Chapter 2: Assessment of the shoulder
The examination really starts before the history is taken. For instance, a handshake may demonstrate the shoulder shrug of a full thickness massive rotator cuff tear (Figure 2.7). Particular attention should be paid to the difficulties the patient has in removing a shirt or jacket. The surgeon must remember that the shoulder is really a series of joints - the sternoclavicular, acromioclavicular, sternothor-acic, subacromial and finally the glenohumeral. The neck should be examined, as should the elbow, wrist and hand. This chapter, however, will consider the shoulder girdle alone.
History
Diagnosis of shoulder disorders depends mainly upon the history. There are often few signs to elicit. Patients will usually complain of either shoulder pain or loss of function. Rarer presentations may include instability, clicking, popping, snapping, a numb or 'dead arm', weakness or stiffness.
There are three key questions that need to be answered:
- Is this true shoulder pain?
- How did the pain start?
- Which movement exacerbates the pain?
True shoulder pain must be differentiated from neck pain, radicular pain and referred pain.
Neck pain originates in the neck and may be referred down to the shoulder, into the interscapular area or up towards the scalp. Root pain may be felt around the shoulder, but originates from the base of the neck and radiates all the way down the arm into the hand. Pain may be referred to the shoulder from diaphragmatic irritation, classically from gallbladder disease to the right shoulder and from the heart to the left shoulder (Figure 2.3).
Is this true shoulder pain?
True shoulder pain is felt at the shoulder and radiates into the upper arm. The patient will describe this in one of two ways. The palm sign describes the patient placing the palm of the unaffected hand over the epaulette area of the painful shoulder and rubbing. This is the usual presentation of glenohumeral or subacromial true shoulder pain (Figure 2.1). The finger sign describes the patient taking the index finger of the opposite hand and pointing to the affected acromioclavicular joint which is pathognomonic
How did the pain start?
The patient may volunteer that the problem started with an injury. If so, a detailed description should be sought
- When was the injury?
- What happened?
- Was it a soft tissue injury, a fracture or a dislocation?
- What was the position of the arm?
- How much energy was absorbed by the arm?
- How was it managed and by whom?
- Were radiographs taken?
Figure 2.1 The 'palm sign': the patient points to the site of glenohumeral pain by rubbing the shoulder with the palm of the opposite hand.
Figure 2.2 The finger sign': the patient points to the acromioclavicular joint pain with one finger directly on the affected joint.
Figure 2.3 Types of shoulder pain. From left to right: neck pain starts at the neck and radiates to the shoulder and up into the scalp (A). Root pain may be maximal at the shoulder but radiates down the length of the arm to the hand (B). Pain may be referred to the shoulder, classically from the diaphragm and gallbladder to the right shoulder and from the heart to the left shoulder (C). True glenohumeral joint pain may radiate both down the arm and also, to a lesser extent, up into the neck (D).
To what degree did it recover and in what time period? Which movement exacerbates the pain?
If there was no injury:
- Did the pain come on suddenly or insidiously?
- Is there any history of arthritis in any other joint?
- Has the patient had any recent infections?
- Is the patient generally well?
Pain at rest is a worrying symptom. The patient may be systemically unwell or well. If the patient is systemically unwell, then sepsis or polymyalgia rheumatica should be considered. If the patient is well, then the pain is usually due to early arthritis of the shoulder or a developing capsulitis (frozen shoulder). These patients will usually have a stiff shoulder on examination with limitation of external rotation and limited flexion and abduction. They may have a terminal painful arc such that elevation is restricted to 100 degrees, with a painful arc between 70 and 100 degrees.
Pain on movement denotes a painful arc of which there are four types: terminal, of the stiff shoulder (capsulitis arc, as above); subacromial; acromioclavicular; and composite (Figure 2.4).
The subacromial painful arc produces an arc of pain which comes on at approximately 70 degrees of elevation or abduction and eases off at approximately 130 degrees to top elevation. This usually indicates pain arising from subacromial impingement. A trap for the unwary is that subacromial impingement in a patient under the age of 40 is often a sign of shoulder instability causing functional impingement (see Chapters 8 and 9). Proof of the pain originating in the subacromial region can be demonstrated by the impingement test (see below).
The acromioclavicular painful arc produces an arc of pain at the extreme of shoulder elevation, between 140 and 170 degrees. This usually denotes pain arising from the acromioclavicular joint which can be blocked by the injection of local anaesthetic.
The composite painful arc has a near normal range of shoulder elevation, but a painful arc from 70 degrees to the top of elevation, a fairly common situation. It occurs in patients with dual pathologies, such as acromioclavicular pain and subacromial impingement.
Figure 2.4 Which movement exacerbates the pain? From left to right: the high painful arc of acromioclavicular joint disease, the common painful arc of impingement, the stiff painful shoulder (frozen shoulder). Some people may have shoulder pain which is not exacerbated by movement.
