Reasons to Perform the Shoulder Impingement Exam [1]
Signs and Symptoms of Supraspinatus Impingement
- Pain, especially when sleeping on affected side
- Painful arc (60-120 degrees of elevation)
- Pain and weakness in supraspinatus and biceps
- "Catching" with flexion and internal rotation
- Pain referral pattern = deltoid insertion and anterior/proximal humerus
- Little to no TTP
- Decreased internal rotation and horizontal adduction ROM
- Posterior capsule tightness; pain with PROM
- (+) tests: Neer's, Hawkins-Kennedy, Speed's, Empty/Full Can and Yocum
- X-rays may reveal decreased joint space, arthritis, calcific tendonitis, hooked acromion; early dx is via MRI
- Should rule out RC tear, TOS, labral tear, & calcific tendonitis
Signs and Symptoms of Coracoid Impingement
- Dull pain in the front of the shoulder provoked by flexion and internal rotation OR abduction and internal rotation
- Weak downward rotators of scapula
- Forward head and kyphosis influences GH alignment
- (+) tests: Neer's, Hawkins-Kennedy, and Impingement Relief
- X-ray will detect decreased joint space and hook acromion
- Should rule out RC tear, TOS, labral tear, & calcific tendonitis
For more information, please refer to the Shoulder Impingement Syndrome page.
External and Internal Impingement [2]
External Impingement
External Impingement occurs when the rotator cuff tendons or the bursa are compressed against the under side of the coracoacromial arch.
Internal Impingement
Internal Impingement occurs between the glenoid labrum and the supraspinatus tendon.
Anatomy
(Image from http://www.orthopaedicsurgeon.com.sg/wp-content/uploads/2011/10/shoulder-anatomy.jpg)
Coracoacromial Arch [3]
(Image from http://2.bp.blogspot.com/-pz8DAQIxK7M/Tzwhq6sgQ7I/AAAAAAAAAEY/F5RVGLOeVkE/s1600/54513.jpg)
The coracoacromial arch is formed by the coracoacromial ligament and the acromion process. The main function is to form the roof of the glenohumeral joint. The contents of the coracoacromial arch and subacromial space include the supraspinatus muscle and tendon, subacromial bursa, and the long head of the biceps tendon.
Musculature [4]
- Shoulder Flexion – Anterior deltoid, coracobrachialis, pectoralis major (clavicular head)
- Shoulder Extension – Posterior deltoid and latissimus dorsi
- Shoulder Abduction – Middle deltoid and supraspinatus
- Shoulder Adduction – Pectoralis major, latissimus dorsi, teres major, coracobrachialis
- Shoulder External Rotation – Teres minor, infraspinatus, posterior deltoid
- Shoulder Internal Rotation – Subscapularis, teres major, pectoralis major, latissimus dorsi, anterior deltoid
- Scapular Elevation – Upper trapezius and levator scapulae
- Scapular Depression – Latissimus dorsi, pectoralis major and minor, lower trapezius
- Scapular Protraction – Serratus anterior
- Scapular Retraction – Middle trapezius and rhomboids
- Scapular Upward Rotation – Upper and lower trapezius together and serratus anterior
- Scapular Downward Rotation – Rhomboids, levator scapulae, pectoralis minor
Posture [2]
- Make sure patient is exposed enough to be able to see symmetry or asymmetry
- Observe how patient removes clothes from upper body, look for compensations, abnormal movements, functional restrictions, pain, and/or weakness
- Must also look at head, cervical spine, thorax (especially posterior), scapula, and entire arm
- Anterior view
- Ensure that head and neck are in the midline of the body and look at their relation to the shoulders
- Note any abnormal bumps or malalignment of the bones that may indicate injury
- Posterior View
- Note any bony or soft tissue abnormalities or asymmetry
- Scapular observations
- Spine of scapula should be at the same angle bilaterally
- Scapula should extend from T2/3 spinous process to about T7/9 spinous process
- Inferior angle of the scapula should be at the same level and same distance from the spinous process
- Look for overall winging or tipping
Palpations [2]
When palpating the shoulder it is important to note any muscle spasm, muscle atrophy or hypertrophy, swelling, tenderness, and bumps or lumps. The examiner should also palpate bilaterally to compare any abnormalities.
