SHOULDER EXAMINATION

b) Sulcus sign The wrist is grasped and inferior traction applied. The area adja- cent to the acromion is observed and dimpling of the skin may indicate a ‘sulcus sign’. This indicates injury to the superior gleno- humeral ligament but may also indicate multi-directional instabil- ity. The acromion and then the space underneath it are palpated to gain an impression of the amount of inferior humeral transla- tion (Fig. 5). c) Apprehension and relocation tests Impending subluxation or dislocation is noted by the patient and is resisted or reproduces symptoms. The most common direction of instability is anterior. The usual position of the arm when sub- luxation or dislocation occurs is abduction and external rotation. i) Anterior apprehension The patient lies supine and the examiner raises the arm to 90º of abduction and begins to externally rotate the humerus. The right hand of the examiner is placed over the humeral head with the thumb pushing from posterior for extra leverage; however, the fin- gers are anterior to control any sudden instability. An impending feeling of anterior instability may be produced, but pain alone is not a positive apprehension sign. ii) Relocation If the anterior apprehension sign is positive, pressure is then placed on the anterior humeral head to push it posteriorly and ‘relocate’ the glenoid to remove the symptoms. iii) Posterior apprehension The patient lies prone with the arm and elbow flexed to 90º. An axial load is applied to the humerus while the other hand palpates the joint posteriorly to detect movement.

7. Palpation • Sternoclavicular joint • Clavicle • Acromioclavicular joint • Greater tuberosity – tenderness is usually due to supraspinatus tendinitis

• Muscles for trigger points - especially upper trapezius, levator scapulae, infraspinatus

• Bicipital region – tenderness in the area of the bicipital groove may indicate tendinitis

This should be augmented by: a) Speed’s test With the elbow extended and forearm supinated, forward eleva- tion of the humerus to approximately 90º is resisted. A positive test elicits pain localised to the bicipital groove area (Fig. 6). b) Yergason’s test This test challenges the supinating function of biceps and pro- duces anterior pain on resisted supination and flexion of the fore- arm. The elbow is flexed to 90º and the forearm pronated. Supination is then resisted and pain in the area of the bicipital groove indicates a lesion in the long head of the biceps.

8. Other tests a) Serratus anterior ‘Push-up’ and ‘push up plus’ looking for scapular winging b) Thoracic outlet i) Adson’s test Tests compression against the anterior scalene muscle and can produce vascular or neural symptoms. The arm is externally rotat-

8 SportEX

ed with the elbow extended. While palpating the radial pulse, the arm is extended and slightly abducted. The patient turns their head to affected side and takes a breath and holds it. Positive test is denoted by a loss of pulse or increase in pain. ii) Roo’s test With the shoulders abducted to 90º and the elbows flexed to 90º, the patient is asked to open and close the fingers slowly for three minutes. Reproduction of symptoms or inability to complete the test may indicate thoracic outlet syndrome.

9. Neurological examination Upper limb tensioning tests may help to differentiate referred pain from musculoskeletal or mechanical pain.

LEVEL MOTOR SENSORY REFLEX C5 Deltoid

Lateral deltoid Biceps Biceps (partial) C6 Biceps

Brachioradialis ECRL and ECRB

C7 Triceps Wrist flexors C8 Finger flexors

Ulnar border Little finger

T1 Intrinsics

Medial side Proximal arm

Table 1: Neurological influences on shoulder

Physical examination check list The examination described above is not exhaustive but is thor- ough and can be performed in just a few minutes. ● Initial cursory impression ● Inspection ● Examination of cervical spine ● Joint motion ● Impingement tests ● Stability assessment ● Palpation ● Other tests ● Neurological assessment

Dr Nick Webborn is a full time sports physician and he lectures widely on sports medicine and particularly on joint examina- tion techniques.

He is medical advisor to both SportEX

Medicine and the National Sports Medicine Institute and med- ical officer to the British Paralympic swimming squad.

With thanks to Martin Dunitz Publishers for their permission to reproduce figs.3-6. From Sports Injuries: Their Prevention and Treatment (3rd Edn). ISBN

1-85317-119-0. The book costs £40 and is available by telephoning 020 7482 2202. Middle finger Triceps Thumb Biceps