Geriatric Physical Diagnosis: The Upper Extremities

Mark E. Williams, MD

Disclosures

November 17, 2009

In This Article

Shoulder Examination

Relevant Anatomy

A fibrous sheet of tissue surrounds the shoulder joint. There are no discrete ligaments and all structures are relaxed in the resting position. No structure remains tense throughout all joint movements. When the arm is abducted 90° and externally rotated, there is a weak point in the anterior shoulder. In this position, the inferior glenohumeral ligament is the only structure that holds the head of the humerus. The rotator cuff muscles stabilize the shoulder. In addition, there is a vacuum in the shoulder joint capsule that holds the humeral head in place. Puncturing this capsule can cause humeral head displacement of over 1 cm.

Inspection

Observe the patient standing from the front, side, and back. Note the sloping contours of the deltoid muscles, bony prominences, and any areas of asymmetry. A tuberculous lung abscess may change the shape of the deltoid to a shallower curve. A lowered axillary fold suggests shoulder dislocation (Bryant's sign).[11]

Bony and Soft Tissue Abnormalities. A dropped shoulder suggests muscle injury or significant hypertrophy in a former athlete. Look for symmetry of the clavicles, sternoclavicular joints, and the humeral head position. Bony enlargement of the medial portion of the right clavicle suggests congenital syphilis (Higoumenakis' sign).[12] Visible swelling of the clavicle suggests clavicular fracture. Swelling of lateral deltoid suggests subacromial bursitis. Anterior swelling at coracoid process suggests a Baker's cyst. Winging of the scapula suggests serratus anterior muscle weakness or damage of the long thoracic nerve (also called external respiratory nerve of Bell).[13] Congenital upward displacement of the scapula is Sprengel's deformity.[14] A gap between the clavicle and the acromion suggests acromioclavicular separation.

Soft Tissue Atrophy. Atrophy of the supraspinatus or infraspinatus muscles suggests severe malnutrition.

Protected Arm Movements. Notice whether the patient protects the arm when moving. If the patient holds the arm tight against his or her body with the palm on the abdomen, this suggests posterior glenohumeral dislocation. If the patient has the arm held close to the body with contralateral hand supporting the elbow, this is the "dead arm" sign[15] of either anterior glenohumeral dislocation or brachial plexus injury.

Palpation

Start at the front and work around to the back. Begin by palpating the sternoclavicular joint along the clavicle to the acromioclavicular joint and the acromion. A painful sternoclavicular joint suggests sternoclavicular separation. Feel the greater and lesser tuberosity of the humerus and palpate for any gaps in the rotator cuff muscles. Move to the glenohumeral joint and palpate the anterior and posterior dimensions. Examine the biceps tendon and progress along the spine of the scapula. Pain along the biceps groove implies bicipital tendonitis. Localized contractions upon tapping the biceps muscle suggest typhoid fever (Goggia's sign).[16]

Muscle spasm over the posterior scapula suggests trapezius strain. Tenderness between the vertebra and the medial border of the scapula suggests rhomboid strain.

Shoulder Range of Motion

If there is back or shoulder pain, always examine the cervical spine before testing the shoulder range of motion.

A useful functional screening test is to have the patient place both hands on his or her head and then touch the hands behind his or her back as if tying an apron. If these movements can be performed, the functional capability of the shoulder is intact. Watch the rhythm of the movement and note any restricted range of motion. Have the person perform this functional screen a second time while feeling for crepitus by placing your hands on the patient's shoulders during these movements.

Limited Range of Motion. Loss of passive and active range of motion of glenohumeral joint suggests anterior dislocation, humeral head fracture, or frozen shoulder. Painful active and passive abduction suggests supraspinatus tendonitis. Limited active but relatively full passive range of motion suggests supraspinatus tendon tear. If passive range of motion on lateral arm raise is less painful than active range of motion, this suggests rotator cuff tear.

Apley's Back Scratch Test. Apley's back scratch test[15] is performed to evaluate active range of motion. Ask your patient to bring his or her affected arm/shoulder around to the back and reach up as if to scratch the back. Normally, the patient can reach his or her thumbs up to around T7 or T8 of the thoracic vertebra from the lower back. If he or she cannot reach that high, consider subscapularis tendonitis or tear.

Next, ask the patient to reach down from the upper back. The normal range of motion from above is to level T4 or T5 of the thoracic spine. Comparing affected with nonaffected arm, one thumb may not reach as far down as the other; if this is the case, consider infraspinatus or teres minor tendonitis or tear.

