INTRODUCTION

The shoulder is a system of joints, and many movements of this system involve the neck. Completely independent action of the shoulder is possible, but independent, simultaneous action of the shoulder and neck is not.

The glenohumeral joint may be affected as part of widespread joint disease (i.e., a polyarthropathy such as rheumatoid arthritis, crystal deposition disease arthropathy, other inflammatory arthropathies, or generalized osteoarthritis). Periarticular conditions can be grouped into categories with and without capsulitis. In the absence of capsular involvement, passive joint motion is largely unaffected, whereas active movement may be limited by pain or weakness or both. In the presence of capsulitis, multidirectional restriction of passive motion is seen. Clinical and radiologic studies differentiate these conditions from articular conditions.

Referred pain to the shoulder can occur with cervical disorders, Pancoast tumor of the lung, a subphrenic pathologic condition, entrapment neuropathies, myofascial pain syndromes, and brachial neuritis (Table 4-3).

TABLE 4-3 COMMON CAUSES OF SHOULDER PAIN

Periarticular Disorders	Regional Disorders	Glenohumeral Disorders
Rotator cuff tendinitis/impingement syndrome Calcific tendinitis Rotator cuff tear Bicipital tendinitis Acromioclavicular arthritis

Cervical radiculopathy

Brachial neuritis

Nerve entrapment syndromes

Sternoclavicular arthritis

Reflex sympathetic dystrophy

Myocardial infarction

Thyroid disease

Diabetes mellitus

Renal osteodystrophy

Inflammatory arthritis

Glenohumeral instability

From Kelley WN, et al: Textbook of rheumatology, ed 5, Philadelphia, 1997, WB Saunders.

Identification of the primary cause of shoulder pain is not always easy. Referred pain to the shoulder girdle region occurs from multiple sources other than the neck. With diaphragmatic irritation, pain is referred along the phrenic nerve to the supraclavicular region, the trapezius, and the superomedial angle of the scapula. Gastric and pancreatic diseases may refer pain to the interscapular region. The rare superior sulcus lung tumor, or Pancoast tumor, occasionally coincident with Horner syndrome, may have shoulder pain as its initial symptom.

TABLE 4-1 SHOULDER JOINT CROSS-REFERENCE TABLE BY ASSESSMENT PROCEDURE

TABLE 4-2 SHOULDER JOINT CROSS-REFERENCE TABLE BY SYNDROME OR TISSUE

The arm as a lever is useless unless it has a fixed base. The fixed base comes largely from the layers of flat muscles piled one on top of another and attached to all surfaces of the scapula.

Paralytic disorders implicating these muscles come into clinical focus when weakness in the fixation mechanism is demonstrated. The serratus anterior, when paralyzed, allows the scapula to swing backward and loosen its attachment to the chest. The trapezius allows the scapula to spin like a pinwheel, which contributes to the loss of fixation.

The mobility of this part of the body results from the configuration of the bony parts and the mechanically advantageous attachment of the multiple muscles. The shallow socket and ball head favor frictionless spinning, and the main joint has four accessory articulating zones that complement and enhance the action of the shoulder.

Everyday activities are made up of acts such as lifting, holding, pushing, turning, and shoving. Through such common and accepted motions, clinical disorders are manifested. These activities are combined pattern motions with contributions from many parts of the shoulder complex. Individual joint and muscle contribution may be analyzed in these acts to aid localization and understanding of injury and disease. Consideration must also be given to the part that the elbow and hand play in shoulder function. Shoulders are used unconsciously during actions of the hand, wrist, and elbow. Injury or disease may hamper normal action of any of these areas; therefore, increased replacement effort is sought from the shoulder. For example, loss of rotatory range, as in arthrodesis of the wrist or elbow, unconsciously results in increased rotation at the shoulder. Weakness or disorder of one muscle group evokes replacement effort in another group. For example, the hunching motion by the trapezius that follows attempted abduction is a replacement effort associated with paralysis of the deltoid. Scrutiny of these purposeful patterns is of great help in understanding disability in this region.

Chronic overuse syndromes with repetitive stretching, as in rowing, swimming, or throwing, are injuries of repetitive microtrauma. Atraumatic disorders generally result from ligamentous laxity or congenital hypoplasia of the glenoid. Impact injuries may be divided into direct and indirect trauma. For direct trauma, the injury force is in direct contact with the shoulder complex. Indirect forces injuring the shoulder usually pass up through the hand, wrist, or elbow and result in a rotational or longitudinal force directed along the humerus.

