Clinical examination of the shoulder
CHAPTER CONTENTS
Referred pain . . . . . . . . . . . . . . . . . . . . . . .
Pain referred to the shoulder . . . . . . . . . . . . . 208
Pain referred from the shoulder . . . . . . . . . . . 208
History . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inspection . . . . . . . . . . . . . . . . . . . . . . . . .
Functional examination . . . . . . . . . . . . . . . . . .
Preliminary examination . . . . . . . . . . . . . . . . 210
Basic functional examination of the shoulder . . . . 210
Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Accessory tests . . . . . . . . . . . . . . . . . . . . . .
Technical investigations . . . . . . . . . . . . . . . . .
Pain in the shoulder is, after low back pain, the most frequent
complaint of orthopaedic patients. Despite the frequency of
shoulder lesions – and the consequent pain and disability –
much confusion still exists as to aetiology, terminology and
treatment,1 in contrast to the statement made by Cyriax:2,3
The shoulder is the most rewarding joint in the whole body. As a
rule, one can always come to a clear diagnosis, and, if treated in the
proper way, most shoulder lesions seem to be curable. Moreover, it
is the most suitable joint for the general practitioner, since almost
no technical aids are required. A good history and full clinical
examination, together with a detailed knowledge of the anatomy,
suffices to solve the majority of the shoulder problems.
Complicated cases that are difficult to diagnose exactly are
encountered. If clinical findings are difficult to interpret, the
following general points should be of help.
© Copyright 2013 Elsevier, Ltd. All rights reserved.
12 
First, it should be realized that double lesions do exist,
208 clouding the diagnosis. For example, it is not uncommon to
find supraspinatus tendinosis together with infraspinatus tendi-
nosis or in association with subdeltoid bursitis. In these doubt-
ful cases, a diagnostic infiltration of a local anaesthetic can be
209 most helpful in isolating the second lesion.
On other occasions, patients present with a painful limita-
209
tion of passive movement together with pain on resisted
210 movements, and the question arises as to whether the problem
is in an inert or a contractile structure. If there is capsular
limitation on examination, the joint should be treated first. If
resisted movements remain painful after the joint has been
managed appropriately, then the tendons should be treated.
215 This approach is the best one, because resisted movements
216 very often become negative after arthritis has disappeared.
The only explanation for the phenomenon is the close rela-
tionship between the capsule of the shoulder and the sur-
rounding tendons.4 It can easily be understood how tension
on the contractile structures may influence the pain originat-
ing in arthritis. Therefore pain on resisted movement(s) in
association with an articular pattern should not be interpreted
as being caused by a simple tendinosis. Of course, a severe
tendinosis can limit active movement, because of the pain.
But passive movements are of full range with a normal end-
feel, even though there might be severe pain at the end of
movement.
An arthritis is an arthritis, a tendinosis is a tendinosis and
both have to be treated as such. It is a common misbelief that,
as long as steroid is injected somewhere in the shoulder area,
it will spread and cure the lesion, no matter where the lesion
lies or where it was injected.5 In fact, if there is one region in
the body which ought to be diagnosed and treated very specifi-
cally it is the shoulder. It is necessary to replace a vague diag-
nosis such as ‘rotator cuff disease’ or frozen shoulder by a
precise one indicating exactly what is wrong.6–8
 The Shoulder

