Table Of ContentRyan J. Warth
Physical Peter J. Millett
Examination of
the Shoulder
An Evidence-Based
Approach
123
Physical Examination of the Shoulder
Ryan J. Warth (cid:129) Peter J. Millett
Physical Examination
of the Shoulder
An Evidence-Based Approach
Ryan J. Warth, M.D. Peter J. Millett, M.D., M.Sc.
Steadman Philippon Research Institute The Steadman Clinic
Vail , CO , USA Steadman Philippon Research Institute
Vail , CO , USA
ISBN 978-1-4939-2592-6 ISBN 978-1-4939-2593-3 (eBook)
DOI 10.1007/978-1-4939-2593-3
Library of Congress Control Number: 2015934007
Springer New York Heidelberg Dordrecht London
© Springer Science+Business Media New York 2015
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Pref ace
P roper diagnosis and treatment of the various physical ailments with which
patients present to health care providers depends on accurate and effi cient
history and physical examination. This is arguably never more important than
in the evaluation of symptoms relating to the shoulder, one of the most com-
plicated of all the bioengineering marvels of the human body, and one of the
most common sources of patient complaints.
The differential diagnosis of shoulder pain requires consideration of a very
long list of potential etiologies that can range anywhere from bursitis and
rotator cuff disease to cervical spine pathology in addition to any number of
coexisting conditions. Appropriate performance and interpretation of the
shoulder examination are essential skills that can answer many questions
regarding etiologies, potential diagnoses and treatment options including sur-
gical planning and postoperative management. This book provides an inte-
grated approach to the diagnosis of numerous shoulder pathologies by
combining discussions of pathoanatomy and the interpretation of physical
examination techniques and was written for any health care professional or
student who may be required to evaluate patients who present with shoulder
pain. This information will allow the clinician to make informed decisions
regarding further testing procedures, imaging and potential therapeutic
options. The primary goal of this book is to provide readers with the knowl-
edge and confi dence required to perform an appropriate examination and to
generate a succinct list of differential diagnoses using an evidence-based
approach.
Vail, CO, USA Ryan J. Warth, M.D.
Peter J. Millett, M.D., M.Sc.
v
Contents
1 About This Book ........................................................................... 1
2 Range of Motion ............................................................................ 5
3 Strength Testing ............................................................................ 39
4 Rotator Cuff Disorders ................................................................. 77
5 Disorders of the Long Head of the Biceps Tendon ..................... 109
6 Glenohumeral Instability ............................................................. 139
7 The Acromioclavicular Joint ........................................................ 183
8 The Sternoclavicular Joint ........................................................... 209
9 Scapular Dyskinesis ...................................................................... 219
10 Neurovascular Disorders .............................................................. 241
Index ....................................................................................................... 271
vii
About This Book 1
The primary purpose of this book is to provide a E xamination of the shoulder has historically
comprehensive guide for anyone who is required been stigmatized as being overly diffi cult or
to examine the shoulder. An online version of this intimidating, especially for the inexperienced
book is provided for easy accessibility. investigator who has yet to develop the necessary
While many books serve as an exhaustive list fund of knowledge to adequately evaluate shoul-
of all the available shoulder examination maneu- der function. As a result, imaging studies have
vers, few have undertaken the task of developing been relied upon to make diagnoses that should
a text that both simplifi es and illustrates the most have been made during the initial physical exam-
important pathoanatomy, procedural elements, ination. There are numerous factors that may be
and clinical data involved with physical exami- involved with the perceived diffi culty of the
nation of the shoulder. The goal of this book was shoulder exam:
to present the most relevant clinical data and 1. Factors in the patient’s history are often
examination maneuvers in a digestible, predict- nonspecifi c .
able manner such that the application and inte- The nonspecifi c nature of many historical
gration of the presented techniques can occur fi ndings is particularly frustrating for the inex-
quickly and seamlessly. perienced clinician. This is especially true for
A lthough there have been numerous indi- physicians who are forced to care for patients
vidual studies evaluating the usefulness of the with musculoskeletal problems without the
various shoulder examination techniques, it is necessary training. As an example, a patient
nearly impossible to understand which maneu- with an anteroinferior labral tear (i.e., Bankart
vers are the most relevant without a complete lesion) may present with a sudden onset of
systematic review of each technique. This book sharp pain with movement, a gradually inten-
provides a literature review that iterates the sifying dull pain or even the absence of pain in
relative utility and effi cacy of the various phys- some cases. This highlights the necessity to
ical examination maneuvers and provides guid- perform a complete examination in each
ance as to which techniques are most important patient with a shoulder condition such that
for each individual diagnosis or series of diag- notable and potentially problematic condi-
noses. In addition, we provide an evaluation of tions can be identifi ed and properly treated.
