Inspection

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  It is important to visualize the entire shoulder during an examination and compare it with the unaffected side (including the scapula).

  
  
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  Check for muscle atrophy, which can indicate neurologic dysfunction or chronic injury.

  
  
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  Examine for scapular dyskinesia or winging.

  
  
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  Note bony prominence that could represent acromioclavicular (AC) separation, clavicle fracture, sternoclavicular (SC) subluxation, or degenerative disease.

Palpation

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  Palpate bony landmarks for tenderness or crepitus—AC joint, clavicle, SC joint, greater tuberosity, and coracoid.

  
  
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  Extension and internal rotation of the arm deliver a greater tuberosity from under the acromion.

Motion

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  It is important to compare active and passive range of motion to the unaffected side. Forward flexion, abduction, and external rotation are measured in degrees from neutral rotation. Internal rotation is measured in relation to the spinal level that can be reached posteriorly ( Fig. 49.1A ).

  
  

  
  

  
  

  

  
  

  
  

  Physical examination of shoulder.

  
  
  
  
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  Does motion cause pain or produce a feeling of instability?

  
  
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  The normal ratio of glenohumeral (GH) to scapulothoracic motion is 2 : 1 ( Fig. 49.1B ).

Manual Muscle Testing

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  Supraspinatus: (Jobe test) Resistance is applied with the patient’s arm abducted 90 degrees, forward flexed 30 degrees, and internally rotated (thumb pointing down).

  
  
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  Infraspinatus/teres minor: Resistance to external rotation with the arm adducted and the elbow preferentially flexed 90 degrees assesses the infraspinatus. Resistance to external rotation with the arm abducted and the elbow flexed 90 degrees assesses both the infraspinatus and teres minor ( Fig. 49.1 ).

  
  
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  Subscapularis: Resistance to internal rotation with the arm adducted and the elbow flexed 90 degrees ( Fig. 49.1F )

Impingement

Positive tests produce pain at the anterior or lateral aspect of the shoulder.

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  Hawkins’ test: The arm is passively forward flexed to 90 degrees and then forcibly internally rotated ( Fig. 49.2A ).

  
  

  
  

  
  

  

  
  

  
  

  Special tests.

  
  
  
  
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  Neer’s sign: The patient’s arm, with the forearm pronated, is passively forward flexed while the scapula is stabilized ( Fig. 49.2B ).

  
  
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  Painful arc: The patient actively elevates the arm in the scapular plane and then lowers it in the same plane. Pain during range of motion between 60 and 120 degrees is positive.

  
  
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  Coracoid impingement sign: The patient’s arm is passively placed in a position of forward flexion, adduction, and internal rotation with pain produced directly over the coracoid.

Rotator Cuff Tear

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  Jobe test: Isolates the supraspinatus (see earlier discussion); pain can also be indicative of subacromial impingement

  
  
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  Champagne toast: The arm is abducted against resistance at 30 degrees of abduction, 30 degrees of forward flexion, and mild external rotation; this test isolates the supraspinatus.

  
  
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  Drop arm sign: The patient fully elevates the arm in the plane of the scapula and then tries to lower it slowly. Sudden drop­ping of the arm or pain while doing so suggests a supraspina­tus tear.

  
  
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  External rotation lag sign: With the arm adducted and the elbow flexed 90 degrees, the arm is passively brought to maximal external rotation. Inability of the patient to actively maintain the arm in the externally rotated position indicates a massive tear involving the infraspinatus ( Fig. 49.2C ).

  
  
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  Lift-off test: The dorsum of the patient’s hand is placed against the lumbar spine ( Fig. 49.2D ). The patient then lifts the hand away from the back, maintaining the elbow in the coronal plane. Inability to do so indicates a lower subscapularis tear.

  
  
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  Belly-press test: The patient places both hands on the abdomen, internally rotates to bring the elbows forward beyond the coronal plane, and then presses the hands into the abdomen. Inability to move the elbow beyond the coronal plane indicates an upper subscapularis tear ( Fig. 49.2D ).

  
  
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  Hornblower’s sign: The patient is asked to hold the arm in a 90-degree abduction and a 90-degree external rotation. A positive sign, wherein the arm falls into internal rotation, represents a teres minor pathology.

Biceps Tendon Pathology

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  Speed’s test: With the forearm supinated and the elbow extended, the patient forward flexes the arm against resistance. A positive test produces anterior shoulder pain.

