A careful history will help establish the diagnosis and formulate a treatment plan.
Important factors include the chief complaint, mechanism of injury, hand dominance, what sport the athlete plays, and prior treatments.
Common complaints are “pain with overhead activities,” “loss of range of motion,” “pain at night when I lie on that side,” and “a feeling of the shoulder coming out of the joint.”
Evaluation of shoulder pathology should include an examination of the cervical spine to rule out referred pain.
It is important to visualize the entire shoulder during an examination and compare it with the unaffected side (including the scapula).
Check for muscle atrophy, which can indicate neurologic dysfunction or chronic injury.
Examine for scapular dyskinesia or winging.
Note bony prominence that could represent acromioclavicular (AC) separation, clavicle fracture, sternoclavicular (SC) subluxation, or degenerative disease.
Palpate bony landmarks for tenderness or crepitus—AC joint, clavicle, SC joint, greater tuberosity, and coracoid.
Extension and internal rotation of the arm deliver a greater tuberosity from under the acromion.
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 ).
Does motion cause pain or produce a feeling of instability?
The normal ratio of glenohumeral (GH) to scapulothoracic motion is 2 : 1 ( Fig. 49.1B ).
Manual Muscle Testing
Supraspinatus: (Jobe test) Resistance is applied with the patient’s arm abducted 90 degrees, forward flexed 30 degrees, and internally rotated (thumb pointing down).
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 ).
Subscapularis: Resistance to internal rotation with the arm adducted and the elbow flexed 90 degrees ( Fig. 49.1F )
Positive tests produce pain at the anterior or lateral aspect of the shoulder.
Hawkins’ test: The arm is passively forward flexed to 90 degrees and then forcibly internally rotated ( Fig. 49.2A ).
Neer’s sign: The patient’s arm, with the forearm pronated, is passively forward flexed while the scapula is stabilized ( Fig. 49.2B ).
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.
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
Jobe test: Isolates the supraspinatus (see earlier discussion); pain can also be indicative of subacromial impingement
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.
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.
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 ).
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.
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 ).
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
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.
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.
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.
It is important to perform these tests on the contralateral extremity for comparison and assessment of the patient’s normal laxity.
Apprehension test: Best performed supine (table stabilizes the scapula); the arm is passively abducted to 90 degrees and then progressively externally rotated while the patient’s response is noted. A positive test produces a patient response of “apprehension” by reproducing the patient’s symptoms of anterior instability.
Relocation test: A posteriorly directed force is applied to the proximal humerus while performing the apprehension test. The test is positive when the patient’s “apprehension” is relieved and greater external rotation can be achieved. Note: If the apprehension test produces pain (as opposed to a feeling of instability) that is relieved by the relocation test , it is suggestive of internal impingement (Jobe relocation test) .
Load and shift test: The humeral head is loaded to center it within the glenoid. It is then translated anteriorly and posteriorly. The amount of translation is graded as follows: grade 0, minimal; grade I, up to the rim of the glenoid; grade II, over the glenoid rim but spontaneously reduces; or grade III, over the glenoid rim and does not spontaneously reduce.
Load and shift test: See previous discussion.
Posterior stress test: Performed supine; the arm is flexed to 90 degrees and internally rotated. A posteriorly directed force is then applied to the humerus. A positive test causes subluxation.
Jerk test: Performed upright; the arm and the elbow are flexed 90 degrees. The arm is internally rotated and the humerus is loaded posteriorly. A positive test can cause posterior subluxation of the humeral head that is then reduced with a “jerk” when extending the arm.
Sulcus sign: Traction is applied to the arm in an inferior direction while observing the area lateral to the acromion for a “sulcus.” Presence of a sulcus >1 cm indicates inferior laxity.
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.
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 ).
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.
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.
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.
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.
Direct palpation over the AC joint causes pain.
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.
O’Brien’s test: Can cause pain localized to the AC joint and should be distinguished from pain deep within the shoulder
Imaging of the Shoulder
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 ).
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.
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
West Point axillary lateral: Provides a tangential view to the anteriorinferior glenoid rim useful for evaluating instability cases
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
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 )
Serendipity view: A 40-degree cephalic tilt view for visualization of the SC joint
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
Specific Shoulder Injuries
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
Description: Most common direction of instability
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
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.
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 .
Differential diagnosis: Multidirectional instability (MDI), rotator cuff tear, SLAP lesion, and proximal humerus fracture
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 .
3D CT: Gold standard to evaluate bony pathology (particularly in recurrent instability to evaluate critical glenoid bone loss)
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 )
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.
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.
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.
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.
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
Description: Tear or stretching of posterior capsulolabral structures leading to dislocation or subluxation
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.
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.
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 .
