findings TEST This is often referred to as the “empty can” test. The patient then attempts to elevate the arms against examiner resistance ( Figure 3). The supraspinatus can be tested by having the patient abduct the shoulders to 90 degrees in forward flexion with the thumbs pointing downward. Conversely, the patient will have normal strength if the arm is not tested in abduction. A patient with subacromial bursitis with a tear of the rotator cuff often has objective rotator cuff weakness caused by pain when the arm is positioned in the arc of impingement. True weakness should be distinguished from weakness that is due to pain. A key finding, particularly with rotator cuff problems, is pain accompanied by weakness. In evaluating the rotator cuff, the patient’s affected extremity should always be compared with the unaffected side to detect subtle differences in strength and motion. (Right) Testing adduction and internal rotation. (Left) Testing abduction and external rotation. The patient attempts to touch the opposite scapula to test range of motion of the shoulder. External rotation should be measured with the patient’s arms at the side and elbows flexed to 90 degrees.Īpley scratch test. Conversely, internal rotation and adduction of the shoulder are tested by having the patient reach behind the back and touch the inferior aspect of the opposite scapula. In this test, abduction and external rotation are measured by having the patient reach behind the head and touch the superior aspect of the opposite scapula. The Apley scratch test is another useful maneuver to assess shoulder range of motion ( Figure 2). Beyond 120 degrees, full abduction is possible only when the humerus is externally rotated (palm up). With the arm internally rotated (palm down), abduction continues to 120 degrees. The first 20 to 30 degrees of abduction should not require scapulothoracic motion. Glenohumeral motion can be isolated by holding the patient’s scapula with one hand while the patient abducts the arm. Shoulder abduction involves the glenohumeral joint and the scapulothoracic articulation. For example, a patient with loss of active motion alone is more likely to have weakness of the affected muscles than joint disease. Active and passive ranges should be assessed. RANGE-OF-MOTION TESTINGīecause the complex series of articulations of the shoulder allows a wide range of motion, the affected extremity should be compared with the unaffected side to determine the patient’s normal range. The anterior glenohumeral joint, coracoid process, acromion and scapula should also be palpated for any tenderness and deformity. Palpation should include examination of the acromioclavicular and sternoclavicular joints, the cervical spine and the biceps tendon. Atrophy of the supraspinatus or infraspinatus should prompt a further work-up for such conditions as rotator cuff tear, suprascapular nerve entrapment or neuropathy. Scapular “winging,” which can be associated with shoulder instability and serratus anterior or trapezius dysfunction, should be noted. Deformity, such as squaring of the shoulder that occurs with anterior dislocation, can immediately suggest a diagnosis. Swelling, asymmetry, muscle atrophy, scars, ecchymosis and any venous distention should be noted. The patient should be properly disrobed to permit complete inspection of both shoulders. The physical examination includes observing the way the patient moves and carries the shoulder. ![]() The neck and the elbow should also be examined to exclude the possibility that the shoulder pain is referred from a pathologic condition in either of these regions. A complete physical examination includes inspection and palpation, assessment of range of motion and strength, and provocative shoulder testing for possible impingement syndrome and glenohumeral instability. ![]()
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