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Shoulder


Clinical Summary and Recommendations

Patient History
Complaints

  • Little is known about the utility of subjective complaints with shoulder pain. Although a report of trauma does not seem clinically useful, a history of popping, clicking, or catching may be minimally helpful in diagnosing a labral tear (+LRs [likelihood ratios] = 2.0).

Physical Examination
Range-of-Motion, Strength, and Muscle Length Assessment

  • Measuring shoulder range of motion has consistently been shown to be highly reliable but is of unknown diagnostic utility. Visual assessments and functional tests of range of motion are more variable and may be adequately reliable in some instances.

  • Assessing strength with manual muscle testing appears to be reliable. Weak abduction and/or external rotation may be fairly useful in identifying subacromial impingement and/or full-thickness rotator cuff tears. Weak internal rotation appears to be very helpful in identifying subscapularis tears (+LR = 7.5 to 20.0).

  • Assessments of shoulder muscle tightness are moderately reliable. However, the single study done to test associated diagnostic utility found tight pectoralis minor muscles in all 90 participants regardless of whether they had shoulder problems or not (100% sensitivity, 0% specificity).

Special Tests

  • Results of studies examining the diagnostic utility of tests to identify labral tears are highly variable. Even though most single tests do not appear very useful, a 2017 metaanalysis found the compression rotation and Yergason tests to be good at identifying labral tears (+LR of 3.9 and 2.5, respectively).

  • Although neither the Hawkins-Kennedy or Neer tests appear to be helpful for ruling in or ruling out subacromial impingement, a 2012 metaanalysis found the lift-off test to be very effective (+LR = 14), and the presence of a “painful arc” during elevation was also found to have some value in identifying the condition (+LR = 2.3).

  • In addition to rotator cuff muscle weakness (above), the external and internal rotation lag signs appear to be very helpful at identifying infraspinatus and subscapularis tears, respectively. Several other tests (the bear-hug, belly-press, and Napoleon tests) appear to be also very useful in diagnosing subscapularis tears.

  • Whereas several signs and symptoms are helpful in identifying brachial plexus nerve root avulsions, the shoulder protraction test appears to be the most useful (+LR = 4.8, −LR = .05).

  • Both the distension test in passive external rotation and the coracoid pain test appear to be moderately helpful in identifying adhesive capsulitis (+LR = 10.2 and 7.4, respectively).

Combinations of Findings

  • Even though combinations of tests are generally better than single tests, combinations of tests are only moderately helpful in identifying labral tears. The most efficient pair seems to be the anterior apprehension and Jobe relocation tests (+LR = 5.4).

  • One study showed that a combined history of popping, clicking, or catching in addition to a positive anterior slide test was moderately helpful in identifying a type II to IV SLAP lesion (+LR = 6.0).

  • Another study reported even better diagnostic utility when specific combinations of three tests were used. By selecting two highly sensitive tests (compression rotation test, anterior apprehension test, and O’Brien test) and one highly specific test (Yergason test, biceps load II test, or Speed tests), users can be fairly confident in both ruling out and ruling in SLAP lesions.

Anatomy

Osteology

Figure 9-1, Anterior humerus and scapula.

Figure 9-2, Superior and inferior surfaces of clavicle.

Arthrology

Figure 9-3, Sternoclavicular joint.

Joint Type and Classification Closed Packed Position Capsular Pattern
Glenohumeral Spheroidal Full abduction and external rotation External rotation limited more than abduction, limited more than internal rotation and flexion
Sternoclavicular Saddle Arm abducted to 90 degrees Not reported
Acromioclavicular Plane synovial Arm abducted to 90 degrees
Scapulothoracic Not a true articulation Not available Not available

Scapulohumeral Rhythm

Figure 9-4, Scapulohumeral rhythm.

