Clinical Examination of the Shoulder

195 Pages·2004·30.596 MB·English

by  Todd S. Ellenbecker, MS, PT, SCS, OCS, CSCS (Auth.)

11830 Westline Industrial Drive
St.Louis,Missouri 63146
CLINICAL EXAMINATION OF THE SHOULDER 0-7216-9807-7
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NOTICE
Physical Therapy is an ever-changing field.Standard safety precautions must be followed,but as new
research and clinical experience broaden our knowledge,changes in treatment and drug therapy may
become necessary or appropriate.Readers are advised to check the most current product information
provided by the manufacturer of each drug to be administered to verify the recommended dose,the
method and duration of administration,and contraindications.It is the responsibility of the licensed
prescriber, relying on experience and knowledge of the patient, to determine dosages and the best
treatment for each individual patient.Neither the publisher nor the editor assumes any liability for any
injury and/or damage to persons or property arising from this publication.
Publisher
Library of Congress Cataloging in Publication Data
Ellenbecker,Todd S.,1962–
Clinical examination of the shoulder / Todd
S.Ellenbecker.
p.;cm.
Includes bibliographical references and index.
ISBN 0-7216-9807-7
1. Shoulder–Examination. 2. Shoulder–Wounds and injuries–Diagnosis. I. Title.[DNLM:
1. Shoulder Joint–injuries. 2. Shoulder Joint–physiopathology. 3. Diagnostic Techniques and
Procedures. 4. Shoulder–injuries. 5. Shoulder–physiopathology.WE 810 E45c 2004]
RC939.E45 2004
617.5¢72044–dc22 2004046718
Acquisitions Editor:Marion Waldman
Developmental Editor:Jacquelyn Merrell
Publishing Services Manager:Linda McKinley
Project Manager:Jennifer Furey
Designer:Amy Buxton
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my wife and best friend—Gail
FM.qxd 5/24/04 4:23 PM Page vii
PREFACE
Advances in basic science and clinical research of the tors can be used to better understand the seemingly com-
shoulder have significantly increased the under- plicated terms of specificityandsensitivity.These terms are
standing of the anatomy,biomechanics,and pathophysiol- spinandsnout,and the use of these terms may make it eas-
ogy of the human shoulder. With these advances has ier to apply the concepts of specificity and sensitivity using
come an influx of clinical tests and methods used to exam- these everyday terms. Spin, used for specificity, indicates
ine the patient with a musculoskeletal shoulder injury. that specificity refers to ruling “in” conditions, whereas
The primary purpose of this book is to provide the reader snout,representing sensitivity,assists in ruling conditions
with an overview of the available research substantiating “out.”While oversimplified,these simple descriptors can
or negating the use of many clinical tests for the patient be used while reading through the often detailed research
presenting with shoulder dysfunction.In addition to sim- on many clinical tests described in this text.
ply providing a detailed description of these tests, each Finally, it is hoped that the practical information
chapter provides an overview of the primary pathology for included in the latter portion of this text on strength test-
which these tests are used and summarizes the research ing,proprioception,and functional evaluation can be used
performed on these tests to provide a level of understand- to provide the most detailed clinical examination of the
ing regarding their effectiveness. high-functioning shoulder. Understanding the clustering
The inclusion of research is not meant to confuse the of signs and symptoms obtained during the clinical exam-
reader,but rather to allow for a more scientific approach ination processes inherent in the “master”clinician’s clini-
to the examination process. Repeated use of the terms cal behaviors is summarized in the final section of this
specificity and sensitivity can be at times intimidating. book in the form of case studies.It is hoped that this book
However,these statistical values can assist the clinician in will provide a valuable clinical reference tool for the prac-
identifying clinical tests that are the most effective for ticing clinician by consolidating practical and research-
patients with shoulder dysfunction.Two simple descrip- specific information in one place.
vii
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ACKNOWLEDGMENTS
While many individuals have provided guidance, I would also like to thank the physicians, therapists,
both in this project and throughout my career, I tennis teaching professionals, and coaches for the daily
would like to acknowledge the following,whom this book opportunity to examine and treat their patients and
could not have been written without—George Davies, athletes and allow me the privilege to focus on clinical
Janet Sobel,Kevin Wilk,Dr.Ben Kibler,and Dr.Robert practice and research of the shoulder.
