From the first days in medical school, physicians are taught that establishing a correct diagnosis depends on obtaining a meaningful and detailed medical history from the patient. This requires the physician to ask specific questions while also actively listening to the responses from the patient. Often physicians formulate their next question without listening to and interpreting the answer to the previous inquiry. Obtaining a good patient history is, in itself, an art that requires experience and patience. One of us (J.J.B.) vividly recalls a mentor stating that all patients come to your office and tell you exactly what is wrong with them when they answer four or five questions. Our task is to decipher their answers to those few questions.
Time is perhaps the most valuable—and least available—commodity in our medical lives in the 21st century. We employ physician extenders to help our efficiency, and we ask patients to fill out reams of paperwork with numerous questions while we are seeing another patient. We thus lose the advantage of directly listening to our patients, observing their expressions, and interpreting their body language. Each of these facets can offer valuable information to help reach a diagnosis of their shoulder problem. We must recognize that often the answer to one question leads to the formation of the next. This valuable opportunity is lost in the hustle of managing medical care in this era, and it is indeed a lost opportunity. Our duty to our patients is to inquire, listen, examine, test, and then formulate a diagnosis. When performed in this logical fashion, the diagnosis is nearly always straightforward and the treatment then easily rendered.
In evaluating the patient, we also must bear in mind that we really are assessing the patient, not just interpreting radiographic studies or laboratory values. In this increasingly technologic world, it is often easy to lose sight of this and to begin treating magnetic resonance imaging scans without treating the patient. For example, nearly every magnetic resonance imaging of the shoulder we have seen in a patient older than 30 years suggests acromioclavicular (AC) joint pathology. Perhaps it is then not surprising that the most overdiagnosed and overtreated condition of the shoulder relates to the AC joint.
As clinicians we must evaluate the patient’s history and perform a thorough physical examination to establish a strong correlation between the features of each pathologic process. Our confidence rises when the patient’s history of the complaint is consistent with the majority of the physical findings. This confidence rises even more when radiographic and laboratory studies are also consistent with the initial diagnosis. When all these features of the patient evaluation point to the same diagnosis, our certainty of the correct diagnosis becomes assured. It is obviously much more disconcerting when a patient’s history suggests rotator cuff pathology, the physical examination is more consistent with instability, the radiographs document osteoarthritis, and the laboratory values suggest gout.
We hope the methods described in this chapter for taking a history and performing a physical examination allow every clinician to determine the pathology primarily responsible for the patient’s shoulder complaints.
Patient history
Taking a history from a patient is an art. We must ask specific questions, actively listen to the response, and only then formulate the next question. The answer to each successive question should ultimately lead the physician to a correct diagnosis. It is important not to develop tunnel vision and lead the patient toward the diagnosis that you think is present.
Recall that many widely varying diagnoses manifest with similar symptoms, and differentiation of these diagnoses can be made only after a complete history and examination. For example, if a patient presents with the inability to elevate or externally rotate the arm, the physician might immediately diagnose a frozen shoulder. However, sending that patient, who actually has advanced osteoarthritis, to physical therapy to increase the range of motion (ROM) would ensure a therapeutic failure. A diagnosis is established only after each phase of the evaluation is complete. Anything less in the name of expedience and efficiency does a disservice to our patients.
Age
Most, if not all, disease processes occur in specific patient age ranges. Although malignancies and traumas can occur at any chronologic age, even these processes tend to stratify by age. Surgical neck fractures of the humerus are typical of a postmenopausal woman with osteoporosis rather than an 18-year-old male football player. Osteosarcomas of the proximal humerus are more common in a 20-year-old than in a geriatric patient. The younger, athletic person in the second or third decade of life is more likely to have instability, whereas the 60-year-old golfer with a painful shoulder is more likely to have rotator cuff disease.
Although not fully studied or accurately analyzed, there is a perception that osteoarthritis of the shoulder is occurring at ever-younger ages. Not only is it in the domain of the 70- and 80-year-old patient; often patients in their 50s and younger present with osteoarthritis. Avascular necrosis, infections, and rheumatoid arthritis can occur at any age; thus age is a poor discriminator for these conditions. Spontaneous hematogenous septic arthritis may be slightly more common during youth, but its clinical presentation is usually so specific that the age of the patient need not be considered.
Shoulder instability and its subsets of pathology are much more common during youth and early adulthood. Labral tears, superior labrum anterior and posterior (SLAP) tears, and biceps tendinitis are commonly seen in patients younger than 30 years. However, some activities that span the entire age range, such as downhill skiing, carry a considerable risk of acute shoulder dislocations. Nevertheless, the implications of a traumatic shoulder dislocation are age specific. In a younger patient who sustains a glenohumeral dislocation, the more likely associated injury involves the labrum or biceps anchor. Conversely, in an older patient, an acute glenohumeral dislocation is more commonly associated with a rotator cuff tear. Similarly, trauma to the shoulder can afflict the AC joint. In a younger patient disruption of the joint is more common, whereas in older patients, clavicular fracture may be more common.
Some less common conditions afflicting the shoulder still display a predilection for certain age groups. Gout and symptomatic calcific tendinitis usually occur in middle age. Adhesive capsulitis appears in midlife (more commonly in women), and diabetic neuropathic disease is more common in older persons. Cuff tear arthropathy is clearly more common in women in their mid-70s.
