Palpation to Reproduce Pain

Once the patient has identified the area of the pain, the next step may be to find the point of maximal tenderness by palpating each of the following areas. Keep in mind that some areas of the shoulder are naturally tender, so comparison to the asymptomatic side might be helpful (Table 16-2; Fig. 16-3).

Table 16-2 Common Sites of Tenderness and Locations/Pearls

Point of Maximal Tenderness

Location/Pearl

Greater tuberosity (Codman's point) (see Fig. 16-3)

Just anterior to anterolateral corner of acromion with dorsum of hand on buttock. Codman's point is the insertion of supraspinatus tendon on greater tuberosity.

Lesser tuberosity

Subscapularis pathology, biceps

AC joint

Follow posterior part of clavicle to acromion. AC joint just anterior to this; push the clavicle down hard enough to move it

Acromion

Do not forget about symptomatic os acromiale

Posterior capsule

Internal impingement lesions are tender posteriorly; SLAP tears may also be tender here

Biceps tendon/bicipital groove

Directly anterior when arm internally rotated 10 degrees

Coracoid

Subcoracoid impingement

Erb's point

Medial to coracoid, inferior to clavicle

AC, acromioclavicular; SLAP superior labrum anterior to posterior.

AC, acromioclavicular; SLAP superior labrum anterior to posterior.

Figure 16-3 Codman's point.

Remember that the patient may say that their pain is "deep" and not really palpable (think intra-articular superior labrum anterior to posterior [SLAP], labral tear, articular cartilage injury). In addition to finding (or not finding) the point of maximal tenderness, there are a number of additional maneuvers that should be performed to further narrow the differential.

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