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12 Clinical examination of the shoulder

CHAPTER CONTENTS
Referred pain . . . . . . . . . . . . . . . . . . . . . . . 208
Pain referred to the shoulder . . . . . . . . . . . . 208
Pain referred from the shoulder . . . . . . . . . . . 208
History . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Inspection . . . . . . . . . . . . . . . . . . . . . . . . . 209
Functional examination . . . . . . . . . . . . . . . . . . 210
Preliminary examination . . . . . . . . . . . . . . . 210
Basic functional examination of the shoulder . . . . 210
Palpation. . . . . . . . . . . . . . . . . . . . . . . . . . 215
Accessory tests . . . . . . . . . . . . . . . . . . . . . . 215
Technical investigations . . . . . . . . . . . . . . . . . 216
Pain in the shoulder is, after low back pain, the most frequent
complaint of orthopaedic patients. Despite the frequency of
shoulder lesions and the consequent pain and disability
much confusion still exists as to aetiology, terminology and
treatment,
1
in contrast to the statement made by Cyriax:
2,3
The shoulder is the most rewarding joint in the whole body. As a
rule, one can always come to a clear diagnosis, and, if treated in the
proper way, most shoulder lesions seem to be curable. Moreover, it
is the most suitable joint for the general practitioner, since almost
no technical aids are required. A good history and full clinical
examination, together with a detailed knowledge of the anatomy,
sufces to solve the majority of the shoulder problems.
Complicated cases that are difcult to diagnose exactly are
encountered. If clinical ndings are difcult to interpret, the
following general points should be of help.
First, it should be realized that double lesions do exist,
clouding the diagnosis. For example, it is not uncommon to
nd supraspinatus tendinosis together with infraspinatus tendi-
nosis or in association with subdeltoid bursitis. In these doubt-
ful cases, a diagnostic inltration of a local anaesthetic can be
most helpful in isolating the second lesion.
On other occasions, patients present with a painful limita-
tion of passive movement together with pain on resisted
movements, and the question arises as to whether the problem
is in an inert or a contractile structure. If there is capsular
limitation on examination, the joint should be treated rst. If
resisted movements remain painful after the joint has been
managed appropriately, then the tendons should be treated.
This approach is the best one, because resisted movements
very often become negative after arthritis has disappeared.
The only explanation for the phenomenon is the close rela-
tionship between the capsule of the shoulder and the sur-
rounding tendons.
4
It can easily be understood how tension
on the contractile structures may inuence the pain originat-
ing in arthritis. Therefore pain on resisted movement(s) in
association with an articular pattern should not be interpreted
as being caused by a simple tendinosis. Of course, a severe
tendinosis can limit active movement, because of the pain.
But passive movements are of full range with a normal end-
feel, even though there might be severe pain at the end of
movement.
An arthritis is an arthritis, a tendinosis is a tendinosis and
both have to be treated as such. It is a common misbelief that,
as long as steroid is injected somewhere in the shoulder area,
it will spread and cure the lesion, no matter where the lesion
lies or where it was injected.
5
In fact, if there is one region in
the body which ought to be diagnosed and treated very speci-
cally it is the shoulder. It is necessary to replace a vague diag-
nosis such as rotator cuff disease or frozen shoulder by a
precise one indicating exactly what is wrong.
68
The Shoulder
208
Fig 12.1 The C4 dermatome.
anterior
posterior
Fig 12.2 The C5 dermatome.
anterior
posterior
Referred pain
Pain referred to the shoulder
Pain referred to the shoulder, and possibly further down the
arm, can be caused by nerve root compression, mainly as the
consequence of a posterolateral cervical disc protrusion. A
good history is important; the pain has usually started in the
neck, probably interscapularly, and has shifted laterally into the
arm and hand. Very often the pain is worst at night and is
accompanied by pins and needles and numbness. Most fre-
quently the C7 nerve root is compressed, causing pain at the
posterior aspect of the whole arm to the second, third and
fourth ngers. Other nerve roots can also be involved in a cervi-
cal disc lesion but this is far less frequent. Referral to the
appropriate dermatome is usual.
In a posterocentral cervical disc lesion with compression of
the dura mater, the pain does not spread beyond the deltoid
area. Therefore arm pain is not present.