Nirschl—for their excellence and guidance in teaching me
shoulder examination and treatment.
ix
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CHAP TER
1
Introduction to Clinical
Examination of the Shoulder
HOW TO USE THIS BOOK actually have the condition (Portney & Watkins, 1993).
This book is designed to present the integral parts of the The sensitivity of a test increases as the number of persons
examination process, combined with clinical research who are correctly identified as having the condition
identifying the effectiveness of the procedures and tech- increases.Another way of thinking of sensitivity is that it
niques used by clinicians, to evaluate the patient with increases when fewer persons with the disorder are
shoulder dysfunction.The research provided in this text missed.Obviously,it is advantageous for a clinician to use
provides crucially important information for the clinician tests that have high indexes of sensitivity.
and contains specific terms,such as specificity, sensitivity,
Specificity
and predictive value. A discussion of these terms is war-
ranted to improve the application of this research to the Specificity is the ability of a test to obtain a negative result
clinical evaluation process. when the condition the clinician is testing for is truly
absent. Specificity is represented by the proportion of
Definition of Key Terms individuals who test negative for the condition out of
The use of terms such as specificity, sensitivity, and both all those who do not have the condition. According to
positive andnegative predictive valueare commonly applied Portney and Watkins (1993), a highly specific test will
in research reporting the accuracy and effectiveness of rarely test positive when a person does not have the
examination techniques on patients. In many studies, disease or condition for which he or she is being tested.
patients are examined clinically and results are compared
to determine the reliability of the clinical test both for one Combining Sensitivity and Specificity
examiner on numerous occasions of testing (intrarater Obviously,using tests with high sensitivity and specificity
reliability) and among several examiners (interrater relia- enhances a clinician’s ability to correctly identify patholo-
bility).Clinical tests contained in this book are also often gy and arrive at the best possible clinical impression and
compared with the results of other diagnostic tests such subsequent treatment plan.As with many clinical scenar-
as magnetic resonance imaging (MRI) or radiographs, ios,however,there are tradeoffs between the two charac-
as well as with intraoperative findings. The presence of teristics.Tests that are designed to be highly sensitive have
injury or pathology at time of surgery confirms or negates testing criteria that are typically less stringent;thus fewer
the result of clinical testing and is a common research cases are missed (Portney & Watkins, 1993). In this
design presented in this book. scenario, the chances of obtaining false-positive results
increase (decreased specificity) because less stringent qual-
Sensitivity ifying responses are used to render a test positive. Like-
The validity of a screening or evaluation test is measured wise,if the test criteria are made more stringent,such that
in terms of its ability to accurately assess the presence or only a narrow range of individuals with the criterion vari-
absence of the target condition (Portney & Watkins, able will test positive,a greater proportion of those who are
1993).Sensitivitycan be defined as the ability of a test or normal will test negative (increasing specificity);however,
evaluation maneuver to obtain a “positive”result when the a larger number of the true cases (individuals who have the
condition the test is testing for is really present.In other condition) will be missed,which decreases sensitivity.
words,sensitivity is the ability of the test to produce a true Sensitivity is most important when the risk associated
positive result when the patient being tested actually has with missing a diagnosis is high,such as identifying can-
the disorder for which the examiner is testing.Sensitivity cer or other life-threatening disease. Using the muscu-
is represented by the percentage of individuals who test loskeletal tests mentioned in this book, including the
positive for the condition out of all those individuals who clinical elimination maneuvers for the glenoid labrum,
3
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4 SECTIONI General Overview
which may render a patient a candidate for a surgical pro- posture that does not allow further testing as a result of
cedure,would also carry a high risk,as an inaccurate diag- decreased relaxation. Therefore careful selection of the
nosis may subject a patient to an unnecessary surgical most important and clinically accurate tests is an impor-
procedure.Specificity is more important when either the tant responsibility of the clinician when performing a
costs or risks involved with further intervention are sub- clinical shoulder examination.