Abnormalities Near the Glenohumeral Joint

Check Osteophony. Tap each olecranon while listening over the manubrium with the bell of your stethoscope. Intact bone gives a bright, crisp tapping sound to percussion. Equal sound transmission on each side is normal. Unequal sound in the form of a muffled, distant quality on one side suggests humeral fracture or glenohumeral dislocation. This is Hueter's sign,[17] sometimes called Auenbrugger's bone sign (not to be confused with Auenbrugger's sign, which is an epigastric bulge produced by a large pericardial effusion).[18]

Locate the Humeral Head. The humeral head is usually felt deep in the fossa under the deltoid. If the humeral head is not palpable, this suggests glenohumeral dislocation. The nature of the dislocation will depend on the location of the humeral head. If the humeral head is medial and below the coracoid process, then there is an intracoracoid glenohumeral dislocation. If the humeral head is inferior to the coracoid, there is a subcoracoid subluxation. If the humeral head is lateral to the coracoid, there is an extracoracoid glenohumeral subluxation. Dugas' sign[19] suggests shoulder dislocation rather than shoulder fracture; to perform this test, have the patient touch his or her opposite shoulder with the affected arm. If the person cannot bring the elbow in close to the body while touching the opposite shoulder, this is a positive Dugas sign.

Pain in the Anterior Shoulder

Inspect and palpate basic shoulder landmarks as explained above. Then check Apley's back scratch test for subscapularis tendonitis or tear.

Carefully search for pain or abnormality at the sternoclavicular joint. Tenderness here suggests sternoclavicular subluxation. A palpable step off or separate edge suggests dislocation.

Check for pain or abnormality in the clavicle that would indicate a fractured clavicle. Listen for osteophony if you suspect a fracture.

Carefully palpate the acromioclavicular joint. No springing movement and no pain is normal. A springing movement and exquisite pain suggests a first-degree separation. Space between lateral clavicle and acromion suggests second or third degree separation.

Check for tenderness deep to the deltoid for subdeltoid bursitis. Swelling below the deltoid muscle suggests bursitis or a Baker's cyst. (The cyst will transilluminate.)

The next step is to look for bicipital tendonitis that will show tenderness over the bicipital groove. Check for discomfort in the biceps groove with supination against resistance. Also see if Yergason's sign[20] is present. Yergason's sign is tenderness over the biceps tendon when the patient "makes a muscle." You can accentuate the tenderness by passive external rotation to isolate the biceps groove. Speed's sign[21] is tenderness over the biceps tendon when the patient pushes his hands together over the abdomen.

Check the belly of the biceps muscle. A lump just below the deltoid suggests biceps tendon rupture. A large bruise and a lump suggest acute tendon rupture or fracture of the humeral head. Two lumps suggest biceps muscle rupture. Next, have the patient place both hands on his or her head; if you cannot palpate the tendon on the affected side, rupture of the biceps tendon is suggested (Ludington's sign).[22] Biceps contraction that is stronger in pronation than in supination suggests possible rupture of the long head of the biceps. Pushing on the medial portion of the biceps and having the hand make a fist suggests hypocalcemia; this occurrence is similar to Trousseau's phenomenon,[23] which is spasmodic contraction of a muscle (or tetany) when pressure is applied to the nerves enervating them.

A fleshy mass on the upper chest wall suggests pectoralis major rupture.

Pain in the Lateral Shoulder

Inspect and palpate basic shoulder landmarks as explained above.

Check Apley's back scratch test as described.[15] If the thumbs can reach T4-T5 from above, then the test is normal. If one thumb is higher than the other, consider infraspinatus or teres minor tendonitis or tear.

Have the patient grasp the opposite shoulder to perform the crossover test, also known as the Scarf test.[24] Tenderness in the acromioclavicular joint suggests acromioclavicular separation. Tenderness in the subacromial area suggests rotator cuff tear, bursitis, or supraspinatus tendonitis.

Look for the Neer and Welsh sign or Neer impingement sign;[25,26] passively raise the patient's hand so the fingers point to the ceiling with the palm facing the head. Push over the greater tuberosity of the humerus or pronate the forearm. Tenderness on this palpation suggests nerve impingement, rotator cuff tear, subacromial bursitis, or supraspinatus tendonitis. Direct shoulder palpation causing pain and pain relief with arm abduction suggests subacromial bursitis (Dawbarn's sign).[27] Pressure on the inner portion of the humerus (compressing the circumflex nerve) that causes pain in the deltoid suggests bursitis.

Have the patient write a sentence. If he or she needs to use the contralateral hand to pull the paper then there is an infraspinatus, teres minor, or subscapularis tear. Check Gerber's lift-off test.[28] Have the patient fully extend and internally rotate the affected arm. If he or she cannot push your hand away from that position, subscapularis tear is suggested. Check the drop test[29] by passively abducting the arm to 90°, then have the patient slowly adduct the arm. A sudden drop in the arm suggests supraspinatus tear. Similarly, Codman's sign[30] looks at the degree of active vs passive abduction. If the passive and active ranges of motion together are less than 90°, then this suggests supraspinatus tendonitis. Shoulder pain on releasing the passively abducted shoulder suggests ruptured supraspinatus tendon (Codman's sign). Limitation of active range of motion but nearly full passive range of motion suggests supraspinatus tear.