One rare disorder causing pain down the arm is a cervical
neuroma. The condition starts with pain in the arm, which
progressively spreads proximally as the tumour increases
in size.
Other possible causes of referred pain at the shoulder are
visceral disorders. The diaphragm is largely developed from the
third and fourth cervical segment, the heart from the eighth
cervical to the fourth thoracic. Therefore both can give rise
to pain in the shoulder and arm. Irritation of the diaphragm
and of the phrenic nerve, for example by blood or air under
the diaphragm, is another well-known source of acute
shoulder pain.
9,10
A pulmonary neoplasm at the base of the lung with involve-
ment of the diaphragm can provoke pain in the shoulder area.
The same may also happen with a tumour of the superior
sulcus (Pancoasts tumour). The majority of these patients
complain of shoulder pain and are often mistakenly thought to
be suffering from a musculoskeletal lesion.
11,12
Pain referred from the shoulder
Most structures around the shoulder are derived from the C5
segment. There is one important exception: the acromiocla-
vicular joint, which is of C4 origin (Fig. 12.1). In acromiocla-
vicular joint problems the pain is felt at the tip of the shoulder,
with little spread. Exceptionally, when the lesion lies at the
inferior acromioclavicular ligament, the pain can spread into
the upper arm.
In a lesion of one of the other shoulder structures, such as
in all types of tendinosis, arthritis and subdeltoid bursitis, the
pain is not so much felt at the tip of the shoulder but rather
starts in the deltoid region and may spread further down the
radial aspect of the arm to the base of the thumb (C5 der-
matome; Fig. 12.2). How far down the arm the pain is referred
depends on the severity of the lesion: the more severe the
inammation, the further the pain will spread. In glenohumeral
arthritis, the degree of pain reference is of particular interest
C H A P T E R 1 2 Clinical examination of the shoulder
209
question is one of the criteria for judging the stage of
arthritis.
Can you lie on the affected side at night? Pain when lying
on the shoulder indicates more severe inammation than
just pain on exercise. Bursitis, tendinosis or arthritis may
make it impossible for the patient to lie on the affected
side at night. Consequently, this question is not of much
help in dening the exact nature of the structure at fault.
However, it is rather important in following the resolution
of the disorder: as the condition improves, the pain at
night diminishes and nally disappears.
Did the pain come on spontaneously or was there any
particular reason for it, such as overactivity or an injury?
It is clear that overactivity may provoke tendinosis. In a
ruptured tendon, however, one should not necessarily
expect recent overuse. Overactivity can also cause arthritis
in a joint that is already osteoarthrotic; this is just as true
for the acromioclavicular joint as it is for the glenohumeral
joint. In haemophilia, haemarthrosis usually comes on
spontaneously; it is more common at the knee but may
occur at the shoulder as well.
For how long have you had the pain? If the pain has
already been present for some months, an acute
subdeltoid bursitis can be excluded because the full
course of this condition is 6 weeks. In addition, onset is
abrupt over a few days, sometimes only hours, as in an
attack of gouty arthritis. Arm pain because of root
compression by a cervical disc protrusion wears off in
about 4 months. Long-standing pain can be the outcome
of a chronic subdeltoid bursitis or a simple tendinosis.
Both can last for years. Monoarticular steroid-sensitive
arthritis can take up to 2 years to disappear spontaneously.
Are any other joints affected? A more generalized
inammatory disorder is expected if other joints have
been previously involved or are attacked at the same time.
Indeed, the shoulder joint can be the seat of rheumatoid
arthritis, lupus erythematosus and ankylosing spondylitis.
How is your general condition? Have you had any
operations? Recent unexplained loss of weight can be the
rst sign of a carcinoma. A primary tumour at the
shoulder or metastases can be a local source of shoulder
pain. A Pancoasts tumour of the lung often provokes pain
in the shoulder area.
Inspection
The inspection starts with checking what position the head is
held in and whether both shoulders are level. It is important
to check for redness, swelling, muscular wasting or any deform-
ity such as scapular winging. A step deformity at the upper
lateral aspect of the shoulder is caused by an acromioclavicular
dislocation, with the distal end of the clavicle lying superior to
the acromion. Atrophy of the upper trapezius may indicate
spinal accessory nerve palsy.
