Have you ever been to a specialist for a consultation and they never laid a hand on you? Their diagnosis and treatment plan was based solely on the MRI. Some patients have become accustomed to this practice pattern. On some consultations, I am asked my treatment recommendation before I can do a physical examination. I strongly believe in the power of this exam to correctly diagnose shoulder pain. I was taught by a wise professor that we treat the patient, not the X-Ray or MRI. Many things seen on an MRI are of no consequence and do not require treatment. Conversely, many things seen on a physical exam that reproduce shoulder pain may not be seen on an MRI. It is important to use the exam to gather as much information as possible to correctly diagnose and treat shoulder pain.
The physical exam is equal parts art and science. The art of the exam is learned by repetition and experience. Medical students are taught the components of a physical exam and the appropriate tests. However, they are always amazed when a senior physician quickly makes a diagnosis that they missed. Just knowing the correct steps does not insure a correct conclusion. The art of the exam is putting all the pieces together. This is the value of experience. A shoulder specialist will have completed thousands of exams and have a large data base of knowledge to reach the best diagnosis.
Some of the steps I use in an examination are:
1. Inspect the appearance of the shoulder.
Simple observation of the shoulder is very helpful. Is there muscle atrophy or wasting? If so, I know that muscle has not been working well for months. It may be due to a tear, lack of appropriate nerve supply to the muscle, or limited use of the muscle. Also, look for areas of swelling or prominence such as from a cyst, fluid collection, possible tumor, bone spur etc.
Infraspinatous muscle wasting *
2. Palpate (press on) different locations to determine whether there is tenderness or muscle spasm.
Palpation is the most helpful part of the exam. Does it hurt when I press on certain structures? The rotator cuff attachment on the side of the shoulder, the biceps tendon, the AC joint and scapular muscle spasms are superficial enough to exam well. If there is no tenderness to palpation, then it is very unlikely that structure is the source of the shoulder pain.
AC joint palpation
3. Test the range of motion in all three planes.
The shoulder joint has the largest range of motion of any joint. It is a ball and socket joint capable of movement in three different planes. The movement must be assessed in all directions both actively (using your muscles to lift the arm) and passively (I move the arm for you). If there is a lack of active movement but no restriction in passive movement, there is either lack of strength to move the arm or the movement is limited by pain. It is important to recognize this difference. A lack of passive movement is typically due to arthritis, a frozen shoulder, previous trauma or an isolated contracture of the shoulder joint lining (capsule).
Test for internal rotation of the shoulder
4. Test the shoulder strength in multiple directions.
Shoulder strength assessment can be difficult because it requires the full effort of the patient. Shoulder pain may prevent someone from holding their arm in certain positions. Others can better tolerate the pain and are capable of demonstrating better strength. Unfortunately, we also may see a patient unwilling to give a full effort in order to appear weaker. There is usually an ulterior motive to this behavior and it requires the careful observation of an experienced physician to recognize it.
Testing shoulder flexion strength
5. Assess the neck and neurologic function further down the arm.
Shoulder pain may not originate in the shoulder. Nerve compression in the neck may present as pain in the shoulder and scapula. It is important to examine the neck to determine if the neck may be involved.
6. Perform more specific tests to determine instability, a possible tear, pain from the neck, inflammation of the tendons, etc.
There are multiple different tests for specific shoulder pathology. An excellent review of the different tests is http://at.uwa.edu/special%20tests/specialtests/UpperBody/shoulder%20Main%20Page.htm
Usually, only a few of these tests are needed based upon the diagnoses obtained from the history. For a more complete review of the shoulder exam, I would recommend the following websites: