2

THE SHOULDER
Murray J. S. Beuerlein • Michael D. McKee • Adel G. Fam

Applied Anatomy l­igaments; and the coracohumeral ligament. The capsule,

which fuses in part with the tendons of the rotator cuff, has
Shoulder movements are a synthesis of motion at four artic- two apertures: one for the long biceps tendon (origin from
ulations: sternoclavicular, acromioclavicular, glenohumeral, the supraglenoid tubercle) and one for the subscapularis
and scapulothoracic. bursa. The labrum, a ring of fibrocartilage that surrounds
and deepens the glenoid cavity, contributes significantly to
GH joint stability. Through a bumper effect, it functions as a
STERNOCLAVICULAR JOINT
“chock block” to prevent translational forces.
The sternoclavicular (SC) joint is a spheroidal joint between The inferior GH ligament complex is the primary liga-
the medial end of the clavicle and both the manubrium and mentous stabilizer of the abducted GH joint and serves to
the first costal cartilage. An intraarticular fibrocartilaginous prevent anteroinferior shoulder dislocation. The middle GH
disk stabilizes the joint and prevents medial displacement of ligament is tensioned at 45° of abduction, and the superior
the clavicle. The joint capsule is reinforced by the anterior GH ligament is tight in adduction.
and posterior SC ligaments. Dynamic stabilizers play an important role in the stability
of the shoulder. They include two musculotendinous layers:
1) an inner stratum, made of the rotator cuff muscles (supra-
ACROMIOCLAVICULAR JOINT
spinatus, infraspinatus, teres minor, and subscapularis) and
The acromioclavicular (AC) joint is a spheroidal joint the long biceps tendon (origin from supraglenoid tubercle
between the lateral end of the clavicle and the acromion pro- from glenoid fossa), and 2) an outer stratum, composed of
cess of the scapula (Figure 2-1). A small, intraarticular fibro the deltoid, teres major, pectoralis major, latissimus dorsi,
cartilaginous disk divides the joint into two compartments. and trapezius muscles.
A subcutaneous, noncommunicating bursa may be present The muscles of the inner stratum stabilize and retain the
over the joint. The stability of the AC joint depends on the humeral head in the glenoid cavity during shoulder move-
capsule and the superior and inferior AC ligaments. The cor- ments (cavity-compression mechanism), while simultane-
acoclavicular ligament (conoid and trapezoid parts) extends ously providing abduction (supraspinatus—origin from the
between the distal clavicle and the coracoid process of the supraspinatus fossa of scapula and insertion into the superior
scapula (Figure 2-2). It suspends the scapula, stabilizes both part of the greater tuberosity), external rotation (infraspina-
the clavicle and the scapula, and maintains a close relation tus and teres minor—origin from the infraspinatus fossa
between the two bones during shoulder movements, thus and axillary border of the scapula, respectively, and inser-
limiting scapular rotation around the AC joint. The AC and tion into the posterior aspect of the greater tuberosity), and
SC joints augment the range of shoulder movements, par- internal rotation (subscapularis—origin from the subscapu-
ticularly abduction and rotation. The joints also allow slight laris fossa and insertion into the lesser tuberosity). At the ini-
axial rotation of the clavicle, as well as elevation/depression tiation of shoulder abduction, both the rotator cuff and the
and forward/backward thrusting of the shoulder. long biceps tendon depress and stabilize the humeral head
against the glenoid cavity to counteract the upward pull of
the more powerful deltoid muscle. The mechanism whereby
GLENOHUMERAL JOINT
these two groups of muscles combine to produce abduc-
The glenohumeral (GH) joint, the main articulation of the tion, the one (deltoid muscle) elevating and the other (rota-
shoulder complex, is a multiaxial, ball-and-socket synovial tor cuff and biceps tendons) stabilizing the humeral head, is
articulation between the glenoid fossa of the scapula and termed force-coupling. The muscles of the outer stratum are
the humeral head (Figure 2-1). The lax articular capsule the prime movers of the shoulder. These provide abduction,
and the small area of contact between the shallow glenoid flexion, extension, adduction, and some degree of rotation.
fossa and the spheroidal humeral head permit a wide range The coracoacromial arch—made up of the coracoid pro-
of motion. The stability of the joint depends on a number of cess, coracoacromial ligament, and acromion—acts as a pro-
static and dynamic stabilizers. Static stabilizers include nega- tective, secondary socket for the humeral head, under which
tive intraarticular pressure; GH bone geometry; the capsule; the rotator cuff tendons and long biceps tendon glide, with
the glenoid labrum; the superior, middle, and inferior GH the subacromial bursa lying in between. The arch prevents
7

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8 THE SHOULDER

Acromioclavicular joint Clavicle

Acromion
Supraspinatus
muscle and tendon
Subacromial
(subdeltoid) bursa
Glenoid fossa and
Greater tuberosity labrum glenoidale
of humerus
Glenohumeral
Lesser tuberosity synovial joint
space
Deltoid muscle
Axillary recess
Bicipital
(intertubercular)
groove
Synovial
Joint capsule membrane
Humerus

FIGURE 2-1 THE SHOULDER.

