REMS: Shoulder examination (geekymedics)

Question 1

(A1) What aids could the patient have with them?

Answer 1

> Sling

Question 2

(A2) What should be inspected from anteriorly?

Answer 2

> Scars - previous surgery / trauma

> Asymmetry of the shoulder girdle:
• scoliosis
• arthritis
• trauma - clavicular fracture / humeral fracture / anterior dislocation of the humeral head

> Swelling - inflammatory disease / effusion / anterior dislocation

> Muscle wasting - deltioids - axillary nerve surgery (traumatic/iatrogenic)

Question 3

(A3) What should be inspected laterally?

Answer 3

> Scars - previous trauma / surgery

> Muscle wasting - deltoid

> Alignment of shoulder girdle - misalignment - dislocation / scoliosis

Question 4

(A4) What should be inspected posteriorly?

Answer 4

> Scars - previous surgery / trauma

> Asymmetry / deformity - winged scapula (long thoracic nerve injury) / scoliosis

> Assess muscle bulk of trapezius - symmetry / wasting

> Para-vertebral muscles - note any swelling / wasting

> Assess muscle wasting in the supra and infraspinatous fossa - wasting of supra and infaspinatous (nerve injury / chronic rotator cuff tear)

Question 5

(A5) Why should you assess the temperature of the shoulder joint?

Answer 5

> warmth may suggest inflammatory arthropathy / infection

Question 6

(A6) What components of the shoulder girdle need to be palpated? What features should be noted?

Answer 6

> Sterno-clavicular joint
> Clavicle 
> Acromio-clavicular joint 
> Corcacoid process - 2cm inferior and medial to clavicular lip 
> Head of humerus 
> Greater tuberosity of humerus 
> Spine of scapula 

> note any swelling / tenderness

Question 7

(A7) What active compound movements should you ask the patient to perform when screening for shoulder joint pathology?

Answer 7

> Put your hands behind your head - external rotation + abduction

> Put your hands as far up your back as you can - internal rotation + adduction

Question 8

(A8) What active movements should you ask the patient to perform when carrying out a full shoulder examination?

Answer 8

> Flexion - ask the patient to raise the arms forwards until they point upwards - normal ROM 150-180

> Extension - ask the patient to keep the arms straight and extend them behind them - normal ROM 40

> Abduction - ask the patient to lift their arms away from their sides as far as possible - normal ROM 180

> Adduction - ask the patient to bring their arms across their trunk to the other sides - normal ROM 30-40

> External rotation - ask the patient to hold their elbows to their body flexed at 90 degrees and then move their forearms outwards in arc-like motion - normal ROM 80-90

> Internal rotation - with the patient’s elbows flexed at 90 degrees (arm by their side) ask them to place their hand behind their back and reach up the spine as far as they can manage - normal T4-T8

> Assess movement of the scapula
• Ask the patient to abduct the shoulder
•Simultaneously palpate the inferior pole of the scapula
• Assess the degree and smoothness of the scapula
•On average 50-70% of the first movement occurs at the glenohumeral joint
•If the glenohumeral joints movement is reduced due to injury of inflammation then the majority of abduction will occur via increased scapula movement over the chest wall

Question 9

(A9) What passive movements should you do to the patient?

Answer 9

> All of the active movements

> Tell patient they should feel no pain and to tell you immediately if they do

> Feel for any crepitus

Question 10

(B1) What special tests of the shoulder should you perform?

Answer 10

> Supraspinatus assessment - Jobe’s test

> The painful arc (impingement syndrome)

> External rotation against rotation

> External rotation in abduction

> Internal rotation against resistance

Question 11

(B2) What does Jobe’s test assess?

Answer 11

> assess the function of the supraspinatus

> weakness in the supraspinatous and/or impingement

> weakness may represent a tear in the supraspinatus or pain due to impingement

Question 12

(B3) What does the painful arc assess?

Answer 12

> assess for impingement of the supraspinatus

> typically causes pain between 60-120 degrees of abduction

> not specific as many other conditions can cause pain in this arc of motion

Question 13

(B4) What does external rotation against resistance assess?

Answer 13

> assess the function of the infraspinatus

> pain may suggest infraspinatous tendonitis

> If arm falls back to internal rotation or there is a loss of power it may suggest a tear in the infraspinatous tendon or muscle wasting

Question 14

(B5) What does external rotation in abduction assess?

Answer 14

> assess the function of teres minor

> If the patient is unable to keep arm in this position (i.e the arm falls back to internal rotation) this may represent a positive horn blower’s sign (pathology in terms minor)

Question 15

(B6) What does internal rotation against resistance assess?

Answer 15

> assess the function of the subscapularis muscle

Question 16

(B7) What further assessments or investigations should you offer?

Answer 16

> Full neuromuscular examination of the upper limbs

> Examine the cervical spine and elbow joint (the joint above and below)

> Perform further imaging if indicated - Xray / MRI

Question 17

(B8) How would you summarise a normal shoulder examination?

Answer 17

> Today I examined the shoulders of Simon, a 24 y/o male. On inspection there was no obvious abnormalities. On palpation there was no tenderness. And there was a full range of active and passive movement. There were no positive findings on any of the special tests.

> To complete my examination, I would like to examine the joint above: the C spine, and the joint below: the elbow. I would also like to look at any appropriate imaging of the shoulder joint.