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The patient must be suitably undressed so that the examiner can observe the bony and soft-tissue contours

of both shoulders and determine whether they are normal and symmetric. When observing the shoulder, the examiner looks at the head, the cervical spine, the thorax (especially the posterior aspect), and the entire upper limb. The hand, for example, may show some vasomotor changes that result from problems in the shoulder, including shiny skin, loss of hair, swelling, and muscle atrophy. It is important to observe the patient as he or she removes clothes from the upper body and later replacc: s them. For example, is the affected arm undressed last or dressed first? This would indicate that the patient is limiting the movement of the arm as much as possible indicating possible pathology. The patient's actions give some indication of functional restriction, pain, and/or weakness in the upper limb.

Anterior View
Figure 5-5
Motor distribution of the radial and axillary nerves.

When looking at the patient from the anterior view (Fig. 5-7A), the examiner should begin by ensuring that the head and neck are in the midline of the body and observing their relation to the shoulders. While observing the shoulder, the examiner should look for the possibility of a step deformity (Fig. 5-SA). Such a deformity may be caused by an acromioclavicular dislocation, with the distal end of the clavicle lying superior to the acromion process. Such a deformity seen at rest indicates both the acromioclavicular and coracoclavicular ligaments have been torn. The deformity may be accentuated by asking the patient to horizontally adduct the arm or to medially rotate the shoulder and bring the hand up the back as high as possible. Occasionally, swelling may be evident anterior to the acromioclavicular joint. This is called the Fountain sign and indicates degeneration has caused communication between the acromioclavicular joint and swollen subacromial bursa underneath. If a sulcus - may be caused by multidirectional instability or loss

-- muscle control due to nerve injury or a stroke, leading to inferior subluxation of the glenohumeral joint. This deformity is lateral to the acromion and should not be confused with a step deformity. This ;sign is also referred to as a sulcus sign because of the appearance of a sulcus or groove below the acromion process (Fig. 5-8B). Flattening of the normally round deltoid muscle area may indicate an anterior dislocantion of the glenohumeral joint or paralysis of the deltoid muscle (Fig. 5-9). With an anterior dislocation, note also how the arm is held abducted because of the -dislocation of the humeral head below the glenoid. If the examiner palpated in the axilla, the head of the huems would be felt. The examiner should note any normal bumps or malalignment in the bones that may indicate past injury, such as a healed fracture of

the clavicle. In most people, the dominant side is lower than the nondominant side. This difference may be caused by the extra use of the dominant side, which results in stretching of the ligaments, joint capsules, and muscles , allowing the arm to "sag" slightly. Tennis players
and others who stretch their upper limbs in a reaching action show even greater differences along with gross hypertrophy of the muscles on the dominant side (Fig. 5-10). If the patient is very protective of the shoulder, however, it may appear that the injured shoulder, whether dominant or nondominant, is higher than the normal side (see Fig. 5- 3). The examiner notes whether the patient is able to assume the normal functional position for the shoulder, which is in the scapular plane with 60 of abduction and the arm in neutral or no rotation. The examiner should be aware that if the patient's arm is medially rotated from this position to bring the hand into midline, the biceps tendon is forced against the lesser tuberosity of the medial wall of the bicipital (intertubercular) groove. If this position is maintained for long periods, there may be increased wear of the biceps tendon, which can lead to bicipital tendinitis or paratenonitis. If the arm is horizontally adducted while it is medially rotated, anterior pain would indicate impingement symptoms (Hawkins-Kennedy test-see special tests). The bicipital groove may vary in width and depth (Fig. 5-11), possibly leading to problems if the shoulder is overused. Especially wide or deep grooves lead to the greatest problems. The wide grooves tend to allow the tendon too much lateral movement, leading to inflammation of the paratenon (paratenonitiS) l7; the deep grooves tend to be too narrow, compressing the tendon especially if it becomes inflammed