Acromioclavicular Clavicle
joint
Coracoclavicular
Acromion
ligament

Coracoacromial
Synovium of the ligament
glenohumeral joint
Subscapularis bursa
Transverse humeral
(intertubercular)
ligament Coracoid process

Humerus Scapula

Tendon and synovial

sheath of the long
head of the biceps

FIGURE 2-2 THE SHOULDER (SYNOVIAL MEMBRANE AND OUTPOUCHINGS).

upward displacement of the humeral head and protects the

SCAPULOTHORACIC MOVEMENTS
head and rotator cuff from direct trauma. The undersurface
of the acromion is commonly flat (type 1); less frequently, it The so-called scapulothoracic articulation is not a true joint
is downwardly curved (type 2) or hooked (type 3), but these but functions as an integral part of the shoulder complex.
conditions are more commonly associated with subacromial The scapula, which is connected to the posterior aspect of
impingement. the chest wall by the axioappendicular muscles, provides
The synovium of the shoulder lines the inner surface the origin for the rotator cuff muscles and deltoid, and the
of the capsule. It has two extracapsular outpouchings, the trapezius inserts into its superior aspect. Scapulothoracic
tenosynovial sheath of the long biceps tendon and the bursa movements that include rotation, elevation, depression,
beneath the subscapularis tendon (Figure 2-2). A commu- protrusion, retraction, and circumduction are important for
nicating infraspinatus bursa is sometimes present. The sub- the normal functioning of the shoulder. The scapulothoracic
coracoid bursa lies between the shoulder capsule and the bursa is located between the serratus anterior and the chest
coracoid process, but it rarely communicates with the joint. wall, just medial to the inferior angle of the scapula.

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 THE SHOULDER 9

NERVE SUPPLY TO THE SHOULDER JOINT Common Disorders of the Shoulder

The shoulder joint derives its nerve supply from three ROTATOR CUFF PATHOLOGY
branches of the brachial plexus: suprascapular, axillary,
and lateral pectoral nerves (C5/C6). The axillary nerve The spectrum of rotator cuff pathology ranges from mild
and the posterior circumflex humeral artery pass through rotator cuff tendinopathy to partial and complete rotator
the quadrilateral or quadrangular space, which lies infero­ cuff tears. If the tear increases in size, a massive rotator cuff
posterior to the GH joint, bounded by the teres minor tear (< 5 cm) may develop. This can lead to the proximal
superiorly, the teres major inferiorly, the long head of migration of the humeral head and secondary GH osteoar-
triceps medially, and the shaft of the humerus laterally thritis (cuff tear arthropathy).
(Figure 2-3). Causative factors include repetitive low-grade trauma or
unaccustomed activities, excessive overhead use in sport or
work, lack of conditioning, aging, and compromise of the
SHOULDER PAIN AND HISTORY TAKING
rotator cuff space by osteophytes on the undersurface of the
Shoulder pain is a common symptom of diverse causes AC joint, type 2 or 3 acromion, or an os acromiale (unfused
(Table 2-1). The pain may originate in the GH or AC acromial epiphysis). Abnormal tensile stresses that exceed
joint or in periarticular structures, or it may be referred the elastic limits of tendons can lead to cumulative micro-
from the cervical spine, brachial plexus, thoracic outlet, failure of the molecular links between tendon fibrils, called
or infradiaphragmatic structures. Important points in the fibrillar creep. With aging, tendons become less flexible and
history include age, hand dominance, occupational and less elastic, making them more susceptible to injury and
sport activities involving heavy lifting or overhead repeti- tears. A short-ended musculotendinous unit, from lack of
tive movements, history of trauma, onset, location, char- regular stretching exercises, is also prone to injury.
acter, duration, radiation of the shoulder pain, aggravating In young persons, rotator cuff tendinopathy is often
and relieving factors, presence of night pain, and the effect caused by a sport-related injury; for example, from use of
on shoulder function. Associated symptoms—shoulder the arm in an overhead position in baseball, racquetball, ten-
stiffness, restriction of movement, grinding, clicking, nis, or swimming. In older individuals, an antecedent his-
instability, or weakness—may also provide useful diag- tory of repetitive movements above the shoulder level or of
nostic clues. strenuous or unaccustomed arm activity is common. Symp-
It is also important to determine whether the shoulder toms include aching pain in the shoulder, lateral aspect of
pain is isolated or associated with other stiff, painful, or the upper arm, and deltoid insertion; pain with movement,
swollen joints. Shoulder pain may be a feature of a more sys- particularly abduction and internal rotation; night pain
temic arthritis. Other joint history, and a history of systemic when rolling onto the affected side; restriction of shoulder
features, may need to be taken into consideration. movements; and sometimes weakness caused by a rotator

Dorsal scapular n.
C4
To phrenic
C4
Superior C5
Trunks Middle
C5
Inferior C6
Suprascapular n.
Lateral C6
Cords Posterior C7
Medial C7
Thoracodorsal n. C8
Lower subscapular n.
T1 T1
Musculocutaneous n.
Axillary n.
T2
Median n.
Long thoracic n.
Nerve to subclavius
Lateral pectoral n.
FIGURE 2-3 ARRANGEMENT
Medial pectoral n.
OF THE BRACHIAL PLEXUS AND ITS
Upper subscapular n.
TRUNKS, CORDS, AND TERMINAL
BRANCHES. (From Rockwood CA, Medial brachial cutaneous n.
Matsen FA, Wirth MA, et al., Medial antebrachial cutaneous n.
eds.:The Shoulder, 4th ed. Radial n.
Philadelphia: Saunders, 2009.) Ulnar n.