Referred pain

Pain referred to the shoulder

Pain referred to the shoulder, and possibly further down the
arm, can be caused by nerve root compression, mainly as the
consequence of a posterolateral cervical disc protrusion. A
good history is important; the pain has usually started in the
neck, probably interscapularly, and has shifted laterally into the
arm and hand. Very often the pain is worst at night and is
accompanied by pins and needles and numbness. Most fre-
anterior
quently the C7 nerve root is compressed, causing pain at the
posterior aspect of the whole arm to the second, third and
fourth fingers. Other nerve roots can also be involved in a cervi- posterior
cal disc lesion but this is far less frequent. Referral to the
appropriate dermatome is usual.
In a posterocentral cervical disc lesion with compression of Fig 12.1 • The C4 dermatome.
the dura mater, the pain does not spread beyond the deltoid
area. Therefore arm pain is not present.
One rare disorder causing pain down the arm is a cervical
neuroma. The condition starts with pain in the arm, which
progressively spreads proximally as the tumour increases
in size.
Other possible causes of referred pain at the shoulder are
visceral disorders. The diaphragm is largely developed from the
third and fourth cervical segment, the heart from the eighth
cervical to the fourth thoracic. Therefore both can give rise
to pain in the shoulder and arm. Irritation of the diaphragm
and of the phrenic nerve, for example by blood or air under
the diaphragm, is another well-known source of acute
shoulder pain.9,10
A pulmonary neoplasm at the base of the lung with involve-
ment of the diaphragm can provoke pain in the shoulder area.
The same may also happen with a tumour of the superior
sulcus (Pancoast’s tumour). The majority of these patients
complain of shoulder pain and are often mistakenly thought to
be suffering from a musculoskeletal lesion.11,12

Pain referred from the shoulder

Most structures around the shoulder are derived from the C5
segment. There is one important exception: the acromiocla-
vicular joint, which is of C4 origin (Fig. 12.1). In acromiocla-
vicular joint problems the pain is felt at the tip of the shoulder,
with little spread. Exceptionally, when the lesion lies at the
inferior acromioclavicular ligament, the pain can spread into
the upper arm.
In a lesion of one of the other shoulder structures, such as
in all types of tendinosis, arthritis and subdeltoid bursitis, the
pain is not so much felt at the tip of the shoulder but rather
starts in the deltoid region and may spread further down the anterior
radial aspect of the arm to the base of the thumb (C5 der-
matome; Fig. 12.2). How far down the arm the pain is referred
posterior
depends on the severity of the lesion: the more severe the
inflammation, the further the pain will spread. In glenohumeral
arthritis, the degree of pain reference is of particular interest Fig 12.2 • The C5 dermatome.