Scapulohumeral rhythm consists of integrated movements of the glenohumeral, scapulothoracic, acromioclavicular, and sternoclavicular joints occurring in sequential fashion to allow full functional motion of the shoulder complex. Scapulohumeral rhythm serves three functional purposes: It allows for greater overall shoulder range of motion; it maintains optimal contact between the humeral head and glenoid fossa; and it assists with maintaining an optimal length-tension relationship of the glenohumeral muscles. To complete 180 degrees of abduction, the overall ratio of glenohumeral to scapulothoracic, acromioclavicular, and sternoclavicular motion is 2:1.

Inman and colleagues were the first to explain scapulohumeral rhythm and described it as two phases that the shoulder complex completes to move through full abduction. During the first phase (0 degrees to 90 degrees), the scapula is set against the thorax to provide initial stability as the humerus abducts to 30 degrees. , From 30 degrees to 90 degrees of abduction, the glenohumeral joint contributes another 30 degrees of range of motion while the scapula rotates upward 30 degrees. The upward rotation results from clavicular elevation through the sternoclavicular and acromioclavicular joints. The second phase (90 degrees to −180 degrees) entails 60 degrees of glenohumeral abduction and 30 degrees of scapular upward rotation. The scapular rotation is associated with 5 degrees of elevation at the sternoclavicular joint and 25 degrees of rotation at the acromioclavicular joint. ,

Ligaments

Figure 9-5, Shoulder ligaments: anterior view.

Ligaments Attachments Function
Glenohumeral Glenoid labrum to neck of humerus Reinforces anterior glenohumeral joint capsule
Coracohumeral Coracoid process to greater tubercle of humerus Strengthens superior glenohumeral joint capsule
Coracoclavicular
(trapezoid) 		Superior aspect of coracoid process to inferior aspect of clavicle Anchors clavicle to coracoid process
Coracoclavicular
(conoid) 		Coracoid process to conoid tubercle on inferior clavicle
Acromioclavicular Acromion to clavicle Strengthens acromioclavicular joint superiorly
Coracoacromial Coracoid process to acromion Prevents superior displacement of humeral head
Sternoclavicular Clavicular notch of manubrium to medial base of clavicle anteriorly and posteriorly Reinforces sternoclavicular joint anteriorly and posteriorly
Interclavicular Medial end of one clavicle to medial end of other clavicle Strengthens superior sternoclavicular joint capsule
Costoclavicular Superior aspect of costal cartilage of first rib to inferior border of medial clavicle Anchors medial end of clavicle to first rib

Figure 9-6, Shoulder (glenohumeral) joint.

Muscles

Posterior Muscles of Shoulder

Figure 9-7, Muscles of the shoulder: posterior view.

Muscles Origin Insertion Nerve and Segmental Level Action
Upper trapezius Occipital protuberance, nuchal line, ligamentum nuchae Lateral clavicle and acromion Cranial nerve XI; C2 to C4 Rotates glenoid fossa upwardly, elevates scapula
Middle trapezius Spinous processes of T1 to T5 Acromion and spine of scapula Cranial nerve XI; C2 to C4 Retracts scapula
Lower trapezius Spinous processes of T6 to T12 Apex of spine of scapula Cranial nerve XI; C2 to C4 Upward rotation of glenoid fossa, scapular depression
Levator scapulae Transverse processes of C1 to C4 Superior medial scapula Dorsal scapular nerve; C3 to C5 Elevates and adducts scapula
Rhomboids Ligamentum nuchae and spinous processes of C7 to T5 Medial scapular border Dorsal scapular nerve; C4 to C5 Retracts scapula
Latissimus dorsi Inferior thoracic vertebrae, thoracolumbar fascia, iliac crest, and inferior ribs 3 and 4 Intertubercular groove of humerus Thoracodorsal nerve; C6 to C8 Internally rotates, adducts, and extends humerus
Serratus anterior Ribs 1 to 8 Anterior medial scapula Long thoracic nerve; C5 to C8 Protracts and upwardly rotates scapula

Anterior Muscles of Shoulder

Figure 9-8, Muscles of the shoulder: anterior view.