Box 4.1 lists common diagnoses associated with typical age ranges. However, it should be remembered that any diagnosis can overlap with any age category.
<30 years old: Instability, superior labrum anterior posterior tears, biceps tendinopathy, acromioclavicular joint injury, labral injury
30–60 years old: Rotator cuff disease, adhesive capsulitis, gout, calcific tendinosis
>60 years old: Arthritis, fractures, diabetic neuropathy
>70 years old: Cuff tear arthropathy
No age association: Avascular necrosis, infection, rheumatoid arthritis/inflammatory arthropathy, malignancy
Sex
Most pathologic processes that afflict the shoulder affect both sexes equally. Trauma can occur to anyone; arthritis, infection, cuff tears, avascular necrosis, calcific tendinitis, and gout can likewise occur with equal frequency in male and female patients. However, three conditions, although not exclusive to women, have a significantly higher prevalence in female patients.
Multidirectional shoulder instability is seen much more frequently in female patients between the ages of 15 and 25 years than in male patients of the same age. Why this is the case remains unclear. Male patients might present with clinical evidence of multidirectional laxity, but perhaps because of stronger and better-conditioned muscles, they are better able to compensate for their ligamentous laxity in ways female patients cannot or do not. It remains doubtful that there is a difference between sexes in the pathophysiology of the condition, but the positive biologic response to the condition seems to favor the male patients. A teenage female athlete who presents with shoulder complaints likely has some type of instability pathology. However, the clinician must remain open to other diagnoses and be sure to distinguish patient symptoms from clinical signs. For example, a young person might present with symptoms of cuff tendinitis that are caused by underlying shoulder instability.
Female patients also tend to present in far greater numbers than males with adhesive capsulitis. This is in contrast to the idiopathic stiff and painful frozen shoulder, which is equally prevalent among male and female patients and describes restricted shoulder ROM associated with pain. A frozen shoulder can result from any number of pathologic processes, such as posttraumatic stiffness, immobilization, and tendinitis. Adhesive capsulitis is a specific diagnosis most prevalent in women 40 to 60 years of age. It is associated with an idiopathic inflammatory process involving the glenohumeral joint capsule and synovium that results in capsular contraction and adhesion formation.
Although massive rotator cuff tears probably occur in greater numbers in men, it is women, classically older than 70 years, who develop the sequelae of these tears. The diagnosis of cuff tear arthropathy, as defined by painful collapse of the humeral head with superior migration (not iatrogenically provoked by prior release of the coracoacromial ligament), is much more common in geriatric women compared with men, for reasons that are unclear.
Presenting complaint
When the physician asks about a patient’s chief complaint during the initial visit, pain is the most common response. Subsequent questioning is directed toward better understanding the characteristics of that pain and a presumptive diagnosis follows. Most presenting complaints related to the shoulder are described by patients as pain, stiffness, loss of smooth motion, instability, neurologic symptoms, or combinations of these.
With respect to shoulder pathology, another chief complaint may be one of joint instability. In this case the patient might have no pain and is concerned only by the sense that the shoulder joint is loose or sloppy or recurrently dislocates. The patient might initially complain of numbness or tingling down the limb, which may be caused by neurologic pathology unrelated to the shoulder. Dissection of this symptom may be more challenging because pathology in the neck might have to be distinguished from shoulder pathology.
Weakness is rarely a sole presenting complaint. Weakness without pain nearly always defines a significant neurologic event or pathologic process. If stiffness of the shoulder is a presenting complaint, it is nearly always accompanied by an element of pain. A patient might present with a complaint of crepitus or popping in and about the shoulder associated with activity or a specific arm motion, but an isolated awareness of crepitus without pain is very rare.
Pain
The discussion of pain is challenging because, by definition, it is a completely subjective complaint. In our vast armamentarium of technology and laboratory analyses, we cannot objectify pain. Pain is a perception of data presenting to our brains. We have all experienced the reality of injuring ourselves with minor scrapes and scratches in our daily lives but have remained fully unaware of this until hours later. Have we all not jumped into a pool of water only to feel cold initially? Within minutes, the initial discomfort fades as we rapidly become conditioned to the water temperature. The water temperature obviously does not change; it is our perception of the same data input to our brain that changes.
The same can be the case with other painful stimuli. Psychologists (and perhaps our own experience) suggest that mood can have a dramatic effect on pain perception. People who are depressed or sullen by nature tend to experience greater discomfort and be more disabled for a given level of painful stimuli, and the opposite is likewise true; energetic, optimistic, and happy patients tend to discount even a significant level of otherwise painful stimuli.
Other societal issues are also known to affect a patient’s perception and response to pain. Specifically, issues related to material gain can have significant influence on patients’ responses to the treatment for the pain. For example, active litigation involving contested remuneration can lead to the perpetuation of a patient’s symptoms. Similarly, patients with workers’ compensation claims might have little incentive to report improvement in their symptoms. There is no pain meter that can substantiate or dispute such claims.
Despite these limitations, obtaining a history related to pain is critically important and valuable. Features of the pain, such as its character, onset, radiating patterns, and aggravating and alleviating factors, nearly always assist the clinician in discerning a diagnosis. Box 4.2 provides an overview of the features of pain that should be evaluated.