ORTHOPEDIC GAMUT 4-1 DIRECT SHOULDER TRAUMA

Direct trauma to the shoulder consists of:

1. Posterior dislocations of the sternoclavicular joint

2. Acromioclavicular subluxations or dislocations after a fall on the posterior superior shoulder

3. Direct blows to the supraclavicular brachial plexus at the base of the neck or axillary nerve as it courses under the deltoid

4. Clavicular fractures

5. Muscle contusions

ORTHOPEDIC GAMUT 4-2 MECHANISMS OF AXILLARY ARTERY INJURY CAUSED BY BLUNT TRAUMA

• Compression with contusion

• Forceful repeated stress

• Direct trauma by a sharp bony fragment

• Avulsion

• Traction

ESSENTIAL ANATOMY

The shoulder joint is a ball-and-socket joint that is the articulation of the humerus and the glenoid fossa of the scapula. To describe the anatomy of the shoulder joint, the term shoulder joint complex may be more accurate. The shoulder joint complex really consists of four joints: the glenohumeral, the acromioclavicular, the sternoclavicular, and the scapulothoracic articulation. The acromioclavicular joint is formed by the lateral end of the clavicle and acromion. The acromioclavicular joint is reinforced by the surrounding capsule and ligaments, containing an anterior, posterior, superior, and inferior component, in addition to the coracoclavicular ligaments, which are made up of two individual ligaments: the coracoid and trapezoid ligaments. The short head of the biceps arises with the coracobrachialis from the scapular coracoid process and runs down the medial side of the long head of the biceps. The two bellies join as a common distal tendon just above the elbow joint as a flattened tendon, only to separate into two distal insertions.

ESSENTIAL MOTION ASSESSMENT

Shoulder motion is interpreted through excursion of the arm from the body and is recorded according to the anatomic planes (Fig. 4-1).

FIG. 4-1 Range of motion of the shoulder. A, Forward flexion and extension. B, Abduction and adduction. C, Internal rotation. D, External rotation.

ORTHOPEDIC GAMUT 4-3 SHOULDER MOVEMENTS

Primary shoulder movements are:

1. Elevation in the coronal (frontal) plane (abduction and adduction)

2. Flexion and extension in the sagittal plane (Figs. 4-2 and 4-3)

3. Horizontal adduction and abduction in the transverse (horizontal) plane (Figs. 4-4 and 4-5)

4. Internal and external rotation (torque around the humerus) (Figs. 4-6 and 4-7)

FIG. 4-2 Flexion is accomplished by the anterior deltoid, pectoralis major, coracobrachialis, and biceps. A retained flexion range of motion that is 160 degrees or less is an impairment of the shoulder in the activities of daily living.

FIG. 4-3 Forty degrees or less of retained extension range of motion is an impairment of the shoulder in the activities of daily living.

FIG. 4-4 Less than 160 degrees of retained abduction range of motion is an impairment of the shoulder in the activities of daily living.

FIG. 4-5 A retained adduction range of motion of 30 degrees or less is an impairment of the shoulder in the activities of daily living.

FIG. 4-6 External rotation is the most important action; and when this rotation is lost, shoulder action is seriously compromised. Sixty degrees or less of retained external rotation is an impairment of the shoulder in the activities of daily living.

FIG. 4-7

ESSENTIAL MUSCLE FUNCTION ASSESSMENT

The muscles surrounding the shoulder joint complex provide the ability to generate motion while simultaneously providing dynamic stability to the glenohumeral joint.

The teres major muscle arises from the lower third of the lateral border of the scapula and travels around the anterior aspect of the humerus and in front of the long head of the triceps to insert onto the crest of the lesser tubercle. The teres minor and deltoid receive their innervation by the axillary nerve, whereas the teres major is supplied by the lower subscapular nerve (Figs. 4-8 to 4-13).

FIG. 4-8 The examiner achieves immobilization by grasping and holding the lower border with one hand. The patient flexes the arm anteriorly to 90 degrees while the forearm is pronated and the elbow slightly flexed.

FIG. 4-9 Extension of the shoulder is tested with the patient’s elbow straightened and the forearm fully pronated (palm posterior) to prevent lateral rotation and adduction. The examiner fixes the scapula as described for testing flexion, and the patient extends the arm posteriorly through the range of motion.

FIG. 4-10 The patient abducts the arm to 90 degrees. This abduction occurs against graded resistance applied by the examiner’s other hand, which is placed proximal to the patient’s elbow.

FIG. 4-11 The patient adducts the arm anteriorly through the horizontal plane of motion and against graded resistance. This resistance is applied by the examiner’s other hand, which is placed over the front of the arm and proximal to the patient’s elbow.

FIG. 4-12 The external rotation of the shoulder is assessed with the patient’s arm abducted to 90 degrees (or at the patient’s side if abduction is not possible), with the elbow flexed to 90 degrees, and with the hand and fingers pointing forward.

