Impingement Syndrome: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

  • General physical examination – including blood pressure, pulse, body weight, height; further:
    • Inspection (viewing).
      • Skin (normal: intact; abrasions/wounds, redness, hematomas (bruises), scars) and mucous membranes.
      • Gait (fluid, limping).
      • Body or joint posture (upright, bent, gentle posture).
      • Malpositions (deformities, contractures, shortenings).
      • Muscle atrophies (side comparison!, if necessary circumference measurements).
      • Joint (abrasions/wounds, swelling (tumor), redness (rubor), hyperthermia (calor); injury indications such as hematoma formation, arthritic joint lumpiness, leg axis assessment).
    • Palpation (palpation) of vertebral bodies, tendons, ligaments; musculature (tone, tenderness, contractures of paraverebral muscles); soft tissue swelling; tenderness (localization! ; restricted mobility (spinal movement restrictions); “tapping signs” (testing for painfulness of spinous processes, transverse processes, and costotransverse joints (vertebral-rib joints) and back muscles); illiosacral joints (sacroiliac joint) (pressure and tapping pain? ; compression pain, anterior, lateral, or saggital); hyper- or hypomobility? Palpation of prominent bone points, tendons, ligaments; musculature; joint (joint effusion? ); soft tissue swelling; tenderness (localization! )Examination procedure: starting medially with the sternoclavicular joint (sternoclavicular joint), followed by clavicle (clavicle), acromio-clavicular joint (ACG; AC joint; acromioclavicular joint)) with simultaneous stability testing, then processus coracoideus (coracoid process), sulcus intertubercularis (groove on the humerus) and tuberculum majus and minus.
    • Determination of the range of motion of the shoulder joint according to the neutral-zero method both actively and passively in a side-by-side comparison: (Neutral-zero method: the range of motion is given as the maximum deflection of the joint from the neutral position in angular degrees, where the neutral position is designated as 0°. The starting position is the “neutral position”: the person stands upright with the arms hanging down and relaxed, the thumbs pointing forward and the feet parallel. The adjacent angles are defined as the zero position. Standard is that the value away from the body is given first. ); Standard values:

      Comparison measurements with the contralateral joint (side comparison) can reveal even small lateral differences.

    • Special inspection of the shoulder, including side comparison – performance of functional tests:
      • Impingement tests:
        • Hawkins test: here, internal rotation (rotational movement of an extremity about its longitudinal axis with the direction of rotation pointing inward when viewed from the front) is forced at 90° of flexion (i.e., with the arm moving forward in the horizontal plane).
        • Neer test: the patient’s shoulder blade is fixed with a strong grip by the examiner, then the corresponding arm is passively internally rotated and flexed (i.e., lifted forward) to provoke a bump of the humeral head on the acromion (shoulder bone).
        • “Painful Arc”: in this case, pain is triggered by active abduction (lateral displacement or spreading of a body part away from the center of the body or the longitudinal axis of an extremity), especially in the range between 60° and 120°. In contrast, passive movements may be painless. Note: A positive “Painful Arc” between 140° and 180° abduction is indicative of ACG pathology (pathological findings of the AC joint (acromioclavicular joint).
      • 90-degree supraspinatus test (Jobe test) – The test is performed as part of the clinical examination of the shoulder joint an impingement syndrome; especially a involvement of the supraspinatus muscle (upper bones muscle) and the supraspinatus tendon can be confirmed or excluded.Performance of the test: The patient’s arm is abducted 90° (i.e. guided parallel to the floor), then moved forward 30° and the hand internally rotated (rotational movement of an extremity around its longitudinal axis, with the direction of rotation pointing inwards when viewed from the front). In this position, only the supraspinatus muscle is tensed in isolation from the entire rotators. Occurrence of pain during static holding speak for a lesion of the aforementioned muscle.
      • If necessary, further testing procedures such as: Testing of the external rotators (M. infraspinatus, M. teres minor); testing of the M. subscapularis; instability tests (so-called “lag-signs”).
    • Assessment of blood flow, motor function and sensitivity:
      • Circulation (palpation of pulses).
      • Motor function: testing of gross strength in a lateral comparison.
      • Sensibility (neurological examination)
  • Further orthopedic examinations wg :
    • Differential diagnoses:
      • Articulosynovitis (chronic inflammation in the joints).
      • Biceps tendon rupture – generic term for the rupture of at least one tendon of the biceps brachii muscle. A distinction is made between proximal biceps tendon rupture (in the shoulder area) and the distal rupture (in the elbow area).
      • Biceps tendinitis (inflammation of the long, upper tendon of the biceps muscle).
      • Bursitis (bursitis) in rheumatoid arthritis (pcP).
      • Diseases of the cervical spine with pseudoradicular pain pattern (nonspecific, localized back pain, which, among other things, radiate into the arm) and root compression syndromes (mechanical irritation of a nerve root in the area of the spine); here especially the root C5 with radiation into the deltoid muscle (triangular skeletal muscle located above the shoulder joint; it serves to lift the upper arm)
      • Malhealed tuberculum majus (large humeral tuberosity).
      • Frozen shoulder (synonyms: periarthritis humeroscapularis, painful frozen shoulder, and Duplay syndrome) – Adhesive capsulitis; extensive, painful suspension of shoulder mobility (painful frozen shoulder).
      • Contracture (functional and movement restriction) of the dorsal (“affecting the back”) capsule.
      • Neuralgic shoulder amyotrophy (acute inflammation of the brachial plexus associated with severe pain and paralysis of the shoulder and arm muscles).
      • Osteophytes (bone neoplasms) in the area of the acromioclavicular joint (acromioclavicular joint).
      • Pseudarthrosis (disturbed bone fracture healing with the formation of a false joint).
      • Shoulder pain caused by changes in the spine (vertebragen), vessels (vascular) or nerves (neurogenic): see if necessary under Omalgia (shoulder pain / differential diagnoses).
      • Tendinosis calcarea (calcified shoulder) – calcification mostly in the area of the attachment tendon of the supraspinatus muscle; prevalence (disease frequency): about 10% in asymptomatic patients / about 50% becomes symptomatic; often spontaneously regressive (regressing); more men than women; frequency of bilateral: 8-40%.
  • Health check

Square brackets [ ] indicate possible pathological (pathological) physical findings.