Severity of pain and function
Once the three key questions have been answered, the surgeon will gain further insight by enquiring into the severity of the pain, its frequency, pain at night (a particular feature of shoulder pain) and functional loss. The patient attending the shoulder clinic may be asked to complete a self-assessment sheet while waiting to see the surgeon (Figure 2.5). This scores pain from nil to severe (1-5), the frequency of pain from none to constant rest pain (1-5), and pain at night from none to unable to sleep every night (1-5). Thus a patient scoring 5s all the way is in severe trouble and is asked to complete a form on each attendance giving an objective assessment of improvement. The patient also marks on the form which movements make the pain worse and any change since the last attendance (better or worse). The surgeon also scores the pain and notes analgesic consumption on a separate assessment sheet (Figure 2.6).
Functional loss is as vital to the patient as pain and this is also scored on the self-assessment form. Reach is assessed to shoulder blades, shelves above head, hair, waist, back of neck, base of spine and opposite axilla. Finally, loss of work, sport and sleep are scored. Functional loss has been used by many surgeons who have tried to devise shoulder scoring systems. The Mayo score includes driving, dressing, sleeping and overhead working; the Neer score emphasizes perineal care, dressing, carrying, throwing and lifting. The Lysholm score is used in Sweden and the Constant score in the United Kingdom. Functional assessment based on the Neer score is included in the computerized diagnosis program used by Johnson, which is a 42-page document detailing medical history, shoulder history, shoulder examination, investigations, and shoulder surgery.
It is vital to know the patient's exact occupation and hand dominance and how this is affected by the shoulder pain, if this has not already been elicited at the start of the interview.
Specific questions
Specific questions may now be asked such as the presence of joint stiffness, clicking, popping or snapping sensations and jamming of the joint.
The patient should also be asked whether the joint has ever been dislocated. If so, the initial event should be documented, together with the number of recurrences, the direction of dislocation, the ease of reduction and any feelings of instability without the joint actually dislocating.
Examination
Examination consists of look, feel, move and x-ray.
An example of a patient's shoulder assessment sheet can be seen below:
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PATIENT'S SELF ASSESSMENT SHEET: SHOULDER NAME..................................................................................................... SHOULDER AFFECTED: RIGHT/LEFT TODAY'S DATE..................................................................................... SEVERITY OF PAIN Choose one of the following by ringing the number. 1 I have no pain. 2 I have mild discomfort. 3 I have moderate pain which forces me to make concessions. 4 I have pain bad enough to need painkilling tablets. 5 I have severe pain. FREQUENCY OF PAIN Choose one of the following by ringing the number. 1 I have no pain. 2 I have occasional pain after unusual activity. 3 I have occasional pain on movement. 4 I have pain whenever I move my shoulder. 5 I have pain present all the time, even at rest. PAIN AT NIGHT Choose one of the following by ringing the number. 1 I have no pain at night. 2 My sleep is disturbed occasionally by pain in my shoulder. 3 I am woken at least once every night by pain in my shoulder. 4 I am woken several times each night by pain in my shoulder. 5 I am unable to get enough sleep every night because of pain in my shoulder. PAINFUL MOVEMENTS Ring all the numbers which apply to you. 1 Pain occurs when reaching behind my neck. 2 Pain occurs when reaching behind my waist. 3 Pain occurs when reaching above my head. 4 Pain occurs when reaching sideways. 5 Pain occurs when reaching forwards. FUNCTIONAL LOSS Ring which number is true when using your 'bad' arm. 1 I cannot reach between my shoulder blades. 2 I cannot reach a shelf above my head. 3 I cannot comb my hair. 4 I cannot reach behind my waist. 5 I cannot wash the back of my neck. 6 I cannot reach the base of my spine. 7 I cannot wash under the opposite arm.
1 I cannot do usual sport. (Name sport). 2 I cannot do usual work. (Name work). 3 I cannot sleep on that side at night. CHANGE SINCE LAST ATTENDANCE Compare your shoulder now with how it was when you last saw the doctor. Ring the number which best describes it. 1 My shoulder is much better. 2 My shoulder is a little better. 3 My shoulder is the same. 4 My shoulder is worse. Figure 2.5 Sample shoulder assessment sheet (filled in by patient). ASSESSMENT OF THE SHOULDER Name .... Address Dominant hand R/L SHOULDER ASSESSMENT SHEET One form to be completed for each shoulder. DOB.......................... Diagnosis.......................... Hospital No. Previous treatment Injection .......................... Other .............................. Surgery............................ Type of operation L or R Occupation............................................................... Date ...... OPERATION DATE (ring arrow) Date (this assessment)
0 = None 1 = Slight or occasional 2 = After unusual activity 3 = Moderate - alters use 4 = Marked - limits activity 5 = Severe - loss of sleep WASTING PAIN ON TEST (P) 0 = None 1 = Mild 2 = Moderate 3 = Severe STRENGTH (S) 0 = Normal 1 = Mild weakness 2 = Severe weakness 3 = Paralysis RANGE OF MOTION (standing) PASSIVE (P) Flex (Arm by side - segment covered by back of hand) (Arm by side) (since operation/treatment) ASSESSOR'S INITIALS: GRADE: 1 = Much better 2 = Better 3 = Same 4 = Worse |
Feel
Palpation is of less value in the shoulder than in many other joints. Specific tenderness may be elicited on pressing over the sternoclavicular or acromioclavicular joints, but tenderness around the glenohumeral joint, hidden as it is under the cloak of the acromion and deltoid, is fairly unhelpful.
