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(English captions by Andrea Matsumoto from[br]the University of Michigan)

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To ensure a thorough assessment it is best[br]to perform the musculoskeletal exam of the

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shoulder in a systematic way.

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The following is a suggested order of exam[br]that incorporates the common techniques for

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diagnosing shoulder injuries.

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The shoulder exam begins with inspection.

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In an anterior view assess the shoulders for[br]asymmetry, clavicle deformity, muscular atrophy,

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or skin changes.

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In a posterior view assess for the same.

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Next evaluate for active range of motion.

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If pain or limitation exists, repeat the motion[br]passively.

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To rule out cervical causes of referred shoulder[br]pain, evaluate neck range of motion: flexion,

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extension, lateral flexion, and rotation.

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Next evaluate active range of motion of the[br]shoulders: flexion, extension, abduction,

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adduction, external rotation, and internal[br]rotation.

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From the posterior view we can further assess[br]the combined adduction and external rotation

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with Apley scratch test of external rotation.

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Have the patient reach overhead and down the[br]spine.

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Most patients can reach past C7.

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Combine adduction and internal rotation with[br]the Apley scratch test of internal rotation.

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Have the patient reach behind the back and[br]up the spine.

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Most patients can reach to T7 or the lower[br]border of the scapula.

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Next assess the strength of the rotator cuff[br]muscles.

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The drop arm test evaluates for a supraspinatus[br]muscle tear.

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Passively adduct the shoulder to 90 degrees,[br]flex to 30 degrees, and point thumbs down.

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The test is positive if the patient is unable[br]to keep arms elevated after the examiner releases.

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Supraspinatus muscle strength testing can[br]also be done using the empty can test.

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In this same position provide resistance as[br]the patient lifts upward.

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Pain suggests possible tendinopathy or tear.

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Infraspinatus and teres minor muscle strength[br]is tested with resisted external rotation.

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Pain or weakness suggests a possibly tendinopathy[br]or tear.

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Subscapularis muscle strength can be tested[br]with resisted internal rotation.

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Subscapularis muscle strength is also tested[br]with the push-off test.

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Have the patient adduct the arm and internally[br]rotate behind their back.

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Provide resistance as the patient pushes their[br]arm away from the body.

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Pain or weakness suggests tendinopathy or[br]tear.

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Next palpate anatomic landmarks for tenderness.

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The suprasternal notch, the sternal clavicular[br]joint, along the clavicle, the AC joint, the

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acromion, the greater tubercle of the humerus,[br]the lesser tubercle of the humerus, the

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long head of the biceps which runs between[br]the greater and lesser trochanter, and as

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you internally and externally rotate you can[br]feel that, and the coracoid.

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Posteriorly look at acromion, the scapular[br]spine, the supraspinatus muscle above the

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spine, the infraspinatus below the spine,[br]teres minor muscle, the trapezius muscle,

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the rhomboid muscle, and look for scapular[br]thoracic articulation, particularly looking

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for winged scapula.

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Specific testing of the shoulder to evaluate[br]for injuries may include but is not limited

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to the following tests.

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Hawkin's test assesses for possible rotator[br]cuff impingement.

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Stabilize the scapula, passively abduct the[br]shoulder to 90 degrees, flex the shoulder

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to 30 degrees, and flex the elbow to 90 degrees,[br]and internally rotate the shoulder.

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Pain is a positive test.

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Neer's test also assesses for possible rotator[br]cuff impingement.

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Stabilize the scapula and with the thumb pointing[br]down passively flex the arm.

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Pain is a positive test.

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The cross arm flexion test also evaluates[br]for acromioclavicular arthritis or subluxation.

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Flex the shoulder to 90 degrees and adduct[br]across body.

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Pain at the acromioclavicular joint is a positive[br]test.

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There are several tests to evaluate for shoulder[br]instability.

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To test inferior glenohumeral stability place[br]traction on the humerus with the arm at the

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patient's side.

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If a gap greater than 1cm appears between[br]the humoral head and the undersurface of the

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acromion it is considered a positive sulcus[br]sign with inferior instability.

