Shoulder Ultrasound (eBook)

2. Basic clinical shoulder examination

David Haeni, Markus Wurm, Giorgio Tamborrini

2.1 Introduction

Pain is usually the first symptom referred by a patient with shoulder disorder. The clinical shoulder examination starts with an accurate medical history. It is fundamental to understand whether a trauma is present or not. The age, the professional and sport activities are important informations in order to understand the patient’s impairment. Duration and onset of pain should be asked in detail. Cervical nerve root disorders can be referred as radiating pain from the neck into the shoulder and should be excluded. Several scores are helpful for the functional assessment of the shoulder. The Constant-Murley Score13 is a 100 points scale composed by four parameters such as pain, activity of daily living, movement and strength. It is one of the most commonly used outcome measurement system by shoulder surgeons.

2.2 Inspection

The first step of the clinical examination is the inspection. Here we look for symmetry of anatomic landmarks such as ac joint, coracoid process and spina scapulae. We assess the presence of a scar due to previous surgery or any hematoma after a fall, that could be a sign of a fracture. A bruise on the anterior part of the shoulder with a positive Popeye sign (distal biceps muscle retraction) is a hallmark of a spontaneous long head of the biceps rupture. We should exclude any atrophy of the deltoid muscle (due to axillary nerve palsy or to prolonged rest) or of the supraspinatus and infraspinatus muscle, that could suggest a suprascapular nerve pathology21. On the posterior side of the shoulder we evaluate the scapulo-thoracic joint balance. Sometimes a functional dyskinesia18can be appreciated, very rarely secondary to long thoracic nerve palsy.

2.3 Range of motion

The following step is the range of motion assessment. We start with the active range of motion (ROM) and we complete the exam with the passive examination (Fig. 1 - 4 ). We assess the flexion, the elevation (flexion in the plane of the spina scapulae), the abduction, the external rotation and the internal rotation. Active and passive external rotation restriction could be a sign of a frozen shoulder26 (also called adhesive capsulitis), a condition characterized by stiffness and pain and associated with diabetes mellitus. The pseudoparalysis of the shoulder is defined as the inability to actively elevate and bring the arm in flexion with full passive ROM15. This condition is secondary to massive cuff tear without neurological paralysis.

flexion (anteversion):

m. pectoralis major, m. deltoideus (pars clavicularis), m. coracobrachialis, m. biceps branchii (caput longum).

extension (retroversion):

m. latissimus dorsi, m. teres major, m. deltoideus (pars spinalis), m. subscapularis, m. triceps brachii (caput longum).

external rotation:

m. infraspinatus, m. teres minor, m. deltoideus (pars spinalis), m. biceps branchii (caput longum).

internal rotation:

m. subscapularis, m. latissimus dorsi, m. teres major, m. pectoralis major, m. deltoideus (pars clavicularis).

abduction:

m. deltoideus (pars. acromialis), m. supraspinatus.

abduction – elevation:

m. serratus anterior, m. trapezius (pars. descendens), m. levator scapulae, m. rhomboideus

adduction:

m. pectoralis major, m. latissimus dorsi, m. teres major, m. coracobrachialis, m. biceps brachii (caput breve), m. deltoideus (pars spinalis and pars clavicularis).

internal rotation: measurement of the vertebra prominens - thumb distance, clasping the hands behind the waist and neck

2.4 Testing

2.5 The rotator cuff

The rotator cuff is composed of four muscles which aim to center the humeral head in the glenoid cavity. Rotator cuff tears are due to either trauma or age-related. They are a common entity and affect almost half the population over 60 years35. Due to a lack or loss of function with regard to one of the muscles a longstanding irregular wear can take place and ultimately end in osteoarthritis. To date there is no clear data on whether one of the below described techniques are superior to another22. It is important to perform an accurate and systematic examination to ensure detection of pathology which can be referred to a specific segment of the rotator cuff. Recently, Micheroli, Tamborrini et al. 24 performed a study in order to compare the findings of clinical examination and high resolution ultrasonography in patients presenting with painful shoulder. It was concluded that for the interpretation of clinical examination test is important to know the sensitivity and specificity of clinical tests (Table 1). Testing of the shoulder should first be carried out in an active fashion. Whenever disabilities or a limited range of motion is detected, the clinical examination is supplemented by a passive testing. Furthermore, functional testing should be performed against resistance. Strength can be objectified by different scales, i.e. Medical

Research Council or modified scales by Janda or Noreau27 29.

Table 124

2.6 Supraspinatus muscle (SSP)

Function: abduction Innervation: suprascapular nerve (C4-6)

Starter Test / 0° abduction test:

Examiner is standing behind the patient. Patient is asked to abduct from neutral-position against resistance (testing in 0° in 20° of abduction). Test is defined positive if pain occurs or a lack or loss of function of the SSP can be detected.

Jobe Test (Empty Can Test), Palm Up Test (Full Can):

Patient is in a seating position and examiner is standing behind the patient. Both arms are in 90° of abduction and 20-30° of horizontal flexion (Fig 5).

Jobe Test (Empty Can Test): 90° of internal rotation (aims to detect lesions of the posterior SSP aspects)

Palm up (Full Can Test): 45° of external rotation (aims to detect lesion of the anterior SSP aspects)

Test is defined positive if pain occurs or lack / loss of motion is detected.

Drop Arm Test

First description was made by Codman in 1931 12. The examiner is standing behind the patient fixing the scapula with the described C-manoeuver36. The arm is passively abducted in 90° and the patient is asked to keep the abducted arm elevated while examiner lessens support. Spontaneous adduction and inability to keep the arm abducted defines the test as positive.

left: jobe supraspinatus test: patient’s shoulder is in elevation / internal rotation, the examiner applies a downward pressure against the arm provocating pain or weakness.

2.7 Infraspinatus muscle and teres minor muscle

Function: abduction, external rotation Innervation:

infraspinatus muscle: suprascapular nerve (C4-6) teres minor muscle: axillary nerve (C5-6)

Biomechanical testing showed a 45% of external force strength formed by the teres minor 34.

However there is no clear position for distinction of the infraspinatus and teres minor muscle17.

External Rotation Test

Examiner is standing behind the patient. The elbow is brought into 90° of flexion and patient is asked to perform a external rotation against resistance of the examiner. Loss of strength indicates insufficiency of external rotators and should be examined in comparison to the unaffected arm. (Fig. 6)

Hornblower’s Sign

Patient is asked to bring the hand to the mouth as to blow a horn. Due to insufficiency (partial) or a complete tear of the infraspinatus and teres minor muscle the patient arm drops in internal rotation. As compensation maneuver the arm is abducted in the glenohumeral joint and...