Severity (scale of 1–10)
Character (dull, sharp, ache, lancinating)
Onset (acute, chronic, insidious, in a defining moment)
Location (e.g., superior, posterior, anterior, scapular)
Patterns of radiation (neck, arm, below elbow, deltoid insertion)
Aggravating factors (e.g., arm position, time of day)
Alleviating factors (e.g., arm position, medications)
Prior injections (site, response)
Prior treatment
Character of the pain.
Despite our inability to measure pain, patients use similar adjectives to describe their pain. These descriptions can offer much insight into its cause. Pain associated with an acute fracture understandably can be severe and disabling, often remaining minimally responsive to narcotic analgesics for days. In contrast, the pain of impingement and rotator cuff pathology is commonly described as dull, boring, and toothache-like in quality. The pain of a frozen shoulder is typified as all or none: when present at the end point of available motion, the pain is truly disabling, whereas when the arm is functioning within its available arcs of motion, pain does not exist. Patients with painful osteoarthritis describe pain that frequently alternates between a sharp stabbing pain under high compressive joint loads and a chronic lower level of pain during less-demanding activities. Patients with severely destructive rheumatoid disease are often so conditioned by the chronicity of their disease that their description of their pain appears to be inconsistent with the degree of joint destruction. These patients tend to be more disabled by their functional loss than by their perceived pain.
Acute calcium deposition in the cuff tendons results in a characteristic type of pain. The pain is so acute and so severe that calcium deposit in the shoulder has been likened to a kidney stone of the shoulder. The pain associated with a kidney stone seems so well understood by the population at large that the pain in the shoulder associated with acute calcific deposit is easily understood as well. Patients with this condition seek a dark, quiet room with minimal competing stimulation. The pain can be so nauseating and disabling that many patients visit an emergency department (ED). The clinical picture is so evident and the radiographs so typical of the condition that the diagnosis is rarely in doubt.
Onset of the pain.
The clinician asks about the onset of the symptoms because this feature has implications in the diagnosis of shoulder pathology. Understandably, with an acute onset of severe pain following a traumatic event, the diagnosis of fracture on a radiograph is not challenging. Other diagnoses may also be discerned by inquiring about the circumstances of the onset of the patient’s pain. Impingement and rotator cuff disease more commonly lack a specific date or time of onset; if the patient recalls an insidious onset of the pain, often dating its initiation many weeks or months in the past without a clearly identifiable event, this should make the physician suspicious for cuff-related pathology. Even if the patient presents with a recent onset of pain in the absence of trauma, inquiry needs to be made regarding a history of pain predating the more recent traumatic event.
Radicular pain of cervical origin is likely to have an insidious onset. Patients might acknowledge that turning the head provokes symptoms. Arm pain while driving often indicates a pain of cervical origin. Pain described as sharp and stabbing and occurring intermittently in the scapular muscles and around the top of the shoulder nearly always has its source in the cervical spine.
Location of pain perception.
Pain is poorly localized around the shoulder girdle. The specific location where the patient perceives the pain is rarely the site of origin of the pain. The most common location for the perception of rotator cuff disease and the associated bursitis is down the arm toward the deltoid muscle insertion. The pain and inflammation associated with bicipital tendinitis is typically perceived down the anterior arm, although the site of pathology is proximal to the intertubercular groove. Pain associated with an AC injury usually radiates medially and results in perceived pain along the mid- and medial clavicle.
Most intrinsic shoulder pathology has a pattern of pain that radiates down the arm to the level of the elbow, and it is distinctly rare for the pain to be perceived as extending below the elbow joint. Conversely, pain of cervical origin usually radiates from the base of the ipsilateral ear toward the posterior shoulder and into the scapular region. A true cervical radiculopathy, which most commonly involves the fifth and sixth cervical nerve roots, provokes symptoms that are perceived to radiate into the forearm and hand in a dermatomal pattern. In contrast to the pain derived from cervical radiculopathy, pain from adhesive capsulitis does not follow a dermatomal pattern, but often radiates along the trapezius muscle and periscapular muscles. That is because these muscles become strained and fatigued by the excessive scapular rotation that must compensate for the decreased glenohumeral motion.
The pain of an intra-articular infection is not unlike that associated with any joint; it is severe, exquisite, and maximally disabling. The clinical picture is so specific that the suspicion of infection is exceedingly high until a definitive laboratory diagnosis is confirmed.
Aggravating factors of pain.
As a part of establishing the history of pain, the clinician needs to elicit circumstances that seem to make the pain worse. Often the pain is influenced by arm position, which can provide insight into its cause. Patients might state that the pain is worse or aggravated when the arm is positioned above shoulder level, such as when washing or combing their hair. Activities that result in a long lever arm with the elbow extended, such as reaching across the car seat or reaching out the car window to use an automatic teller machine, increase the pain of a weak or torn rotator cuff. Increasing pain in the shoulder that occurs while pulling bed covers up at night is strongly associated with impingement and cuff disease.
The occurrence of pain at night needs to be elicited because there appear to be two distinct types of night pain, each associated with a different shoulder condition. The more severe and disabling type of night pain strongly suggests a rotator cuff tear. This pain is described as gnawing, incessant, and unremitting, and it not only awakens patients from sleep but also often precludes any meaningful sleep at all. Patients often relate that the only way they can obtain sleep is to rest semirecumbent in a chair. In a different circumstance, patients might acknowledge night pain that is positional . They can typically fall asleep but are awakened if they roll onto or away from the affected shoulder.