Anterior Structures to Palpate (performed in supine or sitting)
- Clavicle - full length
- Sternoclavicular joint
- Supporting ligaments
- SCM muscle
- Sternal notch
- First rib – apply caudal pressure bilaterally
- Scalene muscles
- Acromioclavicular joint
- Acromioclavicular and coracoclavicular ligaments
- Trapezius
- Subclavius
- Deltoid
- Coracoid process
- Sternum
- Manubrium
- Body
- Xipoid process
- Ribs and costal cartilage
- Sternocostal and chondrocostal articulations
- All ribs around the chest wall
- Humerus and rotator cuff muscles
- Greater and lesser tuberosity of humerus
- Long head of the biceps and bicipital groove
- Tendon of the subscapularis
- Tendons of supraspinatus, infraspinatus, and teres minor
- Glenoid
- Axilla
- Latissimus dorsi
- Pectoralis major muscle
- Serratus anterior
- Lymph nodes
- Brachial artery
Posterior Structures to Palpate (performed in prone or sitting)
- Spine of the scapula
- Scapula
- Medial border
- Trapezius
- Rhomboids
- Inferior angle
- Latissimus dorsi
- Lateral Border
- Serratus anterior
- Long head of the triceps
- Teres minor
- Posterior surface of scapula
- Supraspinatus muscle belly
- Infraspinatus muscle belly
- Medial border
- Spinous processes of lower cervical and thoracic spine
Clearing Joint Above and Below [5]
Cervical Spine
Elbow
Range of Motion [6]
Range of Motion | Normal Degrees | End-feel |
---|---|---|
Flexion | 0-180 degrees | Firm |
Extension | 0-60 degrees | Firm |
Abduction | 0-180 degrees | Firm |
External Rotation | 0-90 degrees | Firm |
Internal Rotation | 0-70 degrees | Firm |
Manual Muscle Testing [7]
- Flexion
- Patient is short sitting with their arm flexed to 90 degrees. Examiner applies downward force over distal humerus just above the elbow.
- Extension
- Patient is prone with arms at side. Patient raises arm off of table. Examiner applies downward force on the posterior arm just above the elbow.
- Abduction
- Patient is short sitting with arms abducted to 90 degrees. Examiner applies downward force just above the elbow.
- External Rotation
- Patient is prone with shoulder abducted to 90 degrees (arm supported on the table). Patient moves arm through external rotation. Examiner uses two fingers to give resistance at the wrist while supporting the elbow.
- Internal Rotation
- Patient is prone with shoulder abducted to 90 degrees (arm supported on the table). Patient moves arm through internal rotation. Examiner uses two fingers to give resistance at the wrist while supporting the elbow.
- Horizontal Abduction
- Patient is prone with shoulder abducted to 90 degrees and forearm off the edge of the table. Patient horizontally abducts while examiner provides downward resistance over posterior arm just above the elbow.
- Horizontal Adduction
- Patient is supine with shoulder abducted to 90 degrees and elbow flexed to 90 degrees. Patient horizontally adducts while examiner provides resistance around the forearm proximal to the wrist.
Neurological Exam and Upper Limb Tension Tests [5]
A neurological examination (dermatomes, myotomes, and reflexes) is performed as needed if symptoms, numbness and tingling, or pain radiate past the tip of the acromion.
Upper limb tension tests are performed in every evaluation as an assessment and reassessment tool.
For details on how to perform a neurological examination and the upper limb tension tests please refer to the Cervical Spine evaluation page.
Special Tests [8]
Neer's Impingement Test
- Test positioning: The subject sits or stands with both upper extremities relaxed. The examiner stands with one hand on the scapula (posteriorly) and the other hand grasping the subject’s elbow (anteriorly).
- Action: With the subject’s scapula stabilized, the examiner passively and maximally forward flexes the test shoulder.
- Positive finding: Shoulder pain and apprehension are indicative of shoulder impingement, particularly of the supraspinatus and biceps long head tendons.
- Special considerations: A false positive test may be elicited if the subject has limited forward flexion to the extent that anatomical impingement is not the limiting factor.
Hawkins-Kennedy Impingement Test
- Test positioning: The subject sits or stands with both upper extremities relaxed. The examiner stands with one hand grasping the subject’s elbow and the other hand grasping the subject’s wrist, both on the test arm.
- Action: The examiner forward flexes the shoulder to 90 degrees and then internally rotates the subject’s test shoulder.