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10 THE SHOULDER

TABLE 2-1 can be confirmed by ultrasonography, magnetic resonance

imaging (MRI), or arthroscopy.
DIFFERENTIAL DIAGNOSIS
OF SHOULDER PAIN
BICIPITAL TENDINITIS
Articular Causes
GH and AC arthritis: OA, RA, PsA, trauma, infection, crystal- Bicipital tendinitis often results from chronic subacromial
induced impingement occurring in association with rotator cuff ten-
Ligamentous and labral lesions dinitis and rotator cuff tears. Primary isolated bicipital tendi-
GH and AC joint instability nitis is rare and develops as an overuse injury resulting from
Osseous: fracture, osteonecrosis, neoplasm, infection repetitive stresses applied to the tendon in certain sports,
Periarticular Causes such as weight lifting and ball throwing. Anterior shoulder
Chronic impingement and rotator cuff tendinitis pain that is increased by overhead activities, shoulder exten-
Bicipital tendinitis sion, and elbow flexion is the main symptom. There is local-
Rotator cuff and long biceps tendon tears ized tenderness over the tendon in the bicipital groove, the
Subacromial bursitis Yergeson sign (see Tests for Biceps Tendon, p. 16) is present,
Adhesive capsulitis
and the speed test is often positive. Passive extension of the
Neurological Lesions About the Shoulder shoulder or resisted flexion of the elbow may also reproduce
Thoracic outlet syndrome the pain. Signs of chronic impingement and GH instability
Acute brachial plexus neuritis are often present. Rupture of the long biceps tendon is asso-
Quadrilateral space syndrome ciated with a positive Popeye sign.
Suprascapular nerve entrapment syndrome
Subluxation of the bicipital tendon is caused by traumatic
Cervical radiculopathy
rupture of the intertubercular (transverse humeral) liga-
Referred and Miscellaneous Causes ment. It is associated with anterior shoulder pain, a clicking
Angina pectoris sensation of the shoulder as it “goes out and pops back in,”
Diaphragmatic and infradiaphragmatic disorders: pericardi- tenderness in the bicipital groove, and a positive transverse
tis, pleurisy, gallbladder disease, subphrenic abscess
humeral ligament test.
Axillary artery or vein thrombosis
Reflex sympathetic dystrophy syndrome and shoulder–hand
syndrome ADHESIVE CAPSULITIS
Polymyalgia rheumatica, myositis
Diffuse fibromyalgia and myofascial pain syndrome Adhesive capsulitis, also known as frozen shoulder, is charac-
Somatization disorder and psychogenic regional pain terized by progressive global restriction of shoulder move-
syndrome ments and is associated with pain and functional disability.
A period of immobility of the shoulder is the most com-
AC, acromioclavicular; GH, glenohumeral; OA, osteoarthritis;
PsA, psoriatic arthritis; RA, rheumatoid arthritis mon predisposing factor. The capsulitis may be secondary
to shoulder trauma, rotator cuff tendinitis or tears, bicipital
tendinitis, or GH arthritis, or it may coexist with diabetes
mellitus, hypothyroidism, or cerebrovascular events. An
cuff tear. The patient typically experiences shoulder pain on initial synovitis phase is followed by fibrous thickening and
active abduction, especially between 60° and 120°, and dif- contracture of the capsular folds, axillary recess, rotator cuff
ficulty with overhead work, lifting, or reaching behind the interval, and coracohumeral ligament. The shortening of the
back when dressing. Clinical findings include a painful arc coracohumeral ligament and rotator cuff interval acts as a
between 60° to 120° of abduction, limitation of active move- tight checkrein, limiting external rotation. Capsular adhe-
ment by pain, and tenderness localized to the rotator cuff and sions are rare.
greater tuberosity. The supraspinatus test, Neer impingement The clinical course can be divided into four overlap-
test, Neer impingement sign, and Hawkins impingement ping stages. In stage I, there is painful limitation of active
sign (see Special Tests of Shoulder, p. 13) are often positive. and passive shoulder movements with diffuse synovitis on
Rotator cuff tears can be partial or complete, acute or both arthroscopy and biopsy. Stage II is a painful “freezing”
chronic, small or massive. In young adults, acute tears often phase; shoulder pain, tenderness, and progressive, pain-
result from direct trauma or a sport-related injury. In older ful, global restriction of movements are present, as well as
patients, minor trauma, superimposed on cuff tendon that characteristic limitation of external rotation in the absence
is already frayed from chronic impingement and age-related of GH arthritis. Synovial inflammation and a tight, thick-
attritional changes, can lead to tears. ened capsule are observed on both arthroscopy and biopsy.
Clinical features include shoulder pain on abduction, In stage III, an adhesive or “frozen” phase, there is minimal
night pain, varying degrees of weakness of abduction and pain; movements are markedly restricted, and the patient
external rotation, local tenderness, wasting of the supra- is unable to elevate the arm to 90° without shrugging the
spinatus and/or infraspinatus muscles, and loss of range of shoulder (positive shrug sign). Disuse atrophy of the deltoid
motion with difficulty elevating the arm to greater than 90° and scapular muscles is common. A thickened, contracted
without shrugging the shoulder (positive shrug sign). The capsule and fibrotic synovitis are observed on both arthros-
supraspinatus test, Neer impingement sign, and Hawkins copy and biopsy. In stage IV, a resolution or “thawing”
impingement sign are usually positive. Rupture of the long phase, pain is minimal with an increasing range of motion.
biceps tendon may also be present. In complete tears, the Criteria for diagnosis of adhesive capsulitis include an
drop-arm sign is positive. The diagnosis of rotator cuff tears insidious onset, true shoulder pain lasting longer than