Muscles Origin Insertion Nerve and Segmental Level Action
Deltoid Clavicle, acromion, spine of scapula Deltoid tuberosity of humerus Axillary nerve; C5 to C6 Abducts arm
Pectoralis major (clavicular head) Anterior medial clavicle Intertubercular groove of humerus Lateral and medial pectoral nerves; C5, C6, C7, C8, T1 Adducts and internally rotates humerus
Pectoralis major
(sternocostal head) 		Lateral border of sternum, superior six costal cartilages, and fascia of external oblique muscle
Pectoralis minor Just lateral to costal cartilage of ribs 3 to 5 Coracoid process Medial pectoral nerve; C8, T1 Stabilizes scapula

Rotator Cuff Muscles

Figure 9-9, Muscles of the shoulder: rotator cuff.

Muscles Origin Insertion Nerve and Segmental Level Action
Supraspinatus Supraspinous fossa of scapula Greater tubercle of humerus Suprascapular nerve; C4 to C6 Assists deltoid in abduction of humerus
Infraspinatus Infraspinous fossa of scapula Greater tubercle of humerus Suprascapular nerve; C5 to C6 Externally rotates humerus
Teres minor Lateral border of scapula Greater tubercle of humerus Axillary nerve; C5 to C6 Externally rotates humerus
Subscapularis Subscapular fossa of scapula Lesser tubercle of humerus Upper and lower subscapular nerves; C5 to C6 Internally rotates humerus
Teres major Inferior angle of scapula Intertubercular groove of humerus Lower subscapular nerve; C5 to C6 Internally rotates and adducts humerus

Nerves

Nerves Segmental Levels Sensory Motor
Radial C5, C6, C7, C8, T1 Posterior aspect of forearm Triceps brachii, anconeus, brachioradialis, extensor muscles of forearm
Ulnar C7, C8, T1 Medial hand, including medial half of digit 4 Flexor carpi ulnaris, medial half of flexor digitorum profundus, most small muscles in hand
Musculocutaneous C5, C6, C7 Becomes lateral antebrachial cutaneous nerve Coracobrachialis, biceps brachii, brachialis
Axillary C5, C6 Lateral shoulder Teres minor, deltoid
Suprascapular C4, C5, C6 No sensory Supraspinatus, infraspinatus
Dorsal scapular Ventral rami of C4, C5 No sensory Rhomboids, levator scapulae
Lateral pectoral C5, C6, C7 No sensory Pectoralis major, pectoralis minor
Medial pectoral C8, T1 No sensory Pectoralis minor
Long thoracic Ventral rami of C5, C6, C7 No sensory Serratus anterior
Upper subscapular C5, C6 No sensory Subscapularis
Lower subscapular C5, C6 No sensory Teres major, subscapularis
Medial cutaneous of arm C8, T1 Medial arm No motor

Figure 9-10, Anterior axilla.

Patient History

Initial Hypotheses Based on Historical Findings

Diagnostic Utility of the Patient History for Identifying the Need for Radiographs After Shoulder Dislocation

Patient Report and Study Quality Population Reference Standard Sens Spec +LR −LR
Quebec Decision Rule:
“prereduction radiography” patients necessary if:

  • (1)

    age < 40 and mechanism involves a motor vehicle collision, a fall from standing height, or sports injury, and

  • (2)

    age ≥ 40 and first time dislocation or humeral ecchymosis

143 patients with shoulder dislocation presenting to emergency department Radiographic evidence of fracture

  • age < 40

  • age ≥ 40

  • .33 (.00, .91)

  • 1.0 (.03, 1.0)

  • .60 (.50, .67)

  • .50 (.28, .72)

  • 0.8 (0.2, 4.2)

  • 2.0 (1.3, 3.0)

  • 1.1 (.50, 2.5)

  • 0

Diagnostic Utility of the Patient History for Identifying Labrum and Rotator Cuff Tears