- Positive finding: Shoulder pain and apprehension are indicative of shoulder impingement, particularly of the supraspinatus tendon
- Special considerations: This test tends to be the most sensitive for assessing subacromial impingement
Empty Can & Full Can (Supraspinatus) Test
- Test positioning: The subject stands with both shoulders abducted to 90 degrees, horizontally adducted 30 degrees, and internally rotated so the subject’s thumbs face the floor.
- Action: The examiner resists the subject’s attempts to actively forward elevate both shoulders.
- Positive finding: Involvement of the supraspinatus muscle and/or tendon is suspected with noted weakness and/or a report of pain.
- Special Considerations/Comments: Weakness of the supraspinatus muscle may be a result of suprascapular nerve involvement. Reported pain may be indicative of tendinitis and/or impingement.
- Full Can Test is performed in the same manner with the patient's thumb pointing up. A positive finding is pain alleviation
Drop Arm Test - There are two possible ways to perform the Drop Arm Test
Drop Arm Test 1
- Test positioning: The subject sits on a table or stands.
- Action: The examiner passively abducts the subject’s involved arm to 90 degrees and then instructs the subject to slowly lower the arm to the side.
- Positive finding: The subject is unable to slowly return the arm to the side and/or has significant pain when attempting to perform the task. This is indicative of rotator cuff pathology.
- Special considerations/comments: If the examiner suspects rotator cuff pathology prior to performing the test, he should prepare to rapidly assist the subject in the event that the subject does experience an inability to control the adduction movement of the arm.
Drop Arm Test 2
- Test positioning: The subject sits on a table or stands
- Action: The patient flexes their shoulder to 90 degrees and the examiner applies a downward force just proximal to the elbow
- Positive finding: The patient is unable to hold against the resistance or experiences pain. This is indicative of rotator cuff pathology.
Crossover Impingement Test
- Test positioning: The subject sits. The examiner stands with one hand on the posterior aspect of the subject’s shoulder to stabilize the trunk and the other hand grasping the subject’s elbow on the test arm.
- Action: With the subject’s trunk stabilized, the examiner passively and maximally horizontally adducts the test shoulder.
- Positive finding: Superior shoulder pain is indicative of acromioclavicular joint pathology. Anterior shoulder pain is indicative of subscapularis, supraspinatus, and/or biceps long head pathology. Posterior shoulder pain is indicative of infraspinatus, teres minor, and/or posterior capsule pathology.
Posterior/Internal Impingement Test
- Test positioning: The subject lies supine on a table with the test shoulder placed in 90-110 degrees of abduction and 10-15 degrees of extension. The test elbow is flexed to 90 degrees. The examiner stands with the distal hand grasping the subject’s wrist and hand and the proximal hand grasping the subject’s elbow
- Action: The examiner slowly rotates the subject’s shoulder into maximal external rotation.
- Positive finding: Reproduction of the subject’s pain in the posterior aspect of the shoulder is indicative of rotator cuff and/or posterior labral pathology.
- Special considerations/comments: This test should not be confused with the Apprehension Test or Relocation test. The Posterior Impingement test will reproduce posterior shoulder pain, while the Apprehension test will reproduce anterior shoulder pain and apprehension.
Mobilizations [5]
Active Physiological Movements
Active Flexion with Overpressure
Patient is standing and flexes both arms at the same time. Examiner applies overpressure with one hand stabilizing the scapula and the other hand proximal to the elbow.
Active Abduction with Overpressure
Patient is standing and abducts both arms at the same time. Examiner applies overpressure with one hand stabilizing the scapula and the other hand proximal to the elbow.
Hand Behind Back (Internal Rotation) with Overpressure
Patient is standing and brings arm behind their back. Examiner applies over pressure into internal rotation, adduction, and extension separately.
Hand Behind Neck (External Rotation) with Overpressure
Patient is standing and interlaces fingers behind neck. Examiner applies over pressure at elbows posteriorly.
Internal and External Rotation at Zero Degrees Flexion for Strength
Patient is standing with arms at 0 degrees abduction and elbows flexed to 90 degrees. Examiner applies force outward (to examine internal rotation) and inward (to examine external rotation).
If patient has full pain free active physiological movement there is no need to do Passive Physiological Movement
Passive Physiological Movements
- Flexion
- Patient is supine close to the edge of the table. Examiner brings shoulder into flexion.
- Abduction to 90 degrees
- Patient is supine. Examiner stabilizes the scapula with one hand, supports the patient's elbow with the other hand, and abducts shoulder to 90 degrees. This tests glenohumeral motion.