stantial (Portney & Watkins, 1993). This book includes
Prevalence
multiple tests in most areas to provide the clinician with a
The concept of prevalence must be considered when
variety of clinical tests,so that the results of several exam-
applying and interpreting clinical tests.The term preva-
inations can be combined to minimize the tradeoffs
lencerefers to the number of cases of a condition that exist
between specificity and sensitivity.
in a certain population at any given time (Portney &
Predictive Value Watkins,1993).When the prevalence is high,the likeli-
hood of identifying cases correctly using tests with a given
To determine whether the performance of a clinical test or
sensitivity and specificity increases.Also,when prevalence
series of clinical tests is feasible and an efficient use of
is high, a test will tend to have a higher PPV. When
both the examiner’s and patient’s time,the test’s predictive
prevalence is low,the chances of obtaining a false-positive
value can be assessed.Positive predictive value (PPV) esti-
result are much higher than when the prevalence of a par-
mates the likelihood that a person who tests positive will
ticular condition is high. When using the empty or full
actually have the condition for which he or she is being
can test to detect a full-thickness rotator cuff tear,knowl-
tested.PPV is the proportion of patients who test positive
edge regarding the prevalence of rotator cuff tears plays a
and who truly have the condition. A clinical test with a
considerable part in applying the results of the test. For
very high PPV provides a strong estimate of the number
example, when testing an 11-year-old elite junior tennis
of patients who actually have the condition.
player with anterior shoulder pain,a positive empty or full
Likewise, negative predictive value (NPV) indicates
can test is unlikely to indicate a full-thickness tear of the
the probability that a person who tests negative on a clin-
supraspinatus tendon, as full-thickness rotator cuff tears
ical test actually does not have the condition for which he
in that young population are less common and occur at a
or she is being assessed.Research by Itoi et al (1999) illus-
very low prevalence.In contrast,if the empty or full can
trates the concept of predictive value. They studied the
test resulted in significant muscular weakness in a 79-
effectiveness of the empty and full can clinical tests in
year-old competitive tennis player with anterior shoulder
identifying patients with full-thickness rotator cuff tears.
pain,the likelihood that this finding would indicate a full-
By using the criterion of muscular weakness,the full can
thickness tear is much greater because of the greater
clinical test had a PPV of 49%.This finding tells clini-
prevalence of full-thickness tears in older individuals.
cians that approximately one of every two patients who
have substantial weakness during the performance of the Summary
full can rotator cuff test actually has a full-thickness rota-
This book provides detailed descriptions of clinical tests
tor cuff tear.Likewise,one of every two patients who test
along with research reporting their sensitivity and speci-
positive during the full can test is actually normal.
ficity, as well as their positive and negative predictive
Applying positive and negative predictive values to the
value.This information provides a better indication of the
clinical environment may at first seem overly scientific and
actual effectiveness of a specific clinical test or group of
academic.However,consider the ramifications of using a
clinical tests,as well as a better understanding of the role
clinical test with a very low PPV during the evaluation of
that an examination maneuver or group of maneuvers can
a patient who presents with symptoms consistent with a
play in the comprehensive evaluation of the patient with
labral tear.If an individual were to test positive for a labral
shoulder pathology.