13
Atrophy of supraspinatus and/or
infraspinatus is caused by either a supraspinous nerve palsy or
long-standing rotator cuff lesions.
14
Effusion of more than
1015 mL arising from the glenohumeral joint is normally
in following the healing process: as the patient improves, the
inammation decreases and the pain spreads less far.
History
The rst question to be elucidated by the history is whether
the pain in the arm is genuinely from a shoulder lesion or
whether it is the consequence of a more proximal lesion, arising
perhaps from the cervical spine. If the answer to this is not
clear from the history, a preliminary examination, including
tests of the cervical spine, shoulder and elbow, is necessary.
In arthritis of the shoulder, the history will be important to
establish the stage (see Ch. 13). In other disorders it is of less
signicance.
The answers to a number of questions (summarized in Box
12.1) will be needed.
What is your age? Age can be relevant in several disorders.
It can be helpful in dening the exact type of arthritis.
Traumatic arthritis will only be met after 40 years of age,
arthritis from immobilization after the age of 60.
Subdeltoid bursitis might be present between 15 and
65 years of age. Tendinosis can occur at any adult age.
What is the pain and does it radiate? Pain starting in the
deltoid area and spreading towards the wrist, along the
radial aspect of the arm, is caused by a lesion that
originates in C5. Such pain may be felt in the whole
dermatome or only in part of it. The majority of the
shoulder structures belong to the C5 segment. The
acromioclavicular joint, a C4 structure, is the main
exception. A patient who indicates the tip of the shoulder
only as the site of pain suggests strongly that there is a
lesion of the acromioclavicular joint. Whether the pain is
caused by arthritis, bursitis or simple tendinosis will make
no difference to where or how far distally the pain is felt.
The distal spread of referred pain depends only on the
degree of inammation. It is routine to ask if the pain
remains above the elbow or radiates below it a matter of
particular importance in arthritis.
Is there any pain in the arm at rest? This gives information
about the severity of the lesion: if spontaneous pain is
present, there is a greater degree of inammation than if
pain is felt only on movement. Again, the answer to this
Box 12.1
Summary of history taking
Age?
Where is the pain? Does it radiate?
Pain at rest or only on use?
Can you lie on that side at night?
How did the pain come on: spontaneously/overuse/injury?
For how long have you had the pain?
Are other joints affected?
General condition? Any operations?
The Shoulder
210
If the examination reveals that the lesion lies in the shoul-
der, the examiner will try to dene in which particular struc-
ture the lesion is situated by carrying out a detailed shoulder
examination; this is comprised of 12 basic tests (summarized
in Box 12.3).
Basic functional examination of
the shoulder
Clinical examination should not begin by palpation for local
tenderness. This widespread habit is a common cause of
misdiagnosis.
The basic shoulder examination consists of 12 tests. It is
important always to perform every basic test and not to stop,
even if the diagnosis appears clear after a limited number of
tests. Stopping too soon can easily lead to an incomplete diag-
nosis. It is important to realize that, in mixed patterns of pain
visible on inspection at the anterior centre of the humeral head.
Local swelling may also be found in acute, haemorrhagic or
chronic subdeltoid bursitis and in acromioclavicular joint
cysts,
15
as well as in tumours.
Functional examination
The shoulder is an easy joint to examine. The intention is to
obtain the maximum information from a minimum number of
tests. Recent studies have shown high inter-rater and intra-
rater reliability of the examination scheme presented.
1618
Preliminary examination
In most cases of shoulderarm pain the history will reveal
whether the pain originates from the shoulder itself or is of
cervical origin. Sometimes, however, the examiner is not quite
sure and will then use a quick survey of all structures between
C1 and T2 to exclude other sources of pain in the upper quad-
rant. It is good practice to perform a preliminary examination
of the upper quadrant in the following situations:
There is or was neck pain
There is or was trapezius pain
The pain is only at the top of the shoulder and/or at the
clavipectoral area
The pain is in the arm but remains quite localized
The pain in the arm is inuenced by movements of the
neck
Coughing, sneezing or taking a deep breath increases the
pain
There is paraesthesia.