  
  
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  Yergason’s test: With the elbow in 90 degrees of flexion, the patient supinates the forearm against a resistive force. A positive test produces pain in the biceps region.

  
  
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  Upper cut test: With the elbow in 90 degrees of flexion and the forearm supinated, an upward and cross body motion is performed against resistance. A positive test will induce pain.

Instability

It is important to perform these tests on the contralateral extremity for comparison and assessment of the patient’s normal laxity.

Labrum

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  Clunk test: Performed supine; the arm is fully abducted, and the examiner’s hand is placed on the posterior aspect of the humeral head. An anterior force is applied to the humerus, while the other hand rotates the humerus. Positive findings include a “clunk,” pain, and grinding.

  
  
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  O’Brien’s test (active compression test): The arm is positioned in 90 degrees of flexion and 10–15 degrees of adduction. A downward force is applied by the examiner as the patient resists, first with the arm internally rotated (thumb down) and then with the arm externally rotated (thumb up). A positive test causes pain felt deep within the joint that is reduced or relieved with the arm externally rotated, which indicates superior/posterior labral pathology ( Fig. 49.2D ).

  
  
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  Kim test: Performed upright; with the arm in a 90-degree abduction, a strong axial load is applied. While the arm is elevated to 45 degrees upward and diagonally, a downward and backward force is applied. A positive test is sudden onset of posterior shoulder pain, which indicates a posteroinferior labral lesion.

  
  
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  Biceps load test: Performed supine; the arm is abducted 120 degrees, maximally externally rotated, the forearm supinated, and the elbow flexed 90 degrees. Active elbow flexion is then performed against resistance. A positive test produces pain suggestive of a superior labrum anterior and posterior (SLAP) tear.

  
  
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  Anterior slide test: The patient’s hands are placed on the hips with the thumbs pointing posteriorly. An axial load is applied at the elbow toward the GH joint against patient resistance. A positive test produces pain suggestive of a SLAP tear.

  
  
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  Modified dynamic labral shear: The arm is flexed 90 degrees at the elbow, abducted in the scapular plane to above 120 degrees and externally rotated to tightness. The arm is then lowered from a 120- to a 60-degree abduction, keeping the arm maximally externally rotated. A positive test produces pain or a painful click and indicates superior labral pathology.

Acromioclavicular Joint

Direct palpation over the AC joint causes pain.

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  Cross-arm adduction test: The arm is flexed 90 degrees and then adducted across the chest. A positive test causes pain at the AC joint.

  
  
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  O’Brien’s test: Can cause pain localized to the AC joint and should be distinguished from pain deep within the shoulder

Radiographs

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  Anteroposterior (AP): Taken in the plane of the thorax; provides an oblique view of the GH joint because of the anteverted position of the scapula on the posterolateral aspect of the thoracic cage ( Fig. 49.3A ).

  
  

  
  

  
  

  

  
  

  
  

  Anterior glenohumeral instability.

  
  
  
  
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  True AP (Grashey view): Taken in the plane of the scapula; provides a true AP view of the GH joint by angling the beam approximately 45 degrees in the medial-to-lateral direction or by rotating the patient and placing the scapula flat on a radiograph cassette.

  
  
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  Axillary view: Important for evaluating dislocations; useful for evaluating fractures of the coracoid and the anterior or posterior glenoid rim; will additionally reveal an os acromiale

  
  
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  West Point axillary lateral: Provides a tangential view to the anteriorinferior glenoid rim useful for evaluating instability cases

  
  
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  Scapular Y view: Lateral radiographs recorded in the scapular plane; helpful in evaluating the relationship of the humerus to the glenoid fossa; tilting the beam caudally by 10 degrees produces a supraspinatus outlet view, which allows assessment of acromion morphology

  
  
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  Stryker notch view: The patient is placed supine with the hand on the superior aspect of the head with the finger directed posteriorly. The beam is aimed 10 degrees cephalad at the coracoid; evaluates compression fractures or defects in the posterolateral aspect of the humeral head (Hill–Sachs lesion) ( Fig. 49.3B )

  
  
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  Serendipity view: A 40-degree cephalic tilt view for visualization of the SC joint

  
  
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  Zanca view: Provides clear view of the AC joint by directing the x-ray beam 10–15 degrees cephalad; allows assessment of AC separations, distal clavicular osteolysis, and distal clavicle fractures

Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging (MRI) is the gold standard for evaluating soft tissue structures and cartilage; magnetic resonance arthrogram (MRA) preferred for labral pathology

Instability

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  Description: Defined as symptomatic, abnormal translation of the humeral head on the glenoid; instability can be classified in several ways— direction of instability ( anterior, posterior, multidirectional ), traumatic versus atraumatic, and degree of instability

Anterior Glenohumeral Instability

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  Description: Most common direction of instability

  
  
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  Mechanism of injury: Direct or indirect trauma leading to tearing and attenuation of the anterior capsulolabral complex; direct trauma involves a blow to the posterior shoulder; indirect trauma involves injury to the arm in a position of abduction, extension, and external rotation position

  
  
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  Presentation: Can present with pain, feeling of weakness, instability, or recurrent dislocations; dislocations in younger patients are associated with Bankart lesions, whereas patients aged over 40 years typically have associated rotator cuff tears. A Bankart lesion is an avulsion of the anteroinferior glenoid labrum.

  
  
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  Physical examination: In acute dislocations, the lateral shoulder will lose its normal contour with fullness present anteriorly. The arm is held in slight abduction and in external rotation. A careful neurovascular examination is important. The nerve most commonly injured is the axillary nerve. The following examination maneuvers will be positive in patients with recurrent anterior instability: apprehension test, relocation test, and load and shift test .

  
  
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  Differential diagnosis: Multidirectional instability (MDI), rotator cuff tear, SLAP lesion, and proximal humerus fracture

  
  
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  Diagnostics:

  
  
  
  
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    Radiographs: A standard shoulder series (AP, axillary, and scapular-Y) to ensure the humeral head is reduced. The Stryker Notch view can detect a Hill–Sachs lesion. The West Point axillary view will provide better evaluation of the anterior glenoid rim for possible bony Bankart lesions .

    
    
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    3D CT: Gold standard to evaluate bony pathology (particularly in recurrent instability to evaluate critical glenoid bone loss)

    
    
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    MRI or MRA: Will demonstrate Bankart lesions , anterior capsule pathology and presence of Hill–Sachs lesion (with associated T2 edema in acute injuries) ( Fig. 49.3C )

  
  
  
  
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  Treatment:

  
  
  
  
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    Acute anterior dislocations require urgent reduction. Several reduction methods have been described. The Stimson technique is a relatively atraumatic technique. The patient is placed prone, and weights are placed on the affected wrist (see Fig. 49.3D ). A variation of this technique can be performed on the field by placing the athlete in the supine position and applying traction on the wrist in forward flexion and counter traction on the chest (see Fig. 49.3D ). Another technique is the Milch technique; this is performed with the physician placing a hand on the superior aspect of the dislocated shoulder while using a thumb to stabilize the humeral head in a fixed position. The arm is then abducted with application of a gentle longitudinal traction while the humeral head is manipulated with the thumb over the glenoid rim. Slight external rotation can help facilitate the manipulation of the humeral head over the glenoid rim. Intra-articular injection of a local anesthetic has been shown to be effective in aiding reduction, although relaxation with an IV sedative may be necessary.

    
    
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    The value of postreduction treatment with sling immobilization (particularly in external rotation) is controversial. There is no consensus in the literature on the utility of sling use, period of immobilization, or the degree of rotation. It is currently recommended for 4–6 weeks of immobilization in neutral rotation.

    
    
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    Initial treatment is physical therapy focusing on strengthening dynamic stabilizers of the GH joint (rotator cuff muscles, deltoid and scapula stabilizers) and maintaining GH motion.

    
    
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    Recurrent instability should be surgically treated with anterior stabilization. Current arthroscopic techniques have results equivalent to those with open techniques ( Fig. 49.3E ). Bony deficiencies of the anterior glenoid or large, engaging Hill–Sachs lesions may have to be addressed for successful outcomes.

  
  
  
  
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  Prognosis and return to play: The re-dislocation rate is approximately 90% in patients aged <20 years and decreases with increasing age. The decision to treat initially with surgical stabilization versus nonoperative therapy must take into account several factors such as patient age, activity level, and the specific sport. Return to play after nonoperative therapy requires near-normal range of motion, strength, and functional ability. Return to play after surgical stabilization is typically after 4–6 months.

