What is the recommended approach for a shoulder physical exam and initial management of suspected shoulder pathology?

Recommended Approach for Shoulder Physical Examination and Initial Management

A systematic shoulder examination should include inspection, palpation, range of motion assessment, strength testing, stability evaluation, and special tests, followed by appropriate imaging with radiographs first and then MRI or MR arthrography for suspected soft tissue pathology. 1, 2

Physical Examination Sequence

1. Patient Positioning

• Seated position with 90° flexion of the elbow joint
• Hand positioned in supination on top of the patient's thigh
• Allow for dynamic examination with active/passive external and internal rotation 1

2. Inspection

• Observe shoulder contour, muscle atrophy, scapular winging
• Look for asymmetry compared to contralateral side
• Note any swelling, erythema, or surgical scars

3. Palpation

• Acromioclavicular joint
• Sternoclavicular joint
• Greater tuberosity
• Bicipital groove
• Coracoid process
• Assess for tenderness, crepitus, or warmth

4. Range of Motion Assessment

• Active and passive motion in all planes:
  • Forward flexion (0-180°)
  • Abduction (0-180°)
  • External rotation (0-90°)
  • Internal rotation (ability to reach behind back)
• Compare with contralateral side
• Note pain arcs and limitations

5. Strength Testing

• Rotator cuff muscles:
  • Supraspinatus (empty can test)
  • Infraspinatus/teres minor (external rotation)
  • Subscapularis (lift-off test, bear hug test)
• Deltoid
• Biceps
• Grade strength on 0-5 scale

6. Stability Assessment

• Anterior instability tests (apprehension, relocation)
• Posterior instability tests
• Inferior instability (sulcus sign)
• Multidirectional instability

7. Special Tests

• Impingement tests (Neer, Hawkins-Kennedy)
• Labral tear tests (O'Brien's, crank test)
• Biceps pathology tests (Speed's, Yergason's)
• AC joint tests (cross-body adduction)

Initial Imaging and Management

Initial Imaging

1. Radiographs - First-line imaging for all shoulder pain:

   • AP view in neutral position
   • Grashey view (30° posterior oblique)
   • Axillary lateral or scapular Y view
   • Special views as indicated (Rockwood view for impingement) 1

2. Advanced Imaging based on suspected pathology:

   • For suspected labral tear/instability (especially in patients <35 years):

     • MR arthrography (gold standard)
     • MRI without contrast (if MR arthrography unavailable)
     • CT arthrography (if MRI contraindicated) 1, 2

   • For suspected rotator cuff pathology:

     • MRI without contrast
     • Ultrasound (if performed by experienced operator) 1

Initial Management Based on Diagnosis

1. Rotator Cuff Pathology:

   • Activity modification
   • NSAIDs for pain control
   • Physical therapy focusing on rotator cuff and scapular stabilization
   • Consider corticosteroid injection for persistent pain 2

2. Shoulder Instability:

   • Physical therapy for strengthening
   • Activity modification
   • Consider surgical referral for young, active patients with recurrent instability 2

3. Adhesive Capsulitis:

   • Range of motion exercises (avoiding aggressive passive movements)
   • Pain management
   • Consider corticosteroid injection 2

4. Impingement Syndrome:

   • Activity modification
   • NSAIDs
   • Physical therapy focusing on posture and rotator cuff strengthening
   • Consider subacromial corticosteroid injection 2

Common Pitfalls and Caveats

• Referred Pain: Always assess cervical spine as shoulder pain may be referred
• Bilateral Examination: Always compare with contralateral shoulder
• Special Populations: Modify examination for elderly or patients with limited mobility
• Avoid Overhead Pulley Exercises: May worsen certain conditions like subluxation 2
• Ultrasound Limitations: While useful for soft tissue evaluation, ultrasound is operator-dependent and may miss labral pathology 1
• Radiographs First: Always obtain plain radiographs before advanced imaging to rule out fractures and other bony abnormalities 1

By following this systematic approach to shoulder examination and initial management, clinicians can accurately diagnose and appropriately treat common shoulder pathologies, improving patient outcomes and quality of life.