208

in following the healing process: as the patient improves, the
inflammation decreases and the pain spreads less far.
History
The first question to be elucidated by the history is whether
the pain in the arm is genuinely from a shoulder lesion or
whether it is the consequence of a more proximal lesion, arising
perhaps from the cervical spine. If the answer to this is not
clear from the history, a preliminary examination, including
tests of the cervical spine, shoulder and elbow, is necessary.
In arthritis of the shoulder, the history will be important to
establish the stage (see Ch. 13). In other disorders it is of less
significance.
The answers to a number of questions (summarized in Box
12.1) will be needed.
• What is your age? Age can be relevant in several disorders.
It can be helpful in defining the exact type of arthritis.
Traumatic arthritis will only be met after 40 years of age,
arthritis from immobilization after the age of 60.
Subdeltoid bursitis might be present between 15 and
65 years of age. Tendinosis can occur at any adult age.
• What is the pain and does it radiate? Pain starting in the
deltoid area and spreading towards the wrist, along the
radial aspect of the arm, is caused by a lesion that
originates in C5. Such pain may be felt in the whole
dermatome or only in part of it. The majority of the
shoulder structures belong to the C5 segment. The
acromioclavicular joint, a C4 structure, is the main
exception. A patient who indicates the tip of the shoulder
only as the site of pain suggests strongly that there is a
lesion of the acromioclavicular joint. Whether the pain is
caused by arthritis, bursitis or simple tendinosis will make
no difference to where or how far distally the pain is felt.
The distal spread of referred pain depends only on the
degree of inflammation. It is routine to ask if the pain
remains above the elbow or radiates below it – a matter of
particular importance in arthritis.
• Is there any pain in the arm at rest? This gives information
about the severity of the lesion: if spontaneous pain is
present, there is a greater degree of inflammation than if
pain is felt only on movement. Again, the answer to this
Box 12.1 
Summary of history taking
• Age?
• Where is the pain? Does it radiate?
• Pain at rest or only on use?
• Can you lie on that side at night?
• How did the pain come on: spontaneously/overuse/injury?
• For how long have you had the pain?
• Are other joints affected?
• General condition? Any operations?
Clinical examination of the shoulder C H A P T E R 1 2 
question is one of the criteria for judging the stage of
arthritis.
• Can you lie on the affected side at night? Pain when lying
on the shoulder indicates more severe inflammation than
just pain on exercise. Bursitis, tendinosis or arthritis may
make it impossible for the patient to lie on the affected
side at night. Consequently, this question is not of much
help in defining the exact nature of the structure at fault.
However, it is rather important in following the resolution
of the disorder: as the condition improves, the pain at
night diminishes and finally disappears.
• Did the pain come on spontaneously or was there any
particular reason for it, such as overactivity or an injury?
It is clear that overactivity may provoke tendinosis. In a
ruptured tendon, however, one should not necessarily
expect recent overuse. Overactivity can also cause arthritis
in a joint that is already osteoarthrotic; this is just as true
for the acromioclavicular joint as it is for the glenohumeral
joint. In haemophilia, haemarthrosis usually comes on
spontaneously; it is more common at the knee but may
occur at the shoulder as well.
• For how long have you had the pain? If the pain has
already been present for some months, an acute
subdeltoid bursitis can be excluded because the full
course of this condition is 6 weeks. In addition, onset is
abrupt over a few days, sometimes only hours, as in an
attack of gouty arthritis. Arm pain because of root
compression by a cervical disc protrusion wears off in
about 4 months. Long-standing pain can be the outcome
of a chronic subdeltoid bursitis or a simple tendinosis.
Both can last for years. Monoarticular steroid-sensitive
arthritis can take up to 2 years to disappear spontaneously.
• Are any other joints affected? A more generalized
inflammatory disorder is expected if other joints have
been previously involved or are attacked at the same time.
Indeed, the shoulder joint can be the seat of rheumatoid
arthritis, lupus erythematosus and ankylosing spondylitis.
• How is your general condition? Have you had any
operations? Recent unexplained loss of weight can be the
first sign of a carcinoma. A primary tumour at the
shoulder or metastases can be a local source of shoulder
pain. A Pancoast’s tumour of the lung often provokes pain
in the shoulder area.
Inspection
The inspection starts with checking what position the head is
held in and whether both shoulders are level. It is important
to check for redness, swelling, muscular wasting or any deform-
ity such as scapular winging. A step deformity at the upper
lateral aspect of the shoulder is caused by an acromioclavicular
dislocation, with the distal end of the clavicle lying superior to
the acromion. Atrophy of the upper trapezius may indicate
spinal accessory nerve palsy.13 Atrophy of supraspinatus and/or
infraspinatus is caused by either a supraspinous nerve palsy or
long-standing rotator cuff lesions.14 Effusion of more than
10–15 mL arising from the glenohumeral joint is normally
209
 The Shoulder

visible on inspection at the anterior centre of the humeral head.