The preliminary examination of the upper quadrant is com-
prised of the following tests (Box 12.2):
1. Six active movements of the cervical spine range of
movement and/or painfulness; quick survey of the cervical
spine
2. Active elevation of the shoulder girdle range of
movement and/or painfulness; quick survey of all the
structures of the shoulder girdle
3. Resisted rotations of the cervical spine and resisted
elevation of the scapulae; quick survey of nerve roots
C1C2C3C4
4. Active elevation of both arms range and pain; quick
survey of shoulder and shoulder girdle
5. Resisted movements of the upper limb strength and
pain; this is both a quick test for peripheral lesions at the
elbowarmwrist and a neurological examination of roots
C5C6C7C8T1 and of the peripheral nerves of the
upper limb
6. Passive examination of the elbow; quick test of the elbow
joint.
Any inuence on the pain or any weakness will guide the
examiner approximately towards the affected area, which is
then examined thoroughly.
Box 12.2
Preliminary examination
Neck
Active movements
1. Flexion
2. Extension
3. Side exion to the left
4. Side exion to the right
5. Rotation to the left
6. Rotation to the right
Resisted movements
7. Rotation to the left (C1)
8. Rotation to the right (C1)
Scapula
9. Active elevation of both scapulae
10. Resisted elevation of both (C2C4) scapulae
Shoulder
11. Active elevation of both arms
12. Resisted abduction (C5)
Elbow
Passive movements
13. Flexion
14. Extension
Resisted movements
15. Flexion (C5, C6)
16. Extension (C7)
Wrist
17. Resisted exion (C7)
18. Resisted extension (C6)
Thumb
19. Resisted extension (C8)
Finger
20. Resisted adduction of the little nger (T1)
C H A P T E R 1 2 Clinical examination of the shoulder
211
Box 12.3
Summary of the basic functional examination of
the shoulder
Elevation
1. Active elevation of both arms
2. Passive elevation
3. Painful arc
Glenohumeral joint
4. Passive scapulohumeral abduction
5. Passive lateral rotation
6. Passive medial rotation
Resisted movements
7. Adduction
8. Abduction
9. Lateral rotation
10. Medial rotation
11. Flexion of the elbow
12. Extension of the elbow
on both passive and resisted movement(s), pain on resisted
movements does not exclude a disorder in an inert structure,
nor pain on passive movements a disorder in a contractile
structure. These results may sometimes lead to diagnostic dif-
culties (see Ch. 4).
Accessory tests may be called for. They will only be per-
formed if, after the basic functional examination, the diagnosis
still remains unclear. After the basic examination is complete,
Fig 12.3 Elevation of the arm: (a) active elevation; (b) passive elevation; (c) painful arc.
(a) (b) (c)
at least a differential diagnosis should be in mind. To arrive at
the nal diagnosis, one or more accessory tests may be useful.
Elevation of the arm
Active elevation
The patient is asked to raise both arms sideways above the
head, as far as possible (Fig. 12.3a). The range of movement
and the inuences, if any, on pain are noted.
This very unselective and broad test investigates both inert
and contractile structures, not only of one single joint, but also
of all ve joints of the shoulder girdle (see online chapter
Clinical examination of the shoulder girdle). Therefore, the
result should always be interpreted in light of the other tests.
As it gives a good idea of the patients willingness to cooperate,
it will also help in identifying a person who has no genuine
lesion but is feigning illness.
Passive elevation
The examiner takes the patients arm just proximal to the
elbow, brings it upwards from the side and pushes it as far as
it will go towards the head. At the same time counterpressure
is applied over the contralateral shoulder, preventing the
patient from side-exing to the other side (Fig. 12.3b). Pain,
range of motion and end-feel are noted. Because this move-
ment comes to a halt when the axillary portion of the capsule
is stretched, the normal end-feel is elastic.
Painful arc
The patient raises the arm, actively, in a frontal plane and
concentrates on pain likely to occur at mid-range, being asked
The Shoulder
212
humerus and scapula takes place. If the movement is impaired,
the glenohumeral or the subacromial joint is at fault.
Passive lateral rotation
The examiner takes the patients arm above the wrist, exes
the elbow to a right angle and pulls the arm with gentle pres-
sure into full lateral rotation, meanwhile avoiding extension by
holding the patients elbow against the side of the abdomen.
