Examination of the Shoulder

Question 1

What is involved in the intro to the examination of the shoulder?

Answer 1

• Wash your hands
• Introduction, identification and consent
• Ask the patient whether they have any pain in the arm, shoulder or neck
• Fully expose the patient’s shoulders, neck and chest (female patients should retain
their bra).

Question 2

What are the key steps of the shoulder exam?

Answer 2

Inspection
Palpation
Assess Range of Motion
Function
Specific Tests
Completion

Question 3

What is involved in the inspection stage of the shoulder exam?

Answer 3

Ask the patient to stand, if this is not possible then the patient may sit on a chair or on the side
of the couch/bed.
With the shoulder fully exposed, inspect from the
o Front
o Side
o Back
From the front compare the two shoulders looking for
• Symmetry
• Posture (observe how the patient is positioning the upper limb)
• Swelling (joint effusion?)
• Deformity
• Bony prominence (sternoclavicular joint; acromioclavicular joint)
• Muscle wasting (Deltoid)
• Scars
• Any other skin changes (e.g. erythema)
From behind inspect
• Muscle bulk (supraspinatus – above scapula wing, infraspinatus – below scapula wing;
trapezius, rhomboids)
• Any abnormalities in the scapula
• Any scars or skin changes

Question 4

What is involved in the palpation stage of the shoulder exam?

Answer 4

• Using the back of your hand, assess the temperature over the shoulder area
• Begin palpating from the front, work from medial to lateral. Palpate for increased
temperature, joint line tenderness, swelling and crepitus
o Sternoclavicular joint (SCJ)
o Clavicle
o Acromioclavicular joint (ACJ)
o Acromion process
o Glenohumeral joint (anterior and posterior joint line)
o Spine of the scapula
o Scapula
• Palpate the muscle bulk of
o Deltoid
o Supraspinatus
o Infraspinatus
o Trapezius

Question 5

How do we asses the range of motion in the shoulder exam?

Answer 5

• Screening examination
o Ask the patient to put their hands behind their head and push their elbows back
as far as they can (external rotation, abduction)
o Ask the patient to put their hands behind their back (internal rotation, abduction)
Look for any difficulty, limitation or pain on movement. Describe how far they can reach
up the back.
• Assess active range of motion
o External rotation: Flex the elbow to 90° and tuck it into the patient’s side- then
ask the patient to rotate the arm outwards. (This is usually the first movement
lost in a frozen shoulder)
o Internal rotation: Flex the elbow to 90° and tuck it into the patient’s side- then
ask the patient to rotate the arm inwards.
o Flexion & Extension: Ask the patient to raise their arms in front and behind
them.
o Abduction: Check Painful Arc
▪ Ask the patient to raise their arm to the side, palm downwards, and then
lower. Normal movement is up to 180°
. Observe from both the front and
behind for symmetry of scapula movement & pain. Assess
glenohumeral movement and scapulothoracic movement.
▪ If the patient has rotator cuff pathology, there is often pain from 60-120° which may be alleviated by repeating with palm facing upwards. Pain only occurring at the end of the movement (120-180°) may indicate
acromioclavicular joint (ACJ) arthritis.

Assess passive range of motion
o After testing active movement, passively test the range of external rotation, internal rotation, flexion, extension and abduction, palpating the shoulder joint for crepitus whilst doing so.

Question 6

How do we assess function in the shoulder exam?

Answer 6

Ask the patient if they
o can dress themselves without difficulty
o can wash their own hair

Question 7

What specific tests are involved in the shoulder exam?

Answer 7

(To be used if indicated by the patient’s history – you be given instructions as to whether these
are to be included in an OSCE station)
• Testing the Rotator cuff
o Resisted active abduction (supraspinatus) initiates abduction - first 15
degrees, deltoid abducts up to 90 degrees; trapezius and serratus anterior
cause scapular rotation for abduction beyond 90 degrees).
o Resisted active external rotation (infraspinatus, teres minor)
o Resisted active internal rotation – “lift off” test (subscapularis). Ask the
patient to place their hand behind their back with the dorsum of their hand
resting over their mid-lumbar spine. The dorsum of the hand is then raised off
the back by maintaining or increasing internal rotation of the humerus and
extension at the shoulder. To perform this test the patient must have full passive
internal rotation so that it is physically possible to place the arm in the desired
position and pain cannot be a limiting factor during the manoeuvre. The ability
to actively lift the dorsum of the hand off the back constitutes a normal lift-off
test. Inability to move the dorsum off the back constitutes an abnormal lift-off
test and indicates subscapularis rupture or dysfunction.

Acromio-clavicular joint pathology
o Place the arm into forced adduction across the body at 90° of flexion at the
shoulder = “scarf test”. Note any pain or tenderness over the ACJ.

Question 8

How do we complete the shoulder exam?

Answer 8

Examine the cervical spine and elbow. When examining the elbow, you should use the
schema ‘look, feel, move’.
• Assess the neurological and vascular status of the limb (In the OSCE, unless you are
given specific instructions to perform this assessment, you should simply state to the
examiner that you would do so).
• Thank the patient and request them to redress
• Wash your hands