Subacromial crepitus, as the patient elevates the arm, can often be impressive, particularly in patients with rotator cuff tears. Some surgeons can feel the defect of a rotator cuff tear with the arm in an extended and adducted position when the impingement area of supraspinatus insertion is brought out from under the acromion, but this requires great experience.
Clicking or snapping should be felt in an attempt to locate the structure from which it emanates. A snapping scapula may be associated with osteochondroma of the blade of the scapula clunking over the ribs as the arm elevates. Clicking on instability testing or elevation may be due to subluxation or a labral tear.
Look
Swelling, deformity or subluxation of the sternoclavicular, acromioclavicular or glenohume-ral joints are noted, as are any swellings or deformity of the clavicle, humerus or scapula. The appearance of the skin is noted, and in particular any scars or incisions are inspected.
Muscle-wasting is of particular importance to the shoulder (Figures 2.8 and 2.9). The rotator cuff has been likened to the quadriceps, in that both have four muscle bellies (subscapu)aris, supraspinal, infraspinatus and teres minor) and both waste rapidly with any abnormality of their associated joint. Wasting of supraspinal and infraspinatus is easily seen and can be compared to the normal side. The thickness of the muscle and the tone in it can also be felt.
If wasting is extreme, then neuromuscular disease should be considered. Fascioscapulo-humeral dystrophy often presents with toss of shoulder function, with marked proximal muscle wasting. Scapular winging may be the presentation of neuralgic amyotrophy. Marked and isolated wasting of supraspinatus and infraspinatus may point the way to a diagnosis of suprascapular nerve entrapment syndrome.
Figures 2.8 and 2.9 Wasting of the cuff muscles, moderate (2.8) and gross (2.9) following rotator cuff tears of long standing.
Move
Active movements
Active movements are assessed first. The patient is asked to elevate the shoulder to demonstrate any limitation of movement or painful arc. If movement is limited then an examining hand placed on the scapula during active elevation will show whether the limitation is glenohumeral or scapulothoracic, or both. A painful arc may be more marked with elevation in abduction rather than flexion. With the elbow locked into the side active external rotation is compared with the unaffected arm, and finally active internal rotation is assessed by comparing how far up the spine the thumb of the affected arm will go compared to the normal side. For this latter test, elbow function must be equal on both sides.
Passive movements
Elevation, external rotation and internal rotation are again measured with the surgeon holding the distal humerus in one hand and the inferior angte of the scapula under the palm of the other hand. The range, pattern of movement, end point, excess over active movement and degree of pain are all noted.
Rotator cuff strength
The clinical test of rotator cuff function is an integral part of every examination of the shoulder.
The supraspinatus test
This test (Figure 2.10) is carried out with the patient standing. With the elbow straight, the arm is placed in 20 degrees of abduction and flexion, and the patient is told to hold it there. The examiner assesses the strength of abduction, and the patient reports the amount of pain produced by this manoeuvre. The examiner then tests the opposite normal shoulder for comparison. Weakness on testing denotes a rotator cuff tear. Unfortunately, if there is a lot of pain, then weakness will be apparent due to pain inhibition, and the test will have to be performed after an impingement injection test.
Figure 2.10 The supraspinatus test: active resisted abduction at 30 degrees tests supraspinatus strength.
The impingement injection test
This test allows the surgeon to establish whether subacromial impingement is causing the painful arc. For the test, 5 ml 1 per cent lignocaine (US: lidocaine) is injected under the anterior edge of the acromion. After 10 minutes the patient is re-examined, and if the painful arc is improved or abolished, then the site of pain has been established.
The infraspinatus test
This test (Figure 2.11) is very similar to the supraspinatus test, and is a test of resisted active external rotation of the shoulder. The infraspinatus is the only efficient external rotator of the glenohumeral joint. Pain and weakness are sought, weakness denoting a rotator cuff tear.
Figure 2.11 The infraspinatus test: active resisted external rotation with the elbow flexed to 90 degrees and the humerus at the side. Pain and weakness may denote a tear of infraspinatus.
The subscapularis test
This test (Figure 2.12) is similar, but opposite, to the infraspinatus test. With the elbow locked against the patient's side active resisted internal rotation of the glenohumeral joint is tested. Unfortunately this movement is produced by pectoralis major and latissimus dorsi, as well as subscapularis, and therefore is not such a sensitive test.
Figure 2.12 The subscapulars test: active resisted internal rotation of the glenohumeral joint.