The organization of this chapter on the clinical evaluation of the shoulder in overhead athletes is different than more traditional textbook approaches. Although we remain committed to a comprehensive, organized approach to the shoulder, the direction here is driven by chief complaint, such that a differential diagnosis is deduced at the beginning of the interview, rather than at the end. This “differential-directed” approach allows the examiner to test the premise of the initial diagnosis throughout the history and physical examination, and allows for a more focused approach to the shoulder as it pertains to the overhead athlete. Although this differs in style from established texts that describe the history and physical examination followed by formation of the differential diagnosis, we intend for this approach to lead to the same destination: an accurate diagnosis for an overhead athlete with shoulder dysfunction. For an organized, comprehensive, traditional approach to examination of the shoulder, refer to Musculoskeletal Examination: An Organized Approach to Musculoskeletal Examination and History Taking (1) and “Clinical Evaluation of Shoulder Problems” in “The Shoulder” (2).

Physical examination of the overhead shoulder for some has become somewhat of a lost art because of the difficulty of the examination itself, the subtleties of the normal athletic shoulder that often make comparison to the opposite side unreliable, and the ever-increasing reliance on magnetic resonance imaging (MRI) for definitive diagnosis. As helpful a tool as MRI is, it is of concern that completely asymptomatic shoulders demonstrate pathology that might be erroneously attributed to an athlete with symptoms. Sher and co-workers demonstrated a 34% rate of tears of the rotator cuff in painless volunteers (3). Miniaci and colleagues showed that 79% of asymptomatic professional baseball pitchers had abnormalities of the glenoid labrum (4). Furthermore, partial thickness rotator cuff tears, a diagnosis common to the throwing and overhead shoulder, may be missed by MRI up to 44% of the time (5). Hence, even with the technologic advances available, we remain convinced that the diagnosis of a shoulder problem in the overhead athlete is made by a proper history and physical examination, not by the scanner.

Although a classic tenet of physical examination is to compare the symptomatic side with the opposite normal side, this is not always reliable in the overhead athlete. There are a number of physiologic adaptations that occur in throwers and other overhead athletes, which, although asymmetric, are not pathologic. These include hypertrophy of the dominant arm, elbow flexion contracture, increased external rotation, and decreased internal rotation (6). Striving to create symmetry in these athletes may “correct” physiologic adaptations that protect the overhead arm and might lead to further problems and dysfunction.

One theme that is emphasized in this chapter is the importance of communication with the athlete to a correct understanding of the athlete’s problem. Many athletes present with shoulders that contain multiple pathologies such as labral tears, impingement, and instability. Communication with the athlete is critical to understanding which of these may be the most important in their disability. Communication is also critical in differentiating between objective signs on physical examination and clinical symptoms. For example, laxity (a physical examination sign) is present in many overhead athletes. It can often be demonstrated on physical examination as a positive sulcus sign or increased translation of the humeral head on the glenoid. Although often more pronounced than in the average person, this finding may be totally asymptomatic, and attempts to “correct” this may do more harm than good. In contrast, symptomatic laxity is instability (a clinical symptom). The key difference is symptomatology. An athlete who can be shifted
over the glenoid rim with a posterior translation maneuver demonstrates laxity. This patient must demonstrate reproduction of symptoms with such a maneuver to raise the level of suspicion to diagnose instability (2). It is only with communication during such maneuvers that these subtle differences can be reliably interpreted.

Another important area of communication exists between physicians and the athlete’s team trainers or physical therapists. A treating physician might be unimpressed with a pitcher’s signs or symptoms in the office only to find out that, once the player throws at more than half speed, he becomes ineffective. Trainers and therapists can often provide key feedback on the mechanism of injury, the degree of disability, and the athlete’s progression with conservative treatment. They are helpful with decisions concerning return to play or when to say rehabilitation is not working and other options should be considered. Such benefits only happen with open lines of communication.

This chapter first describes a throwing athlete who cannot throw well. From this initial presentation, we describe an organized yet focused differential-directed approach to understanding the cause for the dysfunction, which forms the basis for how to resolve the problem. Although much of this chapter is focused on the throwing shoulder, it is important to keep in mind that these principles apply both to the examination of shoulders involved in any repetitive overhead activity (e.g., tennis, volleyball, handball, swimming) and to athletes of all ages and levels of participation.