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 THE SHOULDER 11

3 months, night pain, painful restriction of all active and AC, GH, or SC joint, and the patient may experience swell-
passive movements with external rotation reduced to less ing and tenderness of the affected joints. The shoulder is
than 50% of normal, and a normal radiologic appearance. painful with range of motion in all directions, and range
Although 90% of patients recover some use of the extremity may be limited. Other synovial joints in the body are often
within 12 to 18 months, about 40% develop more prolonged affected, and treatment is generally directed toward the sys-
pain, restriction of movement, and functional disability. temic condition.
Primary osteoarthritis is common in the AC joint and less
common in the GH joint. In some cases it may occur at the
GLENOHUMERAL INSTABILITY GH joint secondary to an inflammatory process. In osteoar-
thritis the shoulder is generally painful with activity and may
Acute Instability get progressively worse over time. It is painful throughout
Acute shoulder instability usually results from a traumatic the range of motion, which is often limited. Crepitus is clas-
event such as a fall, sports injury, or motor vehicle colli- sically felt over the affected joint.
sion. More than 90% of all acute shoulder instability is ante-
rior. Typically the patient will present with a “squared-off ” NEUROLOGIC LESIONS ABOUT
shoulder on inspection and significant pain with any shoul-
THE SHOULDER
der motion. A detailed neurovascular exam of the affected
limb is essential. Following confirmatory x-rays, a closed Thoracic outlet syndrome is often caused by compression
reduction of the shoulder is performed. of the lower brachial plexus and subclavian artery between
Acute posterior dislocations are rare but should be con- the scalene muscles or by a cervical rib. It is associated with
sidered when there is a history of seizure or electrocution. shoulder pain, which often radiates distally along the ulnar
The arm is usually held in internal rotation, and loss of border of the forearm and hand. Pallor, coldness, and numb-
external rotation is a typical physical exam finding. Closed ness, commonly of the ring and little fingers, may occur. The
reduction of this injury is usually successful if the diagnosis Adson maneuver is often positive: the ipsilateral radial pulse
is made promptly. disappears when the patient abducts, extends, and exter-
nally rotates the shoulder while taking a deep breath with
Recurrent Instability the head rotated maximally toward the affected side. Neu-
Most cases of recurrent shoulder instability develop fol- rologic findings are subtle and affect both interosseous and
lowing an initial traumatic shoulder dislocation. A Bankart hypothenar muscles, as well as cutaneous sensation of the
lesion, a traumatic avulsion of the anterior inferior glenoid little and ring fingers and the ulnar aspect of the forearm.
labrum, is the essential lesion in this disorder. Patients with Compression of the subclavian artery can be demonstrated
recurrent anterior shoulder instability complain of “not by MRI-­angiography.
trusting” their shoulder when their arm is away from the Acute brachial plexus neuritis (acute brachial plexitis
body. On exam they have a positive anterior apprehension or brachial neuralgic amyotrophy) is an uncommon dis-
sign and a positive relocation sign. These patents do well order characterized by a rapid onset of burning pain in
with surgical stabilization of the shoulder. the shoulder and upper arm, followed a few days later by
Multidirectional shoulder instability tends to be atrau- profound upper-arm weakness affecting multiple muscles
matic and often bilateral. The history will usually lack a supplied by the upper brachial plexus: supraspinatus,
single traumatic episode. Physical exam often shows gener- infraspinatus, deltoid, and sometimes biceps. Diagnostic
alized ligamentous laxity. A sulcus sign is commonly seen. studies include electromyography (EMG) and MRI. The
Surgery is not as successful in these patients, and rehabili- course of the neuritis is usually one of gradual recovery in
tation is the mainstay of treatment in recurrent multidirec- 3 to 4 months.
tional shoulder instability. Quadrilateral space syndrome is a rare disorder that
results from compression of the axillary nerve and poste-
rior circumflex humeral artery in the quadrilateral space. It
TRAUMATIC LESIONS OF THE
is caused by athletic activities, GH dislocation, or shoulder
ACROMIOCLAVICULAR JOINT
surgery. Nondermatomal pain and paresthesia of the shoul-
Trauma to the AC joint can lead to disruption of the cap- der and upper posterior arm, exacerbated by abduction and
sule, ligaments, and fibrocartilaginous disk. Local pain, ten- external rotation, are the main symptoms. Tenderness over
derness, swelling, and a painful arc from 90° of abduction the quadrilateral space, aggravation of symptoms by external
upward are the main findings. Pain at the AC joint can be rotation, variable atrophy and weakness of the deltoid and
reproduced by passive adduction of the extended shoulder teres minor muscles, and sometimes sensory loss over the
behind the back (adduction stress test) and by abducting the anterolateral aspect of the shoulder and upper arm are the
shoulder 90° and then adducting it across the chest at shoul- principal findings. The diagnosis can be confirmed by EMG,
der height, compressing the AC joint (cross-arm AC-loading MRI, or MRI-angiography.
adduction test). Suprascapular nerve entrapment syndrome is charac-
terized by deep aching pain in the upper posterior aspect
ARTHRITIS OF THE SHOULDER
of the scapula, made worse by shoulder adduction, and by
weakness of abduction and external rotation. It is caused by
Both inflammatory arthritis, such as rheumatoid arthritis, compression of the suprascapular nerve in the suprascapu-
and degenerative arthritis, such as osteoarthritis, can affect lar notch, beneath the suprascapular or transverse scapular
the shoulder joints. Inflammatory arthritis may involve the ligament, or by a ganglion or lipoma. It can also result from

