CLINICAL ASSESSMENT OF THE SHOULDER

Clinical examination follows the order of inspection, palpation, assessment of range of motion and special tests for the shoulder.

Most clinicians follow a stepwise approach summarised as Look, Feel, Move (active then passive), followed by special tests for specific pathology.

Flexion, extension, abduction and adduction can be tested, and the degree of motion can be noted compared to normal.

Internal and external rotation should be tested with elbow at 90° of flexion.

A range of special tests exists for common conditions of the shoulder.

Anterior Instability 

There are a large amount of factors that contribute to joint stability and a deficit in any one of these can lead to recurrent instability.

These stabilising factors can be classified as dynamic or static. Dynamic factors include the rotator cuff, biceps tendons, negative intra-articular pressure as well as scapulothoracic and scapulohumeral motion.

Static factors include the bony architecture of the joint itself as well as the glenoid labrum and intrinsic ligaments of the glenohumeraljoint.

The apprehension test

This test is carried out by flexing the patients elbow to 90°, then abducting the shoulder to 90° and applying an anterior force to the posterior surface of the shoulder, while externally rotating the shoulder (Fig.10): if these actions cause pain, the test is positive (sensitivity of 70%, specificity of 50%).

Fig. 10: The apprehension test: sensitivity of 70%, specificity of 50%.

Posterior Instability

Posterior instability is rare when compared to its anterior counterpart and accounts for up to 10% of cases of shoulder instability.

Initially, posterior instability was thought to be mostly due to capsular laxity however, recent research has showed the importance of the glenoidlabrum and the glenoid depth.

The posterior apprehension test

This test is performed by applying posterior force on the anterior surface of an adducted and flexed shoulder (Fig.11): apprehension by the patient for this movement signifies a positive test (sensitivity of 99%, specificity of 19%).

Fig. 11: The posterior apprehension test: sensitivity of 99%, specificity of 19%.

Rotator cuff pathology

This patological condition can be in the form of a tendonopathy via a partial or a complete tear and these can present as an impingement syndrome with pain on overhead activity.

The causes of rotator cuff tendonopathy are normally theorised into intrinsic factors, extrinsic factors or a combination of both.

The Jobe's test

This test evaluate the supraspinatus.

The patient holds the arm done at 30 degrees of abduction in the plane of scapula with the elbows flexed at 90° and the hands pointing inferiorly with the thumbs directed medially (Fig.12); a positive test consists of pain or weakness on resisting downward pressure on the arms or an inability to perform the tests (sensitivity 81%, specificity 89%).

Fig. 12: The Jobe's test: sensitivity 81%, specificity 89%.

The resisted external rotation test.

This test evaluate the infraspinatus.

Passively flex the elbow to 90° holding the wrist and ask to patient to resist rotating the shoulder to near maximum external rotation (sensitivity 76%, specificity 57%) (Fig.13).

Fig. 13: The resisted external rotation test: sensitivity 76%, specificity 57%.

The belly off test

This test evaluate the subscapularis.

It can only be carried out when the patient is able to develop an internal rotation sufficient to place the hand in the back; normally, the patient can move the hand away from the back, but in the case of a tear, the hand will remain “stuck” to the lumbar region (sensitivity 86%, specificity 91%). (Fig.14).

Fig. 14: The belly off test: sensitivity 86%, specificity 91%.

The external rotation lag sign 

This test evaluate the teres minor.

Passively flex the elbow to 90° holding the wrist to rotate shoulder to near maximum external rotation; tell the patient to maintain the position and release wrist looking for a lag or angular drop (sensitivity 97%, specificity 93%) (Fig.15).

Fig. 15: The external rotation lag sign: sensitivity 97%, specificity 93%.

The Palm Up test

This test evaluate the long head of biceps.

The patient's elbow is extended, forearm supinated and the humerus elevated to 60° and the examiner  resists humeral forward flexion; the test is positive if pain located to bicipital groove an this is commonly interpreted as suggestive of inflammation or lesions related to the long head of biceps (sensitivity of 90%, specificity of  14%). (Fig.16).

Fig. 16: The Palm Up test: sensitivity of 90%, specificity of 14%.

Labral Tear

Tears in the labrum are either restricted to the anterior labrum (as with a Bankart lesion in anterior instability) or extend posteriorly along the superior aspect (superior labral anterior posterior - SLAP lesion).

These lesions most commonly present after other injuries and conditions, such as instability and rotator cuff tears, but they can present alone and can become a significant source of shoulder problems.