FIG. 4-13 The examiner supports the patient’s elbow with one hand, as described previously, while the patient rotates the arm downward (or inward if the shoulder abduction is not possible) against graded resistance that is applied by the examiner’s other hand, which is placed on the patient’s forearm proximal to the wrist.

ORTHOPEDIC GAMUT 4-4 MUSCLES OF THE SHOULDER JOINT COMPLEX

Muscles of the shoulder joint complex fall into three categories:

1. Those attaching to the scapula with their origin from the axial skeleton

2. Those that have their origin from the scapula and insert onto the humerus

3. Those that have their origin from the axial skeleton and insert onto the humerus

ORTHOPEDIC GAMUT 4-5 MUSCLE ATTACHMENTS

The scapula to spine muscle attachments are as follows:

ESSENTIAL IMAGING

The shoulder girdle consists of the two bones that attach the upper limb to the thoracic wall: the scapula and the clavicle. The glenoid fossa of the scapula forms the articulation of the shoulder girdle with the head of the humerus.

The most important films to obtain are the true anteroposterior (AP) and the modified West Point views. Both of these projections provide an excellent view of a glenohumeral joint. The examiner is able to appreciate the characteristic posterior glenoid wear. The acromioclavicular joint can be radiographically evaluated and correlated with the physical examination. The AP view should include the proximal two thirds of the humeral shaft so that the physician can safely estimate the appropriate humeral component diameter. When clinically indicated, the radiographic examination of the shoulder must include a cervical spine series.

ABBOTT-SAUNDERS TEST

Assessment for Biceps Tendinitis

ORTHOPEDIC GAMUT 4-6 BICEPS TENDON

The biceps tendon may luxate medially out of the groove and over the lesser medial tuberosity in one of two patterns:

1. Rupture of the transverse ligament and subluxation of the biceps tendon out of the groove, with the tendon lying anterior to the subscapularis muscle

2. Tendon subluxation beneath the subscapularis muscle belly

PROCEDURE

• With the patient in the seated position, the examiner fully abducts and externally rotates the patient’s arm.

• The examiner then lowers the arm to the patient’s side (Fig. 4-14).

• A palpable or audible click indicates a subluxation or dislocation of the biceps tendon.

• While the examiner’s finger or fingers palpate for the point of maximal tenderness within the bicipital groove, the shoulder is alternately rotated.

• A positive test occurs in biceps tendinitis when the patient feels pain as the tendon glides beneath the examiner’s finger.

FIG. 4-14

CLINICAL PEARL

The biceps tendon will not rupture or dislocate under ordinary stresses unless it is already weak. The predisposing factor to rupture or dislocation is age degeneration, which is probably accelerated by often-repeated friction and angulation at the point where the tendon enters the bicipital groove of the humerus.

ADSON TEST (ALSO KNOWN AS SCALENE MANEUVER AND SCALENUS ANTICUS TEST)

PROCEDURE

• The examiner locates the radial pulse of the involved extremity.

• The patient’s head is rotated to the involved extremity.

• The patient extends the neck as the examiner externally rotates and extends the shoulder.

• The patient takes a deep breath and holds it (Fig. 4-15).

• Loss of the pulse is a positive test.

• If the test is negative, it is repeated by having the patient rotate the head to the uninvolved extremity.

FIG. 4-15

CLINICAL PEARL

Radiographic demonstration of a cervical rib does not prove that it is the cause of the symptoms. The condition has to be distinguished (1) from other causes of pain and paresthesia in the forearm and hand, (2) from other causes of muscle atrophy in the hand, and (3) from other causes of peripheral vascular changes in the upper extremity.

ALLEN MANEUVER

Assessment for Thoracic Outlet Syndrome

ORTHOPEDIC GAMUT 4-8 THORACIC OUTLET SYNDROME CLASSIFICATIONS

Thoracic outlet syndrome (TOS) is categorized in three types:

• Vascular (vTOS). Unilateral arm swelling without thrombosis, when not caused by lymphatic obstruction, may be caused by subclavian vein compression at the costoclavicular ligament because of compression by either that ligament or the subclavius tendon most often because of congenital close proximity of the vein to the ligament. Patients with compression of the subclavian artery and vein are classified into two other groups as vascular TOS: arterial TOS or venous TOS.

• Neurogenic (nTOS) compromises the majority of these symptomatic individuals with brachial plexus and T1 nerve palsy. Neck trauma is also the most common cause of nTOS in patients with abnormal ribs. Involvement of the brachial plexus causes the nTOS that comprises two groups: one corresponding to patients harboring the true or classic signs and symptoms and electromyographic (EMG) findings (nTOS) and the other corresponding to patients with nonspecific clinical and EMG findings (nonspecific nTOS).