tear using a test with a very low PPV, considerable time
and additional resources would be required to further COMPARISON OF CLINICAL
determine whether that initial clinical test was actually EVALUATION FINDINGS WITH
correct.In some cases,the use of clinical tests with a very OTHER DIAGNOSTIC TESTS AND
low PPV or NPV is not worth the potential discomfort SURGICAL FINDINGS
and time required.Another potential problem with using One of the most common methods of determining the
tests with low predictive value is that alternative tests are effectiveness of a group of clinical examinations of the
often required to confirm the results of the first test.For shoulder is to compare the results with established diag-
example, use of a clunk test to identify labral pathology nostic tests. Naredo et al (2002) compared the results of
may place the patient in a more apprehensive clinical physical examination to ultrasound testing in 31 consecu-
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CHAPTER 1 Introduction to Clinical Examination of the Shoulder 5
tive patients with a first episode of shoulder pain.Exami- tion 51% of the time and with the diagnostic categories
nations were performed by two rheumatologists, with a 80% of the time (Magarey et al, 1989). Further research
third rheumatologist blinded to the results of the clinical on the use of diagnostic categories as well as continued
examination performing the ultrasound. The clinical comparison of clinical test results with arthroscopic
examination consisted of active and passive range of evaluation will assist in determining accuracy and guide
motion and 10 special examination maneuvers.Results of therapists in both the performance and especially the
the comparison showed very low sensitivity in the clinical interpretation of clinical examination methods for the
diagnosis of nearly all shoulder lesions,especially rotator shoulder.
cuff tears; however, specificity was high for rotator cuff
tear,tendonitis of the subscapularis and infraspinatus,and
acromioclavicular joint injury.Specificity was very low for GENERAL CONCEPTS APPLIED
supraspinatus tears, biceps tendonitis, and rotator cuff DURING CLINICAL EXAMINATION
impingement. This study emphasized that pain elicited OF THE SHOULDER
during impingement testing by placing the rotator cuff Several general concepts are important when performing
beneath the acromial arch can be diagnostic for many clinical examination of the shoulder.These concepts are
types of rotator cuff lesions,and the induced pain cannot referred to throughout this book, but are described in
be clearly diagnostic for one particular condition. The detail here.They are essential to the successful examina-
authors concluded that clinical assessment by experienced tion of the patient with shoulder pathology.
physician examiners of the patient with a first-time
injured shoulder was often inaccurate and that ultra- Resting Position of the Glenohumeral Joint
sonography should be used whenever possible to improve The resting position of the human glenohumeral joint is
diagnostic accuracy. generally considered to be the position of maximum range
Research results comparing MRI with clinical evalua- of motion and laxity, as a result of minimal tension or
tion is also available.These studies are covered in greater stress in the supportive structures surrounding the joint
detail in Chapter 13. MRI has been reported to have a (Hsu et al,2002).This position has been referred to as the
high sensitivity (100%) and specificity (95%) for the diag- loose-pack position of the joint. Kaltenborn (1989) and
nosis of rotator cuff tears (Ianotti et al,1991) and can dif- Magee (1997) have both reported that the resting position
ferentiate normal rotator cuff tendons from tendons with of the glenohumeral joint ranges between 55 and 70
“tendonitis”(93% sensitivity,87% specificity). degrees of abduction (trunk humeral angle) in the scapu-
Liu et al (1996a) introduced the crank test for clinical lar plane (see definition of scapular plane in this chapter).
identification of labral tears and reported a higher sensi- This loose-pack position is generally considered to be in
tivity of 90% compared with sensitivity of MRI (59%) and mid-range position,but only recently has been subjected
a specificity that equaled that of MRI (85%).This study to experimental testing.
found that a clinical test was more accurate than MRI in Hsu et al (2002) measured maximal anteroposterior
identifying labral tears in 62 patients who had an average displacements and total rotation range of motion in
of 3 months of shoulder symptoms that did not resolve cadaveric specimens, with different positions of gleno-
with physical therapy. humeral joint elevation in the plane of the scapula.They
Finally, comparison of clinical examination findings identified the loose-pack position,where maximal antero-
with arthroscopic shoulder surgery continues to be one of posterior humeral head excursion and maximal total rota-
the more common means to measure the validity of clini- tion range of motion occurred within the proposed range
cal tests.Itoi et al (1999) used this approach to study the of 55 to 70 degrees of humeral elevation in the scapular
effectiveness of the empty and full can clinical test to plane (trunk-humeral angle) at a mean trunk humeral
identify supraspinatus tears. Magarey et al (1989) com- angle of 39.33 degrees.This rate corresponded to 45% of
pared the results of a clinical examination of the shoulder the available range of motion of the cadaveric specimens.