The biceps load test

The patient is supine and the examiner sits at the side of the patient’s involved extremity. The examiner places the patient’s shoulder in 120° of abduction, the elbow in 90° of flexion, and the forearm in supination. The examiner moves the patient’s shoulder to end-range external rotation (apprehension position) and examiner asks the patient to flex his or her elbow while the examiner resists this movement (Fig.17). A positive test is indicated as a reproduction of concordant pain during resisted elbow flexion (sensitivity of 39%, specificity of 67%).

Fig. 17: The biceps load test: sensitivity of 39%, specificity of 67%.

 Shoulder Impingement

Shoulder impingement syndrome is a common cause of shoulder pain accounting for between 44% and 65% of shoulder pain complaints in general practice.

Shoulder impingement is caused by a narrowing of the subacromial space, resulting in an intrusion of the tissues within.

This can be caused by a number of pathological conditions such as a bursitis, tendonitis or a partial or full thickness tendon tear.

The main presentation of this is pain anterolateral to the acromion, which may radiate to the lateral aspect of the humerus as far as the mid shaft area.

The Hawkins-Kennedy test

This test is performed by examining the patient in sitting position with their arm at 90° and their elbow flexed to 90°, supported by the examiner to ensure maximal relaxation. The arm is then quickly moved into internal rotation (Fig.18).

Pain in the subacromial space denotes a positive sign (sensitivity of 80% and specificity of 56%).

Fig. 18: The Hawkins-Kennedy test: sensitivity of 80% and specificity of 56%.

Adhesive capsulitis

Coracoid pain test

The pain elicited by pressure on the coracoid area may be considered a pathognomonic sign of adhesive capsulitis: the test is considered positive when pain on the coracoid region is more severe than 3 points (VAS scale) with respect to the acromioclavicular joint and the anterolateral subacromial area(sensitivity of 96%; specificity of 88%). (Fig.19 A,B,C).

Fig. 19: Coracoid pain test: sensitivity of 96%; specificity of 88%.

Acromio-clavicular joint pathology

Passive cross chest adduction

This test is performed by passively bringing the patient's arm into maximal adduction across his chest; it may elicit pain that suggests A-C joint pathology (sensitivity of 82%; specificity of 28%) (Fig.20).

Fig. 20: Passive cross chest adduction: sensitivity of 82%; specificity of 28%.

ULTASONOGRAPHIC ASSESSEMENT OF THE SHOULDER: DINAMIC HIGH-RESOLUITION ULTRASOUND

Ultrasonography (US) is an established and well-accepted modality that can be used to evaluate articularand peri-articular structures around the shoulder.

Long Head of Biceps Brachii Tendon (LHBBT)

The patient is sitting opposite to the examiner, the forearm is flexed 90° with the arm resting on the thigh, slightly internally rotated, palm facing up; holding the transducer in a horizontal position (Fig.21 A,B), localize the bicipital groove (between small and large tuberosity ofthe humerus).

Fig. 21: Long head of biceps tendon (short axis). A. Anatomical scheme of the intra- and extra-articular sections of the long head of biceps tendon (*). H,humerus; G, scapular glenoid; A, acromion; C, coracoid. B. Long head of biceps tendon (short axis). (a) Transducer placement over the bicipital groove to obtain a transverse scan of the tendon.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

This structure shall be used as a landmark to assess the long head of biceps brachii tendon on an axial scan (Fig.22).

Fig. 22: Long head of biceps tendon (short axis). US image showing the vertical portion of LHBT (asterisk); dashed line, bicipital groove;GT, greater tuberosity; LT, lesser tuberosity; D, deltoid muscle.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

To avoid any anisotropy artifacts, the transducer must be kept as perpendicular as possible to tendon surface (Fig.23).

Fig. 23: “Empty groove” sign. Anisotropy artifact affecting the LHBT due to wrongprobe positioning. This hypoechoic appearance of the LHBT (asterisk) is due to theprevalence of diffracted echoes over reflected ones. When the US beam is perfectlyperpendicular to the tendon, there is a prevalence of reflected echoes and the LHBBTtendon can be correctly evaluated.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

The probe must then slide caudally to evaluate the vertical part of the LHBBT up to the myotendinous junction, located under the humeral insertion of the pectoralis major tendon (Fig.24); in case of complete rupture of LHBBT, this area is where the retracted tendon stump can usually be seen.

Fig. 24: The axial scan shows the humeral insertion aponeurosis of the pectoralis major muscle (arrowheads). H, humerus;B,biceps brachii.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Then the probe must be rotated 90° clockwise to evaluate the LHBBT along its long axis (Fig.25 A,B).

Fig. 25: Long head of biceps tendon (long axis). A. Anatomical scheme of the intra- and extra-artic-ular sections of the long head of biceps tendon (*). H,humerus; G, scapular glenoid; A, acromion; C, coracoid. B.Transducer placement for the long axis evaluation of the tendon.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Note that the LHBBT has an oblique course, from up to down and from anterior to posterior; for such reason, optimal visualization of the tendon can be obtained by slightly pressing the distal edge of the probe on the skin (Fig.26).

