Shoulder Pain Assessment

Complaints can be divided into Acute vs Chronic Acute are usually injuries that can be divided into

Bony (Fractures) Soft tissue (Tendon and Ligament injuries)

Chronic Joint (OA)Soft Tissue (Tendon and Ligament)

As a ‘general rule’ the first question to ask the Patient is ‘point to where the worst pain is?’(Point of Maximal Pain = POMP)Anterior – Long Head of Biceps Tendon (LHBT)(NB: can be isolated but are often related to other shoulder pathology such as

rotator cuff, SLAP)Top of the Shoulder – usually rotator cuff or ligament injuryBack of the shoulder – usually shoulder dyskinesia.

Examination1. Inspection – look for deformity, bruising, scars, atrophy.2. Palpation – always examine the neck, scapula then start at the sternoclavicular joint,

along the clavicle, AC joint, biceps and rotator cuff. Test nerve integrity

- Brachial plexus- Axillary nerve (sensation over the upper outer humeral area)

- Supraclavicular nerve – atrophy and weakness of SS and IS. Pain over the suprascapular notch

Bicep: with elbow 90 degrees, palpate bicipital grooveScapula – Full flexion with pressure – watch for winging. Assess for tenderness over the scapular corner – pain associated with subscapular bursitis.

3. Range of Motion 1) Apley scratch test (pt touches opposite shoulder, ‘hand cuff’ position with hand up as high on the spine as possible, and reach over ipsilateral shoulder as far down the spine as possible)

Apley Test

Specific Rotator Cuff exam:Some authors suggest if you do a Painful Arc test, Drop Arm test and Weakness in

external rotation and all 3 are negative there is very low chance of a rotator cuff tear. If all 3 tests are positive, then a significant tear is likely.

1) Painful arc - pain with resisted abduction. Usually, will start from 40 + degrees. May have apprehension or pop at 60+ degrees with tendinopathy. Likewise bringing the arm down from full abduction may feel pain or pop as SS tendon goes under acromial process.

2) Drop Arm test – Passively adduct arm to 90 with arm externally rotated. Have the Pt then hold that position. Inability to do so or control downward motion suggests SS +/- IF tear. Alternate is to fully abduct arm and have patient lower the arm.

3) Resist external rotation of arm with elbow flexed at 90. Pain and weakness suggest infraspinatus tear.

4) Supraspinatus- Jobe’s test (empty can): arm is extended 90 and 45 from body with thumb

down. Compress arm down against resistance. If pain but no weakness, suggests partial tear. If no pain and weakness, suggests full thickness tear. (stabilize scapula as scapular dyskinesia can contribute to weakness)

- Resistance testing (isometric strength) of the SS from 0-30 digress for over 30 seconds assesses SS strength (deltoid fatigue occurs allowing assessment of the SS)

-5) Subscapularis

Gerber or Lift off test – hand behind back and push against resistance posteriorly. Pain and weakness suggests tendon tear.

Pain and no weakness suggests tendinopathy or minor tear.

Bear-Hug test: Pts hand holds opposite shoulder with arm horizontal. Try to pull hand off the shoulder. Weakness or dropping of the elbow suggests subscap tear

Tests for Shoulder Impingement 1. Passive Painful Arc – passively flex the shoulder while preventing shrugging.

- Pain at 90 degrees suggests mild impingement- Pain at 60-90 suggests moderate impingement- Pain at 45 degrees suggests severe impingement

2. Hawkins-Kennedy test – elbow flexed 90 degrees, internally rotate shoulder with your hand. Pain with internal rotation suggests impingement.

Labral Pathology (SLAP tears) - Superior Labrum Anterior Posterior tears = tears of the glenoid labrum that extend anterior to posterior in a curved pattern.

- Patients usually complain of vague anterior pain, with episodic clicking especially when

arm is in cocked position with throwing.

- Usually with a history of shoulder dislocation, subluxation or ‘shoulder sprain’. - SLAP tears are often associated with other shoulder pathology.

- No one test is specific for SLAP tears. - Usually, the diagnosis is made with imaging or arthroscopy.

O’Brien Test (Active Compression Test): - Arm is flexed to 90 with elbow extended. - Then adduct 10 degrees and internally rotate arm (thumb down). Examiner pushes arm down. Assess for deep pain or clicking. Then externally rotate arm (thumb up). - If pain/click with internal rotation but less or none with external = positive test for SLAP, but can be associated with OA pain (OA often occurs with night pain, but not in SLAP tears. - If there is no pain, but patient complains of anterior shoulder pain, consider isolated LHBT pathology

Referral under 35 in suspected SLAP tears is preferred. Over 35 may not be surgical

candidates. All should receive prolonged physio prior.

Bicep PathologyPatients usually complain of anterior shoulder pain. Most commonly is the Long Head Biceps Three most common conditions are

TendinopathyLHBT tears – partial or completeSubluxation

1. Tendinopathy – usually painful with palpation or stress testing the bicep. Treatment can be physio or cortisone injection.

2. Partial tears can be painful and are difficult to see on U/S3. Complete tears give the ‘Popeye’ sign and often have bruising. Proximal tears are usually

treated conservatively. Distal tears should be referred4. Subluxation/dislocation can be seen on ultrasound.

subluxation of bicep tendon

LHBT tear LHBT partial tear (transverse)

Summary Shoulder ExamInspection Palpation – neck, scapula, SC jt to AC jointNeuro – axillary, supraclavicular n. ROM – Apley, abduction. Rotator Cuff

Painful arc – supraspinatus Drop arm – supraspinatus +/- infraspinatus Isometric resistance

external rotation – infraspinatus abduction – supraspinatus

Jobe’s (empty can) – supraspinatus Gerber or Lift off – subscapularis Bear Hug – subscapularis Passive Painful arc – impingement Hawkins-Kennedy – impingement O’Brien test – SLAP tear