Patients with positional night pain rarely convey the degree of frustration with sleep interruption that is experienced by those with a cuff tear. Although patients with positional night pain may be annoyed by the sleep interruption, they can generally fall back to sleep easily and do not develop that deep sense of misery associated with persistent sleep deprivation. Positional night pain is most often associated with loss of shoulder internal rotation through muscle stiffness or loss of capsular compliance. Painful arthritis of the AC joint can also result in positional night pain and is caused by the compressive loads borne by that joint when lying on the affected side. The pain of these conditions might also be aggravated by lying on the unaffected shoulder; in this position, the weight of the affected arm falling across the chest in adduction also results in AC joint compression and posterior capsular stretch.
Patients with adhesive capsulitis describe pain that is characterized by its sudden severity and aggravated by clearly reproducible arm positions. They have no pain until they reach the end point of their available motion, when their pain becomes immediate and severe. As their condition progresses, they note an increasing inability to perform their activities of daily living, including reaching overhead or reaching behind their back for dressing or personal hygiene.
With an intra-articular process, such as glenohumeral arthritis, patients usually note that aggravation of symptoms comes with activities associated with the repetition of a similar motion. Painting, sweeping, polishing, vacuuming, ironing, and washing a car are activities that predictably aggravate the pain of arthritis and impingement. Loading of the joint and simultaneously performing a repetitious act is particularly aggravating to joint conditions that result from incongruent joint surfaces, such as avascular necrosis, osteoarthritis, and rheumatoid arthritis.
Although inquiry about and analysis of aggravating factors in the assessment of shoulder pain are rarely in itself fully diagnostic, it remains a very important consideration as the history taking progresses.
Factors that alleviate pain.
In the same way that analysis of aggravating factors provides insight into the etiology of the shoulder problem, so too does inquiry into the features and factors that alleviate or improve the symptoms. Many times the alleviating factor provides the best information in arriving at the correct diagnosis. Although there is much overlap in diagnoses with respect to aggravating factors, it would be unusual to find one alleviating factor that relieves several different problems. For example, if a patient finds that an over-the-counter antiinflammatory truly improves the symptoms, it would logically follow that the patient has an inflammatory condition. Certainly, an antiinflammatory would not solve the apprehension of a shoulder instability problem, nor would it likely manage the pain of an acute fracture. Patients with a frozen shoulder characteristically state that there is absolutely no improvement in their pain with nonsteroidal antiinflammatories. Alleviating factors can include activity modification, positional changes, medications, narcotics, antiinflammatories, injections, or physical therapy. Physical therapy stretching over long time spans usually improves symptoms and needs to be assessed during history taking.
Patients with rotator cuff disease often note that placing the affected arm over their head significantly improves their pain. Often this arm position is the only way they can find meaningful sleep. This is called the Saha position ( Fig. 4.1 ), named after the orthopedic surgeon who recognized this phenomenon.
The response to local anesthetic injections in specific anatomic locations around the shoulder can be very instructive and diagnostic. In a patient with chronic subacromial impingement, 5 mL of 1% lidocaine placed in the subacromial space provides immediate and dramatic relief of pain ( Fig. 4.2 ). This response is therefore diagnostic of a subacromial process, and it is especially valuable when trying to discern whether the patient’s perceived pain is originating in the shoulder or is referred pain from the neck. A similar local injection test is useful in evaluating the AC joint as the source of the patient’s pain. Alleviation of pain with arm adduction following an injection of lidocaine directly into the AC joint strongly suggests pathology at this joint. Intra-articular and biceps sheath injections can provide similar supporting information regarding the source of a patient’s symptoms.
These specific injection tests are valuable in establishing the pathologic process, and, in the case of subacromial impingement, the response to the local anesthetic can predict the response to surgical treatment. Moreover, a negative response to a subacromial local anesthetic can predict a negative response to subacromial surgical treatment.
Response of symptoms to self-prescribed treatment.
With the current advent and ubiquity of the Internet, patients have become more involved in their health care decisions. Countless websites dedicated to patient information help patients to self-diagnose, although not always with great clarity or accuracy. There are likely even more websites from which patients can receive a wide variety of treatment recommendations for their self-diagnosed shoulder condition. An Internet search for the term “physical therapy” brings up millions of hits, and searching for “shoulder-specific physical therapy” brings up well more than 1 million websites. No doubt that only few patients arrive at the physician’s office these days without some knowledge, opinion, or effort at self-management of their shoulder pain.
It is important to take time to explore which methods, medications, and modalities the patient might have tried before coming to the physician. The physician should explore the realm of nutraceuticals and ask specifically about the common ones, including glucosamine, chondroitin, shark cartilage, and methylsulfonylmethane, because many patients do not consider these to be medicines and do not include them in their medication lists. Many patients consume seemingly countless vitamins and vitamin combinations in their efforts to improve their physical well-being. With the exception of glucosamine and chondroitin, which themselves have not been subjected to the rigors of the scientific method to prove their efficacy, there is little published objective information to make recommendations to patients. Nevertheless, many patients seem certain that some combination of herbs, vitamins, and supplements has affected their medical condition in some way or another. It is important to query and document these treatments during the overall evaluation of the patient with a shoulder problem.
Instability
In this discussion, it is imperative that the concept of instability is understood as referring to a patient experiencing symptoms of some shoulder problem. Many asymptomatic shoulders exhibit increased joint translation and are clearly loose during a physical examination. These are defined as lax , not unstable. To have shoulder instability means, by definition, that the shoulder is symptomatic for the patient.
