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 promi