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The load and shift test evaluates for anterior[br]and posterior glenohumeral stability.

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Provide an axial load on the humerus compressing[br]the glenohumeral joint, then move the humeral

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head anteriorly and posteriorly.

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Anterior or posterior displacement is positive[br]for instability.

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The apprehension and relocation tests also[br]evaluate for anterior glenohumeral stability.

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With the patient supine, abduct shoulder to[br]90 degrees and externally rotate the arm to

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place stress on the glenohumeral joint.

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If the patient feels apprehensive that the arm[br]may dislocate it is a positive apprehension arm.

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The relocation test is performed using the[br]examiner's hand to place a posteriorly directed

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force on the glenohumeral joint.

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Relief of apprehension is a positive test.

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There are several tests that assess for injuries[br]of the biceps tendon and glenohumeral labrum.

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To perform a Speed's test flex the shoulder[br]to 90 degrees with the arm supinated.

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Provide downward resistance against the shoulder[br]flexion.

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Pain indicates possibly bicepital tendon[br]or labral tear.

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To perform Yergason's test flex elbow to[br]90 degrees, shake hands with patient and provide

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resistance against supination.

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Pain indicates a possible bicepital tendon[br]or associated labral tear.

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To perform O'Brien's Test point the thumb[br]down and flex shoulder to 90 degrees.

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Adduct the arm across midline, provide resistance[br]against further shoulder flexion and evaluate

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for pain.

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Repeat with the thumb pointing up and again[br]evaluate for pain.

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If pain was present with the thumb down but[br]relieved with the thumb up, it is considered

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a positive test, suspicious for labral tear.

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To perform the Biceps Load Test supinate the[br]arm, abduct shoulder to 90 degrees, and flex

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elbow to 90 degrees.

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Externally rotate the arm until patient becomes[br]apprehensive and provide resistance against

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elbow flexion.

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Pain indicates possible bicepital tendonopathy[br]or associated labral tear.

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To perform the Biceps Tension Test supinate[br]the arm, abduct shoulder to 90 degrees, flex

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elbow to 90 degrees, and externally rotate[br]arm until patient becomes apprehensive and

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pronate arm.

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Pain indicates possible bicepital tendonopathy[br]or associated labral tear.

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To perform the Crank Test, fully abduct the[br]shoulder and provide an axial load on the

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humerus.

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Internally and externally rotate the arm.

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Pain, catching, or painful clicking is considered[br]a positive test suggestive of a labral tear.

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There are several tests to evaluate for thoracic[br]outlet syndrome as a cause for the patient's

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shoulder pain.

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To perform the Costoclavicular Maneuver draw[br]the patient's shoulders inferiorly and posteriorly.

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If patient has reproduction of arm pain or[br]numbness, consider thoracic outlet syndrome.

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To perform Roos' Test abduct the shoulder[br]to 90 degrees, flex elbow to 90 degrees, and

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rapidly open and close hands for up to 3 minutes.

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If the patient has reproduction of pain or[br]numbness, consider thoracic outlet syndrome.

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To perform Adson's Test locate the radial[br]pulse.

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Have the patient take a deep breath and extend[br]neck, and rotate head towards the painful

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shoulder.

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If radial pulse diminishes on the affected[br]side, it is considered a positive test suspicious

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for thoracic outlet syndrome.

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Spurling's Test evaluates for cervical root[br]impingement.

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With the head extended and rotated toward[br]the painful shoulder, apply an axial load

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to the cervical spine.

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Reproduction of pain or paresthesias with[br]this maneuver is a positive test.

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In concluding the shoulder exam it is important[br]to document a neurovascular exam.

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Here we demonstrate a brief exam.

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Resisted wrist extension tests the radial[br]nerve.

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Resisted opposition of the thumb tests the[br]median nerve.

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Resisted digit abduction tests the ulnar nerve.

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Radial artery pulse and capillary refill testing.

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Further neurologic or vascular exam may be[br]indicated by history.

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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.