In the younger and active age groups, the symptom of shoulder instability may be the patient’s presenting complaint. Although there is often a history of an acute traumatic event that resulted in an initial, well-defined onset, in many cases there is no history of such traumatic event. Indeed, since the 1980s, genetic factors in ligamentous laxity have been recognized as significant factors in patients’ perception of shoulder instability.
The diagnosis of shoulder instability can be very easy when the patient presents with an appropriate history of trauma. Nearly always there has been a trip to the ED and radiographs to document the events. However, with the increasing availability of sports trainers at most of the high school, college, and professional competitions, reduction of a dislocation by those personnel results in a history only; there are no ED records or radiographs. Although the history in these situations is still strong, an examination and radiographs even a few days following the event make this a less-than-challenging diagnosis.
A more challenging problem occurs in patients with a sense of slipping and looseness in their shoulder without a history of macrotrauma. More often than not, this more subtle instability pattern is associated with a nondescript level of discomfort and diffuse pain around the shoulder girdle. The discomfort is poorly localized and may be more scapular in location. The association of such symptoms with paresthesia down the arm is nearly always related to shoulder instability. There may be a history of repetitive microtrauma with such activities as frequent swimming, gymnastics, or ballet. Although these activities may not appear to be highly stressful to the joint, they demand muscle function defined by high endurance. Conventional thought suggests that when the ligament quality and integrity do not contribute to joint stability, the surrounding muscle activity and appropriate proprioceptive activity become more important to maintain a functioning joint.
The sense of instability might occur with the arm only in certain positions, or it may be present regardless of arm placement or position. True symptomatic multidirectional instability is typically symptomatic in midrange positions before the ligament tension reaches the end of its range. The physician must carefully inquire about which activities and arm positions provoke the symptoms. Patients with this type of instability might have symptoms that are so incapacitating that they tend to avoid extremes of glenohumeral motion. Pain is the more common symptom with a shoulder instability based on ligamentous laxity, whereas apprehension is more common with unidirectional traumatic instability. Box 4.3 lists these categories of instability.
AMBRI: Atraumatic etiology, multidirectional instability, bilateral shoulders, rehabilitation with rotational strengthening, and inferior capsular tightening
TUBS: Traumatic etiology, unidirectional, Bankart ligamentous detachment, surgical repair
The classic patient with traumatic instability is a male athlete who sustained an identifiable traumatic event during the course of a violent activity. Football tackling, a high-speed fall or collision while downhill skiing, and a hyperextension force on an extended arm (e.g., a basketball blocking shot) are very common scenarios that result in an acute traumatic shoulder dislocation. Conversely, the classic patient with multidirectional shoulder instability is the young, asthenic female ballet dancer, swimmer, or volleyball player with nondescript shoulder pain that also involves the scapula and provokes paresthesia down the arm, occurring in the absence of a defined traumatic event.
Isolated symptomatic posterior shoulder instability is most often associated with a very specific event or process. Although falling on the outstretched arm is a common scenario because the arm is most often placed in the scapular plane to brace the fall and protect the head, and a posterior force is only placed on the hand. As the body continues to fall to the ground, the arm is extended at the shoulder, placing an anterior force on the shoulder. Such circumstances therefore result much more commonly in anterior dislocation; posterior shoulder dislocations are rarely associated with traumatic events that include falls.
Posterior shoulder instability is seen most often in the scenario of electric shocks and epilepsy. It appears that electrical stimulation to the muscles around the shoulder, when provided in a pathologic setting, can result in posterior shoulder dislocations. Severe electrical discharges, whether from within (major grand mal seizure) or extrinsic (e.g., an electric shock), appear to result in the posterior shoulder musculature actually pulling the shoulder out of joint. Historically, there has also been an increase in posterior dislocations of the shoulder associated with excessive consumption of alcohol and the social activities that can follow. Falling asleep on a park bench with the arms over the back of the bench while inebriated has been associated with posterior shoulder dislocations.
Box 4.4 lists the queries that should accompany a history that suggests instability.
Nature of onset (traumatic or atraumatic)
Perceived direction (anterior, posterior, inferior, or combination)
Degree (subluxation or dislocation)
Method of reduction (spontaneous or manipulative)
Character of symptoms (apprehension, pain, paresthesias)
Frequency (daily or intermittently)
Volition (voluntary, involuntary, or obligatory)
Ease of dislocation (significant energy or minimal energy)
Arm position associated with apprehension
Paresthesia
The most common shoulder-related pathology associated with a perception of numbness, tingling, or paresthesia down the arm is instability. The patient’s perception of this neurologic symptom is usually nondermatomal if the process occurs in the shoulder girdle. A patient with multidirectional instability might note a tingling all the way down the arm involving several peripheral nerve dermatomes. In contrast, a cervical root irritation of a herniated cervical disk predictably results in a specific dermatomal pattern of symptoms. An intrinsic shoulder problem, such as a rotator cuff tear, can result in secondary neurologic symptoms. In an effort to support the painful arm, the patient might rest it on an armrest for a prolonged time and develop cubital tunnel syndrome. Similarly, a patient who is protecting the arm and minimizing functional elevation can develop carpal tunnel symptoms from inadequate fluid mobilization and prolonged dependency of the limb.
