MSK - Shoulder

Question 1

How should you observe the patient?

Answer 1

Both shoulders exposed.

Consider using a mirror if available.

Question 2

What do you look at the front, side and back for? (5)

Answer 2

1) Look for scars, wounds, sinuses, discolouration of skin (bruising) or swelling
2) Loss of symmetry or deformity – loss of shoulder contour may indicate dislocation.
3) Look at level of shoulders
4) Winging of scapula

5) Look for muscle wasting - deltoid/supraspinatus/
infraspinatus

Question 3

On which muscles do you look for wasting?

Answer 3

Deltoid
Supraspinatus
Infraspinatus

Question 4

What do you feel for?

Answer 4

1) Feel for temperature at joint and adjacent areas (remember 4 joints in shoulder)
2) Palpate bony landmarks for tenderness: start at sterno-clavicular joint and palpate along clavicle to the acromioclavicular joint.
3) Palpate the acromion process and along scapula, spine of scapula and greater tuberosity of humerus.
4) Palpate the anterior and posterior joint lines of the humerus.
5) Palpate muscles - supraspinatus, infraspinatus and deltoid
6) Check axillary nerve sensation in “badge area” (lateral aspect mid upper arm)

N.B. When you palpate, check and look at the patient for pain

N.B. it is unlikely to feel temperature difference in shoulder joint as it is a deep joint.

Question 5

What active movements do you ask for when assessing the shoulder?

Answer 5

1) Abduction and external rotation. Ask patient to “put hands behind head”
2) Internal rotation. Ask patient “to put hands behind back” and give a measure e.g.mid thoracic level or thoracic vertebra number
3) Assess full extension and full flexion. Extension like “raising hand”
4) Assess full abduction.
5) External and internal rotation of shoulder. Elbows flexed to 90° and tucked in to sides of body and rotate (useful to diagnose frozen shoulder (adhesive capsulitis) and posterior dislocation).

Question 6

What passive movements do you do for when assessing the shoulder?

Answer 6

1) Repeat all movements passively with hand on top of shoulder to detect crepitus (for flexion/extension & abduction)

2) Assess extension/flexion/abduction
- Abduction - is there a Painful Arc? (pain between 10°-120°)

3) Assess external rotation with elbows at 90° (for frozen shoulder, posterior dislocation).

4) Assessment of scapular movement.
- From behind, assess scapular movement during abduction by both feel and observation.
- Place finger and thumb on tip of scapula to feel start of scapular movement.
- How many degrees involve gleno- humoral & how many scapulo-thoracic rotational movement? Should be 90:90

Question 7

How do you assess shoulder function?

Answer 7

Already assessed with hands behind head and back

Examination of the cervical spine and elbow (joint above and below)