Shoulder

Question 1

What are the key stages of the shoulder exam

Answer 1

WIPERQQ
Look (general and shoulder - anterior, lateral, posterior)
Feel
Move (active and passive)
Special tests
Further investigations

Question 2

What general clinical signs are you looking for when examining a patient in a shoulder exam (3)

Answer 2

Body habitus: obesity is a significant risk factor for joint pathology due to increased mechanical load (e.g. osteoarthritis).

Scars: may provide clues regarding previous upper limb surgery.

Wasting of muscles: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron lesion.

Question 3

What 6 things should you look for in the anterior inspection of the shoulder

Answer 3

Scars: note the location of the scar as this may provide clues as to the patient’s previous surgical history or suggest previous joint trauma.

Bruising: suggestive of recent trauma or surgery.

Asymmetry of the shoulder girdle: may be caused by scoliosis, arthritis, fractures or dislocation.

Swelling: note any evidence of asymmetry in the size of the shoulder joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, dislocation).

Abnormal bony prominence: may indicate fracture (e.g. clavicular fracture) or anterior dislocation of the glenohumeral joint.

Deltoid wasting: note any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary nerve injury.

Question 4

What 2 things should you look for in the lateral inspection of the shoulder

Answer 4

Scars: again look for scars indicative of previous trauma or surgery.

Deltoid wasting: note any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary nerve injury.

Question 5

What 5 things should you look for in the posterior inspection of the shoulder

Answer 5

Scars: again 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: suggestive of muscle wasting secondary to chronic rotator cuff tear or a suprascapular nerve lesion.

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.

Question 6

What 5 things should you look for in the posterior inspection of the shoulder

Answer 6

Scars: again 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: suggestive of muscle wasting secondary to chronic rotator cuff tear or a suprascapular nerve lesion.

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.

Answer 7

Scars: again 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: suggestive of muscle wasting secondary to chronic rotator cuff tear or a suprascapular nerve lesion.

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.

Question 8

What do you feel for in a shoulder exam

Answer 8

temperature and then palpate the joint

Question 9

What is the importance of feeling the temperature in a shoulder exam

Answer 9

Increased temperature of a joint, particularly if also associated with swelling and tenderness may indicate septic arthritis or inflammatory arthritis.

Question 10

What 8 areas do you palpate in the shoulder exam

Answer 10

Sternoclavicular joint: the joint between the sternum and the clavicle.

Clavicle: extends between the sternum and the acromion of the scapula.

Acromioclavicular joint: the joint between the acromion and the clavicle.

Acromion: a continuation of the scapular spine and the most superolateral bony prominence of the shoulder.

Coracoid process of the scapula: a small hook-like bony prominence located 2cm inferior and medial to the clavicular tip.

Head of the humerus: located 1cm inferolateral to the coracoid process.

Greater tubercle of the humerus: located slightly anterolateral to the head of the humerus.

The spine of the scapula: easily palpable on the posterior aspect of the scapula, running from the acromion towards the thoracic vertebrae.

Question 11

Which compound movements do you ask the patient to do in a shoulder exam

why

Answer 11

External rotation and abduction of the shoulder joint: Ask the patient to put their hands behind their head and point their elbows out to the side.

Internal rotation and adduction of the shoulder joint: Ask the patient to place each hand behind their back and reach as far up their spine as they are able to.

Question 12

What are the active actions you need to assess in a shoulder exam

Answer 12

flexion
extension
AB/ADduction
external rotation
internal rotation
scapular movement

Question 13

What is the normal range of movement of active shoulder flexion

How do you assess this

Answer 13

Normal range of movement: 150°- 180°

Instructions: Ask the patient to raise their arms forwards until they’re pointing up towards the ceiling.

Question 14

What is the normal range of movement of active shoulder extension

How do you assess this

Answer 14

Normal range of movement: 40°

Instructions: Ask the patient to stretch out their arms behind them.

Question 15

What is the normal range of movement of active shoulder ABduction

How do you assess this?

Answer 15

Normal range of movement: 180°

Instructions: Ask the patient to raise their arms out to the sides in an arc-like motion until their hands touch above their head.

Question 16

What is the normal range of movement of active shoulder ADduction

How do you assess this?

Answer 16

Normal range of movement: 30°- 40°

Instructions: Ask the patient to keep their arms straight and move them across the front of their body to the opposite side.

Question 17

What is the normal range of movement of active shoulder external rotation `

How do you assess this?

Answer 17

Normal range of movement: 80° – 90°

Instructions: Ask the patient to keep their elbows by their sides flexed at 90° whilst they move their forearms outwards in an arc-like motion.

Question 18

What is the normal range of movement of active shoulder internal rotation `

How do you assess this?