Box 12.2 
Local swelling may also be found in acute, haemorrhagic or
chronic subdeltoid bursitis and in acromioclavicular joint
cysts,15 as well as in tumours.
Preliminary examination
Neck
Active movements
Functional examination 1. Flexion
2. Extension
3. Side flexion to the left
The shoulder is an easy joint to examine. The intention is to
4. Side flexion to the right
obtain the maximum information from a minimum number of
5. Rotation to the left
tests. Recent studies have shown high inter-rater and intra-
6. Rotation to the right
rater reliability of the examination scheme presented.16–18
Resisted movements
7. Rotation to the left (C1)
Preliminary examination 8. Rotation to the right (C1)
Scapula
In most cases of shoulder–arm pain the history will reveal 9. Active elevation of both scapulae
whether the pain originates from the shoulder itself or is of 10. Resisted elevation of both (C2–C4) scapulae
cervical origin. Sometimes, however, the examiner is not quite
Shoulder
sure and will then use a quick survey of all structures between
C1 and T2 to exclude other sources of pain in the upper quad- 11. Active elevation of both arms
rant. It is good practice to perform a preliminary examination 12. Resisted abduction (C5)
of the upper quadrant in the following situations: Elbow
• There is or was neck pain Passive movements
• There is or was trapezius pain 13. Flexion
• The pain is only at the top of the shoulder and/or at the 14. Extension
clavipectoral area Resisted movements
• The pain is in the arm but remains quite localized 15. Flexion (C5, C6)
• The pain in the arm is influenced by movements of the 16. Extension (C7)
neck
Wrist
• Coughing, sneezing or taking a deep breath increases the
17. Resisted flexion (C7)
pain 18. Resisted extension (C6)
• There is paraesthesia.
Thumb
The preliminary examination of the upper quadrant is com-
19. Resisted extension (C8)
prised of the following tests (Box 12.2):
1. Six active movements of the cervical spine – range of Finger
movement and/or painfulness; quick survey of the cervical 20. Resisted adduction of the little finger (T1)
spine
2. Active elevation of the shoulder girdle – range of
movement and/or painfulness; quick survey of all the If the examination reveals that the lesion lies in the shoul-
structures of the shoulder girdle der, the examiner will try to define in which particular struc-
3. Resisted rotations of the cervical spine and resisted ture the lesion is situated by carrying out a detailed shoulder
elevation of the scapulae; quick survey of nerve roots examination; this is comprised of 12 basic tests (summarized
C1–C2–C3–C4 in Box 12.3).
4. Active elevation of both arms – range and pain; quick
survey of shoulder and shoulder girdle Basic functional examination of
5. Resisted movements of the upper limb – strength and the shoulder
pain; this is both a quick test for peripheral lesions at the
elbow–arm–wrist and a neurological examination of roots Clinical examination should not begin by palpation for local
C5–C6–C7–C8–T1 and of the peripheral nerves of the tenderness. This widespread habit is a common cause of
upper limb misdiagnosis.
6. Passive examination of the elbow; quick test of the elbow The basic shoulder examination consists of 12 tests. It is
joint. important always to perform every basic test and not to stop,
Any influence on the pain or any weakness will guide the even if the diagnosis appears clear after a limited number of
examiner approximately towards the affected area, which is tests. Stopping too soon can easily lead to an incomplete diag-
then examined thoroughly. nosis. It is important to realize that, in mixed patterns of pain

210
 Clinical examination of the shoulder C H A P T E R 1 2 

on both passive and resisted movement(s), pain on resisted at least a differential diagnosis should be in mind. To arrive at
movements does not exclude a disorder in an inert structure, the final diagnosis, one or more accessory tests may be useful.
nor pain on passive movements a disorder in a contractile
structure. These results may sometimes lead to diagnostic dif- Elevation of the arm
ficulties (see Ch. 4).
Accessory tests may be called for. They will only be per- Active elevation
formed if, after the basic functional examination, the diagnosis The patient is asked to raise both arms sideways above the
still remains unclear. After the basic examination is complete, head, as far as possible (Fig. 12.3a). The range of movement
and the influences, if any, on pain are noted.
Box 12.3  This very unselective and broad test investigates both inert
and contractile structures, not only of one single joint, but also
Summary of the basic functional examination of of all five ‘joints’ of the shoulder girdle (see online chapter
Clinical examination of the shoulder girdle). Therefore, the
the shoulder
result should always be interpreted in light of the other tests.
Elevation
As it gives a good idea of the patient’s willingness to cooperate,
1. Active elevation of both arms it will also help in identifying a person who has no genuine
2. Passive elevation lesion but is feigning illness.
3. Painful arc
Glenohumeral joint Passive elevation
The examiner takes the patient’s arm just proximal to the
4. Passive scapulohumeral abduction
elbow, brings it upwards from the side and pushes it as far as
5. Passive lateral rotation
it will go towards the head. At the same time counterpressure
6. Passive medial rotation
is applied over the contralateral shoulder, preventing the
Resisted movements patient from side-flexing to the other side (Fig. 12.3b). Pain,
7. Adduction range of motion and end-feel are noted. Because this move-
8. Abduction ment comes to a halt when the axillary portion of the capsule
9. Lateral rotation is stretched, the normal end-feel is elastic.
10. Medial rotation
11. Flexion of the elbow Painful arc
12. Extension of the elbow The patient raises the arm, actively, in a frontal plane and
concentrates on pain likely to occur at mid-range, being asked

(a) (b) (c)

Fig 12.3 • Elevation of the arm: (a) active elevation; (b) passive elevation; (c) painful arc.