One of the early skills taught to medical students is how to perform a history and physical examination. It forms the structure and base of the clinical encounter, wherein a diagnosis is formulated and treatment subsequently planned. Students are taught to be organized and thorough, and although much of the necessary knowledge base comes later, the structure must be stressed early and often to have a framework from which to fill in new knowledge. Traditionally, this framework follows a fairly strict order of history, physical examination, review of imaging, and creation of a differential diagnosis. This differential diagnosis is the end result of the sum total of information gained throughout the encounter. One common directive in teaching students is to not let them see any of the past notes or diagnostic conclusions during their evaluation, because such information might “tip them off” as to what to look for during the encounter, leading the student to focus on the expected findings of the examination and be too quickly directed toward the diagnosis. This teaches the young clinician completeness and avoids the pitfall of jumping to conclusions or making assumptions that the diagnosis purported by another clinician is correct. Even though this process is valuable to the development of any promising diagnostician, once the framework is ingrained, the clinician learns which findings in each specific clinical encounter are pertinent and which are superfluous. To perform every aspect of the physical examination on every patient is unrealistic and often results in a great amount of data with no comprehension of what those data mean. It is far easier “to find what you are looking for when you know what you seek.” This premise is the basis for the differential-directed approach. If one can be taught to develop a suspicion of what may be problematic in the overhead shoulder at the beginning of the clinical encounter, one stays directed, efficient, and accurate. We do not sacrifice thoroughness and completeness, because often other pathologic diagnoses may not have been suspected at the beginning of the examination and may only be elucidated with appropriate physical examination maneuvers. However, we use this differential-directed approach to allow for patient-appropriate specific versus “screening” examination techniques, and we believe that the development of these initial suspicions is not only possible but is the natural history of becoming more “focused” as a diagnostician. This focus comes with experience but can be accelerated by modifying the approach to both the history and physical examination. It becomes obvious that the success of the evaluation is directly related to the initial differential diagnosis. The quality of the differential diagnosis is dependent upon the clinician’s understanding of shoulder pathologies and the various tests that are available for each. The better one’s understanding of the pathologies presented in this book, the higher the quality of the initial differential diagnosis and the better the clinician becomes. This creates a dynamic relationship between knowledge and skill that can continue to improve throughout one’s career. The experienced clinician learns to “go for the money” and yet not miss more subtle diagnoses.

The differential for pathology in the overhead shoulder is initially formed from two important pieces of information: (a) the athlete’s chief complaint and (b) the athlete’s age. For example, in a 60-year-old male tennis player with shoulder pain, even though a diagnosis is not guaranteed with such limited information, the astute clinician has a working differential diagnosis from the beginning of the examination. Throughout the examination, certain findings are expected to be positive. In this example, impingement signs with associated weakness with supraspinatus testing would strongly suggest a rotator cuff tear. At the same time, features of the examination that focus on subtle glenohumeral instability might be less emphasized. This format emphasizes attention on a set of expected findings and makes the diagnosis that much more specific.

The first step in the differential-directed approach is to understand how pathologies present as chief complaints, so that the initial differential is complete but focused. This is rarely as easy as in the aforementioned simple example. If a
20-year-old baseball pitcher with pain is the example, rather than suspecting just a rotator cuff tear, the initial differential might include instability, labral pathology, impingement, internal impingement, or a combination of these. Thus, a deeper understanding of the chief complaint and how it relates to the history is necessary to come to an accurate differential. Even in difficult presentations, we still formulate an initial differential that may “tip us off” to what we are looking for while keeping us directed toward the appropriate diagnosis.

Once this differential is formulated, the remainder of the history proceeds in an organized fashion with expectations already in mind. If the differential is correct, answers to queries within the history validate the initial diagnosis. If, however, the answers given by the athlete are not as expected, the clinician is alerted early to suspect another diagnosis and thus take the examination in a different direction. By the completion of the history, the clinician should have clear expectations of what to look for and emphasize in the physical examination.

It would be ideal if we could exactly reproduce an athlete’s symptoms during the physical examination, but this is only occasionally possible. Many tests for pain are not specific enough to be reliable, and patients with instability are often too guarded to allow provocative testing. In the throwing and overhead athletic population, many pathologies coexist and make presentations confusing. It is therefore important for the physical examination to remain organized and systematic. One of the dangers of having a short list of differential diagnoses in mind is that the clinician’s attempts to be focused could result in an incomplete examination. Although we recommend reorganizing the examination according to the differential, the essential tenets of “inspect, palpate, and move” the shoulder remain (1,2).

