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Phase 2b Sheffield Medicine > Shoulder Examination > Flashcards

Shoulder Examination Flashcards

1
Q

What should you do before commencing a shoulder exam?

A

● Adequately expose the patient’s upper body and provide a blanket to cover the patient when not being examined.
● Position the patient standing for initial part of the exam
● Ask the patient if they have any pain before proceeding with the clinical examination

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2
Q

What is the first step in a shoulder exam?

A

● General inspection of clinical signs and observation of objects or equipment

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3
Q

What clinical signs should be noted when performing a general inspection in a shoulder exam?

A

● Body habitus
● Scars
● Wasting of muscles

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4
Q

Why is it important to take note of body habitus during a general inspection of a shoulder exam?

A

● Obesity is a significant risk factor for joint pathology due to increased mechanical load (e.g. osteoarthritis).

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5
Q

Why is it important to take note of scars during a general inspection of a shoulder exam?

A

● May provide clues regarding previous upper limb surgery.

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6
Q

Why is it important to take note of wasting of muscles during a general inspection of a shoulder exam?

A

● Suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron lesion.

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7
Q

What objects or equipment may be present when completing a general inspection during a shoulder exam?

A

● Aids and adaptations: support slings are often used to manage shoulder joint pathology.
● Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications (e.g. analgesia).

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8
Q

How would you ask the patient to move so you are able to inspect different views of the shoulder?

A

● Ask the patient to stand and turn in 90° increments as you inspect the upper limbs from each angle for evidence of pathology.

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9
Q

What positions should be inspected when performing a closer inspection of the shoulder during a shoulder exam?

A

● Anterior inspection
● Lateral inspection
● Posterior inspection

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10
Q

What clinical signs should you look out for on anterior inspection during a shoulder exam?

A

● Scars
● Bruising
● Asymmetry of the shoulder girdle
● Swelling
● Abnormal bony prominence
● Deltoid wasting

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11
Q

What would scars be suggestive of when performing an inspection during a shoulder exam?

A

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

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12
Q

What would bruising be suggestive of when performing an anterior inspection during a shoulder exam?

A

● Suggestive of recent trauma or surgery.

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13
Q

What would asymmetry of the shoulder girdle be suggestive of when performing an anterior inspection during a shoulder exam?

A

● May be caused by scoliosis, arthritis, fractures or dislocation.

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14
Q

What would swelling be suggestive of when performing an anterior inspection during a shoulder exam?

A

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

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15
Q

What would an abnormal bony prominence be suggestive of when performing an anterior inspection during a shoulder exam?

A

● May indicate fracture (e.g. clavicular fracture) or anterior dislocation of the glenohumeral joint.

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16
Q

What would deltoid wasting be suggestive of when performing an anterior/lateral inspection during a shoulder exam?

A

● Note any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary nerve injury.

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17
Q

What clinical signs should you look out for on lateral inspection during a shoulder exam?

A

● Scars
● Deltoid wasting

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18
Q

What clinical signs should you look out for on posterior inspection during a shoulder exam?

A

● Scars
● Trapezius muscle asymmetry
● Supraspinatus and infraspinatus asymmetry
● Scoliosis
● Winged scapula

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19
Q

What may trapezius muscle asymmetry be suggestive of when performing a posterior inspection in a shoulder exam?

A

● Suggestive of muscle wasting secondary to disuse atrophy or a spinal accessory nerve lesion.

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20
Q

What may supraspinatus and infraspinatus asymmetry be suggestive of when performing a posterior inspection in a shoulder exam?

A

● Suggestive of muscle wasting secondary to chronic rotator cuff tear or a suprascapular nerve lesion.

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21
Q

What is scoliosis?

A

● Lateral curvature of the spine that may be congenital or acquired.

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22
Q

Describe how may you assess for a winged scapula in a shoulder exam?

A

● 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.

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23
Q

What would the steps be following a closer inspection in a shoulder exam?

A

● Feel and compare the temperature of the shoulder joint
● Palpate the shoulder joint across the girdle

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24
Q

Describe how you would assess the temperature of the joint during a shoulder exam?

A

● Assess and compare shoulder joint temperature using the back of your hands.

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25
Q

What may increased temperature of the shoulder joint indicate during a shoulder exam?

A

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

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26
Q

What landmarks of the shoulder would you palpate during a shoulder exam?