Fig. 26: Long head of biceps tendon (long axis). US scan; arrowheads, vertical portion of the tendon; D, deltoid muscle; H, humerus.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Subscapularis Tendon

Keeping the probe on the bicipital groove, the forearm should be extrarotated to expose the subscapularis tendon; note that the elbow must be as close as possible to the thoracic wall (Fig.27 A,B).

Fig. 27: Subscapularis tendon (long axis): A. Anatomical scheme; B. Transducer placement over the lesser tuberosity of the humerus with the patient’s arm externally rotated.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

On the long axis, the subscapularis tendon should be evaluated sliding the US transducer caudally (Fig.28); including the coracoid in the scan also allows evaluation of coracohumeral ligament.

Fig. 28: Subscapularis tendon (long axis): Corresponding US image; subS, subscapularis tendon; C, coracoid; arrowheads, coracohumeralligament (not completely stretched); D, deltoid muscle; LT, lesser tuberosity of thehumeral head.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

The subscapularis must then be evaluatedon the short axis, turning the probe 90° clockwise (Fig.29 A,B).

Fig. 29: Subscapularis tendon (short axis); A. Anatomical scheme; B Transducer placement for the evaluation of the tendon on its short axis, with the patient’s arm externally rotated.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

This scan shows the complex anatomy of the subscapularis tendon, formed by an alternation of tendinous and muscular fibers (Fig.30); this scan is particularly helpful in the case of partial tears to assess the longitudinal extension of the split.

Fig. 30: Subscapularis tendon (short axis): Corresponding US image showing its typical multilayered appearance; arrows, ten-don fascicles of the subscapularis; arrowheads, muscle tissue interposed betweentendon fascicles; LT, lesser tuberosity of the humeral head.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Supraspinatus Tendon and Subacromial-Subdeltoid Bursa(SASD)

Move patient upper limb from the position used to evaluate the subscapularis tendon so his hand is on the posterior region of the iliac wing (on his “back pocket”, in modified Crass position); note that the flexed elbow should be as medial as possible, and once the tendon is identified, the probe should be oriented along the long axis of the tendon (Fig.31 A,B).

Fig. 31: Supraspinatus tendon (long axis): A. Anatomical scheme; B. Transducer placement over the anterior aspect of the shoulder, with the patient in modified Crass position.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

A correct scan is obtained when the humeral head cartilage, the anatomical neck of the humerus and the greater humeral tuberosity are seen together: the tendon is limited anteriorly by the LHBBT; anisotropy artifacts could particularly affect the insertional area of the tendon on the humeral neck, so to avoid these artifacts, slightly tilt the probe laterally to have the US beam as perpendicular as possible to tendon fibers (Fig.32).

Fig. 32: Supraspinatus tendon (long axis):Corresponding US image; SS, normal fibrillar architecture of supraspinatus tendon;asterisk, insertional portion of supraspinatus fibers; arrowheads, articular carti-lage; arrows, subacromial–subdeltoid bursa; circle, hypoechoic artifact related toanisotropy; dashed line, footprint; GT, greater tuberosity of the humerus; D, deltoidmuscle.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

US can only show the portion of the sub-acromial-subdeltoid bursa located superficially to the supraspinatus tendon and deep to the deltoid muscle, while the portion located deeply to the acromion cannot be evaluated; for a complete evaluation of the bursa, anterior, posterior, and lateral scans should be performed.

After evaluating the supraspinatus tendon along its longitudinal axis, the probe should be rotated 90° clockwise, to assess the short axis (Fig.33 A,B, Fig.34).

Fig. 33: Supraspinatus tendon (short axis): A.Anatomical scheme; B. Transducer placement for the shortaxis evaluation of the tendon, with patient’s arm in modified Crass position.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Fig. 34: Supraspinatus tendon (short axis): Corresponding US image. SS, supraspinatus tendon; arrows, subacromial–subdeltoidbursa; asterisks, articular cartilage; D, deltoid muscle; GT, greater tuberosity of thehumeral head.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Coracoacromial Ligament

The patient sits opposite the examiner, with the arm along the body; position the probe with the medial edge on the coracoid and turn the lateral edge medially and cranially to the acromion to see the coracoacromial ligament (Fig.35 A,B, Fig.36).