The trunk is immobilized by bringing the other hand around
the patients contralateral shoulder (Fig. 12.5b).
This movement comes to a stop by stretching the anterior
portion of the capsule. Therefore the end-feel is elastic. The
normal range is about 90. Since individual differences exist,
both sides should always be compared.
Besides the anterior portion of the joint capsule, other struc-
tures, such as the subcoracoid bursa, the acromioclavicular
joint and the subscapularis tendon, are tested as well. Limita-
tion of the movement is mainly found if something is wrong
with the scapulohumeral joint itself; in this event, a harder
end-feel is usually present.
19,20
A simple tendinosis of the sub-
scapularis does not cause limitation of the movement but may
render it very painful.
Passive medial rotation
With one hand still just above the patients wrist and exing
the patients elbow to 90, the arm is brought into full medial
rotation, without extension. The examiners other hand is
placed dorsally between the scapulae (Fig. 12.5c). The normal
amplitude is about 90. As before, this movement should be
compared on both sides.
Occasionally a painful arc can be present on medial rotation.
This has the same diagnostic value as a painful arc on elevation
and bears the practical consequence that in order to test for
real limitation of movement the examiner must persist to get
beyond the painful arc.
Resisted movements
Resisted adduction
The patient is asked to pull the right arm towards the body as
hard as possible. The examiner puts one hand around the elbow,
and the other at the patients ipsilateral side (Fig. 12.6a).
Resisted abduction
The test is performed with the arm hanging down, a few
degrees of abduction being permitted. The examiner asks the
patient to push his or her arm to the side, meanwhile applying
counterpressure at the elbow. The examiners other hand sta-
bilizes the patient on the contralateral side (Fig. 12.6b).
Resisted lateral rotation
The patient is asked to bend the elbow to a right angle and to
push the forearm away from the body. To avoid any movement
of the trunk, the other hand is put on the patients contralateral
shoulder (Fig. 12.7a). Counterpressure is applied just above
the wrist and care must be taken to get two details right. First,
the patient should keep the elbow against the body, so that
there is no element of abduction. Second, extension of the
elbow during lateral rotation is avoided. This is easily checked
to indicate where pain starts and where it stops on further
elevation (Fig. 12.3c).
A painful arc is dened as the symptom appearing some-
where around the halfway mark, with the arm near the hori-
zontal and disappearing before the end of the movement (Fig.
12.4). This description holds even if pain is again present at
the end-point. Some patients have an ascending arc, others a
descending one; both are regarded as a real painful arc and no
diagnostic distinction is made between them. Sometimes an
arc becomes visible to the examiner, i.e. when the patient
avoids the painful movement by bringing the arm towards the
front of the body during elevation.
A painful arc is more likely to occur during active elevation
rather than during passive movement because contraction of
the abductor muscles pulls humerus and acromion closer to
each other. It always implies a lesion in the subacromial area
or its neighbourhood. Because of their localization between
acromion and greater or lesser humeral tuberosity, the affected
structures can be painfully pinched.
Three tests for the glenohumeral joint
Passive scapulohumeral abduction
The lower angle of the scapula is immobilized by the thumb
and index. With the other hand, the examiner takes the
patients arm just above the elbow and lifts it up until the
scapula starts to move (Fig. 12.5a). It is important for
the patient not to assist this movement actively because then
the scapula immediately starts to rotate, so making the move-
ment a compound one involving several joints.
The normal range of scapulohumeral abduction is about 90.
Performed in the way described, only movement between
Fig 12.4 Painful arc.
C H A P T E R 1 2 Clinical examination of the shoulder
213
applied to the distal part of the forearm just above the wrist.
The other hand is placed on the patients ipsilateral shoulder
(Fig. 12.8a).
Resisted elbow extension
In the same position as for exion, the patient attempts to
extend the elbow. To be able to hold the patients elbow at 90
of exion, the examiner puts his or her own elbow on the iliac
crest, the arm in an almost vertical position underneath the
patients wrist. The other hand rests on the patients ipsilateral
shoulder (Fig. 12.8b).
if the examiner puts the little nger underneath the patients
wrist: extension at the elbow causes the digit to move down.