211
 The Shoulder
Fig 12.4 • Painful arc.
to indicate where pain starts and where it stops on further
elevation (Fig. 12.3c).
A painful arc is defined as the symptom appearing some-
where around the halfway mark, with the arm near the hori-
zontal and disappearing before the end of the movement (Fig.
12.4). This description holds even if pain is again present at
the end-point. Some patients have an ascending arc, others a
descending one; both are regarded as a real painful arc and no
diagnostic distinction is made between them. Sometimes an
arc becomes visible to the examiner, i.e. when the patient
avoids the painful movement by bringing the arm towards the
front of the body during elevation.
A painful arc is more likely to occur during active elevation
rather than during passive movement because contraction of
the abductor muscles pulls humerus and acromion closer to
each other. It always implies a lesion in the subacromial area
or its neighbourhood. Because of their localization between
acromion and greater or lesser humeral tuberosity, the affected
structures can be painfully pinched.
Three tests for the glenohumeral joint
Passive scapulohumeral abduction
The lower angle of the scapula is immobilized by the thumb
and index. With the other hand, the examiner takes the
patient’s arm just above the elbow and lifts it up until the
scapula starts to move (Fig. 12.5a). It is important for
the patient not to assist this movement actively because then
the scapula immediately starts to rotate, so making the move-
ment a compound one involving several joints.
The normal range of scapulohumeral abduction is about 90°.
Performed in the way described, only movement between
212
humerus and scapula takes place. If the movement is impaired,
the glenohumeral or the subacromial joint is at fault.
Passive lateral rotation
The examiner takes the patient’s arm above the wrist, flexes
the elbow to a right angle and pulls the arm with gentle pres-
sure into full lateral rotation, meanwhile avoiding extension by
holding the patient’s elbow against the side of the abdomen.
The trunk is immobilized by bringing the other hand around
the patient’s contralateral shoulder (Fig. 12.5b).
This movement comes to a stop by stretching the anterior
portion of the capsule. Therefore the end-feel is elastic. The
normal range is about 90°. Since individual differences exist,
both sides should always be compared.
Besides the anterior portion of the joint capsule, other struc-
tures, such as the subcoracoid bursa, the acromioclavicular
joint and the subscapularis tendon, are tested as well. Limita-
tion of the movement is mainly found if something is wrong
with the scapulohumeral joint itself; in this event, a harder
end-feel is usually present.19,20 A simple tendinosis of the sub-
scapularis does not cause limitation of the movement but may
render it very painful.
Passive medial rotation
With one hand still just above the patient’s wrist and flexing
the patient’s elbow to 90°, the arm is brought into full medial
rotation, without extension. The examiner’s other hand is
placed dorsally between the scapulae (Fig. 12.5c). The normal
amplitude is about 90°. As before, this movement should be
compared on both sides.
Occasionally a painful arc can be present on medial rotation.
This has the same diagnostic value as a painful arc on elevation
and bears the practical consequence that in order to test for
real limitation of movement the examiner must persist to get
beyond the painful arc.
Resisted movements
Resisted adduction
The patient is asked to pull the right arm towards the body as
hard as possible. The examiner puts one hand around the elbow,
and the other at the patient’s ipsilateral side (Fig. 12.6a).
Resisted abduction
The test is performed with the arm hanging down, a few
degrees of abduction being permitted. The examiner asks the
patient to push his or her arm to the side, meanwhile applying
counterpressure at the elbow. The examiner’s other hand sta-
bilizes the patient on the contralateral side (Fig. 12.6b).
Resisted lateral rotation
The patient is asked to bend the elbow to a right angle and to
push the forearm away from the body. To avoid any movement
of the trunk, the other hand is put on the patient’s contralateral
shoulder (Fig. 12.7a). Counterpressure is applied just above
the wrist and care must be taken to get two details right. First,
the patient should keep the elbow against the body, so that
there is no element of abduction. Second, extension of the
elbow during lateral rotation is avoided. This is easily checked