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12 THE SHOULDER

repetitive trauma due to excessive overhead movements. s­ welling, crepitus, or masses. This will help localize the site
Local tenderness over the suprascapular notch and variable of a patient’s complaint and narrow the potential differential
weakness and wasting of the supraspinatus and infraspinatus diagnosis.
muscles are the main findings. Arthritis of the SC and AC joints is associated with local
Cervical radiculopathy, caused by a cervical disk lesion, tenderness, synovial swelling, effusion, and sometimes
is associated with pain in the shoulder, radicular sensory crepitus on shoulder shrugging. Arthritis of the GH joint is
symptoms, motor weakness, and reflex changes. Radicular characterized by global tenderness felt through the overly-
pain and/or paresthesia may be reproduced by one of two ing deltoid in the anterior, lateral, and posterior subacromial
tests. The Spurling test involves a combination of cervi- areas.
cal spine extension and tilt toward the affected extremity Bicipital tenosynovitis is associated with localized tender-
with pressure applied downward on the patient’s head. In ness over the tendon in the bicipital groove as the patient
the upper extremity root extension test, the patient’s arm is externally rotates the shoulder. The groove normally faces
extended, abducted, and externally rotated with the elbow anteriorly when the shoulder is internally rotated 10°.
and wrist extended, and the head is tilted to the opposite Scapulothoracic bursitis is associated with posterior
side. Diagnostic studies include cervical spine radiography, subscapular pain and “grinding” or crepitus with scapulo-
MRI, and nerve conduction studies. thoracic movements. In the so-called snapping scapula syn-
drome, protraction and retraction of the scapula is associated
with audible and palpable grating, best felt at the superome-
Physical Examination dial corner of the scapula. This is caused by rubbing of the
scapula over the underlying ribs.
INSPECTION
RANGE OF MOTION
With the patient sitting or standing and disrobed to the
waist, both shoulders are inspected for symmetry, abrasions, Range-of-motion testing should include both active and
scars, erythema, swelling, deformity, or muscle wasting. Sub- passive assessments of shoulder forward flexion, exten-
luxation of the AC joint is associated with a step deformity, sion, abduction, adduction, internal rotation, and exter-
with the acromion lying inferior to the clavicle. Swelling and nal rotation. Limitations in active range of motion when
prominence of the SC or AC joint may indicate arthritis or passive range is maintained points to a deficit in the
subluxation. Inferior subluxation of the GH joint is charac- motor unit for that movement. This may be a problem
terized by a positive sulcus sign: presence of a hollow, or with the motor nerve, muscle, or tendon responsible for
sulcus, just below the acromion, made prominent by down- the motion. Loss of passive range of motion is commonly
ward traction on the arm. Flattening of the rounded lateral associated with degenerative disorders, such as arthritis,
aspect of the shoulder may indicate anterior dislocation of or adhesive capsulitis.
the GH joint or deltoid paralysis. Posterior dislocation of the Shoulder abduction involves synchronous movements
GH joint is associated with flattening of the rounded ante- of the GH, SC, and AC joints and rotation of the scapula
rior aspect of the shoulder. on the chest wall. The initial 30° of abduction, achieved
Rupture of the long biceps tendon is associated with by contraction of the supraspinatus, takes place at the GH
bunching up of the belly of the biceps muscle distally, made joint with little movement of the scapula. Beyond 30°, an
prominent by resisted elbow flexion and forearm supination approximate 2:1 ratio exists between GH and scapular
(Popeye sign or Popeye deformity). In contrast, in a distal movements. The combined movement is referred to as the
biceps tendon rupture, there is retraction of the muscle belly scapulohumeral rhythm. Normal shoulder abduction is 180°
proximally. In thoracic scoliosis, one shoulder often appears (Figure 2-4).
lower than the other. Sprengel deformity is characterized by To test forward flexion of the shoulder (deltoid, coraco-
a congenitally small, high-riding scapula, sometimes associ- brachialis, and biceps muscles; normal range 180°; Figure
ated with underdeveloped ipsilateral scapular muscles and 2-5), the patient flexes the joint with the elbow extended,
webbing of the neck. Winging of the scapula, in which the while the examiner stabilizes the scapula with one hand and
medial border of the scapula moves away from the posterior resists forward flexion with the other hand placed over the
chest wall, indicates injury to the long thoracic nerve with upper arm. To test extension (latissimus dorsi, teres major,
serratus anterior paralysis or other causes, such as clavicular and deltoid muscles; normal range 60°; see Figure 2-5), the
malunion. Winging of the scapula is made more prominent patient extends the shoulder, with the forearm fully pro-
by performance of a modified push-up against the wall with nated, while the examiner immobilizes the scapula and
hands outstretched. Wasting of the supraspinatus muscle resists extension. With the shoulder abducted to 90° and the
suggests a tear of the supraspinatus tendon or a suprascap- elbow flexed at 90°, the normal range of internal and exter-
ular nerve lesion. Atrophy of the infraspinatus muscle can nal rotation is 90° each (Figure 2‑6). With the elbow placed
result from a tear of the infraspinatus tendon or a suprascap- at the side at the waist, the normal range of external rotation
ular nerve injury. is about 45° to 90°, and internal rotation is about 55° to 80°
before its motion is stopped by the body; it may be as much
as 120° if the patient can reach behind the back to touch the
PALPATION
inferior angle of the opposite scapula (Apley scratch test).
Palpation should begin with assessment of all four shoul- This is a functional movement required for daily activi-
der articulations (sternoclavicular, acromioclavicular, gle- ties, such as reaching a back pocket, scratching the back, or
nohumeral, and scapulothoracic) for warmth, tenderness, cleansing the perineum.