Resisted medial rotation
This is tested in the same position as resisted lateral rotation,
but the patients arm is held at the inner part of the wrist and
the forearm is pulled towards the body (Fig. 12.7b).
Resisted elbow exion
With the elbow still bent at a right angle and the forearm
supinated, the forearm is pulled up. Counterpressure is
Fig 12.5 Three tests for the glenohumeral joint: (a) passive
scapulohumeral abduction; (b) passive lateral rotation; (c) passive
medial rotation.
(a) (b)
(c)
The Shoulder
214
Fig 12.6 Resisted movements: (a) adduction; (b) abduction.
(a) (b)
Fig 12.7 Resisted rotation: (a) lateral; (b) medial.
(a) (b)
C H A P T E R 1 2 Clinical examination of the shoulder
215
Passive horizontal adduction
The patients arm is brought horizontally in front of the body.
At the end of the movement the elbow is pressed gently
further towards the contralateral shoulder (Fig. 12.9). Twisting
of the patients trunk is prevented by the examiner bringing
the other hand behind this shoulder.
Palpation
General palpation for heat and swelling is done after the func-
tional examination. These may be present in bacterial arthritis
and in primary and secondary tumours of the humeral head,
glenoid and acromion, and in acute and chronic subdeltoid
bursitis.
Palpation for pain is only performed when the basic exami-
nation proves that the lesion lies within the reach of a nger.
As already indicated, it always follows the clinical examination
and never precedes it. Comparison between the two sides is
essential. Palpation for tenderness is mainly done in acute and
chronic subdeltoid bursitis and in a sprained superior ligament
of the acromioclavicular joint.
Accessory tests
Sometimes the diagnosis is still not clear after the basic exami-
nation and a differential diagnosis has to be undertaken. At
other times, the exact structure at fault has been identied by
this stage of the examination but the precise localization of the
lesion within that particular structure remains uncertain. In
both cases, one or more accessory tests may be required (Box
12.4). Passive horizontal adduction is the only one which is
explained here. The other tests are discussed, together with
the corresponding disorders, in the following chapters.
Fig 12.8 Resisted exion (a) and extension (b) of the elbow.
(a) (b)
Box 12.4
Summary of accessory tests of the shoulder
Passive horizontal adduction
Passive horizontal lateral rotation
Apprehension test for anterior instability
Apprehension test for posterior instability
Load and shift manuvre
Sulcus sign
Yergasons test
Resisted horizontal adduction
Resisted horizontal extension
Resisted horizontal adduction with the arm forwards
Resisted exion
Resisted extension
Pressure against a wall
Scapular adduction against resistance
The Shoulder
216
such as tumours and metastases, and identication of calcica-
tions in or around tendons. Plain radiographs may also be
helpful in the evaluation of anterior and posterior instability.
Although ultrasonography is nowadays the most frequently
used method to evaluate rotator cuff lesions, plain X-ray exam-
ination can be of use in the detection of accompanying appear-
ances, such as changes in the coracoacromial arch, an unusual
form or a spur off the acromion.
26
Radiography is also still
advocated in long-standing massive cuff tears.
27,28
Ultrasound scanning
Ultrasound scanning is mainly advocated for the detection of
full or partial rotator cuff lesions. In experienced hands it can
reveal not only the integrity of the rotator cuff but also the
thickness of its various component tendons. Through careful
positioning and through knowledge of the dynamic anatomy of
the cuff, the experienced ultrasonographer can image selec-
tively the upper and lower subscapularis, the biceps tendon,
the anterior and the posterior supraspinatus, the infraspinatus
and the teres minor. Ultrasonography has further advantages:
it is non-invasive and safe, bilateral examinations are quickly
performed, the shoulder can be examined dynamically and,
above all, the procedure is inexpensive.
29
One important disadvantage, however, is that the method
has a long learning curve. The results are examiner-dependent
and a good outcome can only be expected in experienced
hands.
30
Specicity and sensitivity of as high as 98% and 91%
respectively in comparison with surgical ndings were claimed
by Mack et al.
31
Others have found an overall sensitivity of
97% in diagnosing full cuff tears and of 91% in partial thickness
tears.