(a)
(c)
if the examiner puts the little finger underneath the patient’s
wrist: extension at the elbow causes the digit to move down.
Resisted medial rotation
This is tested in the same position as resisted lateral rotation,
but the patient’s arm is held at the inner part of the wrist and
the forearm is pulled towards the body (Fig. 12.7b).
Resisted elbow flexion
With the elbow still bent at a right angle and the forearm
supinated, the forearm is pulled up. Counterpressure is
Clinical examination of the shoulder C H A P T E R 1 2 
(b)
Fig 12.5 • Three tests for the glenohumeral joint: (a) passive
scapulohumeral abduction; (b) passive lateral rotation; (c) passive
medial rotation.
applied to the distal part of the forearm just above the wrist.
The other hand is placed on the patient’s ipsilateral shoulder
(Fig. 12.8a).
Resisted elbow extension
In the same position as for flexion, the patient attempts to
extend the elbow. To be able to hold the patient’s elbow at 90°
of flexion, the examiner puts his or her own elbow on the iliac
crest, the arm in an almost vertical position underneath the
patient’s wrist. The other hand rests on the patient’s ipsilateral
shoulder (Fig. 12.8b).
213
 The Shoulder

(a) (b)

Fig 12.6 • Resisted movements: (a) adduction; (b) abduction.

(a) (b)

Fig 12.7 • Resisted rotation: (a) lateral; (b) medial.

214
 Clinical examination of the shoulder C H A P T E R 1 2 

(a) (b)

Fig 12.8 • Resisted flexion (a) and extension (b) of the elbow.

Palpation Box 12.4 

General palpation for heat and swelling is done after the func- Summary of accessory tests of the shoulder
tional examination. These may be present in bacterial arthritis • Passive horizontal adduction
and in primary and secondary tumours of the humeral head, • Passive horizontal lateral rotation
glenoid and acromion, and in acute and chronic subdeltoid • Apprehension test for anterior instability
bursitis. • Apprehension test for posterior instability
Palpation for pain is only performed when the basic exami- • Load and shift manœuvre
nation proves that the lesion lies within the reach of a finger. • Sulcus sign
As already indicated, it always follows the clinical examination • Yergason’s test
and never precedes it. Comparison between the two sides is • Resisted horizontal adduction
essential. Palpation for tenderness is mainly done in acute and • Resisted horizontal extension
chronic subdeltoid bursitis and in a sprained superior ligament • Resisted horizontal adduction with the arm forwards
of the acromioclavicular joint. • Resisted flexion
• Resisted extension

Accessory tests •
•
Pressure against a wall
Scapular adduction against resistance

Sometimes the diagnosis is still not clear after the basic exami-
nation and a differential diagnosis has to be undertaken. At
other times, the exact structure at fault has been identified by
this stage of the examination but the precise localization of the
lesion within that particular structure remains uncertain. In
both cases, one or more accessory tests may be required (Box
12.4). Passive horizontal adduction is the only one which is
explained here. The other tests are discussed, together with
the corresponding disorders, in the following chapters.
Passive horizontal adduction
The patient’s arm is brought horizontally in front of the body.
At the end of the movement the elbow is pressed gently
further towards the contralateral shoulder (Fig. 12.9). Twisting
of the patient’s trunk is prevented by the examiner bringing
the other hand behind this shoulder.

