Neck. Cervical nerve compression may cause shoulder pain. It is useful to rule out significant neck dysfunction by simply asking the patient to flex and extend their neck and look from one side to the other to see if this produces pain or if there is a restriction of movement.
Stiffness : Stiffness can be ruled in or out as a cause of a shoulder problem early on in the exam by simply having the patient place their elbow by their side while the examiner gently externally rotates the arm. Pain does not usually limit external rotation as this manoeuvre is not very provocative. A block to external rotation, especially if it is rubbery or bony, implies either adhesive capsulitis or osteoarthritis. This can be confirmed by moving the arm in the other planes of movement. In adhesive capsulitis and osteoarthritis movements in all planes will be restricted. However, pay particular attention to the movement of the scapula, as in stiff shoulders the scapula will move with the humerus and give the false impression of movement at the glenohumeral joint.
Rotator Cuff Tear
- A positive impingement sign
- Weakness in external rotation,
- Weakness in superscript.
If two of these tests are positive and the patient is over 60, there is a 98% chance of having a rotator cuff tear. If all three tests are positive the patient also has a 98% chance of having a rotator cuff tear. If two are positive and the patient is under 60, or if one is positive, then the examination is indeterminate. Perhaps most importantly, if none are positive a rotator cuff tear can be ruled out.
Specific Signs / Impingement Signs are useful to identify pain in the subacromial space. For the external rotation impingement sign, the arm is abducted to 90 degrees and externally rotated. For internal rotation impingement, the arm is abducted to 90 degrees, brought across the body and then internally rotated. The aim of both manouvers is to impinge the rotator cuff and bursa underneath the acromion. A positive sign is when the patient has pain. They are not particularly helpful in making a specific diagnosis, however. Nearly any cause of shoulder pain can lead to a positive impingement sign.
The O’Brien Sign is useful for identifying a superior labral (SLAP) lesion. The patient is asked to resist the examiner while holding the arm in the illustrated position (90° forward flexion, 10° adduction and the thumb pointing down). A positive test occurs when pain is elicited and that pain is reduced when retested with the patient’s palm facing upwards.
Instability : If the practitioner is concerned about joint instability, there are a number of tests that can be performe. A useful sign is the sulcus sign – pulling the arm distally and looking for a sulcus underneath the acromion. A sulcus sign of two centimetres or more is an indicator of multidirectional instability. It is an indication that there is gross laxity in the shoulder capsule. A negative sulcus sign does not rule out instability. The apprehension sign and its variants – augmentation and relocation signs – are very useful for confirming the diagnosis of traumatic anterior instability.
To carry out the apprehension test, the patient is placed supine and the arm is externally rotated. The test is most reliable when the patient expresses apprehension that the shoulder will “come out”, rather than pain. There are several variants which are helpful: augmentation – increased apprehension when the humeral head is translated anteriorly; and relocation – decreased apprehension when the humeral head is translated posteriorly.
Bell Sign : A modification of this test, the modified O’Brien’s sign or Bell sign is a useful test for AC joint pathology. In this situation, when the patient has their thumb down, the examiner should stand in front of them, put his other hand on their opposite shoulder and then ask them to push the affected arm upwards and outwards towards the top corner of the room against resistance. This manoeuvre loads the AC joint and is a very effective test for evaluating AC joint pathology. It is helpful to palpate the AC joint to confirm this is the location of the pain. If the AC joint tests are positive, the next step then would be to do image guided injection into the AC joint with local anaesthetic and corticosteroid. The local anaesthetic should relieve the pain, confirming the diagnosis of AC joint pain. A corticosteroid is often a good first step measure for managing AC joint pain.