Diagnostic injections can be helpful in determining the source of symptoms. The goal is to eliminate the athlete’s clinical signs and physical symptoms with the use of a short-acting local anesthetic placed in the specific anatomic area that seems to be responsible for the symptoms. This maneuver is the equivalent of the Neer subacromial “impingement test” (Fig. 3-1) and can be applied to a variety of other conditions in the differential diagnosis. There are limitations, in that differential injections are time consuming and often are not applicable for diagnoses such as instability. When pain is the presenting complaint, a diagnostic injection in a specific location that quickly (within 5 to 10 minutes) takes away nearly 100% of the athlete’s pain often leads to the area of pathology and the correct diagnosis.

The organization of this chapter is according to chief complaint, followed by the specific historical questions and physical examination maneuvers that are applicable to each entity. This is an alternative approach from traditional texts wherein it is more common to separate the history from the physical examination and from diagnostic injections. Nevertheless, we believe that this organization more closely resembles how we approach the evaluation of the throwing and overhead shoulder.

Regardless of how one approaches the history, it is crucial that this approach is organized and systematic so that the clinician is thorough yet efficient. The general categories of chief complaint, history of present illness, past medical history, and review of systems (followed by the physical examination) remain the backbone of the clinical evaluation. We organize this evaluation according to the chief complaint for several reasons. First, it is the impetus behind the athlete’s request for help, so organization by chief complaint keeps the interview patient-directed. Second, organization by chief complaint keeps the clinician focused and efficient. Third, knowing the age and the chief complaint provides a high index of suspicion for the diagnostic probabilities (1, 2, 3,5). Such an understanding provides an immediate differential diagnosis that can be tested throughout the history and physical to arrive at the correct diagnosis. It allows each step in the examination to help confirm or refute the diagnosis, providing dynamic confirmation when the initial diagnosis is right, and a series of red flags throughout the examination when the initial diagnosis is erroneous.

Once the examiner completes an organized history, there should be a clear idea of the differential, which should direct which aspects of the physical examination should be emphasized. Just as in the history, there will be certain expected responses (both positive and negative) for the differential-directed physical. During the examination, one should note whether the physical examination expectations are met (in which case the suspicion of the correct diagnosis is strengthened) or whether the expectations are not met (in which case one must reconsider the appropriate diagnosis). Although we organize our approach based on complaint, there are certain aspects to the physical examination that should be ingrained in any competent examiner. Depending on the differential, some of these areas are more emphasized than others. Nevertheless, especially in the overhead athlete in whom multiple pathologies often exist and there is considerable overlap for many chief complaints, we repeatedly emphasize that the following tenets should be remembered:

The patient should be prepared by removing the outer garment for a view of the bare shoulders. For women, a sports bra or designed halter top type gown preserves modesty while allowing the examiner to pick up on often subtle aspects of the examination such as atrophy or winging (Fig. 3-2). Attention to the asymptomatic side remains important, but the examiner must remember those physiologic adaptations that often are present in overhead athletes. With this in mind, the examiner should attempt to reproduce the conditions that bring on the chief complaint. This may involve more emphasis on range of motion when instability is suspected, or palpation and special tests when pain is the chief complaint. This does not mean that we ignore range of motion in the patient with pain or palpation in the patient with instability—it is just that a different set of red flags and expectations arise for each patient with this approach.

In this section, we define the various chief complaints common to the overhead athlete and discuss what initial differential corresponds to each chief complaint. Next, we describe the specific historical questions that should narrow the focus and sharpen the differential. Finally, we demonstrate the various physical examination techniques that may rule in or rule out a specific diagnosis in the overhead athlete. This differential-directed approach is intended to provide an organized template for the correct diagnosis right from the initial history, to tip off the examiner on what to expect and what not to expect throughout the physical examination, to reinforce each step of the workup, and to create solid evidence for the diagnosis by the completion of the encounter.

Perhaps no chief complaint is as common as pain in the shoulder and none has a broader list of possible causes. Many of these causes overlap or play a role in the pathology of other processes. In addition, there is often more than one source of pain in the throwing athlete, making the approach not nearly as clear as one would like (4). The following discussion
describes the differential for pain and how to narrow down the list to a few diagnoses to test on physical examination. See Table 3-1 for a list of common causes for pain as chief complaint. Such a list can be daunting unless the examiner stays organized. With a few early questions, the differential can be established and narrowed down. One question to begin with is simply, “Where is the pain?” Although this is a seemingly basic question, it is often difficult to get the patient to be specific about this. We often ask patients to point with one finger to the area. Most patients respond in one of the following ways listed in Table 3-2.