Weakness
Common causes of weakness include cerebral dysfunction, nerve transmission dysfunction, musculotendinous deficiency, pain, and biochemical causes. With cerebral dysfunction, the patient is not generating the electrical signal (malingering). Nerve transmission dysfunction, such as Parsonage-Turner syndrome, can result from primary neuronal injury. Biochemical problems result from synaptic biochemical pathology, as in myasthenia gravis, polymyalgia rheumatica, and dystrophies.
In a clinical setting, the most common cause of weakness is likely a rotator cuff tear, and although some tears are pain free, most patients experience some pain associated with the weak arm. It is important to ascertain other potential causes of weakness in the complete evaluation of a shoulder-related complaint.
Crepitus
A patient’s perception of crepitus around the shoulder is rarely seen without other associated symptoms. Chronic rotator cuff tendinitis and chronic inflammation of the subacromial bursa can result in a crunching sensation and cause the patient to report a noise coming from the shoulder. Because these are inflammatory conditions, they are nearly always associated with some perception and complaint of pain as well. Scapulothoracic bursitis and snapping scapula syndrome can cause a painful crunching sensation in the patient’s upper chest posteriorly when the patient elevates the arm. This usually is also associated with some pain.
Following surgery for rotator cuff repair, patients often become aware of painless crepitus in the subacromial space. Although the exact etiology remains unclear, it is likely to be related to the regeneration of the bursa that had been excised as part of the initial surgical procedure. It seems to become most apparent during physical therapy rehabilitation at approximately the sixth week, and it can linger for several months. Although patients predictably hear the crepitus and perceive the vibration, only rarely is there an accompanying complaint of pain.
Other intra-articular processes can cause noise to be perceived in the shoulder. Minor subluxations may be perceived as a “thunking” sound. Labral tears similarly can cause a low-frequency noise that a patient either hears or feels. Identifying noises and their specific causes can be frustrating and elusive. Fortunately, many other history and physical examination features offer substantive clues to a correct diagnosis.
Physical examination
Cervical spine (neck)
The physical examination of the shoulder begins at the neck. Pathology within the cervical spine can manifest with arm pain and nerve symptoms that radiate down the arm. The patient might believe the source of the problem to be somewhere other than the neck. The examiner begins by standing behind the patient and observing the neck and shoulder girdle for symmetry, muscle mass, scars, and deformity. The examiner then assesses the shoulder’s ROM, including extension, flexion, rotation, and bending; this is best done while standing behind the patient. Because it is difficult to use a goniometer to make measurements, surface relationships are commonly substituted.
Neck extension is recorded by estimating the angle by which the imaginary line from the occiput to the mentum of the chin extends above the horizontal ( Fig. 4.3 ). Flexion is recorded by noting how many fingerbreadths the chin is from the chest when the patient flexes the neck as much as possible ( Fig. 4.4 ). For lateral flexion, the patient leans the head to the side while looking forward, and the distance from the shoulder to the ear is recorded ( Fig. 4.5 ). Lastly, the patient turns the head from side to side and the examiner notes the degree of rotation ( Fig. 4.6 ). These cervical spine motions are made actively (by the patient) rather than passively (by the examiner).
The Spurling test ( Fig. 4.7 ) is used to assess cervical radiculopathy and has been shown to decrease the foraminal cross-sectional area of all cervical neuroforamina by 70%. This test is performed by placing the cervical spine in extension and rotating the head toward the affected shoulder. An axial load is then placed on the spine. Reproduction of the patient’s shoulder or arm pain is considered to be a positive response. Conversely, the patient’s symptoms may be relieved by flexing and rotating the neck to the contralateral side. Studies have shown a low sensitivity and moderate to high specificity for the Spurling test, ranging from 30% to 50% and 74% to 92%, respectively. Box 4.5 lists common cervical radiculopathies and their associated upper extremity pain patterns.
C4: Base of neck pain, trapezial pain
C5: Lateral arm pain (deltoid region)
C6: Lateral forearm pain, along with thumb and index finger pain
C7: Long finger pain
C8: Ring and small finger pain
T1: Medial forearm pain
Although a detailed neurologic examination is beyond the purview of most shoulder examinations, clinical judgment determines the degree of peripheral nerve assessment necessary to establish a correct and complete diagnosis. Examining the strength of the trapezius, deltoid, spinati, and biceps and triceps muscles suffices for most general shoulder examinations. However, in some situations a more thorough examination needs to be completed, which includes assessment of the motor and sensory distributions of each peripheral nerve of the upper extremity or extremities.
Shoulder
Inspection
Inspection of both shoulders can reveal pathology that would otherwise go unnoticed if the examiner relied solely on the patient history or physical examination ( ). Both shoulders need to be exposed ( Fig. 4.8 ). First, observe the clavicles for deformity at both the sternoclavicular joint and the AC joint. A prominent sternoclavicular joint can be due to an anterior dislocation, inflammation of the synovium, osteoarthritis, infection, or condensing osteitis. A loss of sternoclavicular joint contour is consistent with a posterior dislocation of the medial clavicle, which is worked up urgently to confirm the diagnosis. The AC joint is often prominent secondary to osteoarthritis and needs to be compared with that of the opposite side for symmetry.