Fig. 35: Coracoacromial ligament: A. Anatomical scheme; B. Transducer placement with the medial edgeon the lateral aspect of the coracoid and the distal edge over the lateral aspect of theacromion.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Fig. 36: Coracoacromial ligament: Corresponding US image; arrowheads, coracoacromial ligament as ahypoechoic fibrillar structure drawn from the coracoid to the acromion; C, coracoid;A, acromion; SS, supraspinatus; D deltoid.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Infraspinatus and Teres Minor Tendons

The patient sits opposite the examiner,with their elbow flexed and palm on the opposite shoulder; the probe should be oriented vertically to localize the scapular spine, which separates the fossa supraspinata from the fossa infraspinata and within the fossa infraspinata, infraspinatus and teres minor muscles can be seen.

The probe should then be slid laterally to assess both tendons on a short axis view (Fig.37 A,B,C).

Fig. 37: Infraspinatus and teres minor tendons (short axis): A. Anatomical scheme of infraspinatus tendon; B. Anatomical scheme of teres minor tendon; C. Transducer placement over the infraspinous fossa, under the scapular spine; D. Corresponding US image showing the muscle bellies of the infraspinatus (IS) and teres minor (TM),respectively on the left and on the right of the image; S, body of the scapula; D,deltoid muscle.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Turn the probe by 90° and asses each tendon along its longitudinal axis (Fig.38 A,B,C, Fig.39 A,B,C); for a better view of insertional region of the tendon it is useful to have the patient’s arm slightly externally rotated.

Fig. 38: Infraspinatus tendon (long axis). A. Anatomical scheme of infraspinatus tendon; B. Transducer placement over the posterior aspect of the gleno-humeral joint for the evaluation of the infraspinatus tendon and the posterior gleno-humeral joint recess; C. Corresponding US scan showingthe infraspinatus tendon on its long axis; arrowheads, infraspinatus tendon fibers;H, humerus; D, deltoid muscle; J, infraspinatus myotendinous junction; asterisk,posterior gleno-humeral joint recess.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Fig. 39: Teres minor tendon (long axis): A. Anatomical scheme of teres minor tendon; B. Transducer placement as for the teres minor tendon; C. long axis evaluation and moving down the proximal edge of the probe. (b) Corresponding US image; asterisks, teres minor tendon fibers; J, teres minor myotendinous junction; D, deltoid muscle; H, humerus.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

US can also be used to assess the gleno-humeral joint posterior recess; Slide the probe medially on the posterior side of the joint and extrarotate patient’s arm (in the same position used to evaluate the subscapularis tendon)(Fig.40).

Fig. 40: Posterior gleno-humeral joint recess. A. Anatomical scheme of posterior gleno-humeral joint recess; B. Transverse US image over the posterior aspect of the gleno-humeral joint; asterisk, posterior glenoid labrum; arrow, posterior joint recess; G, glenoid; IS,infraspinatus myotendinous tendon; D, deltoid muscle; H, humerus.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Suprascapular nerve

To assess this nerve, the probe can be placed in the same position used to evaluate the acromion-clavicular joint but slightly more medial and posterior. There, the nerve in the supraspinous notch can be seen. After passing behind the scapular spine, the nerve could be tracked downwards up to the spinoglenoid notch (Fig.41 A,B,C).

Fig. 41: Suprascapular nerve: A. Anatomical scheme of suprascapular nerve; B. Transducer placement over the supraspinosus fossa; C. Corresponding US image (of B) showing the nerve course in the supraspinousnotch (curved arrow); asterisk, suprascapular nerve course; SS, supraspinatus muscle; S, scapula; D. Transducer placement over the infraspinous fossa; E. Corresponding US image (of D) showing the nerve course in the spinoglenoid notch (curved arrow); asterisk, suprascapular nerve course; SS, infraspinatus muscle; G, glenoid.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Note that the nerve is very small and can be frequently undetectable. As it is always accompanied by vascular structures, power-Doppler can be used to easily detect the whole neurovascular bundle. Of note, in the suprascapular area, the artery is superior to the suprascapular nerve. Evaluation of this nerve is important, as it can be occasionally compressed by large ganglia arising from glenoid labrum tears, thus resulting in supraspinatus and/or infraspinatus muscles atrophy.

Acromion-Clavicular Joint

The acromion-clavicular joint can be assessed by placing the probe on a coronal-oblique plane on the top of the shoulder (Fig.42, Fig.43).

Fig. 42: Acromioclavicular joint: anatomical scheme.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

Fig. 43: Acromioclavicular joint: corresponding US image; A,acromion; C, clavicular bone; arrowheads, acromioclavicular joint capsule.
References: Corazza A et al. Dynamic high-resolution ultasound of the shoulder: how we do it. Eur J Radiol. 2015 Feb;84(2):266-77.

From this position, abduct the patient’s upper limb flexed to 90 degrees to evaluate the presence of subacromial impingement of the supraspinatus tendon.