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 THE SHOULDER 13

180 90

0

90 90

90

0 0

FIGURE 2-6 SHOULDER INTERNAL AND EXTERNAL ROTATION.

FIGURE 2-4 SHOULDER ABDUCTION: SIDEWAYS ARC, CORONAL

PLANE. As the patient elevates the arm in abduction, the exam-
iner can assess for the presence of a painful arc. Abduc-
tion to 45° to 60° is often painless. A painful arc between
60° and 120° is characteristic of subacromial impingement
with rotator cuff tendinitis or subacromial bursitis. The
pain often decreases beyond 120°, as the compression of the
180 rotator cuff beneath the coracoacromial arch lessens. Pain
between 120° and 180° may indicate abnormalities of the AC
joint, whereas GH arthritis causes pain throughout the arc
of abduction.
Reverse scapulohumeral rhythm, or greater scapulo-
thoracic than GH movements during abduction, occurs in
adhesive capsulitis; instead of the normal, smooth abduc-
tion, the patient appears to be “hitching” the entire shoulder
complex upward. The capsular pattern of restricted shoul-
Forward der movements typically observed in adhesive capsulitis is
flexion characterized by greater limitation of external rotation than
of other movements. In GH arthritis, abduction and rota-
tion are the earliest and most severely restricted movements.

60 SPECIAL TESTS
Special tests for the shoulder are plentiful. These tests
Extension are designed to elicit evidence of impingement, rotator
cuff dysfunction, superior labral anterior and posterior
0 (SLAP) lesions, irritation of the long head of the biceps,
and shoulder instability. The sensitivity and specific-
ity of each of these tests has been an area of much study.
A recent meta-analysis on this topic reveals significant
variability in the sensitivity and specificity of these tests,
depending on the population studied and the pretest
probability of the condition in the population being
studied. A summary of these findings is presented in
FIGURE 2-5 SHOULDER FORWARD FLEXION AND EXTENSION. Table 2-2.

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14 THE SHOULDER

TABLE 2-2
SENSITIVITY AND SPECIFICITY OF COMMON SPECIAL TESTS OF THE SHOULDER
Special Test Sensitivity (%) Specificity (%) N Reference
Neer impingement sign 86 49 552 Park et al., 2005
Hawkins impingement sign 76 45 552 Park et al., 2005
Jobe sign, empty can sign 53 82 552 Park et al., 2005
Lift-off test 17 92 68 Barth et al., 2006
Belly press test 40 98 68 Barth et al., 2006
Yergeson sign 13 94 132 Parentis et al., 2006
Speed test 40 75 552 Park et al., 2005
O’Brien test 63 50 132 Parentis et al., 2006
Crank test 13 83 132 Parentis et al., 2006
Anterior apprehension test 72 96 363 Farber et al., 2006
Relocation test 81 92 363 Farber et al., 2006

FIGURE 2-7 NEER IMPINGEMENT TEST.