The relative height of each shoulder is noted as the patient sits with arms by the sides. Small differences in shoulder height are often found in the general population, and such normal differences can be confirmed by asking the patient whether his or her shirt sleeves seem longer on one side than the other. Pathologic causes of a difference in shoulder height can be explained by problems with the articulation of the scapula and thorax or glenohumeral joint. Drooping of the scapula can be caused by trapezius paralysis, scapular winging, scoliosis, pain that results in splinting of the scapula, fractures of the scapula, or disruption of the scapula-clavicular suspensory complex. Deltoid dysfunction can cause the humerus to hang lower on the unaffected side.
Muscle inspection begins with the three portions of the deltoid muscle. Marked atrophy is easy to identify, but deficiencies in the posterior or middle deltoid are more difficult to appreciate until active shoulder motion is initiated ( Fig. 4.9 ). In patients with a large amount of subcutaneous tissue, palpation of the muscle belly may be the only way to distinguish a pathologic muscle contraction from the normal side. Inspection from the back allows assessment of the muscle bulk of the supraspinatus and infraspinatus muscles as well as the trapezius muscle ( Fig. 4.10 ). The anterior and posterior axillary folds are observed for muscle contours of the pectoralis major and latissimus dorsi, respectively.
Once the muscle bulk has been assessed, the static position of the scapulae must be noted. If the soft tissue obscures the view of the medial border or the scapular spine, palpation of these landmarks can help to visualize the attitude of the scapula at rest. Excessive lateral rotation of the scapula or an increased distance between the medial border of the scapula and the spine could be caused by trapezius palsy. This can also be accompanied by a prominent inferior tip of the scapula. A laterally prominent inferior scapula tip can also be caused by serratus anterior muscle weakness related to a long thoracic nerve injury, but this might only be recognized during active shoulder motion.
The most common skin manifestations of shoulder pathology are ecchymosis, which occurs after fractures, dislocations, or traumatic tendon ruptures, and erythema, which occurs with infection and systemic inflammatory conditions. Less commonly, the skin around the anterior shoulder is swollen and enlarged due to a subacromial effusion and a chronic rotator cuff tear ( Fig. 4.11 ). The examiner should note the presence of any scars and their location and character. A widened scar can indicate a collagenopathy, often seen in association with shoulder instability.
Palpation
All the joints around the shoulder girdle and any potentially pathologic tissue are palpated for deformity, tenderness, or asymmetry with the normal side ( ). These locations include the sternoclavicular and AC joints, acromion, greater tuberosity, bicipital groove, trapezius, superomedial tip of the scapula, and posterior glenohumeral joint line. The sternoclavicular joint should not be tender and should not move relative to the manubrium.
Localization of the AC joint is easy in thin patients, but many patients require the identification of other more easily palpable landmarks. The examiner can start on the medial clavicle and continue laterally until the AC joint is felt. In addition, the soft spot where the spine of the scapula meets the clavicle can usually be palpated even in obese patients. Just anterior to the soft spot is the AC joint ( Fig. 4.12 ). Lateral to the soft spot is the acromion. The AC joint should not be mobile relative to the acromion and should not be tender to palpation. The posterior edge of the acromion can be palpated as an easy landmark to distinguish the lateral edge of the acromion. This is especially useful in obese patients who do not have other easily identifiable landmarks. Knowing where the lateral acromion ends allows palpation of the greater tuberosity and the insertion of the supraspinatus. Any crepitus with passive motion of the shoulder is noted because it can be felt in patients with a rotator cuff tear or calcific tendinitis. Crepitus is difficult to palpate during active motion because the contracted deltoid masks this finding.
Palpation of the deltoid muscle may be necessary to ensure that the muscle belly contracts when visualization is obscured by the subcutaneous tissue. Where a fracture is present, small movements in the anterior, lateral, and posterior directions can allow the examiner to quickly assess all three muscle bellies of the deltoid while minimizing patient discomfort.
The bicipital groove is palpated with the forearm rotated in a neutral position or directed straight in front of the patient. The groove is in line with the forearm and approximately 1 cm lateral to the coracoid process when the arm is in neutral rotation. Moving the arm in short arcs of internal and external rotation with the arm at the patient’s side allows the examiner to palpate the ridge of the lesser and greater tuberosities, thereby revealing the location of the groove. Many patients have tenderness in this location, especially near the acromion, because of the proximity of the rotator cuff and the subacromial bursa, any of which may be inflamed and tender.
Joint motion
In measuring and recording ROM, it is important that both affected and normal shoulders be examined passively and actively ( through ). Furthermore, the active elevation against the force of gravity is recorded both while the patient is supine and while sitting.
Many years ago, the American Shoulder and Elbow Surgeons Society agreed to measure and record the three cardinal planes of motion: elevation in the scapular plane, external rotation with the elbow near the side, and internal rotation using spinal segments as the reference points. Abduction (elevation with the arm in the coronal plane) is not considered a cardinal plane of shoulder motion. However, instability assessment does record both internal and external rotation with the arm in 90 degrees of abduction.
Because shoulder motion is the result of four separate articulations (glenohumeral, scapulothoracic, AC, and sternoclavicular), only the total motions are recorded, not those occurring at the individual joints. The examination begins by measuring the motion of the unaffected arm initially.
Passive shoulder elevation.