• Disputed neurogenic TOS (dnTOS). Upper extremity arterial compromise caused by this compacted thoracic outlet may also occur with a resulting limb ischemia. Patients often complain of a painful upper extremity after exercise albeit limb claudication symptoms. Discolored, pale, underperfused arms with absent or decreased arterial pulse is a common finding in these individuals with an arterial form of TOS. This group includes patients with signs and symptoms of posttraumatic neurovascular compression (Paget-Schroetter syndrome).

PROCEDURE

• The patient’s elbow is flexed to 90 degrees.

• The shoulder is abducted and externally rotated.

• As the examiner palpates the radial pulse, the patient rotates the head away from the involved extremity (Fig. 4-16).

• If the pulse disappears when the head is rotated, the test is positive for thoracic outlet syndrome.

FIG. 4-16

CLINICAL PEARL

Altered relative position of the shoulder girdle to the neurovascular bundle, or vice versa, is a common element of thoracic outlet syndrome. However, a group of symptoms may be separated in which a static or gradual process may be underway that appears as a more general development without specific, separate, irritating incidents. Such a condition is labeled postural because of the alteration of the normal girdle relationship to the rest of the body.

APLEY TEST (ALSO KNOWN AS APLEY SCRATCH TEST)

Assessment for Degenerative Tendinitis of One of the Tendons of the Rotator Cuff, Usually the Supraspinatus Tendon

PROCEDURE

• The patient is seated and is instructed to place the affected hand behind the head and touch the opposite superior angle of the scapula (Fig. 4-17).

• The patient is then instructed to place the hand behind the back and attempt to touch the opposite inferior angle of the scapula (Fig. 4-18).

• Exacerbation of the patient’s pain indicates degenerative tendinitis of one of the tendons of the rotator cuff, usually the supraspinatus tendon.

FIG. 4-17

FIG. 4-18

CLINICAL PEARL

Apley inferior is a useful test of internal rotation and extension. With severe restriction, the patient will not be able to get the hand behind the back at all. This movement is commonly affected in adhesive capsulitis.

APPREHENSION TEST

Assessment for Anterior Shoulder Dislocation Trauma and Posterior Dislocation of the Humerus

PROCEDURE

• The patient’s shoulder is abducted and externally rotated.

• If the patient shows apprehension or alarm and resists further motion, the test is positive (Fig. 4-19).

• This test may elicit a feeling that resembles the pain felt when the shoulder was previously dislocated.

• This test is performed slowly and cautiously; if the action is performed too quickly, the humerus may dislocate.

• Anterior shoulder dislocation trauma is suggested by a positive test.

• To evaluate posterior shoulder dislocation, the shoulder is flexed and internally rotated (Fig. 4-20).

• A posterior force is applied on the patient’s elbow.

• If the patient exhibits apprehension and resists further motion, the test is positive.

• A posterior dislocation of the humerus is suggested by a positive test.

FIG. 4-19

FIG. 4-20

CLINICAL PEARL

These maneuvers are also known as the drawer tests of Gerber and Ganz. Any movements, clicks, or patient apprehension support the diagnosis of recurrent shoulder dislocation. Axial diagnostic images are made to confirm the diagnosis.

BRYANT SIGN

Assessment for Dislocation of the Glenohumeral Articulation

ORTHOPEDIC GAMUT 4-9 SHOULDER DISLOCATIONS

Shoulder dislocation classification relative to:

1. The degree of instability (dislocation or subluxation)

2. The cause of the instability (traumatic or atraumatic)

3. The direction of the instability (anterior, posterior, or multi-directional)

ORTHOPEDIC GAMUT 4-10 AXILLARY PSEUDOANEURYSM

Accurate detection and diagnosis of axillary pseudoaneurysm after anterior glenohumeral joint dislocation presents difficulties:

• Limited abduction of the arm, as a result of pain and muscle spasm, prevents appropriate and full clinical examination of the axillary region.

• The gradual onset of clinical changes and the delayed radiologic evidence of a pseudoaneurysm may prevent attribution of clinical findings being associated with traumatic glenohumeral joint dislocation.

• An axillary hematoma may be concealed by bone and muscle tissue or bruising mistakenly attributed to the dislocation itself.

• Pulsation of the pseudoaneurysm may be obscured by overlying tissues.

• The motor and sensory disturbances related to ischemia may be mistakenly attributed to brachial plexus damage, which is a more common complication of glenohumeral joint dislocation.

• The robust collateral circulation may maintain the radial pulse, allowing ischemia to go undetected.

