II. What we will check in ‘Look’ or ‘Inspection’
1. From front :
- Skin – From the front side examination, we can check any scars, paleness, venous prominence and blebs.
- Position and deformities – These can be any dislocation, like hip dislocation. And sometimes any nerve injury which can cause palsy like Erbs palsy.
- Contour – Here we look for the shape and symmetry of any swelling, clavicle and deltoid bulge.
- Others – Anterior axillary fold, Deltopectoral groove, Supraclavicular and Infraclavicular fossae, and pectoralis muscle bulge.
2. From behind :
From behind we look for :
- Scapular symmetry
- Any abnormalities like ‘winging of scapula’ and ‘scoliosis’, posterior axillary fold, supraspinatus and infraspinatus fossae.
3. From side :
Examination from the side, we can see some features like :
- Any swelling
- Sides of the arm
- Skin and contour
- Deltoid bulge
- Presence of any groove in the deltoid
4. From above :
From the above view, we look for ;
- Supraclavicular fossae
- Infraspinatus fossae
- Angle of acromion
III. What we will check in ‘Feel’ or ‘Palpation’
Incase of palpation of the shoulder joint, we will look for mainly seven things, and they are :
- Temperature – using the back of the fingers the examiner checks and compares the temperature of the both shoulders.
- Tenderness – During the bony and soft tissue palpation, the examiner notes that and makes a comment on those tenderness.
- Bone palpation – This follows a order like , Suprasternal notch –> Sternoclavicular joint –> Clavicle and acromioclavicular joint –> Coracoid process –> Acromion –> Greater tuberosity –> Bicipital groove.
- Soft tissue palpation – This is done in passively extended shoulder. We mainly palpate around the rotator cuff. In inferior of the anterior border of the acromian, we can palpate the supraspinatus, infraspinatus, and teres minor.
- Subacromial and Subdeltoid bursa – The bursae may extend up to the bicipital groove from the acromion’s anterior margin. The bursae runs from the acromion’s lateral edge under the deltoid muscle, separating it from the rotator cuff.
- Axilla – Using the index and middle finger of the hand, the examiner used to palpate the axilla. And makes a note about the lymph node enlargement, axillary pulse, any swellings, walls of the axilla.
- Muscles – The examiner used to check the Pectoralis major, Biceps, Deltoid, Sternocleidomastoid, Rhomboids, Latissimus doors, and Serratus anterior.
IV. What we will do in checking movements
A. Flexion-Extension :
Standing behind the patient, the clinician stabilises the scapula with one hand while grasping the patient’s distal arm slightly above the elbow with the other. The tester next swings the arm posteriorly to check for extension and then anteriorly to check for flexion.
B. Abduction-Adduction :
- Abduction – The clinician stabilizes the scapula by firmly fixing the inferior angle of the scapula with one hand or pressing down firmly on top of the shoulder with one hand, and move the patient’s arm with the other hand, gripping the flexed elbow.
- Abduction – Because the body obstructs adduction in the proper plane, it is not possible. The examiner stands in front of the patient and moves the arm across the front of the body for cross body adduction.
C. External and Internal Rotation :
- External rotation by abduction – The patient is asked to touch the supero-medial angle of the opposite sides scapula from behind his head.
- Internal rotation by adduction – The patient is asked to contact the opposing sides acromion. The examiner next instructs the patient to reach behind his back and try to touch the inferior angles of the scapula on opposing sides.
V. What are the measurements of shoulder Joint
A. Linear Measurement :
In linear measurement of the shoulder joint, we mainly check the Length of the arm.
B. Circumferential Measurement :
Here we measure the :
- Girth of the arm in the pathological side first
- Girth of the arm in the normal side
VI. What are the Special tests
1. Drop arm test :
- The drop arm test is used to assess a patient’s capacity to maintain humeral joint motion with eccentric contraction when the arm is moved from abduction to adduction throughout its full range of motion. It will determine whether or not the patient has rotator cuff dysfunction.
- The drop arm test looks for a tear or weakening in the supraspinatous tendon by subluxing the humeral head.
If the patient cannot control the motion of adducting the arm back to the body or if the patient gets discomfort while doing this test, it is considered a positive test.
2. Yergason test :
- The Yergason’s test is an unique orthopaedic examination of the shoulder and upper arm region, with a focus on the biceps tendon.
- It detects the presence of a biceps tendon or glenoid labrum pathology.
- Pain in the bicipital groove, indicating biceps tendinitis, subluxation of the long head of the biceps brachii muscle, and the presence of a SLAP(Superior labrum from anterior to posterior) tear are among the test’s particular positive findings.
- Palpating the long head of the biceps tendon in the bicipital groove is a common way to diagnose biceps tendonitis or subluxation. In the bicipital groove, the patient will experience discomfort, cracking, or both.
- Bicipital tendinopathy is characterised by pain without accompanying popping.
- A snapping suggests a tear or laxity in the transverse humeral ligament, preventing the ligament from anchoring the tendon in the groove.
- A SLAP rupture causes pain in the superior glenohumeral joint.
3. Speed test :
- Speed’s test was created to detect disease in the long head of the biceps in its groove, but it has also been used to detect SLAP lesions.
- The elbow is extended, the forearm is supinated, and the humerus is lifted to 60 degrees. The examiner opposes forward flexion of the humerus.
- The pain is in the bicipital groove. This is usually taken to mean that there is inflammation or lesions in the long head of the biceps or the biceps/labral complex.
4. Belly press test :
- The belly-press test is performed to isolate the subscapularis muscle and to check for tears or dysfunction in the subscapularis muscle. It’s frequently used as a substitute for the lift-off test when the lift-off test isn’t possible due to shoulder pain or limited internal rotation range of motion.
- The belly-press test is performed to isolate the subscapularis muscle and to check for tears or dysfunction in the subscapularis muscle. It’s frequently used as a substitute for the lift-off test when the lift-off test isn’t possible due to shoulder pain or limited internal rotation range of motion.
- If the patient adjusts for the movement by starting wrist flexion, shoulder adduction, or shoulder extension, the test is positive for subscapularis muscle dysfunction.
- The elbow would descend behind the trunk as a result of this instinctive compensatory movement.
5. Patte test :
- This test is used to determine whether the teres Minor muscle has irreversible fatty degeneration or an infraspinatus tear. To perform the tests, the patient should be seated with his or her arm abducted to 90 degrees in the scapular plane.
- The examiner next instructs the patient to undertake external rotation against the examiner’s resistance by flexing the elbow to 90 degrees.
- If the test is positive, the patient will be unable to externally rotate in this posture.
6. Lift-off test :
A normal lift-off test is the ability to actively lift the dorsum of the hand off the back. An abnormal lift-off test is defined as the inability to move the dorsum off the back, which shows subscapularis rupture or dysfunction.
7. External rotation stress test :
- The syndesmotic ligaments’ integrity can be determined using the external rotation test. The patient is seated with his knee flexed to 90 degrees. With the ankle locked in neutral, the foot is softly grabbed and turned laterally.
- When the patient has pain above the syndesmosis, the test is positive.
8. Apprehension test for anterior dislocation shoulder :
- In either the supine or upright posture, put the patient’s shoulder into a position of 90° abduction and 90° external rotation to elicit anterior apprehension.
- When in this provocative position, a favourable exam finding is the subjective impression of impending subluxation or dislocation.