current research surrounding the different 2. Physical examination fi ndings commonly
examination techniques thereby identifying overlap across multiple pathologies.
knowledge gaps upon which improvements can There are many shoulder pathologies that
be sought. present in similar ways. For example, the
R.J. Warth and P.J. Millett, Physical Examination of the Shoulder: An Evidence-Based Approach, 1
DOI 10.1007/978-1-4939-2593-3_1, © Springer Science+Business Media New York 2015
2 1 About This Book
active compression test, initially developed tis, rotator cuff tears, labral lesions, acromio-
for the identifi cation of labral pathology, is clavicular pathology, and/or various fractures
also sensitive for acromioclavicular joint among a long list of other potential
pathology in certain patients. The identifi ca- pathologies.
tion of biceps tendon pathology and SLAP 5. There may be multiple coexisting conditions
tears can also be diffi cult since there does not that present similarly.
exist an examination maneuver with adequate O ne of the most diffi cult aspects of the
sensitivity and/or specifi city values. Although shoulder examination is discerning the fi nd-
a positive test can be useful in many cases, it ings of different pathologies that may be pres-
is important to recognize the ability of each ent in the same patient. These fi ndings may
test to detect various other pathologies. This overlap on many occasions, forcing the inex-
book will identify these discrepancies and perienced clinician to guess at the correct
provide strategies for the avoidance of diagnosis. This book will provide the reader
confusion. with the tools required to make these impor-
3. The utility of palpation is limited due to over- tant distinctions thus allowing for an accurate
lying muscle and fat. diagnosis and the development of a focused,
The deltoid is a large, thick muscle that structured treatment plan.
often precludes the ability to palpate normal 6. Signifi cant pathologies may be asymptomatic.
or abnormal structures around the shoulder Sometimes the most important historical
complex. Even though palpation is diffi cult, fi ndings are those that do not exist. This is
it is still a necessary portion of the physical especially important for shoulder conditions
examination process as there are certain that tend to progress over time—the devel-
clues that can be obtained with superfi cial or opment of symptoms often go unnoticed to
deep palpation. Another diffi culty is that the patient for a signifi cant period of time.
deep palpation may engender pain as a result However, it is still important to recognize
of the pressure from the examiner’s fi ngers how these pathologies affect the patient’s
rather than from the pathologic process. This shoulder function. Thus, it is always impor-
is especially important when evaluating tant to complete a full, structured examina-
anterior shoulder pain as a result of coracoid tion even if the patient denies symptoms.
impingement—deep palpation of the cora- One important example is that of rotator cuff
coid will generate pain in most patients who disease. While it is well recognized that the
are not extremely thin; however, this may or prevalence of rotator cuff disease increases
may not be the result of subscapularis with age [ 1 –3 ], the development of symp-
impingement underneath the coracoid toms does not always follow this pattern of
process. progression [4 ]. However, studies have
4. Specifi c pain patterns are variable and have found that patients with asymptomatic rota-
not been fully defi ned for the shoulder. tor cuff tears develop changes in glenohu-
In most cases, the precise location, inten- meral range of motion, changes in shoulder
sity, onset, timing, and quality of shoulder strength [ 5 , 6 ], and changes in radiographic
pain have not been fi rmly attached to any spe- parameters [7 ] . As the tear biology changes
cifi c diagnosis. Although certain pain patterns and progresses, symptoms may eventually
are helpful and may lead the clinician to per- become noticeable and potentially disabling.
form certain maneuvers, this information A study by Yamaguchi et al [4 ]. found that
should not be considered a reliable indicator patients with asymptomatic rotator cuff tears
for any one condition. As an example, anterior developed symptoms at an average of 2.8
shoulder pain can be the result of osteoarthri- years independent of whether an increase in