• Where recurrent dislocation is experienced, limited hemorrhage may result caused by scar tissue from previous dislocation.

PROCEDURE

The examiner views the characteristic lowering of the axillary fold (anterior and posterior pillars of the armpit) that is seen after trauma when dislocation of the glenohumeral articulation ensues (Fig. 4-21).

FIG. 4-21

CLINICAL PEARL

With dislocations of the shoulder, the axillary nerve may be injured. The patient is unable to contract the deltoid muscle, and a small patch of anesthesia over the muscle may be noted. This anesthesia is usually a neurapraxia, which recovers spontaneously after a few weeks or months. The posterior cord of the brachial plexus occasionally is injured. This occurrence is somewhat alarming, but it usually recovers with time.

CALLOWAY TEST

Assessment for Dislocation of the Humerus

PROCEDURE

• The test consists of measuring the girth of the shoulder joints bilaterally.

• This test is helpful in the examination of obese patients.

• The examiner loops a flexible tape measure through the axilla (Fig. 4-22).

• The girth is measured at the acromial tip.

• In a positive test, the girth of the affected joint is increased.

• The test is significant for dislocation of the humerus.

FIG. 4-22

CLINICAL PEARL

Shoulder dislocation results in severe pain. The patient supports the arm with the opposite hand and is hesitant to permit any kind of examination. The lateral outline of the shoulder may be flattened, and if the patient is not too muscular, a small bulge may be seen and felt just below the clavicle. The arm must always be examined for nerve and vessel injury.

CODMAN SIGN (ALSO KNOWN AS DROP ARM TEST)

PROCEDURE

• The patient’s arm is passively abducted.

• The examiner suddenly removes support at some point above 90 degrees, which makes the deltoid contract suddenly (Fig. 4-23).

• If shoulder pain occurs and the patient demonstrates a hunching of the shoulder because rotator cuff function is absent, the sign is present for rotator cuff tear or, more specifically, rupture of the supraspinatus tendon.

• In a modification of Codman sign, the patient’s shoulder is abducted to 90 degrees passively.

• The patient tries to lower the arm slowly to the side in the same arc of movement.

• If the patient is unable to return the arm to the side slowly or has severe pain, the test is positive.

• A positive test suggests a tear in the rotator cuff complex.

FIG. 4-23

CLINICAL PEARL

The cardinal sign of cuff rupture is persistent weakness. The patient may be conscious of this weakness, but the examiner must often point it out. Sometimes the weakness is easily overlooked. The patient may be able to lift the arm into full abduction or beyond the point of a full-thickness cuff tear. However, if this action is resisted a little, sometimes by as little as the pressure of one finger, even a very strong patient may be unable to abduct or flex the shoulder well.

COSTOCLAVICULAR MANEUVER

Assessment for Thoracic Outlet Syndrome

ORTHOPEDIC GAMUT 4-12 THORACIC OUTLET SYNDROME

Depending on the mechanism and level of compression, several disorders are included under the title of thoracic outlet syndrome:

1. Cervical rib syndrome

2. Scalenus-anticus syndrome

3. Wright hyperabduction syndrome

4. Pectoralis minor syndrome

5. Costoclavicular syndrome

PROCEDURE

• The radial pulse is palpated while the patient’s shoulders are drawn down and in extension.

• The cervical spine is flexed maximally (Figs. 4-24 and 4-25).

• If the pulses are lost, the test is positive.

• Thoracic outlet syndrome is suggested by a positive test.

FIG. 4-24

FIG. 4-25 An alternative is to have the patient actively abduct the shoulders and flex the elbows to 90 degrees. The examiner palpates the radial pulse of the affected arm and externally rotates the arm. The test is positive if the pulse disappears.

CLINICAL PEARL

Radiating discomfort from neurovascular compression can be associated with sleep or recumbency. This discomfort is a common disturbance that has many descriptive terms applied to it, including Wartenberg nocturnal dysesthesia, sleep tetany, waking numbness, nocturnal palsy, and morning numbness.

DAWBARN SIGN

PROCEDURE

• With the patient’s arm comfortably at the side, deep palpation of the shoulder by the examiner elicits a well-localized, tender area.

• With the examiner’s finger still on the painful spot, the patient’s arm is passively abducted by the examiner’s other hand.

• The sign is present if the painful spot under the examiner’s nonmoving finger disappears as the arm is abducted (Fig. 4-26).

• The sign is significant for subacromial bursitis.

FIG. 4-26

CLINICAL PEARL

Subacromial bursitis is not common as a primary condition. The condition may be caused by a direct blow over the shoulder. This blow causes an inflammatory reaction that is aggravated by further motion. Bursitis is usually a secondary reaction. The examiner should search for a primary lesion before beginning treatment.

