Careful examination of the shoulder can provide valuable information and help the physician determine when imagine studies may or may not be helpful.
- Inspection: Observe both shoulders together. Note any atrophy or asymmetry.
- Exert pressure on the subacromial bursa, which lies lateral to and beneath the acromion. Subacromial bursitis is a common cause of shoulder pain.
- Palpate the bicipital tendon in the biciptial groove as the patient rotates the humerus internally and externally. Tenderness on this maneuver is consistent with bicipital tendinitis.
- Palpate the acromioclavicular joint. Note tenderness, bony hypertrophy, or (rarely) synovial swelling.
- OA & RA often affect the acromioclavicular joint; however, OA rarely involves the glenohumeral joint (exceptions include traumatic or occupational causes of shoulder pain).
- Palpate the glenohumeral joint by placing the thumb over the humeral head (medial and inferior to the coracoid process) while the patient rotates the humerus internally and externally.
- Tenderness is indicative of glenohumeral pathology.
- Very rarely a synovial effusion can be palpated. If appreciated, it may indicate RA, infection, or acute rotator cuff tear.
- Range-Of-Motion: With patient sitting up, put both shoulders through full range of motion actively and passively.
- Suspect fibromyalgia when glenohumeral pain accompanies diffuse periarticular pain and point tenderness.
- Rotator cuff pathology is a common cause of shoulder pain.
Suspect rotator cuff pathology if:
pain is elicited by active abduction against resistance, but not passive abduction
pain is located over the lateral deltoid
presence of night pain
a positive "impingement sign": Impingement syndrome occurs when the space is narrowed between the acromion and the greater tuberosity of the humorous. This can be caused by many things, including formation of bone spurs in osteoarthritis.
Impingement sign: Physician raises patient arm into forced flexion while stabilizing the scapula and so preventing its rotation. Pain developing before 180 degrees of forward flexion is considered positive.
Neer Sign: Place one hand over the shoulder then forward flex the arm 90 degrees in front of the patient followed by internal rotation of the whole arm at the shoulder, finally continue to raise the arm --> pain at shoulder is a positive test
Hawkins Sign: Ask patient to forward flex arm their arm 90 degrees in front of them, then flex the elbow 90 degrees, then have your patient rotate the should internally while you apply resistance with external rotation --> pain at shoulder is a positive test
A positive "drop arm test"
Drop Arm Test: Ask patient raise arm to 90 degrees of abduction and lower it slowly. A suddenly dropped arm is considered positive and suggestive of a rotator cuff tear.
Tendinitis or tear of the rotator cuff can be confirmed by MRI or ultrasound.
Consult the Expert
Dr. Mark Genovese
Dr. Mark Genovese is a Professor of Medicine and certified in rheumatology. He is actively involved in house staff training at Stanford University. He is involved in research including clinical trials and interventions in rheumatic diseases such as rheumatoid arthritis, psoriatic arthritis, & osteoarthritis.
If a careful exam does not elicit significant pain or laxity, imaging studies are extremely unlikely to provide further useful information.
Key Learning Points
- Learn the checklist and technique of the shoulder exam (see video)
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