Patient Report and Study Quality Population Reference Standard Sens Spec +LR −LR
History of trauma 55 patients with shoulder pain scheduled for arthroscopy Glenoid labral tear observed during arthroscopy .50 (.35, .65) .36 (.08, .65) .79 (.46, 1.34) 1.38 (.60, 3.17)
History of popping, clicking, or catching .55 (.40, .69) .73 (.46, .99) 2.0 (.73, 5.45) .63 (.38, 1.02)
Patient report of weakness 100 patients with shoulder pain Rotator cuff tear observed via MRI arthrogram .34 .54 0.8 1.2
Patient report of night pain .89 .19 1.1 .58
History of trauma 448 patients with shoulder pain scheduled for arthroscopy Rotator cuff tear observed during arthroscopy .36 .73 1.33 .88
Reports of night pain .88 .20 1.10 .60

Range-of-Motion Measurements

Reliability of Range-of-Motion Measurements

Figure 9-11, Range-of-motion measurements.

Test Procedure and Study Quality Instrumentation Population Interexaminer Reliability
Passive flexion Universal goniometer 21 patients with shoulder pain ROM: ICC = .70 (.40, .87)
Pain: κ = .70 (.39, .99)
Passive abduction ROM: ICC = .76 (.5, .89)
Pain: κ = .33 (.0, .72)
Passive external rotation ROM: ICC = .74 (.44, .89)
Pain: κ = .60 (.26, .95)
Passive internal rotation ROM: ICC = .3 (.16, .65)
Pain: κ = .49 (.19, .80)
Passive horizontal adduction ROM: ICC = .46 (.03, .74)
Pain: κ = −.22
Passive abduction Inclinometer 50 patients with adhesive capsulitis ICC = .83
Passive external rotation ICC = .90
Passive internal rotation ICC = .85
Passive external rotation ICC = .90
Passive flexion Universal goniometer 100 patients referred for physical therapy for shoulder impairments Intraexaminer: ICC = .98
Interexaminer: ICC = .89
Passive extension Intraexaminer: ICC = .94
Interexaminer: ICC = .27
Passive abduction Intraexaminer: ICC = .98
Interexaminer: ICC = .87
Active elevation Visual estimation of range of motion 201 patients with shoulder pain Affected side: ICC = .88 (.84, .91)
Unaffected side: ICC = .76 (.67, .82)
Passive elevation Affected side: ICC = .87 (.83, .90)
Unaffected side: ICC = .73 (.66, .79)
Passive external rotation Affected side: ICC = .73 (.22, .88)
Unaffected side: ICC = .34 (.00, .65)
Passive horizontal adduction Affected side: ICC = .36 (.22, .48)
Unaffected side: ICC = .18 (.04, .32)
Active scaption (scapular plane shoulder elevation) Goniometer 30 asymptomatic subjects Intraexaminer: ICC = .87 (.74, .94)
Interexaminer: ICC = .92 (.83, .96)
Digital inclinometer Intraexaminer: ICC = .88 (.75, .94)
Interexaminer: ICC = .89 (.77, .95)
ICC, Intraclass correlation coefficient.

Reliability of Functional Range-of-Motion Tests

Figure 9-12, Hand behind back (functional internal rotation of shoulder test).

Test and Measure and Study Quality Description Population Reliability
Hand behind back Distance measured from PSIS to distal radius after reaching as high as possible behind back 50 patients with adhesive capsulitis ICC = .91
Active abduction Range of motion assessed visually to nearest 5 degrees. Pain assessed as “no pain,” “little pain,” “much pain,” or “excruciating pain” 91 patients with shoulder pain Range of motion (ROM): ICC = .96
Pain: κ = .65
Passive abduction ROM: ICC = .96
Pain: κ = .69
Painful arc with active abduction Presence of: κ = .46
Starting ROM: ICC = .72
Ending ROM: ICC = .57
Painful arc with passive abduction Presence of: κ = .52
Starting ROM: ICC = .54
Ending ROM: ICC = .72
Passive external rotation ROM: ICC = .70
Pain: κ = .50
Hand behind back As above, except range of motion graded on a scale of 0 to 7 ROM: κ = .73
Pain: κ = .35
Hand on neck ROM: κ = .52
Pain: κ = .52
Spring test for first rib Examiner exerts force with the second metacarpophalangeal joint on the first rib of the patient, assessing range of motion (normal or restricted), pain (present or absent), and joint stiffness (present or absent) ROM: κ = .26
Stiffness: κ = .09
Pain: κ = .66
Hand to neck Visual estimation of range of motion graded on a scale of 0 to 3 or 4 46 patients with shoulder pain Intraexaminer: ICC = .80 (.63, .93)
Interexaminer: ICC = .90 (.69, .96)
Hand to scapula Intraexaminer: ICC = .90 (.72, .92)
Interexaminer: ICC = .90 (.69, .94)
Hand to opposite scapula Intraexaminer: ICC = .86 (.65, .90)
Interexaminer: ICC = .83 (.75, .96)

Physical Examination Tests

Assessing Strength and Proprioception

Reliability of Assessing Muscular Strength and Endurance

Test and Measure and Study Quality Description Population Reliability
Deltoid Standard manual muscle test using grades 1–5 21 patients with shoulder pain. Estimates reported for right shoulder only κ = .47 (.00, .93)
Bicep κ = .45 (.00, 1.0)
Tricep κ = .77 (.34, 1.0)
External rotation κ = .30 (.00, .68)
Internal rotation κ = .32 (.00, 1.0)
Serratus anterior κ = .89 (.64, 1.0)

Figure 9-13, Internal rotation resistance strength test.

Zaslav investigated the usefulness of the internal rotation resistance strength (IRRS) test in distinguishing intraarticular pathologic conditions from impingement syndrome in a group of 115 patients who underwent arthroscopic shoulder surgery. The IRRS test is performed with the patient standing. The examiner positions the patient’s arm in 90 degrees of abduction and 80 degrees of external rotation. The examiner applies resistance against external rotation and then internal rotation of the arm in this position. The test is considered positive for an intraarticular pathologic condition if the patient exhibits greater weakness in internal rotation than in external rotation. If the patient demonstrates greater weakness with external rotation, the test is considered positive for impingement syndrome. The IRRS test had a sensitivity of .88, a specificity of .96, a +LR of 22.0, and a –LR of .13.

Reliability of Assessing Passive Accessory Joint Motion

Test and Measure and Study Quality Description Population Reliability
Inferior glenohumeral motion Based on comparison to the opposite shoulder and based on the clinician’s experience examining other patients with shoulder disorders, each motion was judged to be hypomobile, normal, or hypermobile 21 patients with shoulder pain. Estimates reported for right shoulder only Mobility κ = .26 (0, .66)
Pain κ = .61 (.01, 1.0)
Anterior glenohumeral motion Mobility κ = .58 (.20, .95)
Pain κ = .58 (.15, 1.0)
Posterior glenohumeral motion Mobility κ = .83 (.50, 1.0)
Pain κ = .39 (.00, .86)
Glenohumeral distraction Mobility κ = .02 (.00, .50)
Pain κ = .32 (.00, 1.0)
Anterior to posterior AC joint motion Mobility κ = .02 (.00, .41)
Pain κ = .77 (.46, 1.0)
Anterior to posterior SC joint motion Mobility κ = .24 (.00, .75)

Reliability of Assessing Proprioception

Test and Measure and Study Quality Description Population Test-Retest Reliability
Joint position sense With patient standing, examiner measures full external rotation and internal rotation of shoulder with inclinometer. Target angles are determined as 90% of internal rotation and 90% of external rotation. With patient blindfolded, examiner guides patient’s arm into target angle position and holds it for 3 seconds. The patient’s arm is returned to neutral. The patient is instructed to return the arm to the target angle. Examiner takes measurement with inclinometer 31 asymptomatic subjects Internal rotation ICC = .98
External rotation ICC = .98

