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Shoulder History, Observation,

and Palpation

History

Observation
Palpation

*Information from (unless otherwise cited): C. Starkey and J. Ryan, Evaluation of Orthopedic and Athletic Injuries, F.A. Davis Company, 2002, Pages 424-444.

History

Location of Pain

It is extremely important to accurately assess the location of pain in the shoulder due to possibly injury, because many important internal structures radiate pain to the shoulder when they are in distress, which is known as referred pain .

It is also important to have the patient describe the quality of the pain in these terms:

Sharp
Dull
Diffuse
Radiating
Chronic
Acute
Pain with activity
Pain after activity
Constant pain

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Onset of Pain

The onset of pain is indicative of the underlying shoulder pathology.

Acute onset
- Fracture
- GH joint Dislocation
- GH joint Subluxation
- AC joint sprain
- Ligamentous Tears
Insidious Onset
- Tendinitis
- Bursitis
- Osteoarthritis

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Mechanism of Injury and Activity

It is important to know the mechanism of injury as well as the activity that was being done when the injury occurred because it allows the structures that may possibly be injured to be more readily identified. For example:

An External Force (perhaps a direct blow or exceptional joint force) results in acute soft tissue or bony injury
Repetitive overhead motion (as in pitching, swimming, or tennis) may lead to injuries such as rotator cuff inflammation

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Symptoms

Symptoms that should be noted in order to assess the damaged structures include:

Resting Pain
Pain with Movement
Dysfunction of the Shoulder Complex

Patients may describe the following things

The shoulder "Going out of place" (GH instability)
Decreased velocity or accuracy with throwing
Discomfort with overhand motions (Inflammation)

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Prior Injury

It is important to note prior injuries, as injuries to the AC and GH joints can alter the biomechanics of the shoulder. The changes in the biomechanics of the shoulder may make the patient more susceptible to another injury.

*Cervical spine or thorax injuries must also be noted, as pain from one of these injuries can be referred to the shoulder. When cervical spine or thorax injury is discovered, the examiner should further evaluate the cervical and peripheral nerves so that a differentiation between referred pain and actual shoulder pain can be made.

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Observation

Initial Observation

*Make sure the patient is wearing appropriate clothing that allows full inspection of the shoulders, cervical, thoracic, and lumbar spine.

Position of the Head
- Normally upright
  - NOTE: If the patients head is bent or rotated this may indicate a muscle spasm, pressure on a cervical nerve root, or stretching of the cervical nerves
Position of the Arm and the Willingness of the patient to move the limb
- Splinted or hanging
- Guarded limb
- Note the use of gesturing with injured arm
- Note the duplication of the movement which caused the injury (is the patient willing to perform it?)
- Note willingness to move the arm throughout the examination
  - Lack of movement may mean apprehension or increased severity of the injury.

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Observation of Anterior Structures

Level of the Scapula
- Observe the heights of the AC joints, the clavicle, and the SC joints
  - Should be bilateral (dominant arm may be slightly lower)
- Painful shoulders tend to be held in an elevated position
  - Could also indicate a trapezius hypertrophy when unilateral
  - Bilaterally raised shoulders could be the result of highly trained Trapezius muscles
- Bilateral or unilateral shoulder depression can lead to pressure on arterial, venous, and nerve supply to the arms.
  - Rounded shoulders can indicate the tightness of the pectoralis major and minor muscles
Contours of the Clavicles
- Inspect clavicles noting:
  - SC Joint
  - Shaft of the clavicle
  - The distal 3^rd of the clavicle ending at the AC Joint
- SC and AC joint sprains generally marked by visible deformity at the articulation
  - Previous history significant because deformity may be due to a previous injury
- Clavicular fractures
  - Gross deformity of the shaft
  - Patients often support injured arm and turn head to the opposite side
    - When suspected, terminate examination immediately, immobilize arm with sling, and refer the patient to a physician
Symmetry of the deltoid muscle groups
- Look for bilateral symmetry of muscle group
  - Normally rounded
  - The dominant arm may be hypertrophied compared to non-dominant
  - Atrophy
    - Lack of use
    - Pathology to C5 and C6 nerve roots
  - Dislocated GH joint flattens the deltoid group passing over the head of the humerus
    - Humeral head may protrude anteriolaterally
    - Distal pulses should be bilaterally checked
      - If not found in injured arm, could mean impingement of the neurovascular bundle, which supplies the arm, wrist and hand

Anterior Humerus and Biceps Brachii group
- Note the shape, size and any unilateral bulges within the biceps
- Tendon Rupture characterized by muscle shortening

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Observation of Lateral Structures

Deltoid muscle group
- As in the anterior observation continue to note contour of the muscle group
  - Focus on the comparison with the contralateral side
Acromion Process of the Scapula
- Normally appears smooth and even at junction between clavicle and acromion process
- Look for step deformity
  - Clavicle is superior to the acromion:
    - Indicates AC sprain
    - Can be confirmed using the piano key sign and the AC traction test
Position of the Humerus
- Normally hangs in anatomical position
  - Could be guarded by the patient if the following occur:
    - Adhesion with GH joint
    - Muscle spasm
    - Or pain from bursitis or tendinitis

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Observation of Posterior Structures

Alignment of the vertebral column
- Evaluate for scoliosis in the spine
  - Cervical
  - Thoracic
  - Lumbar
- Scoliosis may alter the biomechanics of the shoulder
Position of the Scapulae
- Look bilaterally for equal distances between the medial border of the scapulae and the thoracic vertebra
- Note the position of the spinous process and the inferior angle
  - The spinous process generally resides at the level of T2, except for the most medial portion which resides at T3
  - The inferior angle generally resides at the level of T7
- Look for a winging scapula
  - Where the inferior angle lifts away from the thorax
- Note unilateral protraction, retraction, and or tilting of the scapula
- Look for Sprengel’s deformity
Muscle Tone
- Look for muscular symmetry posteriorly
- Note any spasm, deformity, or discoloration of muscle or skin
- Note prominence of the scapular spine
  - May indicate atrophy of supra- and infraspinatus
Position of the Humerus
- Check for posterior GH dislocation
  - Humerus generally rests in infraspinous fossa
  - Associated with the following damage
    - Bony injury
    - Articular surface injury
    - Neurovascular damage