215
 The Shoulder
Fig 12.9 • Passive horizontal adduction.
The indications for this test are:
• Sprain of the acromioclavicular joint21
• Subcoracoid bursitis
• Subscapularis tendinosis.
Technical investigations
All technical investigations of the shoulder have in common
the fact that they are performed to search for anatomical
changes. This is in contrast with the objective of a clinical
examination, which aims to detect functional deficiencies and/
or pain. Anatomical changes that are not causing functional
disturbances (remain asymptomatic) are very common in the
shoulder region and their frequency increases with age.22–24
Therefore, one should always interpret technical diagnoses
with care and even reluctance, for it is perfectly possible that
the lesion seen on imaging is in fact asymptomatic and another
lesion that is not shown is at the root of the disability. A
common mistake is the combination of a symptomatic gleno-
humeral arthritis that remains undiagnosed with sonography
and an asymptomatic rotator cuff tear that is easily detected
with the same technique. We therefore fully agree with Kessel,
who states: ‘An X- ray is best used to check a hypothesis which
has been formed by history and clinical examination. One
should eschew the temptation of a shortcut to the X-ray room
or scanner.’25
Plain radiography
The main indications for radiography of the shoulder are evalu-
ation of fractures and dislocations, imaging of bony disorders
216
such as tumours and metastases, and identification of calcifica-
tions in or around tendons. Plain radiographs may also be
helpful in the evaluation of anterior and posterior instability.
Although ultrasonography is nowadays the most frequently
used method to evaluate rotator cuff lesions, plain X-ray exam-
ination can be of use in the detection of accompanying appear-
ances, such as changes in the coracoacromial arch, an unusual
form or a spur off the acromion.26 Radiography is also still
advocated in long-standing massive cuff tears.27,28
Ultrasound scanning
Ultrasound scanning is mainly advocated for the detection of
full or partial rotator cuff lesions. In experienced hands it can
reveal not only the integrity of the rotator cuff but also the
thickness of its various component tendons. Through careful
positioning and through knowledge of the dynamic anatomy of
the cuff, the experienced ultrasonographer can image selec-
tively the upper and lower subscapularis, the biceps tendon,
the anterior and the posterior supraspinatus, the infraspinatus
and the teres minor. Ultrasonography has further advantages:
it is non-invasive and safe, bilateral examinations are quickly
performed, the shoulder can be examined dynamically and,
above all, the procedure is inexpensive.29
One important disadvantage, however, is that the method
has a long learning curve. The results are examiner-dependent
and a good outcome can only be expected in experienced
hands.30 Specificity and sensitivity of as high as 98% and 91%
respectively in comparison with surgical findings were claimed
by Mack et al.31 Others have found an overall sensitivity of
97% in diagnosing full cuff tears and of 91% in partial thickness
tears.32
Arthrography
Single-contrast arthrography can be helpful in diagnosing com-
plete tears of the rotator cuff, incomplete deep surface tears
and instability problems.33 It will show loss of axillary-fold
space and diminished joint capacity in adhesive capsulitis, but
because this disorder is so easy to detect clinically, arthrogra-
phy should never be required. It is of no assistance in clarifying
the differential diagnosis in cases of impingement, in the
absence of a rotator cuff tear.
Arthroscopy
Arthroscopy is useful for both diagnosis and treatment.34–39 It
should be regarded as an adjuvant in those cases where the
normal diagnostic aids are insufficient.35 As it offers an excel-
lent view of the glenoid, labrum and capsule, it is an excellent
technique in repair of shoulder instability.36
However, confronted with the almost perfect results
obtained through examination technique, the physician should
never forget that full and partial tears of the rotator cuff exist
in a substantial part of a normal asymptomatic population.
Both cadaveric studies37,38 and imaging studies39,40 on asympto-
matic individuals have demonstrated that cuff defects become
increasingly common after the age of 40 and that most occur
without substantial clinical manifestations.
 Clinical examination of the shoulder C H A P T E R 1 2 

Magnetic resonance imaging the glenohumeral capsule. Nevertheless, MRI is to be preferred

because it is more accurate in tendinopathies and no X-ray
Magnetic resonance imaging (MRI) has rapidly become a com-
exposure occurs.49 In shoulder instability, CT-arthrography
monly used technique for shoulder evaluation, proving its
seems to be the best diagnostic method.50
utility in the evaluation of muscle, tendons, hyaline and fibrous
cartilage, joint capsule, fat, bursae and bone marrow.41 Today
it is the most accurate non-invasive method available for Bursoscopy
imaging the rotator cuff.42 The major advantages of this modal- Bursoscopy can be performed under general or local anaesthe-
ity include its non-invasive nature, lack of ionizing radiation, sia. Although there are almost no indications for bursoscopy,51
excellent contrast and anatomic resolution, multiplanar imaging it may be of help in diagnosing lesions of the bursal part of the
capability, and ability as a single imaging modality to evaluate rotator cuff. At the same time, it offers visualization of the
simultaneously for a wide variety of pathologic processes.43 acromial roof.
One disadvantage is that small foci of soft tissue calcification
may be missed on MRI.44 As with all techniques that provide
optimal visualization, one should always take into account the   Access the complete reference list online at
high rate of asymptomatic lesions and never rely simply on the www.orthopaedicmedicineonline.com
outcome of the technique to make a diagnosis and start a
treatment.45–48

Computed tomography
Computed tomography (CT) is equally as accurate as MRI for
evaluation of the glenoid rim and labrum, the humeral head and

217

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