DUGAS TEST

Assessment for Shoulder Dislocation

ORTHOPEDIC GAMUT 4-15 ANTERIOR SHOULDER DISLOCATION

Radiographic appearances of anterior shoulder dislocation:

1. Bankart lesion, which is an avulsion of a small fragment of the glenoid rim at the site of the triceps insertion

2. Flap fracture, an avulsion of the greater tuberosity

3. Hill-Sachs (hatchet) deformity, an impaction fracture of the posterosuperior surface of the humeral head produced by repetitive traumatization by the inferior glenoid rim after recurrent anterior glenohumeral joint dislocation

ORTHOPEDIC GAMUT 4-16 CHRONIC RECURRENT DISLOCATIONS

Four subsets of chronic recurrent dislocations are:

1. Voluntary habitual (emotionally disturbed)

2. Voluntary

3. Not willful (muscular control)

4. Involuntary positional and involuntary unintentional (not demonstrable by patient)

PROCEDURE

• The patient places the hand of the affected shoulder on the opposite shoulder and attempts to touch the chest with the elbow.

• The test is positive if the patient cannot touch the chest wall with the elbow (Fig. 4-27).

• The test is positive in shoulder dislocation.

FIG. 4-27

CLINICAL PEARL

In exceptional circumstances, the humeral head can become jammed below the glenoid with the arm pointing directly upward (luxatio erecta), presenting a spectacular appearance sometimes mistaken for hysteria. This condition is a true inferior dislocation. In contrast to anterior dislocation, the humeral head in this situation lies against the vessels and can cause ischemia. The rotator cuff is always damaged.

GEORGE SCREENING PROCEDURE

PROCEDURE

• With the patient seated, the examiner assesses the patient’s blood pressure bilaterally and records it (Fig. 4-28).

• The examiner also assesses the character of the patient’s radial pulse bilaterally (Fig. 4-29).

• A difference of 10 mm Hg between the two systolic blood pressure readings and a feeble or absent radial pulse suggest possible subclavian artery stenosis or occlusion on the side of the feeble or absent pulse.

• If the test is negative, the examiner places a stethoscope over the supraclavicular fossa and auscultates the subclavian artery for bruits (Fig. 4-30).

• If bruits are present, subclavian artery stenosis or occlusion is suspected.

FIG. 4-28

FIG. 4-29

FIG. 4-30

CLINICAL PEARL

The shoulder joint can be linked with the hand in a symptom complex presenting the features of a reflex sympathetic disturbance. The shoulder symptoms may be caused, in part, by the neurovascular upset that develops as a result of sympathetic stimulation. The shoulder complaint is usually secondary to some other factor, but the reflex dystrophy phenomenon has become so predominant that it is mislabeled as the cause when it is actually a result.

HALSTEAD MANEUVER

PROCEDURE

• As the radial pulse of the affected arm is palpated, downward traction is applied on the extremity.

• The neck is hyperextended (Fig. 4-31).

• Loss or diminution of the pulse suggests a positive test.

• If the test is negative, it is repeated with the patient rotating the head to the opposite side.

• Thoracic outlet syndrome is suggested by a positive test.

FIG. 4-31

CLINICAL PEARL

Raynaud disease, acroparesthesia, and thromboangiitis obliterans may be confused with thoracic outlet compression syndromes, but the former three conditions actually differ profoundly from outlet compression syndromes because Raynaud disease, acroparesthesia, and thromboangiitis obliterans are not accompanied by shoulder discomfort, have no correlation to arm or shoulder movement, and are not affected by body posture.

HAMILTON TEST

Assessment for Dislocation of the Shoulder

ORTHOPEDIC GAMUT 4-21 CAUSES OF POSTTRAUMATIC OSTEOARTHRITIS

• Fracture of the humeral head or glenoid and traumatic dis-location

• Osteoarthritis caused by dislocation is sometime called:

• Postdislocation osteoarthritis

• Dislocation arthropathy

• Dislocation-induced arthropathy

PROCEDURE

• If a straight edge (ruler or yardstick) can rest simultaneously on the acromial tip and the lateral epicondyle of the elbow, the test is positive (Fig. 4-32).

• The positive test is significant for dislocation of the shoulder.

FIG. 4-32

CLINICAL PEARL

Fractures of the humeral head that result in several fragments are usually accompanied by dislocation. Fracture dislocations of the humeral head present several problems: (1) The fragment may obstruct reduction and make open reduction necessary, (2) the reduction will be very unstable, (3) soft-tissue damage and hemorrhage into and around the shoulder lead to joint stiffness, and (4) avascular necrosis of the humeral head can follow fractures through the anatomic neck.

