OSCE - MSK Shoulder Flashcards
Describe the introduction steps in the shoulder examination.
- Introduce self: Name, role and type of examination
- Confirm the patient’s name and age
- Briefly explain the examination using patient-friendly language
- Gain consent and ask if patient is in any pain
- Patient positioning (standing)
- **Wash hands **
What 3 steps should always be undertaken prior to moving to general inspection?
- Ask the patient if they have any pain before proceeding with the examination
- Also tell the patient to inform you if they experience any pain throughout
- Wash hands
On General inspection, what signs are being looked for?
Clinical signs
- Alertness
- Distress Level
- Body habitus
- Scars/skin changes
- Muscle wasting
- Swelling at the shoulder joints
Objects or equipment
- Aids and adaptations
Closer inspection of the shoulder includes (3 steps)?
Anterior inspection
Lateral inspection
Posterior inspection
Anterior inspection of the shoulder involves inspecting for (4)?
- Head and neck posture abnormalities
- Muscle (anterior deltoid) wasting
- Alignment of shoulders/shoulder girdle
- Scars/skin changes
Lateral inspection of the shoulder involves inspecting for (2)?
- Scars/Skin changes: indicative of previous trauma or surgery
- Muscle (middle deltoid) wasting:
Any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary nerve injury
Posterior inspection of the shoulder involves inspecting for (5)?
- Scars: Look for scars indicative of previous trauma or surgery
- Trapezius muscle asymmetry: suggestive of muscle wasting secondary to disuse atrophy or a spinal accessory nerve lesion
- Supraspinatus and infraspinatus asymmetry:
- Scoliosis: lateral curvature of the spine that may be congenital or acquired.
- Winged scapula: ask the patient to push against a wall with both hands spaced shoulder-width apart whilst you inspect the back. The protrusion of a scapula (known as scapular winging) is suggestive of ipsilateral serratus anterior muscle weakness, typically secondary to a long thoracic nerve injury.
Temperature is felt at what areas in a shoulder examination and how?
Sternoclavicular, Acromioclavicular, Glenohumeral joints
Assess and compare shoulder joint temperatures (backs of hands)
- Increased temperature of a joint (+ swelling and tenderness) = septic arthritis or inflammatory arthritis
Shoulder joint palpation
What areas are palpated in a shoulder examination (8)?
- Sternoclavicular joint
- Along Clavicle
- Acromioclavicular joint: the joint between the acromion and the clavicle.
- Acromion Process
- Sub-acromial space: find the edge of the acromion and palpate immediately below until a space is felt
- Greater tuberostity of humerus - palpate directly below subacromial space
- Biceps tendon: anterioly from the greater tuberosity. tendon sits in between the greater and lesser tuberosities
- Scapula spine
Name the movements tested in a shoulder examination?
Flexion
Extension
Abduction
Adduction
External rotation
Internal rotation
When are passive movements indicated on a shoulder examination?
If abnormalities are noted on active movements (e.g. restricted range of movement), assess joint movements passively.
Repeat the shoulder movements, feeling for any crepitus during the movement of the joint.
What are passive movements?
Refers to a movement of the patient, controlled by the examiner.
This involves the patient relaxing and allowing examiner to move the joint freely to assess the full range of joint movement.
Further assessments and investigations for the shoulder would include (3)?
- Neurovascular examination of the upper limbs.
- Examination of the joints above and below (cervical spine and elbow joint).
- Further imaging if indicated (e.g. X-ray and MRI).
Outline the steps involved in completion of a shoulder examination
- Explain to the patient that the examination is finished.
- Thank the patient for their time.
- Dispose of PPE appropriately and wash your hands.
- Summarise your findings.
Name the 3 Special Tests assessed in a shoulder examination?
- Supraspinatus assessment (empty can test/Jobe’s test)
- External rotation against resistance
- Internal rotation against resistance (Gerber’s lift-off test)
Describe the following movement in terms of
a) Normal range
b) how to perform it
Shoulder Flexion
Active shoulder flexion
a) Normal range of movement: 150°- 180°
b) Instructions: Ask the patient to raise their arms forwards until they’re pointing up towards the ceiling.
Describe the following movement in terms of
a) Normal range
b) how to perform it
Shoulder Extension
Active shoulder extension
a) Normal range of movement: 40 - 60°
b) Instructions: Ask the patient to stretch out their arms behind them.
Describe the following movement in terms of
a) Normal range
b) how to perform it
Shoulder Abduction/Adduction
Active shoulder Abduction
a) Normal range of movement: 180°
b) Instructions: Ask the patient to raise their arms straight out to the sides in an arc-like motion until their hands touch above their head.
Active shoulder Adduction
a) Normal range of movement: 30°- 40°
b) Instructions: directly after the abduction test. While patient has their hands above their head, Ask the patient to keep their arms straight and move them across the front of their body to the opposite side.
Supraspinatus assessment (empty can test)
a) What does this assess
b) how is it performed
a) This clinical test assesses the function of the supraspinatus muscle.
b)
1. Abduct the patient’s arm to 90° and then angle the arm forwards by approximately 30° so that the shoulder is in the plane of the scapula.
2. Internally rotate the arm so that the thumb points down towards the floor.
3. Now push down on the arm whilst the patient resists.
How is the supraspinatus test interpreted?
This test assesses for weakness and/or impingement of supraspinatus.
Weakness may represent a tear in the supraspinatus tendon or pain due to impingement.