The patient is placed supine on the examination table without a pillow (unless severe kyphosis or a cervical spine disease necessitates one). The examiner passively lifts the arm over the patient’s head and records the highest part of the arc that the elbow makes while the axis of the humerus generally points toward the opposite hip ( Fig. 4.13 ). Because the elbow begins at the patient’s side (0 degree), as the arm is passively elevated, the elbow traverses an angle (in the sagittal plane) as the arm is brought overhead. One standard point is the patient’s forehead, which typically represents 160 degrees. If the arm can be brought up only so it points to the ceiling, the elbow has traversed 90 degrees. Motion is not measured along the axillary crease. The elevation angle is ideally recorded in increments of 10 degrees.
Active elevation (supine).
After the passive motion is recorded, the patient elevates the arm under his or her own power in the same fashion as during the passive examination. Once again, the arc of motion recorded is the arc that the elbow makes in the sagittal plane, and the elevation angle is measured to the nearest 10 degrees.
Active elevation (standing).
The patient is positioned standing with his or her back against a wall, which prevents hyperextension of the back. The patient lifts the arm toward the ceiling, and the arc of motion is recorded. The patient is observed from the lateral perspective, and the arc of motion that the elbow has traversed is recorded as the active elevation of the arm ( Fig. 4.14 ).
Passive external rotation.
While the patient remains supine, passive external rotation is measured. The elbow is flexed to 90 degrees and the elbow is moved away from the side (slight shoulder abduction) to a distance about the width of the examiner’s fist. This establishes an orthogonal angle between the long axis of the humerus and the central axis of the glenoid, which relaxes the superior glenohumeral ligament and the coracohumeral ligament. The examiner cradles the humerus to hold the humeral shaft parallel to the long axis of the spine and prevent the arm from being in relative shoulder extension. The arm is externally rotated by using the forearm as the handle ( Fig. 4.15 ). The arc of motion is recorded from 0 to 90 degrees (or potentially greater with multidirectional instability). The motion is recorded to the nearest 10 degrees.
Passive external rotation in 90 degrees of abduction.
The patient is positioned supine, with the humerus abducted in the coronal plane to 90 degrees. With the elbow flexed to 90 degrees, the forearm is rotated toward the patient’s head and the degree of motion is recorded ( Fig. 4.16 A). Zero degree is the starting point with the forearm pointed toward the ceiling. The motion is recorded to the nearest 10 degrees.
Passive internal rotation in 90 degrees of abduction.
With the patient remaining supine, the humerus is abducted in the coronal plane to 90 degrees. The elbow remains flexed to 90 degrees as the forearm is rotated toward the patient’s foot, and the degree of motion is recorded (see Fig. 4.16 B). Zero degree is the starting point with the patient’s forearm pointed toward the ceiling. The motion is recorded to the nearest 10 degrees.
Internal rotation.
The patient reaches behind his or her back and then reaches up between the scapulae (in the fashion of passing a belt or fastening a bra). The examiner pulls the tip of the patient’s thumb up the back, and the tip of the thumb determines the level along the spine, which is recorded as the degree of internal rotation ( Fig. 4.17 ). The position of the scapula of the arm that is not being examined provides the proper levels to interpolate. The superior angle of the nonmeasured side is opposite T4, and the inferior angle is opposite T7. The iliac crest is at the L4 level. Occasionally the shoulder is so stiff that the patient can reach only the sacrum or greater trochanter of the ipsilateral hip. Severe scoliosis or a stiff elbow on the affected side invalidates these measurements.
Active cross-body adduction.
Standing or sitting, the patient elevates the arm to the shoulder level, with the upper arm in the scapular plane (0 degree). The patient then brings the arm across the front of the chest while maintaining it at shoulder level. The arc of motion is recorded.
Functional strength testing
General principles of functional strength testing.
Strength testing in the evaluation of a shoulder problem requires a systematic, bilateral assessment of the primary muscles responsible for shoulder ROM. When evaluating patients with more subtle symptoms related to dynamic activities or high levels of athletic performance, a more global assessment of whole-body muscle strength may be needed. This would identify deficits in lower body or core muscle strength, which may be responsible for kinetic chain problems causing overload and injury to the shoulder.
Functional strength testing in the three cardinal planes—elevation in the plane of the scapula, external rotation, and internal rotation—is necessary for understanding a patient’s functional limitations and the effect of these on activities of daily living. Assessment of functional strength is often a good place for the orthopedic surgeon to start the strength testing because it can indicate where a more detailed examination of muscle strength should be performed. Isolated muscle strength testing is covered later in the neurologic testing section. Table 4.1 lists the grading system for the assessment of muscle strength.
| Grade | Description |
|---|---|
| 0 | Complete muscle paralysis, absence of muscle fasciculation |
| 1 | Visible or palpable muscle contraction that is too weak to move the affected joint, even when not working against gravity |
| 2 | Muscle contraction that can move the involved joint in the absence of gravity but that is too weak to move the joint through its range against gravity |
| 3 | Muscle strength is adequate to move the involved joint through its range against gravity without any added resistance |
| 4 | Muscle contraction is adequate to move the joint through its range against gravity with added resistance, but the range is less than full compared with the contralateral side |
| 5 | Normal and full range compared with the contralateral side |
Functional strength assessment
To test strength with active elevation in the plane of the scapula, the patient raises both arms over his or her head. Because most people naturally perform overhead reaching activities by elevating the arm in the plane of the scapula, this simple maneuver usually results in a good demonstration of functional forward elevation strength and allows the assessment of grade 0 to 3 functional strength. Muscle strength of grades 4 or 5 is tested by the patient raising the arms in the scapular plane to shoulder level and then resisting a downward force ( Fig. 4.18 ).