Tests for Shoulder Impingement

The Neer impingement sign is elicited with the patient FIGURE 2-8 HAWKINS IMPINGEMENT SIGN.
seated and the examiner standing. Scapular rotation is pre-
vented by one hand, as the other elevates the patient’s arm
midway between abduction and flexion. In a positive test,
the patient experiences pain in the overhead position near
the end of shoulder elevation, as the greater tuberosity
impinges against the acromion (Figure 2-7). The pain can be
relieved by subacromial injection of 5–10 mL of 1.0% lido-
caine (Neer impingement test).
In the Hawkins impingement sign, the humerus is for-
ward flexed to 90° and internally rotated, while the exam-
iner’s other hand restricts scapular movements (Figure 2-8).
This causes impingement of the greater tuberosity against
the anterior acromion with reproduction of the patient’s
symptoms. In patients with impingement and supraspinatus
tendinitis or a tear, the Jobe test, supraspinatus isolation
test, or empty can sign is positive: pain is elicited on resisted
elevation of the arm to 90° midway between abduction and
forward flexion, with the thumb pointing downward in
internal rotation (Figure 2-9). FIGURE 2-9 SUPRASPINATUS TEST (EMPTY CAN SIGN).
In subcoracoid impingement, there is impingement of
the rotator cuff between the lesser tuberosity and the lateral
aspect of the coracoid process during abduction and internal or flexed 90°, because this position produces the narrowest
rotation. It commonly occurs in the throwing athlete. This coracohumeral distance. Combined forward flexion, inter-
type of impingement is associated with anteromedial shoul- nal rotation, and cross-arm adduction (coracoid impinge-
der pain and a positive Gerber subcoracoid test: painful ment test) also causes pain. The coracoid impingement
restriction of internal rotation when the shoulder is abducted test differs from the O’Brien active compression test for

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 THE SHOULDER 15

superior labral tears, in which the patient actively resists the fixes the scapula with one hand and resists abduction with
examiner while performing the maneuver. The pain of sub- the other hand. This is known as the Jobe test, the supra-
coracoid impingement can be relieved by a lidocaine injec- spinatus isolation test, or the empty can sign (see Figure
tion between the humeral head and the coracoid ­process. 2-9). In complete supraspinatus tears, the drop-arm test is
­positive: the patient is unable to actively maintain 90° of pas-
Tests of the Rotator Cuff sive shoulder abduction or to slowly lower the arm to the
The supraspinatus (suprascapular nerve) is tested with the side. With a partial supraspinatus tear, there is wasting and
shoulder abducted 90°, flexed 30°, and internally rotated weakness of the supraspinatus muscle. The supraspinatus
with the thumb pointing downward, while the examiner test, Neer impingement sign, and Hawkins impingement
sign are often positive.
Infraspinatus and teres minor tears are associated with
weakness of external rotation and a positive external rota-
tion lag sign (ERLS): with the patient sitting, elbow 90°
flexed, and the shoulder held by the examiner at 20° to 90°
abduction and maximal external rotation, the patient is
asked to actively maintain the position of external rotation
as the examiner releases the wrist, and a “lag” or “angular
drop” occurs. An alternative maneuver is the Hornblower
Test. This test involves external rotation with the shoul-
der in 90° of abduction in the scapular plane. The elbow
is flexed 90°, and the patient externally rotates against the
resistance of the examiner’s hand (Figure 2-10). Weakness
of external rotation in this position constitutes a positive
test.
Subscapularis tears are associated with weakness of inter-
nal rotation and a positive subscapularis lift-off test: after
maximal internal rotation of the shoulder with the dorsum
of the hand held against the inferior aspect of scapula, the
patient is unable to lift the hand off his back (Figure 2-11).
A subscapularis tear is also detected by the belly press test
(Figure 2-12). The patient presses the abdomen with the
palm of the hand (internal rotation), and if the subscapu-
laris is intact, the patient can maintain pressure without the
elbow dropping backward; if there is a subscapularis tear,
maximal internal rotation cannot be maintained, and the
elbow drops back behind the trunk (positive belly press test).
The patient exerts pressure on the abdomen by extending
FIGURE 2-10 HORNBLOWER TEST. This test involves external the shoulder rather than by internally rotating it. The test is
rotation with the shoulder in 90° of abduction in the scapular particularly useful in those patients with restricted internal
plane. The elbow is flexed 90°, and the patient externally rotates rotation who cannot place the hand behind the back to per-
against the resistance of the examiner’s hand. form the lift-off test.

A B
FIGURE 2-11 LIFT-OFF TEST.

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16 THE SHOULDER

FIGURE 2-12 BELLY PRESS TEST. FIGURE 2-14 THE O’BRIEN ACTIVE COMPRESSION TEST.