- Abduction
- Patient is supine close to the edge of the table. Examiner brings shoulder into abduction. This tests glenohumeral and scapulothoracic motion.
- Internal rotation at 90 degrees abduction
- Patient is supine with shoulder abducted to 90 degrees. Examiner rests their elbow over the GH joint to feel movement and grasps patient's wrist with their other hand. Examiner brings patient's shoulder into internal rotation.
- External rotation at 90 degrees abduction
- Patient is supine with shoulder abducted to 90 degrees. Examiner rests their elbow over the GH joint to feel movement and grasps patient's wrist with their other hand. Examiner brings patient's shoulder into external rotation.
- Horizontal abduction
- Patient is supine at the edge of the table with their shoulder abducted to 90 degrees. Examiner stabilizes anteriorly while applying force into horizontal abduction.
- Horizontal adduction
- Patient is supine with shoulder flexed to 90 degrees. Examiner stabilizes the axilla with one hand while supporting the forearm with the other hand. Examiner applies force into horizontal adduction.
- Shoulder quadrant
- Patient is supine at the edge of the table. Examiner stabilizes the scapula from underneath the patient's shoulder with their fingers over the trapezius muscle. The other hand is supporting the patient's elbow. Examiner flexes, abducts, and externally rotates the patients shoulder through the quadrant arc.
- Shoulder lock
- Patient is supine at the edge of the table. Examiner stabilizes the scapula from underneath the patient's shoulder with their fingers over the trapezius muscle. The other hand is supporting the patient's elbow. Examiner brings the patient's arm into shoulder abduction and extension. The examiner then applies a force into internal rotation until the shoulder feels "locked out."
Passive Accessory Movements
Glenohumeral (GH) Longitudinal (Caudad)
Patient is supine. Examiner supports the elbow with one hand and grasps the forearm just distal to the elbow. Examiner moves the humerus caudally. This can be performed at 0 degrees, 45 degrees, and 90 degrees of shoulder abduction.
GH AP
Patient is supine. Examiner holds patient's arm in slight flexion and places their thenar compartment over the anterior humeral head. Examiner applies an AP movement. An alternate position is with the shoulder flexed to 90 degrees and elbow bent. An AP force is applied at the elbow.
GH PA
Patient is supine, lying diagonally, with their shoulder off the table. Examiner places both thumbs on the posterior humeral head. Examiner produces a PA movement with adduction of their arms (not fingers/hands).
GH Lateral and Medial Glides
Patient is supine. Examiner grasps the proximal humerus with both hands and aligns forearms with the patient's humerus. Examiner distracts or compresses the humeral head. Using the heel of their hand, the examiner applies a medial or lateral force.
GH Compression
Patient is supine. Examiner places one hand over the anterior GH joint and grasps the patient's distal humerus at elbow. Examiner applies an upward force along the shaft of the humerus.
Acromioclavicular (AC) AP
Patient is supine. Examiner places thumbs anterior to the patient's acromioclavicular joint. Examiner applies an AP force.
AC PA
Patient is supine. Examiner places thumbs posterior to the patient's acromioclavicular joint. Examiner applies a PA force.
AC Caudal Glide
Patient is supine. Examiner places thumbs superior to the patient's acromioclavicular joint. Examiner applies a caudal force.
Sternoclavicular (SC) Caudad
Patient is supine. Examiner places thumbs superior to the patient's sternoclavicular joint. Examiner applies a caudal force.
SC AP
Patient is supine. Examiner places thumbs anterior to the patient's sternoclavicular joint. Examiner applies an AP force.
SC Cephalad
Patient is supine. Examiner places thumbs inferior to the patient's sternoclavicular joint. Examiner applies a superior force.
Scapulothoracic (ST) Elevation
Patient is side-lying facing the examiner. Examiner grasps the inferior angle and superior border of the scapula. Examiner applies an upward force on the inferior angle of the scapula.
ST Depression
Patient is side-lying facing the examiner. Examiner grasps the inferior angle and superior border of the scapula. Examiner applies a downward force on the superior border of the scapula.
ST Protraction with Upward Rotation
Patient is side-lying facing the examiner. Examiner grasps the inferior angle and superior border of the scapula. Examiner applies a force into protraction and upward rotation.
ST Retraction with Downward Rotation
Patient is side-lying facing the examiner. Examiner grasps the inferior angle and superior border of the scapula. Examiner applies a force into retraction and downward rotation.
By: Kelly McGraw and Jessica Zink