Differential diagnosis: MDI, rotator cuff tear, SLAP tear, and proximal humerus fracture
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 ).
CT: Improved assessment of glenoid deformities contributing to instability (i.e., retroversion)
MRI or MRA: Will demonstrate reverse Bankart lesions (posterior labral tear) or a redundant, attenuated posterior capsule ( Fig. 49.4D )
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.
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.
Prognosis and return to play: Criteria are similar to those for anterior instability.
Multidirectional Instability (MDI)
Description: Symptomatic instability in more than one direction—inferior plus anterior or posterior
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
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.
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.
Differential diagnosis: Unidirectional instability, rotator cuff tear, and SLAP lesions
Radiographs: Usually normal but may reveal a Hill–Sachs or bony Bankart lesion
MRA: Can demonstrate excessive capsular volume and if have superimposed unidirectional instability, will demonstrate a Bankart lesion
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.
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
Description: Primary tendonitis is an isolated inflammatory condition of the long head of the biceps (LHB) brachii tendon in the intertubercular (bicipital) groove. More commonly, it occurs as a secondary process in conjunction with pathologic changes to surrounding structures in the shoulder such as rotator cuff pathology, impingement syndrome, bursitis, and AC joint disorders. This results in fraying or degeneration of the proximal LHB tendon.
Mechanism of injury: Overuse injury causing repetitive trauma to the LHB tendon. Chronic inflammation can lead to the tendon sheath becoming thickened and the tendon developing degenerative changes. These changes lead to scar tissue formation and the LHB becomes fixed within the bicipital groove.
Presentation: Pain in the anterior aspect of the shoulder that may radiate down the biceps; usually, a history of overuse and no history of trauma
Tenderness anteriorly over the bicipital groove
Speed’s, Yergason’s, and upper cut tests are positive
Because of its association with impingement, Hawkins’ and Neer’s tests are often positive.
Differential diagnosis: Rotator cuff pathology and labral tear
Radiographs are normal in primary bicipital tendonitis; they may show an acromial spur suggestive of impingement associated with secondary bicipital tendonitis.
Ultrasound will show thickened tendon within the bicipital groove, but this test is heavily reliant on operator technique.
MRI is the gold standard and may show edema in or around the tendon or a thickened or split tendon. MRI is additionally helpful at showing associated pathology.
Treatment: Begins with nonoperative therapy consisting of rest and nonsteroidal anti-inflammatory drugs (NSAIDs), followed by range-of-motion exercises. Corticosteroid injections have utility in the bicipital sheath (via ultrasound guidance) or in the intra-articular space or subacromial space (particularly for secondary tendonitis). Surgery is indicated for those who fail conservative therapy. Surgical options include tenotomy or tenodesis with concomitant management of associated pathology.
Prognosis and return to play: Once pain has resolved enough to allow near-normal range of motion and strength. For isolated biceps tenodesis, a sling is typically used for 3–4 weeks with light work allowed at 4 weeks and completely unrestricted activity at 3–4 months.
Description: The LHB tendon subluxates out of the bicipital groove.
Mechanism of injury: Invariably associated with complete or partial tear of the subscapularis and structures of the rotator interval that comprise the bicep pulley system
Presentation: Similar to bicipital tendonitis; patients may also report popping during shoulder motion
Physical examination: Similar to bicipital tendinitis
Differential diagnosis: Bicipital tendonitis and rotator cuff pathology
Diagnostics: Radiographs will be normal. MRI will reveal injury to the subscapularis and dislocation of the proximal biceps tendon from the bicipital groove, if present. Ultrasound is both sensitive and specific for diagnosing subluxation.
Treatment: Conservative therapy is similar to that for bicipital tendonitis. Surgical intervention (tenotomy or tenodesis) is more appropriate as primary treatment in young active patients or in those who fail conservative therapy. It is important to address associated cuff pathology as well.
Prognosis and return to play: Those undergoing tenotomy can return to play when near-normal strength and range of motion has returned. Tenodesis procedures will require 4–6 months to allow adequate healing and rehabilitation.
Description: Disruption of the LHB tendon
Mechanism of injury: Most commonly caused by forceful elbow flexion against resistance
Presentation: In acute traumatic ruptures, patients present with pain and ecchymosis anteriorly. Ruptures in older patients are often the result of attritional degeneration or chronic tendonitis. Such patients are often unaware that they have sustained a rupture.
Physical examination: Acutely, patients will experience tenderness over the anterior shoulder and the upper arm. Swelling and ecchymosis will be present. The classic “Popeye” deformity will be present because the biceps will be more prominent in the middle of the arm ( Fig. 49.5 ). Patients may experience a slight decrease in the strength of elbow flexion and forearm supination.