SHOULDER HISTORY TAKING AND

EXAMINATION

Prepared by
Dr.Mohammed Faya’a
Dr.Saleem Bahran

Supervisor
Dr. Khalid Swilem -Dr.Abdullkarim Almahdi
 HISTORY TAKING
•Personal hx.
Name
Age (young, middle, old)
Occupation
Special habits
Handedness
• Chief complaint and duration
4 questions
1- What is the problematic area?
2-How did the problem occur? (Mechanism of Injury (If Applicable)
3-When did the problem develop?
4- Where did the problem occur? ( location of symptoms)
History of present illness
 Symptoms:
Pain
o character or type of pain( aching , sharp or catching , after activity , or at night)
o localized or generalized
o aggravating factors (during which of the following 1- midrange of arm elevation 2- terminal
range of arm elevation 3- throwing )
 Symptoms:
Instability
Weakness and loss of motion
Stiffness (Rest stiffness/ early morning stiffness )
Swelling, deformity and crepitus
Sensory changes
Function of daily living
Red flag
Associated or referred symptoms ( to lateral aspect of shoulder , elbow or distal upper extremity)
Presence of night pain and sleeping position
• Past hx.
Related past history to the current problem (e.g mature athlete with rotator
cuff injury from overhead activity fall onto the lateral aspect of the shoulder
or a shoulder separation shed light on the patient’s impingement-type
symptoms)
what treatment your recived for this problem (Previous surgical procedures,
steroid injections, therapeutic modalities, and exercise programs )
What are your expectation for us
 EXAMINATION
• Introduce yourself
• Take permission
• Exposure
• Hand washing
• The examination consists of:
Look, feel, move and special tests.
 EXAMINATION
• In standing position:
 Inspection
o from infront :
1. Alignment: ask the pt. to stand facing you
normal: the pt. keep the arms by the sides
posterior dislocation: arm held in internal rotation
inferior dislocation: arm held in abduction
Erb’s palsy: internal rotation of arm and flexion
of wrist
2. Shoulder level: normally both shoulders at the same level
if one shoulder higher than the other → painful shoulder
→ sprengel’s deformity

if one shoulder lower than the other → trapezius paralysis (drooping shoulder)
1. Scar:
 Type
 Position
 Size
 Healing
1. Muscle wasting:
 Trapezius muscle:
•Normally symmetrical bilateral
•Wasting due to injury of spinal
accessory nerve
 Deltoid muscle: it makes the normal contour of the shoulder
•Atrophy is due to injury of axillary nerve or disuse of shoulder joint
•Swelling is due to fracture neck humerus
•Flattening of shoulder and prominence of acromion lateral edge is due to ant.
dislocation
Swollen subacromiial bursa in rheumatoid Prominent lat. Edge of the
arthritis acromion in ant. shoulder dis-
location
1. Deformity and swelling:
 Clavicle : asymmetry of clavicle usually due to fracture or malunion
 Acromioclavicular joint : Its prominence varies between individuals but when
symmetrical it is normal.
prominent ACJ is due to:
1- subluxation or dislocation
2- degenerative arthritis
3- acute or chronic inflammation
 Sternoclavicular joint : this is easily seen in most patients though more diffi cult
in the obese.
prominent SCJ is due to:
1- ant. dislocation or subluxation
2- infection
3- arthritis
4- tumor
Less prominent SCJ is due to post. dislocation
 Inspection:
o From the side: look for scar or deformity
such as :
1- ACJ: prominence ( dislocation or subluxation)
2- Deltoid muscle middle fibers ( atrophy or swelling)
3- Acromion: prominence ( ant. dislocation of shoulder
or deltoid muscle atrophy.
4- Deltoid tubercle
5-Biceps brachii muscle
o From behind:
1. Shoulder level → slight elevation of the dominant shoulder may be seen
→ drooping shoulder (injury to spinal accessory nerve)
→ elevated shoulder ( painful shoulder or sprengel’s deformity)
2. Muscle wasting
a- trapezius: atrophy and drooping shoulder (injury to spinal accessory nerve)
b- deltoid: Middle and posterior fibers are best visualized from behind. Posterior swelling
seen with posterior dislocation of the shoulder
3. Scapula:
a. Size and position:
 Normal: both equal in size and at the same position and borders are not prominent
 Sprengel’s deformity (prominent, small and high level scapula)
 Prominent medial border:
• Internal rotation of the arm (normal)
• Tight posterior and/or inferior capsule of the shoulder joint
• Atrophy of serratus anterior/ trapezius/ rhomboid muscle
 Prominence of lateral border of scapula → Atrophy of latissimus dorsi
→ brachial plexus injury (Thorcodorsal nerve C6, 7, 8 nerve
roots)
 Prominent Superior border → trapezius muscle sever atrophy
 b. supra. And infraspinatus fossae:
Normal: equal in both side and no prominent scapular spine
Muscle wasting: prominent scapular spine
• Atrophy of supraspinatus/trapezius (above the spine of the scapula) →
rotator cuff tear or suprascapular nerve palsy (entrapment at the
suprascapular notch)
• Infraspinatus and teres minor muscles (below the spine of the scapula) →
rotator cuff tear or suprascapular nerve palsy (entrapment at the
spinoglenoid notch)
4- Scar
5- Deformity
o Inspect for scapular winging to examine
serratus ant. muscle power
(long thoracic nerve injury)
 Palpation:
From the front
o Sternoclavicular joint
Tender in 1- injury
2- infection
3- tumor
o Clavicle
Tenderness or swelling due to: 1- Fracture Non-union
2- nondisplaced fracture of acromion, greater tuberosity or coracoid process