by two physical therapists with findings obtained during Anteroposterior humeral head translations and maximal
arthroscopic surgery. The two therapists independently total rotation ranges of motion were significantly less,at 0
reached the same conclusion regarding the “tissue source” degrees of abduction and near 90 degrees of abduction
of the patient’s pain 100% of the time. There was 72% in the plane of the scapula, and were greatest near the
agreement in their ability to place the patient into one of experimentally measured resting position of the gleno-
four diagnostic categories: impingement, tendonitis, humeral joint.This study provides key objective evidence
tendon rupture, and instability. The use of arthroscopy for the clinician to obtain the maximal loose-pack posi-
to identify tissue source agreed with the clinical examina- tion of the glenohumeral joint by using the plane of the
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6 SECTIONI General Overview
Figure1-1 Balance point position allowing clinician to support the patient’s extremity with one hand. Note the position of the hand
near the epicondyles of the elbow.
scapula and approximately 40 degrees of abduction.This retically required to allow for full overhead elevation in
information is important to clinicians who wish to evalu- the scapular plane (Inman et al, 1944).Throughout this
ate the glenohumeral joint in a position of maximal excur- book, the scapular plane position is used during specific
sion or translation to determine the underlying accessory evaluation techniques,including humeral head translation
mobility of the joint. tests and impingement tests.
This cadaveric research provides additional clinical
guidance for identifying relative or percent of abduction Balance Point Position of the Upper Extremity
range of motion where this position occurs. In patients The balance point position concept, used frequently in
with restrictions in humeral elevation resulting from clinical tests to evaluate the glenohumeral joint, is not
capsular tightness, the loose-pack position occurs in less technically based on a calculated or measured balancing
abduction than in individuals with full range of abduction point for the human upper extremity.Rather,this concept
range of motion. Clinicians should use this information refers to the position the clinician can use when grasping
during both evaluation and treatment of the human and supporting the patient’s extremity with only one
shoulder. hand,allowing use of the other hand for additional stabi-
lization or function.
Scapular Plane Position Figure 1-1 shows the approximate position and grip
According to Saha (1983), the scapular plane is defined that can be used to control or balance the patient’s upper
as being 30 degrees anterior to the coronal or frontal plane extremity. This position is referred to throughout this
of the body. Placement of the glenohumeral joint in the book as the balance pointposition.Note the location near
scapular plane optimizes the osseous congruity between the elbow and the use of the fingers and thumb to opti-
the humeral head and the glenoid and is widely recom- mize contact on a rather wide area at the elbow.This posi-
mended as an optimal position for performing both tion allows the clinician to influence humeral rotation,as
various evaluation techniques and many rehabilitation well as move the glenohumeral joint in flexion,abduction,
exercises (Saha, 1983; Ellenbecker, 1995). With the and circumduction.Care should be taken to avoid overly
glenohumeral joint placed in the scapular plane, bony aggressive grasping of the patient’s elbow,as this can lead
impingement of the greater tuberosity against the to an increase in patient apprehension and unwanted
acromion does not occur because of the alignment of the muscular activation. Repetitive practice with both the
tuberosity and acromion in this orientation (Saha,1983). clinical tests and patient contact enables the clinician to
Also,no internal or external rotational movement is theo- use optimal patient contacts throughout the upper ex-
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CHAPTER 1 Introduction to Clinical Examination of the Shoulder 7
tremity and ensures that an adequate amount of pres- that is widely recommended and followed closely is the
sure is used to stabilize and handle the patient’s extremity, ordering of the initial extremity to be evaluated. It is
while avoiding a painful or apprehensive response. recommended that the examiner perform clinical test pro-
cedures on the uninjured extremity first, followed by the
Extremity Examination Sequence involved extremity.Following this order promotes greater
The sequence of actual tests used in shoulder evaluation patient relaxation during examination of the involved
varies based on several factors.Although each clinician or extremity,which is often painful,and reduces the appre-
educator may prefer a specific sequence of elements when hension often encountered during the examination
performing the shoulder examination, few objectively process because the patient may be unsure of which move-
based criteria exist.One aspect of the examination process ments or maneuvers the examiner will be performing.