Ernest Armory Codman (1869-1940)[31] is remembered today mostly as a crusader for the reform of hospital standards, a zealous effort that cost him his position at the Harvard Medical Faculty. Codman graduated from Harvard Medical School in 1895 and subsequently completed his internship at Massachusetts General Hospital. He joined the surgical staff of the hospital and became a member of the Harvard Faculty, but lost his staff privileges there in 1914 when the hospital refused to institute his plan for evaluating the competence of surgeons.

Basically shunned by his colleagues, Codman was forced to develop his own private hospital in order to test his management concepts. Around the time that he presented his "end result system of hospital standardization," the American College of Surgeons was founded. The "End Result" System became the stated objective of the College. His work in quality assessment eventually led to the founding of what is now the Joint Commission on Accreditation of Health Care Organizations (JCAHO).

"Every hospital should follow every patient it treats long enough to determine whether the treatment has been successful, and then to inquire 'if not, why not' with a view to preventing similar failures in the future."

Codman invented a number of surgical instruments (drill, sponge, vein stripper, wire passing drill), and is remembered for numerous eponyms: Codman's tumor of connective tissue, Codman's radiographic triangle in osteosarcoma, Codman's sign in rupture of the supraspinatus tendon, and Codman's exercises in shoulder injury.


Next, search for Jobe's sign.[32] Passively abduct the arm to 90°, then passively lower the arm to 0° and ask the patient to actively abduct the arm to 30°. If the patient can abduct to 30° but no further, then deltoid muscle paresis should be suspected. If the patient cannot get to 30°, but if passively placed at 30° can actively abduct the arm further, consider supraspinatus tear. If the patient uses the hip to propel the arm from 0° to beyond 30°, then suspect supraspinatus injury.

A Painful Neck and Posterior Shoulder (Upper Back)

If the patient presents with the neck tilted and spasm of the trapezius, then suspect torticollis.

The next step is to palpate the neck muscles. Tenderness over the trapezius suggests trapezius muscle strain or referred pain from below the diaphragm. Tenderness over the paraspinal muscles suggests muscle strain as does tenderness over the rhomboid muscles.

Palpate the spinous processes to check for bony lesions such as epidural abscess, metastatic disease, or vertebral compression fracture.

Next, palpate the supraclavicular fossa while the patient tries to place the contralateral ear on the corresponding shoulder to stretch the brachial plexus. Pain along the involved shoulder or arm suggests a brachial plexus injury or cervical radiculopathy.

Check Spurling's test[33] by placing one hand on the patient's head and compressing the neck by passively extending the neck, rotating the head toward the side of discomfort, and gently pushing down on the head. Pain radiating down the arm suggests cervical radiculopathy.

Roy Glenwood Spurling (1894-1968)[34] served for 2 years as surgical house officer at Peter Bent Brigham Hospital in Boston, Massachusetts. His experience there with Harvey Williams Cushing (1869-1939),[35] professor at Harvard and chief surgeon, influenced him to direct his high intellect and boundless energy to neurosurgery. In 1925 he became the neurosurgical consultant at Louisville General Hospital (Louisville, Kentucky) while still a resident surgeon, and his practice became heavily weighted toward surgery of the brain and spine. In 1931 Spurling took the initiative to form the organization that became the Harvey Cushing Society,[36] now the American Association of Neurological Surgery. He was also one of the founders of the American Board of Neurological Surgery.

During World War II, working at the Walter Reed General Hospital in Washington, DC, Spurling became the hospital's first chief of neurosurgery and organized neurosurgery for the entire US Army. When he was posted in London in March 1944, he became responsible for all neurosurgical services in the European theatre. On his way home to Louisville in December 1945, he was summoned back to Europe to attend to General George Patton, Jr., following the auto accident that was to take the general's life.


Check for a cervical rib (thoracic outlet syndrome). Auscultate over the subclavian artery for a bruit and feel for a decrease in the radial pulse. Provocative tests include Adson's sign[37] (whereby the pulse disappears when the head is extended and rotated toward the side being tested) and having the patient lying supine raising the arms over the head and squeezing a tennis ball. Another test is to have the patient sit and move the shoulders back and down. Hearing a systolic bruit over the brachial artery suggests aortic aneurysm (Glasgow's sign).[38]

Alfred Washington Adson (1887-1951)[39] became a pioneer of neurosurgery while working at the Mayo Clinic. He was one of the first to use sympathectomy for the treatment of hypertension, and cervical sympathectomy for Raynaud's syndrome. Adson invented a new forceps and a new retractor and is remembered for his maneuver to test for thoracic outlet syndrome. The radial pulse is palpated and the patient's chin and head are rotated to the side being palpated on deep inspiration. In the presence of compression of the thoracic outlet (eg, scalenus anticus syndrome) the radial pulse will disappear.

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