Posterior Glenohumeral Instability

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  Description: Tear or stretching of posterior capsulolabral structures leading to dislocation or subluxation

  
  
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  Mechanism of injury: Posterior subluxation or dislocation can result from a traumatic event with the arm in a position of flexion, adduction, and internal rotation causing a reverse Bankart lesion ( Fig. 49.3E ); more commonly, it can result from repetitive microtrauma causing a labral tear or capsular attenuation. This mechanism is commonly associated with an offensive lineman in football jamming his opponents while blocking.

  
  
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  Presentation: Posterior dislocation is rare compared to an anterior dislocation, and are easily missed upon initial evaluation. Patients presenting after a seizure or electrical shock should raise suspicion of a posterior dislocation. More commonly, posterior instability presents as pain or a feeling of instability posteriorly with a load to the arm in a position of forward flexion, adduction, and internal rotation.

  
  
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  Physical examination: In acute posterior dislocations, the arm is held in adduction and internal rotation. A prominent coracoid anteriorly and posterior fullness are present. The following maneuvers will be positive in patients with recurrent posterior instability: load and shift test, posterior stress test, and jerk test .

  
  
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  Differential diagnosis: MDI, rotator cuff tear, SLAP tear, and proximal humerus fracture

  
  
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  Diagnostics:

  
  
  
  
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    Radiographs: A standard shoulder series (AP, scapular- Y , and axillary view) to ensure the humeral head is reduced. AP view may reveal “lightbulb sign.” Plain radiograph films will also reveal reverse Hill–Sachs lesions indicative of a posterior dislocation and allow for evaluation of bony contributions to posterior instability, such as glenoid fractures, hypoplasia, or excessive retroversion ( Fig. 49.4 A, B, and C ).

    
    

    
    

    
    

    

    
    

    
    

    Posterior glenohumeral instability.

    
    
    
    
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    CT: Improved assessment of glenoid deformities contributing to instability (i.e., retroversion)

    
    
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    MRI or MRA: Will demonstrate reverse Bankart lesions (posterior labral tear) or a redundant, attenuated posterior capsule ( Fig. 49.4D )

  
  
  
  
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  Treatment:

  
  
  
  
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    Acute posterior dislocations require reduction. This is often more difficult than reduction of an anterior dislocation. With the patient supine, traction is applied in line with the deformity while the humeral head is guided into the joint. Avoid external rotation to prevent proximal humerus fracture.

    
    
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    For recurrent posterior instability, a majority will improve with physical therapy focusing on dynamic stabilizers of the shoulder, particularly the posterior deltoid and external rotators. Surgery is indicated for patients who fail nonoperative treatment. Surgery is directed at the pathology with capsular plication for attenuated capsule and repair of reverse Bankart lesions . Bony abnormalities of the glenoid must be identified and addressed if present.

  
  
  
  
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  Prognosis and return to play: Criteria are similar to those for anterior instability.

Multidirectional Instability (MDI)

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  Description: Symptomatic instability in more than one direction—inferior plus anterior or posterior

  
  
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  Mechanism of injury: Often atraumatic in the setting of generalized laxity or from repetitive microtrauma, most common in overhead athletes such as swimmers and volleyball players; the primary pathology is an attenuated inferior capsule with associated globally increased capsular volume

  
  
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  Presentation: A majority are young adults and often bilateral. Patients present with pain, instability, and occasionally transient neurologic symptoms. Symptoms when carrying heavy objects at one’s side are indicative of inferior instability.

  
  
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  Physical examination: Examine for signs of generalized laxity, such as hyperextension of the elbows or ability to bring the thumb to the forearm (Beighton score). A positive sulcus and/or Gagey sign indicates inferior instability. Apply the tests described earlier to evaluate for anterior and posterior instability.

  
  
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  Differential diagnosis: Unidirectional instability, rotator cuff tear, and SLAP lesions

  
  
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  Diagnostics:

  
  
  
  
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    Radiographs: Usually normal but may reveal a Hill–Sachs or bony Bankart lesion

    
    
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    MRA: Can demonstrate excessive capsular volume and if have superimposed unidirectional instability, will demonstrate a Bankart lesion

  
  
  
  
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  Treatment: A majority of patients respond to physical therapy to strengthen the dynamic stabilizers of the shoulder. Those who fail nonoperative treatment are candidates for surgical stabilization via capsular shift/plication.

  
  
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  Prognosis and return to play: Even with surgical stabilization, a majority of patients return to a competitive level. The time frame for return to play after surgery is similar to unidirectional instability.

Biceps Tendon Pathology