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Clinical Evaluation-Physical Examination

After completing a detailed history, a focused examination can be undertaken. It is critical to compare extremities as the unaffected shoulder can serve as a “normal” template to which one can compare. One should survey for atrophy or asymmetry, especially in the supra and infraspinatus fossae. Long-standing rotator cuff tears are often accompanied by significant, visible atrophy.

Examination should include assessment of range of motion, both active and passive, observing forward flexion, abduction in the scapular plane, internal rotation, and external rotation both in abduction and with the elbow at the side. Careful evaluation of scapular tracking should be included as poor scapulo-thoracic mechanics can lead to secondary subacromial pathology.

In some instances of suspected impingement, simply treating scapular dyskinesia can alleviate secondary subacromial space symptoms. Strength testing should be performed in an attempt to isolate the different components of the rotator cuff to assess weakness. The “lift-off” test can help to assess subscapularis integrity.

Although clinically useful, placing the arm in the testing position can be provocative and difficult to achieve, especially in the older population. The “belly-press” test (or Napolean sign) can also help determine integrity of the subscapularis, is less provocative than the “lift-off” test and can actually be quantified to assess partial tears as well.Resisted external rotation with the elbow by the side is useful in detecting tears extending into the infraspinatus.

This manual test is critical for assessing the posterior transverse force couple while the “belly-press” test determines subscapularis function. If significant weakness is noted in either or both muscle groups, loss of humeral head containment is imminent if not already present.

Loss of the normal distance between the humeral head and acromion should be evident, and one must proceed with great caution if a decompression is undertaken. Violation of the arch in conjunction with inadequate transverse force couples may ultimately lead to erosion of the acromion by the humeral head and subsequent anterior-superior humeral head migration.

The impingement sign as originally described by Neer involves stabilizing the scapula while elevating the shoulder in the scapular plane. Pain elicited in the arc from 70 to 120 degrees is indicative of the impingement phenomenon. Confirmation of this finding in the form of the impingement test consists of complete resolution of pain during the painful arc of motion after an anesthetic has been injected into the subacromial space.

A variation of the impingement sign is the Hawkin’s test in which the shoulder is placed in 90 degrees of forward flexion, the elbow is flexed 90 degrees and the shoulder is then internally rotated. Rotation of the greater tuberosity under the arch in this position decreases space for the rotator cuff leading to impingement pain.

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