Shoulder examination

Question 1

What is the first part of any introduction to an examination?

Answer 1

Wash hands
Intro self
Pt details

Question 2

Explain a shoulder exam to a patient

Answer 2

I’ve been asked to examine your shoulder today, it’s going to involve me having a general inspection, feel, asking you to perform some movements and then performing some special tests, would that be okay?

Question 3

What else would you include in your intro?

Answer 3

Expose ok?
Chaperone?
Pain or discomfort?

Question 4

When inspecting the bedside what are you looking for?

Answer 4

Any aids or adaptations -> sling.

Question 5

When inspecting from the front what are you looking for?

Answer 5

Scars -> Previous surgery/trauma.

Asymmetry of the shoulder girdle –> Scoliosis / Arthritis / Trauma = Clavicular/humeral fracture and anterior
dislocation of the humeral head.
Bony prominence ->
- Sternoclavicular joint
- Acromioclavicular joint.

Swelling –> Inflammatory joint disease/effusion/anterior dislocation.

Muscle wasting –> Deltoids = Axillary nerve injury
(traumatic/iatrogenic).

Question 6

When inspecting from the side what are you looking for?

Answer 6

Scars -> Previous surgery/trauma.

Question 7

When inspecting from the back what are you looking for?

Answer 7

Scars -> Previous surgery/trauma.

Asymmetry/deformity –> Winged scapula = Long thoracic
nerve injury.
Scoliosis.

Paravertebral muscles –> Swelling/wasting.

Look for muscle wasting in the supra and infraspinatus fossa –> Wasting of supra or infraspinatus (nerve
injury/chronic rotator cuff tear).

Question 8

How do you assess for a winged scapula?

Answer 8

Get the patient to put hands fully extended against wall.

Question 9

What do you feel in a shoulder exam?

Answer 9

Assess temperature of shoulder joints

Palpate the various components of the shoulder girdle noting any swelling/tenderness

Palpate the muscle bulk the shoulder muscles

Question 10

What are the components of the shoulder girdle?

Answer 10

Sternoclavicular joint (SCJ).

Clavicle.

Acromioclavicular joint.

Glenohumeral joint (anterior/posterior joint line).

Coracoid process (2cm inferior and medial to the clavicular tip)

Head of humerus.

Greater tuberosity of humerus.

Spine of scapula.

Question 11

What muscles do you palpate in a shoulder exam?

Answer 11

Deltoid.

Supraspinatus.

Infraspinatus.

Trapezius.

Question 12

What types of movement do you assess in a shoulder exam?

Answer 12

Compound, active and passive

Question 13

What compound / screening movement do you assess?

What instructions do you give to the patient?

Answer 13

EXTERNAL ROTATION + ABDUCTION =
Ask the patient to put their hands behind their head + push their elbows back as far as they can

INTERNAL ROTATION + ADDUCTION
Ask the patient to put their hands behind their back and push back
- Look for any difficulty, limitation or pain on movement.
- How far can they reach up the back.

Question 14

What active movement do you assess?

What instructions do you give to the patient?

Answer 14

External rotation –
Flex the elbow to 90° and tuck it into patient’s side, ask them to rotate the arm outwards;

Internal rotation –
Flex the elbow to 90° and tuck it into patient’s side, ask them to rotate the arm inwards.

Flexion + extension –
Ask the patient to raise arms in front and behind them.

Abduction/adduction (check painful arc) –
Ask patient to raise their arm to the side, palm downwards + then lower.
Normal movement is 180°
Bring the arms across each other for adduction.
Observe from both in front and behind for symmetrical scapula movement + pain.
Assess glenohumeral movement + scapulothoracic movement.

Question 15

What is the first movement lost in frozen shoulder?

Answer 15

External rotation

Question 16

Where is their usually pain in rotator cuff pathology?

How may it be alleviated?

Answer 16

60–120°

Repeating with palm facing upwards

Question 17

What may indicate ACJ arthritis?

Answer 17

Pain only occurring at the end of the movement (120–180°)

Question 18

What passive movements are assessed?

What should you do?

Answer 18

External/internal rotation.
Flexion/extension.
Abduction/adduction.

Feel the shoulder joint for crepitus

Question 19

What screening questions should you ask?

Answer 19

Dress themselves without difficulty?
Wash their own hair?

Question 20

What special tests do you do in a shoulder exam?

Answer 20

Supraspinatus, resisted abduction

Infraspinatus, teres minor, resisted active external rotation.

Subscapularis, resisted internal rotation – “Lift-off test”;

ACJ pathology / scarf test?

Question 21

How do you perform a lift off test?

Answer 21

Ask the patient to place dorsum of their hand behind their lower back.
Apply light resistance to the hand (pressing it towards their back).
Ask the patient to move their hand off their back.
Loss of power indicates subscapularis pathology (tendonitis/tear).

Question 22

How do you perform the scarf test?

Answer 22

Ask patient to put arm across chest to the opposite shoulder.
Note any pain/tenderness over the ACJ.

Question 23

Upon completing the exam what do you do first?

Answer 23

Thank patient
Wash hands

Question 24

To complete my exam…

Answer 24

I’d like to examine the patients cervical spine and elbow joints and perform a full neurological and vascular examination of the patient’s upper limbs

Question 25

Summarise a normal shoulder exam.

Answer 25

Today, I examined ____ a ___ y/o ____.

On general inspection, _____ appeared comfortable at rest.

No abnormalities were detected on inspection.

On palpation, there was no tenderness.

Full range of movement in all modalities tested.

Special tests were negative.

To conclude, this is consistent with a normal shoulder examination