History

The following may be noted in the patient’s history:

History of injections in and around the site of involvement
Similar contractures in other parts of the body
Family history of similar contractures
Significant limitation of the activities of daily living
Pain near the shoulder and neck
A dimple on the skin over the deltoid
A fibrous, palpable band
Scapular winging
An inability to pull the arm fully down to the side of the body

Physical Examination

Examine neck motion, looking for Sprengel deformity (high riding scapula) and other congenital abnormalities.

Examine shoulder and upper extremity to evaluate glenohumeral and scapulothoracic motion and stability.^{[15, 23]}

Assess for winging of the scapula and freedom of scapular motion.^[2]

Look for evidence of contractures elsewhere in both the upper and the lower extremities.

Perform a complete neurovascular examination.

Examine the thoracic and lumbar spine, looking for scoliosis or chest wall abnormalities.

The contracted portion of the deltoid determines the problems encountered by the patient. The shoulder is abducted when only the middle portion is involved. If the anterior portion is involved, the arm assumes a flexed and abducted position. If the posterior portion is involved, the arm is extended and abducted. As the arm is progressively extended or flexed, subluxation of the humeral head may occur

Most contractures are full thickness. However, a small group of individuals with only undersurface bands has been reported. These individuals experienced impingement and rotator cuff tears. Individuals in this group were skeletally mature.

Recurrent dislocation has been reported, as well as chronic labral injury. Radiologic evaluation of glenohumeral joint stability may be difficult because of changes in scapular position causing a relative overlap of the glenoid and humeral head. A bony projection can be present from the superolateral acromion and can indicate the formation of a traction enthesophyte. Computed tomography (CT) and magnetic resonance imaging (MRI) may be required for adequate evaluation of the status of the glenohumeral articulation and the muscular architecture itself.^{[16, 24]}

In patients who are skeletally immature, flattening of the humeral head and changes in acromial morphology (drooping) may be seen. As the abduction contracture increases,^[25] the weight of the arm causes the inferior border of the scapula to rotate medially, resulting in winging of the scapula. Frequently, the skin may dimple, and a fibrous band may be palpable. Muscle aching about the shoulder girdle frequently accompanies the winging. Scoliosis secondary to more severe abduction contracture has been reported.

Individuals usually present with inability to move the arm across the body. Abduction of the arm releases the tension of the fibrous band and allows cross-body movement. An appropriate full physical examination should be conducted by an orthopedic surgeon.

Workup

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Media Gallery

Deltoid muscle.

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Author

Brian G Cothern Wright State University, Boonshoft School of Medicine

Brian G Cothern is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Coauthor(s)

Jedediah H May, MD Resident Physician, Department of Orthopedics, Wright State University, Boonshoft School of Medicine

Jedediah H May, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Matthew J DiPaola, MD Shoulder and Elbow Surgeon, UBMD Orthopaedics & Sports Medicine

Matthew J DiPaola, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Association of American Physicians and Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mohit N Gilotra, MD, MS, FAAOS, FAOA Associate Professor, Department of Orthopaedics, Shoulder and Elbow Service, Associate Residency Program Director, Co-Director of Resident Research, University of Maryland School of Medicine; Chief of Orthopaedics, VA Maryland Healthcare

Mohit N Gilotra, MD, MS, FAAOS, FAOA is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Shoulder and Elbow Surgeons, Maryland Orthopaedic Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Tigon<br/>Serve(d) as a speaker or a member of a speakers bureau for: Arthrex<br/>Received research grant from: Orthofix.

Additional Contributors

Cato T Laurencin, MD, PhD University Professor, Albert and Wilda Van Dusen Endowed Distinguished Professor of Orthopedic Surgery, and Professor of Chemical, Materials, and Biomolecular Engineering, University of Connecticut School of Medicine

Cato T Laurencin, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Mark Brodersen, MD Assistant Professor, Department of Orthopedic Surgery, Mayo Medical School

Mark Brodersen, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Clinical Orthopaedic Society, Florida Medical Association, and Mid-America Orthopaedic Association

Disclosure: Nothing to disclose.