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CHAP TER
2
Examination: Patient History
INTRODUCTION reader is referred to a summary of nonmusculoskeletal
A thorough,organized history of the patient with shoul- causes of shoulder region pain in Chapter 5.To perform
der dysfunction is required in the complete examination a complete and thorough patient examination, careful
process.It is important to include both general questions analysis of subjective information provided in the patient’s
with regard to shoulder pathology and specific questions history is required to alert the examiner to the possible
based on the patient’s sport or activity.Although there are presence of nonmusculoskeletal causes.This information
many approaches to history taking,one example of a thor- directs the clinician to a broader base of examination tech-
ough history applicable for a patient with shoulder dys- niques and possible referral to specialists to rule out non-
function is listed in Box 2-1.This chapter covers several musculoskeletal contribution of shoulder dysfunction.
areas of the patient history in greater detail.
PAST HISTORY
IMMEDIATE HISTORY A thorough understanding of the patient’s past history of
One of the initial areas of focus on the subjective evalua- shoulder injury and disability is essential to a successful
tion is the patient’s immediate history, which typically subjective evaluation.Using the example of a patient with
includes the chief complaint. Although many types of shoulder instability, it is important to delineate whether
questions can be asked,the following four questions sum- the patient has “one time” anterior dislocation from a
marize one approach to obtaining the immediate history: traumatic event (TUBS classification of Matsen [Trau-
1. What is the problematic area? matic, Unidirectional, Bankart, Surgery]) or a repeated,
2. How did the problem occur? chronic instability of the glenohumeral joint from repeti-
3. When did the problem develop? tive stresses and an acquired atraumatic onset of injury
4. Where did the problem occur? (AMBRI classification of Matsen [Atraumatic, Multi-
Although these questions may seem simplistic, they can directional, Bilateral Laxity, Rehabilitation, Inferior
effectively elicit the basic information required from the Capsular Shift]). Knowledge of the patient’s pertinent
patient (Maughon & Andrews,1994). past shoulder history influences not only the sequence and
The description of the chief complaint or complaints inclusion of specific tests used in the evaluation but
typically involves pain, weakness, instability, sensory treatment procedures as well. Examination of a mature
changes,and crepitus.Attempts by the examiner to quan- athlete with a rotator cuff injury from overhead activity is
tify the degree,severity,and exact location of these factors another example of the importance of obtaining a thor-
via the patient’s subjective responses involve sequential, ough history relating to shoulder pathology. Complete
organized dialogue between the patient and examiner. questioning often can reveal a fall onto the lateral aspect
During the subjective evaluation of the shoulder,attempts of the shoulder as long ago as 20 to 30 years or a shoulder
should be directed toward delineating and localizing the separation in high school football that can shed light on
symptoms to the injured segment or segments.Identifica- the patient’s impingement-type symptoms. Encroach-
tion of radicular symptoms into the distal upper extrem- ment of the subacromial space as a result of degenerative
ity, constant pain without change or relief, and the changes in the acromioclavicular joint from previous
presence of headaches, low back or neck pain, and psy- injury has been reported as an etiologic factor in impinge-
chosocial stresses that may be influencing the patient’s ment lesions (Neer,1983).
overall health provide rationales for further objective Specific questioning regarding previous treatment
evaluation outside the upper extremity kinetic chain.For to the injured shoulder is also of interest to the rehabilita-
a more detailed discussion of differential diagnosis, the tion specialist. Previous surgical procedures, steroid
9