Answer 18

Normal range of movement: the patient is able to reach to the level of T4-T8

Instructions: Ask the patient to place each hand behind their back and reach as far up their spine as they are able to.

Question 19

How do you assess a patient’s scapular movement in a shoulder exam

Answer 19

Instructions: Ask the patient to abduct their shoulder, whilst you simultaneously palpate the inferior pole of the scapula. Assess the degree and smoothness of scapular movement.

On average 50-70% of the scapula’s initial movement occurs at the glenohumeral joint.

If the glenohumeral joint’s movement is reduced due to injury or inflammation then the majority of abduction will occur via increased scapular movement over the chest wall.

Question 20

Which shoulder movements need to be assessed passively

what should you feel for

Answer 20

flexion
extension
AB/ADduction
external rotation
internal rotation
scapular movement

crepitus

Question 21

What is frozen shoulder and how does it present

Answer 21

Adhesive capsulitis involves stiffness and pain in the shoulder joint associated with a significant reduction in the range of both active and passive movement.

Palpation of the joint does not typically cause pain and clinical examination reveals a significantly reduced range of active and passive movement.

The underlying aetiology is unclear however risk factors include surgery, prolonged immobility and trauma.

Question 22

What is the typical cause of axillary nerve palsy and what clinical features are associated

Answer 22

Axillary nerve palsy is typically caused by shoulder dislocation. Clinical features include loss of sensation over the lateral deltoid region (known as the regimental patch) and deltoid muscle weakness (loss of shoulder abduction).

Question 23

What are the rotator cuff muscles

Answer 23

Subscapularis.
Infraspinatus.
Teres minor.
Supraspinatus.

Question 24

How do you assess the function of supraspinatus in a shoulder exam

What may weakness suggest

Answer 24

Empty can test/Jobe’s test

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.

Weakness may represent a tear in the supraspinatus tendon or pain due to impingement.

Question 25

How do you test for impingement syndrome in the shoulder exam

Answer 25

The Painful Arc

1. Passively abduct the patient’s arm to its maximum point of abduction.
2. Ask the patient to lower their arm slowly back to a neutral position.

Impingement or supraspinatus tendonitis typically causes pain between 60-120° of abduction, however, this test is not specific as many other conditions can cause pain in this arc of motion and therefore it should not be used in isolation for diagnosis.

Question 26

What is shoulder impingement syndrome

Answer 26

Shoulder impingement syndrome (SIS) involves the inflammation of tendons of the rotator cuff muscles as they pass through the subacromial space. SIS is most often associated with supraspinatus tendonitis. Symptoms of SIS include pain, weakness and a reduced range of active movement in the affected shoulder (normal passive range of motion is preserved). Symptoms are usually exacerbated by overhead movement of the limb, typically during abduction between 60-120°, which is referred to as a ‘painful arc’ of movement.

Question 27

Which clinical test assesses the function of the infraspinatus muscle and teres minor?

What are the instructions for this and what is the interpretation?

Answer 27

External rotation against resistance

1. Position the patient’s arm with the elbow flexed at 90°and in slight abduction (the abduction tests whether the patient can keep the arm externally rotated against gravity).
2. Passively externally rotate the arm to its maximum.

Interpretation:
Pain on resisted external rotation may suggest tendonitis (infraspinatus/teres minor).

If the arm falls back to internal rotation or there is a loss of power it may suggest a tear in the infraspinatus or teres minor tendon, muscle wasting and/or a lower motor neurone lesion (suprascapular or axillary nerve).

Question 28

How do you assess subscapularis function

Answer 28

Internal rotation against resistance (Gerber’s lift-off test)
This clinical test assesses the function of the subscapularis muscle.

1. Ask the patient to place the dorsum of their hand on their lower back.
2. Apply light resistance to the hand (pressing it towards their back).
3. Ask the patient to move their hand off their back.

Interpretation
If the patient is unable to move their hand off their back this may indicate pathology of the subscapularis muscle (e.g. tendonitis/tear) or a subscapular nerve lesion.

Question 29

Which of the special tests in the shoulder exam doesn’t assess a rotator cuff muscle?

Give the instructions and interpretation

Answer 29

The scarf test assesses the function of the acromioclavicular joint.

1. Passively flex the shoulder joint to 90° and ask the patient to place the hand on the side you are examining on to the contralateral shoulder.
2. Apply resistance to the elbow in the direction of the contralateral shoulder.

Interpretation
If the patient experiences pain the test is considered positive and suggestive of acromioclavicular joint pathology (e.g. osteoarthritis).

Question 30

What further investigations would you do at the end of a shoulder exam

Answer 30

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).

Question 31

What are common shoulder bone fractures

Answer 31

Fractures of shoulder bones can include clavicular fractures, scapular fractures, and fractures of the upper humerus.