32
Arthrography
Single-contrast arthrography can be helpful in diagnosing com-
plete tears of the rotator cuff, incomplete deep surface tears
and instability problems.
33
It will show loss of axillary-fold
space and diminished joint capacity in adhesive capsulitis, but
because this disorder is so easy to detect clinically, arthrogra-
phy should never be required. It is of no assistance in clarifying
the differential diagnosis in cases of impingement, in the
absence of a rotator cuff tear.
Arthroscopy
Arthroscopy is useful for both diagnosis and treatment.
3439
It
should be regarded as an adjuvant in those cases where the
normal diagnostic aids are insufcient.
35
As it offers an excel-
lent view of the glenoid, labrum and capsule, it is an excellent
technique in repair of shoulder instability.
36
However, confronted with the almost perfect results
obtained through examination technique, the physician should
never forget that full and partial tears of the rotator cuff exist
in a substantial part of a normal asymptomatic population.
Both cadaveric studies
37,38
and imaging studies
39,40
on asympto-
matic individuals have demonstrated that cuff defects become
increasingly common after the age of 40 and that most occur
without substantial clinical manifestations.
The indications for this test are:
Sprain of the acromioclavicular joint
21
Subcoracoid bursitis
Subscapularis tendinosis.
Technical investigations
All technical investigations of the shoulder have in common
the fact that they are performed to search for anatomical
changes. This is in contrast with the objective of a clinical
examination, which aims to detect functional deciencies and/
or pain. Anatomical changes that are not causing functional
disturbances (remain asymptomatic) are very common in the
shoulder region and their frequency increases with age.
2224

Therefore, one should always interpret technical diagnoses
with care and even reluctance, for it is perfectly possible that
the lesion seen on imaging is in fact asymptomatic and another
lesion that is not shown is at the root of the disability. A
common mistake is the combination of a symptomatic gleno-
humeral arthritis that remains undiagnosed with sonography
and an asymptomatic rotator cuff tear that is easily detected
with the same technique. We therefore fully agree with Kessel,
who states: An X- ray is best used to check a hypothesis which
has been formed by history and clinical examination. One
should eschew the temptation of a shortcut to the X-ray room
or scanner.
25
Plain radiography
The main indications for radiography of the shoulder are evalu-
ation of fractures and dislocations, imaging of bony disorders
Fig 12.9 Passive horizontal adduction.
C H A P T E R 1 2 Clinical examination of the shoulder
217
the glenohumeral capsule. Nevertheless, MRI is to be preferred
because it is more accurate in tendinopathies and no X-ray
exposure occurs.
49
In shoulder instability, CT-arthrography
seems to be the best diagnostic method.
50
Bursoscopy
Bursoscopy can be performed under general or local anaesthe-
sia. Although there are almost no indications for bursoscopy,
51

it may be of help in diagnosing lesions of the bursal part of the
rotator cuff. At the same time, it offers visualization of the
acromial roof.
Access the complete reference list online at
www.orthopaedicmedicineonline.com
Magnetic resonance imaging
Magnetic resonance imaging (MRI) has rapidly become a com-
monly used technique for shoulder evaluation, proving its
utility in the evaluation of muscle, tendons, hyaline and brous
cartilage, joint capsule, fat, bursae and bone marrow.
41
Today
it is the most accurate non-invasive method available for
imaging the rotator cuff.
42
The major advantages of this modal-
ity include its non-invasive nature, lack of ionizing radiation,
excellent contrast and anatomic resolution, multiplanar imaging
capability, and ability as a single imaging modality to evaluate
simultaneously for a wide variety of pathologic processes.
43

One disadvantage is that small foci of soft tissue calcication
may be missed on MRI.
44
As with all techniques that provide
optimal visualization, one should always take into account the
high rate of asymptomatic lesions and never rely simply on the
outcome of the technique to make a diagnosis and start a
treatment.
4548
Computed tomography
Computed tomography (CT) is equally as accurate as MRI for
evaluation of the glenoid rim and labrum, the humeral head and
C H A P T E R 1 2 Clinical examination of the shoulder
217.e1
Copyright 2013 Elsevier, Ltd. All rights reserved.
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