points downward, the examiner applies downward pressure

on the proximal forearm against the patient’s resistance (Fig-
ure 2-14). The shoulder is then externally rotated, and the
forearm is supinated, after which the maneuver is repeated.
The test is positive if pain is elicited with the first maneuver
but not with forearm supination. The thumb-down position
(internal rotation) compresses the biceps–glenoid–labrum
anchor, causing pain or a click deep in the shoulder if a
SLAP lesion is present. In traumatic AC joint lesions, the
O’Brien test may also produce more superficial pain on top
of the shoulder.
Kim et al. (2001) described the biceps load II test to assess
for the presence of a SLAP lesion. In this test, the patient lies
supine with the arm abducted 120°, the elbow flexed to 90°,
and the forearm supinated. The patient then flexes the elbow
against the resistance of the examiner. Pain elicited by this
maneuver constitutes a positive test.
FIGURE 2-13 YERGESON SIGN. The crank test is also used to detect a SLAP lesion. In this
test the arm is abducted 160° with the elbow flexed 90°. The
examiner then applies a compressive load across the joint
while performing rotation of the shoulder. Pain, usually with
Tests for Labral Tears and Biceps Tendon external rotation of the shoulder, constitutes a positive test
Pathology (Figure 2-15).
In bicipital tenosynovitis, pain in the bicipital groove is
­reproduced by resisted supination of the forearm with Tests for Glenohumeral Instability
the elbow 90° flexed (Yergeson sign or supination sign; With the patient supine, the shoulder is 90° abducted and
­Figure 2-13) and by the more sensitive Speed test, in which 90° externally rotated; the examiner then applies forward
there is pain on resisted flexion of the shoulder with the pressure to the posterior aspect of the humeral head (Figure
elbow extended and the forearm supinated. 2‑16A). In the presence of GH instability and recurrent ante-
In the O’Brien active compression test, with the patient rior subluxation, the patient suddenly becomes ­apprehensive
standing, elbow extended, and the shoulder forward flexed and complains of pain in the shoulder (­positive anterior
90°, adducted 15°, and internally rotated, so that the thumb apprehension test). The relocation test or containment

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 THE SHOULDER 17

FIGURE 2-15 THE CRANK TEST. This test is also used to detect a
SLAP lesion.

sign (Figure 2-16B) is then performed by applying poste-

rior pressure on the anterior aspect of the humeral head, to
push the subluxed humeral head back in the glenoid fossa.
Patients with GH instability and secondary impingement B
experience marked pain relief (positive relocation test). The
examiner may then be able to externally rotate and extend FIGURE 2-16 A, Anterior apprehension test. B, Containment sign.
the shoulder several degrees further while maintaining the
posteriorly directed force on the humeral head. On release of
the pressure on the humerus at this point, the patient com-
plains of sudden pain (positive anterior release sign). The
sign is more sensitive than the apprehension-relocation test
in detecting occult GH instability.
With the patient standing or sitting and the arm at the side,
the examiner stabilizes the scapula with one hand while draw-
ing the humeral head anteriorly or posteriorly with the other
hand. GH instability is associated with anterior and posterior
displacement (translation) of the humeral head on the fixed
scapula (positive anterior and posterior drawer signs). Laxity
of the shoulder capsule and ligaments results in inferior sublux-
ation of the humerus on downward traction of the arm, which
produces a depression or hollow between the lateral edge of the
acromion and the humeral head (positive sulcus sign).

ASPIRATIONS AND INJECTIONS

FIGURE 2-17 SOME REQUIRED EQUIPMENT FOR INJECTIONS AND
Aspirations and injections are done about the shoulder for ASPIRATIONS.
a number of indications. These include aspiration of a joint
for synovial fluid analysis to aid in the diagnosis of inflam- further treatment. When performing these injections, sterile
matory or septic arthritis. Injections of local anesthetic and technique should always be adhered to. An example of the
antiinflammatory medications can be both diagnostic and required equipment is shown in Figure 2-17.
therapeutic. Injection of a specific site, if accompanied by For subacromial bursa and rotator cuff tendinitis, with the
symptomatic relief, can help confirm the diagnosis and aid patient sitting and the shoulder slightly externally rotated, the

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18 THE SHOULDER

Posterior acromion

Humerus

A B
FIGURE 2-18 INJECTION OF SUBACROMIAL BURSA AND ROTATOR CUFF TENDONS (POSTERIOR SUBACROMIAL APPROACH).

FIGURE 2-19 ASPIRATION AND INJECTION OF SUBACROMIAL

BURSA (LATERAL APPROACH).

FIGURE 2-21 INJECTION OF THE LONG BICEPS TENDON SHEATH.

needle is inserted about 1 cm below the posterior border of the

acromion and directed medially, anteriorly, and slightly superi-
orly toward the tip of the coracoid process to a depth of 2 to 3 cm
into the subacromial bursa (posterior subacromial approach,
Figure 2-18). A fluid-distended subacromial bursa can be aspi-
rated and injected via a lateral approach (Figure 2-19).
The GH joint is injected using a posterior approach.
The entry point is two fingers’ breadth medial and inferior
to the palpated posterolateral border of the acromion. The
needle is directed anteromedial toward the coracoid process
(­Figure 2-20).
For injection of the bicipital tendon sheath, the patient is
sitting or supine, and the tendon is palpated in the bicipital
groove while the shoulder is externally rotated. The point of
maximum tenderness is marked, and the needle is inserted
at an angle of 30° to 45° into the sheath. It is then directed
superiorly along the tendon for about 2 cm before the sheath
FIGURE 2-20 INJECTION OF THE GLENOHUMERAL JOINT. is aspirated and injected (Figure 2-21). Care is taken to avoid

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 THE SHOULDER 19

A B
FIGURE 2-22 INJECTION OF THE ACROMIOCLAVICULAR JOINT.

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