o Acromioclavicular joint
Tenderness 1- type II ACJ injury ( with tenderness in coracoclavicular ligament)
2- Arthritis ( usually with swelling)
 Palpation:
 From the front
o Coracoid
Tenderness: adhesive capsulitis due to involvement of the coracohumeral ligament or pectoralis minor
enthesopathy.
o Coracoclavicular ligament: tenderness in type II ACJ injury
o Acromion
If painful: Fracture
Os acromiale
Subacromial bursitis
Rotator cuff tear (variable)
 Palpation:
 From the front
o Subacromial bursa
Tenderness in: 1- subacromial bursitis
2- Rotator cuff impingement or tear
o Long Head Biceps Tendon
Tenderness in: 1- Biceps tendenitis
2- Rotator cuff disease
o Pectoralis Major
Discontinuity in: intratendinous tear or avulsion
 Palpation:
 From behind:
o Trapezius
Tenderness and trigger points may be elicited, which are usually associated with cervical
spine pathology or local muscle injury.
o Scapular body and spine
Tenderness : fracture
o Supra. And infraspinatus fossae
o Soft spot of the posterior shoulder
 Range of motion: active then passive
Flexion: forward flexion (160-180 degree)
If limited → arthritis
→ adhesive capsulitis
→ large rotator cuff tear
passive forward flexion< active forward flexion
→ muscular weakness or tendon injury
(injury to the rotator cuff tendons or
weakness or paralysis of the scapular
stabilizers)
 Extension: normal range 20- 30 degree
from the sagittal plane
 Abduction: normal range 160 – 180 degree
o Decrease in: Arthritis of the glenohumeral joint
Adhesive capsulitis
o Painful in:
 Pain only between 60–120° (Painful arc)
→ impingement
→ rotator cuff tear
 Pain in terminal degrees of abduction
→ ACJ pathology
o If the patient cannot initiate abduction
→ weakness of deltoid
→ massive rotator cuff tear
 Adduction: with arm in the side or cross-chest, normal range is 30 degree and reach the
opposite shoulder respectively
o Pain in: ACJ pathology
o Limited in:
anterior dislocation of the
shoulder.
 External rotation at 0 and 90 degree abduction: normal range 45 – 90 degree
o limited external rotation which can be increased passively
→ Massive rotator cuff tear involving subscapularis
o Decreased external rotation
→ Adhesive capsulitis
→ Glenohumeral arthritis
→ Posterior dislocation of
the shoulder (Rowe’s sign)
Internal rotation at 0 and 90 degree abduction : normal range 30-45 degree in abduction
position and spinous process of T7-T9
o Limited internal rotation → adhesive capsulitis
Muscle power of the periscapular muscles:
 Scapular stabilizers:
 Trapezius ( spinal accessory nerve and C3,4)
If weak the resting position of the scapula may be more lateral than normal
If weak or paralyzed → rotaty winging scapula when arm move against resistant
Serratus Anterior (Long Thorascic Nerve C5,6,7)
If weak or paralyzed → medial border of the scapula moves away from the chest wall
(scapular winging)
Rhomboid (dorsal scapular nerve C5)
 HUMERAL ADDUCTOR/INTERNAL ROTATORS
Lattismus dorsi ( thoracodorsal nerve C6,7,8)
Pectoralis major (Lateral Pectoral Nerve C5, 6)
 HUMERAL ABDUCTORS
Deltoid ( axillary nerve C5,6)
 Sensory testing :
 Axillary nerve
 Musculocutaneous nerve
 Special tests:
 Rotator cuff muscles ( power and special tests)
1- Supraspinatus (C5,6): power(Jobe’s or supraspinatus isolation test) and drop arm test
o Drop arm test indicated when passive abduction is greater than active
It is +ve → large rotator cuff tear
2- Infraspinatus ( suprascapular nerve C5,6): power and external rotation lag (drooping) test
o If +ve external rotation lag test → damage to the infraspinatus tendon and accompanying
muscle atrophy
3- Teres minor ( axillary nerve C5,6): power and Hornblower’s sign
o If Hornblower’s sign +ve → weakness of the teres minor
4- Subscapularis (Suprascapular Nerve C5,6): power (Gerber’s lift off test), internal rotation
lag test and belly press test
o +ve lift off test → unfunctioning subscapularis muscle
o +ve internal rotation lag test → unfunctioning subscapularis muscle
o If +ve Belly press test → significant subscapularis weakness
 Impingement:
1- Neer’s sign:
2- Neer’s test:
3- Hawkin Keendy’s sign:
ACJ special tests:
1- Scarf test ( cross body adduction test):
2- O’Brien’s test:
 Labral tear ( SLAP) special tests:
1- O’Brien’s test
2- Crank test:
 Special tests for biceps muscle pathology:
1- Speed test ( resisted forward shoulder elevation):
2- Yergason’s test:
3- Biceps instability test:
 Thoracic outlet special tests:
1- Roo’s test
2- Adso’s test:
3- Hyperabduction test:
 Special tests for instability: before begin the tests ask the pt. if he feels instability and in
which direction
1- Sulcus sign:
2- Anterior and posterior drawer:
3- Circumduction:
• Supine position:
1- Anterior instability:
a. Anterior apprehension, relocation and release tests:
b. Posterior instability test:
o Posterior apprehension test:
o Jerk test:
o Kim test:
c. Anterior and posterior load and shift tests:
• To complete your examination you should examine the pt. for Bighton’s score, cervical spine
elbow and neurovascular examination of upper limb.
THANK
YOU