IMPINGEMENT SIGN

Assessment for Overuse Injury to the Supraspinatus or Biceps Tendons

Comment

The terminology for impingement lesions had led to confusion. Many names and causes for this condition have been cited, including bursitis, tendinitis, acute trauma, overuse, instability, aging, tendon degeneration, vascular deficiencies, and mechanical impingement (Table 4-4). The rotator cuff is the only tendon situated between two bones.

TABLE 4-4 CLINICAL PRESENTATIONS OF THE MOST COMMON SHOULDER CONDITIONS

Disorder	Age Group Affected	Key Diagnostic Features
Rotator cuff impingement	Middle-aged	Painful arc within full ROM
Rotator cuff tear	Middle-aged and older adults	Selective weakness of supraspinatus/infraspinatus
Frozen shoulder	Middle-aged	Restriction of passive ROM, external rotation
Calcific tendonitis	Middle-aged	Severe pain; full passive ROM; calcific deposit on radiograph
Acromioclavicular osteoarthosis	Middle-aged and older adults	Pain over joint; radiographic changes
Glenohumeral osteoarthosis	Middle-aged and older adults	Loss of passive ROM; radiographic changes
Shoulder instability	Age <40 years	Recurrent dislocation or subluxation symptoms; clinical signs of instability

ROM, Range of motion.

Adapted from Frost A, Michael Robinson C: The painful shoulder, Surgery (Oxford) 24(11):363-367, 2006.

ORTHOPEDIC GAMUT 4-22 IMPINGEMENT SYNDROME

The four stages of impingement syndrome are as follows:

Phase 1: Edema and swelling (correlated with overuse tendonitis from activities requiring repetitive overhead arm action)

Phase 2: Thickening and fibrosis (correlated with incomplete thickness rotator cuff tears)

Phase 3: Comprises complete thickness tearing and bone changes

Phase 4: Cuff tear arthropathy (occurs in a small percentage of neglected cuff tears)

PROCEDURE

• The patient’s arm is slightly abducted and moved fully through flexion (Fig. 4-33).

• This move causes a jamming of the greater tuberosity into the anteroinferior acromial surface.

• A positive result is pain in the shoulder.

• A positive test suggests injury to the supraspinatus and sometimes to the biceps tendons.

FIG. 4-33 As an alternative, the examiner can internally rotate the affected shoulder. This rotation occurs while the shoulder is abducted to 90 degrees and flexed at the elbow. The arm can also be moved into flexion, which will produce the same jamming effect.

CLINICAL PEARL

The archaic concept of the hunching girdle rhythm as the telltale mark of supraspinatus ruptures needs to be discarded. Without resistance, a decrease in the range of motion may not be apparent. Motion must always be assessed against resistance. The presence of consistent weakness helps differentiate a tear from simple chronic tendinitis.

LUDINGTON TEST

Assessment for Rupture of the Long Head of the Biceps Tendon

PROCEDURE

• The patient clasps both hands behind the head.

• The biceps tendons are in resting positions.

• The patient alternately contracts and relaxes the biceps muscles.

• As the patient contracts the muscles, the examiner palpates the biceps tendons (Fig. 4-34).

• The tendon will be felt to contract on the uninvolved side but not on the affected side.

• A positive test result is the loss of tendon contraction.

• A positive test suggests rupture of the long head of the biceps tendon.

FIG. 4-34

CLINICAL PEARL

A double defect sometimes occurs, with the cuff giving way from the tuberosity on both sides of the tendon. Cuff laxity at this point seriously interferes with biceps function, and the tendon may slip medially over the lesser tuberosity and off the head.

MAZION SHOULDER MANEUVER (ALSO KNOWN AS SHOULDER ROCK TEST)

Assessment for Significant Pathologic Process of the Shoulder

PROCEDURE

• While standing or sitting, the patient places the palm of the affected upper limb over the top of the opposite clavicle.

• From this position, the patient moves the elbow from the chest to the forehead, giving it an inferior to superior rocking motion (Fig. 4-35).

• The maneuver is positive if this action produces or aggravates shoulder or arm pain on the ipsilateral side.

• The pain of any significant pathologic process of the shoulder will be intensified and localized by this maneuver.

FIG. 4-35

CLINICAL PEARL

Adhesive capsulitis is a common but ill-understood affliction of the glenohumeral joint. Capsulitis is characterized by pain and uniform limitation of all movements but without radiographic change and with a tendency to a slow spontaneous recovery. No evidence of inflammatory or destructive change is seen.

REVERSE BAKODY MANEUVER

PROCEDURE

• While in the seated position, the patient actively places the palm of the affected extremity on top of the head, raising the elbow to a height approximately level with the head.

