Examination

Neck

 

Cervical nerve compression, a potential cause of shoulder pain, underscores the importance of assessing neck function during diagnosis. Our clinic’s approach includes a simple but crucial neck flexibility test, where patients are asked to perform neck flexion, extension, and lateral rotation. This helps determine if neck movements trigger pain or reveal any movement restrictions, guiding us in identifying cervical spine issues. 

Stiffness

 

Early in the examination process, assessing shoulder stiffness is crucial. A simple yet effective technique involves the patient keeping their elbow at their side while the examiner gently externally rotates the arm. This test, focusing on external rotation, helps differentiate between general pain and movement limitations. A noticeable block in this movement, particularly with a rubbery or bony feel, often points towards adhesive capsulitis or osteoarthritis. Further confirmation comes from testing the arm’s mobility in other movement planes. Both adhesive capsulitis and osteoarthritis typically show restricted movements across all planes. It’s important to observe the scapula’s movement carefully, as in stiff shoulders, it may move in tandem with the humerus, giving a misleading impression of glenohumeral joint mobility. 

Shoulder Stiffness

Rotator Cuff Tear

 

At George Murrell Shoulders, we use the following technique in identifying a rotator cuff tear, which involves specific tests: 

1) A positive impingement sign

2) Assessing weakness in external rotation

3) Evaluating weakness in the supraspinatus muscle

 

Our clinic’s diagnostic approach highlights the importance of these tests. For patients over 60, having two positive results from these tests indicates a 98% likelihood of a rotator cuff tear. This probability remains the same if all three tests are positive. For younger patients under 60, or if only one test is positive, the results are less definitive, warranting further examination. Crucially, if a patient does not exhibit any of these signs, a rotator cuff tear can generally be ruled out. 

Specific Signs / Impingement Signs

 

At George Murrell Shoulders, we employ impingement signs to identify subacromial space pain. The external rotation impingement sign involves abducting the arm to 90 degrees and externally rotating it, while the internal rotation impingement sign involves similar abduction, cross-body movement, and internal rotation. These manoeuvres aim to impinge the rotator cuff and bursa beneath the acromion, with pain during these tests indicating a positive sign. While these signs are effective in indicating shoulder pain, they are not exclusively diagnostic of a specific condition, as various shoulder issues can result in a positive impingement sign. 

Specific Signs / Impingement Signs
Specific signs

The O’Brien Sign

 

The O’Brien Sign – originally described by Dr Stephen O’Brien at the Hospital for Special Surgery, a key diagnostic tool used at George Murrell Shoulders, is instrumental in detecting superior labral (SLAP) lesions. During this test, the patient resists the examiner’s force while maintaining a specific arm position: 90° forward flexion, 10° adduction, and the thumb downwards. A positive O’Brien Sign is indicated by elicited pain, which notably diminishes when the test is repeated with the patient’s palm facing upwards. This method is particularly effective in pinpointing SLAP lesions, although it’s part of a comprehensive diagnostic approach, as shoulder conditions can be multifaceted. 

The O'Brien Sign

Instability

 

At George Murrell Shoulders, we assess joint instability with key tests like the sulcus sign, which measures the gap under the acromion when the arm is pulled downwards. While a significant sulcus indicates multidirectional instability, its absence doesn’t rule out instability. For traumatic anterior instability, we use the apprehension test and its variants – augmentation (increased apprehension with anterior humeral head translation) and relocation (decreased apprehension with posterior translation). 

Shoulder Instability

Bell Sign

 

The modified O’Brien’s sign, or Bell sign, described by Prof Simon Bell in Melbourne, is a key diagnostic test for AC joint pathology at George Murrell Shoulders. This test involves the patient pushing their arm upwards and outwards against resistance, with the thumb pointing downwards. By performing this manoeuvre, we specifically load the AC joint, making it an effective method to evaluate potential AC joint issues. Palpation of the AC joint during the test helps confirm the pain location. Positive AC joint tests lead us to consider image-guided injections of local anaesthetic and corticosteroid into the joint. The anaesthetic offers immediate pain relief, aiding in confirming the diagnosis of AC joint pain, while corticosteroids can be an effective initial treatment strategy. 

Bell Sign