Assessing Muscle Length

Reliability of Determining Muscle Length

Test and Measure and Study Quality Description Population Test-Retest Reliability
Posterior shoulder tightness
2019 Metaanalysis 		Seven different measurement techniques (low flexion, extension with internal rotation, horizonal adduction, internal rotation, diagnostic ultrasound, scapular-plane abduction, and myotonometer) Pooled data from 12 studies on intrarater reliability and 6 studies on interrater reliability Intrarater ICC = .93 (.90, .95)
Interrater ICC = .89 (.80, .94)
Pectoralis minor muscle length With the participant supine with hands resting on the abdomen, examiner measures the linear distance from the treatment table to the posterior aspect of the acromion using a plastic right angle 45 patients with shoulder pain and 45 asymptomatic persons Single measure: ICC = .90 to .93
Mean of 3 measures: ICC = .92 to .97
Pectoralis minor muscle length Patient is in supine position, with the elbows extended alongside the body and both palms placed on the examining table. The distance between the inferomedial aspect of the coracoid process and the caudal edge of the fourth rib at the sternum is measured with a vernier caliper during exhalation by the patient 25 patients with shoulder impingement symptoms and 25 controls Patients:
Intraexaminer ICC = .87 to .93
Interexaminer ICC = .65 to .72
Controls:
Intraexaminer ICC = .76 to .87
Interexaminer ICC = .64 to .67
Pectoralis minor muscle length Based on comparison to the opposite shoulder, and based on the clinician’s experience examining other patients with shoulder disorders, each muscle was judged to be short or normal 21 patients with shoulder pain. Estimates reported for right shoulder only κ = .59 (.16, 1.0)
Pectoralis major muscle length κ = .71 (.41, 1.0)
Latissimus dorsi muscle length κ = .77 (.46, 1.0)
Latissimus dorsi muscle length With the subject supine with hips and knees flexed and feet flat on the treatment table in posterior pelvic tilt, the examiner passively flexes the subject's shoulder until a firm flexion end feel is noted or until the humerus begins to medially rotate. One arm of a goniometer is aligned with the humerus, the other arm of the goniometer is aligned parallel with the treatment table, and the axis of the goniometer is aligned with the center of the glenohumeral joint 30 asymptomatic subjects Intraexaminer: ICC = .19

Diagnostic Utility of a Tight Pectoralis Minor Muscle in Identifying Shoulder Pain

Figure 9-14, Measuring pectoralis minor muscle length.

Test and Study Quality Description and Positive Findings Population Reference Standard Sens Spec +LR −LR
Tight pectoralis minor muscle As above, with a positive test being a measurement of less than 2.6 cm (1 inch) 45 patients with shoulder pain and 45 asymptomatic persons Self-report of shoulder pain and/or restriction of shoulder movement 1.0 ∗ 0.0 ∗ 1.0 Undefined

∗ These results are due to the fact that all 90 symptomatic and asymptomatic participants were classified as “tight” using this definition.

Palpation

Reliability of Palpating the Subacromial Space

Figure 9-15, Palpation of subacromial space.

Test and Measure and Study Quality Description Population Reliability
Palpation of subacromial space Examiner palpates subacromial space and estimates distance as ¼, ½, ¾, or whole finger’s breadth 36 patients with shoulder subluxation Intraexaminer ICC = .90 to .94
Interexaminer ICC = .77 to .89

Reliability of Palpating the Myofascial Trigger Points and the Subacromial Space

Test and Measure and Study Quality Description Population Reliability
Upper trapezius trigger point Systematic palpation of each muscle of symptomatic side. Positive if at least 1 painful nodule 26 patients with symptoms of unilateral shoulder impingement syndrome Intraexaminer κ = .65
Interexaminer κ = −.11
Lower trapezius trigger point Intraexaminer κ = .29
Interexaminer κ = .26
Infraspinatus trigger point Intraexaminer κ = .50
Interexaminer κ = .19
Supraspinatus trigger point Intraexaminer κ = .48
Interexaminer κ = .37
Pectoralis minor trigger point Intraexaminer κ = .30
Interexaminer κ = .44
Middle deltoid trigger point Intraexaminer κ = .65
Interexaminer κ = .44
Palpation of subacromial space Examiner palpates subacromial space and estimates distance as ¼, ½, ¾, or whole finger’s breadth 36 patients with shoulder subluxation Intraexaminer ICC = .90 to .94
Interexaminer ICC = .77 to .89

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