• By elevating the arm, interscalene compression increases.

• The sign is present when the radiating pain appears or is worsened with this maneuver (Fig. 4-36).

• The sign helps differentiate between cervical foraminal compression and interscalene compression.

FIG. 4-36

CLINICAL PEARL

Radiographs will show the abnormal rib. If it is small, it is clearly observed in the oblique projections. In cases of suspected vascular obstruction, arteriography is required.

ROOS TEST

Assessment for Thoracic Outlet Syndrome

ORTHOPEDIC GAMUT 4-25 COSTOCLAVICULAR NEUROVASCULAR SPACE

The following actions narrow the costoclavicular neurovascular space:

1. Raising the arm rotates the clavicle posteriorly into the space.

2. Displacing the shoulder posteriorly and interiorly rotates the clavicle posteriorly.

3. Inhaling deeply raises the first rib into the space because the clavicle does not rise with inspiration.

PROCEDURE

• While in the seated position, the patient positions both arms at 90 degrees and abducts and externally rotates them.

• The patient repeatedly opens and closes the fists for up to 3 minutes.

• If this maneuver reproduces the usual symptoms of discomfort, the patient probably has thoracic outlet syndrome (Fig. 4-37).

FIG. 4-37

CLINICAL PEARL

Because all of the neurologic, arterial, and venous symptoms are consistently aggravated by both exercise and arm elevation, the most reliable test for the diagnosis of thoracic outlet syndrome is the 3-minute elevated-arm stress test.

SHOULDER COMPRESSION TEST

Assessment for Hyperabduction Type of Thoracic Outlet Syndromes

ORTHOPEDIC GAMUT 4-26 THORACIC OUTLET

The following signs generally do not implicate the thoracic outlet:

1. Long tract signs such as brisk reflexes or extensor plantar response

2. Loss of tendon reflexes in the arms

3. Horner syndrome

4. Weakness of the upper arm or shoulder

PROCEDURE

• While the patient is seated upright, the examiner palpates the distal apex of the coracoid process and marks it with a flesh pencil.

• With a hypothenar contact, the examiner applies downward pressure over the marked area (Fig. 4-38).

• Production of symptoms that are similar to neurovascular compression of the subclavian artery and brachial plexus constitutes a positive test.

• The test is significant for coracoid pressure syndrome, which is identical to the hyperabduction type of thoracic outlet syndromes.

FIG. 4-38

CLINICAL PEARL

The neurovascular bundle may be compressed in the zone distal to the clavicle as the bundle passes beneath the costocoracoid membrane and pectoralis minor. The pectoralis minor has a particular contribution in this process and is a significant factor in creating the shoulder and radiating symptoms. A patient’s degree of skeletal maturation has a great influence on the type of fracture that may result from trauma and the concern physicians have about the sequelae of such injuries. First, the relative softness of the bones of newborns and toddlers increases the likelihood of trauma producing a greenstick fracture rather than an ordinary fracture completely separating the two bone fragments. Another crucial consideration in the evaluation of fractures in children is the possible involvement of the epiphyseal plates of the bone in the fracture. If the line of a fracture crosses one of these areas of bone growth, the posthealing alignment of the bone on opposite sides of the plate is disturbed, and the subsequent growth and development of the bone will be asymmetric.

SPEED TEST

Assessment for Bicipital Tendinitis

PROCEDURE

• Shoulder flexion by the patient is restricted.

• The patient further resists forearm supinating and elbow extension.

• A positive test is indicated by increased tenderness in the bicipital groove (Fig. 4-39).

• A positive test suggests bicipital tendinitis.

FIG. 4-39

CLINICAL PEARL

Tenosynovitis in the bicipital groove may develop into complete adherence of the tendon, which interdicts any extensive range of motion of the shoulder. The shoulder motion may remain restricted, or the biceps may rupture proximal to the groove.

SUBACROMIAL PUSH-BUTTON SIGN (ALSO KNOWN AS MAZION CUFF MANEUVER)

Assessment for Rotator Cuff Tear of the Supraspinatus Tendon

Comment

Ruptures of the rotator cuff result from continued deterioration and degeneration (Table 4-5). The tear may be partial or complete.

TABLE 4-5 GOUTALLIER GRADING SYSTEM OF FATTY DEGENERATION OF MUSCLE

Stage	Findings (MRI/CT)
Stage 0	Normal muscle; no fatty streaking
Stage 1	Occasional fatty streaking
Stage 2: fat < 50% of cross	Sectional area (fat < muscle)
Stage 3: fat = 50% of cross	Sectional area (fat = muscle)
Stage 4: fat > 50% of cross	Sectional area (fat > muscle)