A

● Sternoclavicular joint
● Clavicle
● Acromioclavicular joint
● Acromion
● Coracoid process of the scapula
● Head of the humerus
● Greater tubercle of the humerus
● The spine of the scapula

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27
Q

What is the sternoclavicular joint?

A

● The joint between the sternum and the clavicle.

28
Q

What is the acromioclavicular joint?

A

● The joint between the acromion and the clavicle.

29
Q

What is the acromion?

A

● Continuation of the scapular spine and the most superolateral bony prominence of the shoulder.

30
Q

Where would you palpate the coracoid process of the scapula?

A

● A small hook-like bony prominence located 2cm inferior and medial to the clavicular tip.

31
Q

Where would you palpate the greater tubercle of the humerus?

A

● Located slightly anterolateral to the head of the humerus.

32
Q

When you move onto the ‘move’ section of a shoulder exam, should you perform the exam on one or both arms?

A

● The shoulder joint of each arm should be assessed and compared.
● If the patient is known to have an issue with a particular shoulder, you should assess the ‘normal’ shoulder first for comparison.

33
Q

What is active movement?

A

● Active movement refers to a movement performed independently by the patient.

34
Q

What is passive movement?

A

● Passive movement refers to a movement of the patient, controlled by the examiner.

35
Q

What compound movements can be used as a screening during a shoulder exam?

A

● External rotation and abduction of the shoulder joint - hands behind back of their head.
● Internal rotation and adduction of the shoulder joint - each hand behind their back and place their hands as high as they can go.

36
Q

What movements should you ask the patient to perform during the active movement component of a shoulder exam?

A

● Active shoulder flexion
● Active shoulder extension
● Active shoulder abduction
● Active shoulder adduction
● Active external rotation
● Active internal rotation
● Scapular movement

37
Q

What is the normal range of movement for active shoulder flexion

A

● 150°- 180°

38
Q

How would you instruct a patient to flex their shoulders?

A

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

39
Q

What is the normal range of motion for active shoulder extension?

A

● 40°

40
Q

How would you instruct a patient to extend their shoulders?

A

● Ask the patient to stretch out their arms behind them.

41
Q

What is the normal range of motion for active shoulder abduction?

A

● 180°

42
Q

How would you instruct a patient to abduct their shoulders?

A

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

43
Q

What is the normal range of movement for active shoulder adduction?

A

● 30°- 40°

44
Q

How would you instruct a patient to adduct their shoulder?

A

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

45
Q

What is the normal range of motion for active internal rotation of the shoulder?

A

● 80° – 90°

46
Q

How would you instruct a patient to internally rotate their shoulder?

A

● Ask the patient to keep their elbows by their sides flexed at 90° whilst they move their forearms inwards across their body.

47
Q

What is the normal range of motion for active external rotation of the shoulder?

A

● 80° – 90°

48
Q

How would you instruct a patient to externally rotate their shoulder?

A

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

49
Q

How would you assess active scapular movement during a shoulder exam?

A

● 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.

50
Q

What causes axillary nerve palsy and what are the features?

A

● 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).

51
Q

What rotator cuff muscle does Jobe’s test (empty can test) assess the function of?

A

● This clinical test assesses the function of the supraspinatus muscle.

52
Q

Describe how you would perform Jobe’s test during a shoulder exam?

A
  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.
53
Q

How would you interpret Jobe’s test during a shoulder exam?

A

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

54
Q

What rotator cuff muscle does the painful arc test assess for impingement of?

A

● This clinical test assesses for impingement of supraspinatus.

55
Q

Describe how you would perform the painful arc test during a shoulder exam?

A
  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.
56
Q

How would you interpret the painful arc test during a shoulder exam?

A

● Impingement or supraspinatus tendonitis typically causes pain between 60-120° of abduction.

● NOTE. 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.

57
Q

What rotator cuff muscle does external rotation against resistance assess the function of?

A

● This clinical test assesses the function of the infraspinatus muscle and teres minor.

58
Q

Describe how you would perform external rotation against resistance in a shoulder exam?

A
  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.
59
Q

How would you interpret pain on resisted external rotation during a shoulder exam?

A

● 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 neuron lesion (suprascapular or axillary nerve).

60
Q

What rotator cuff muscle does Gerber’s lift off test assess the function of?

A

● This clinical test assesses the function of the subscapularis muscle.

61
Q

Describe how you would perform Gerber’s lift off test in a shoulder exam?

A
  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.
62
Q

How would you interpret Gerber’s lift off test during a shoulder exam?

A

● 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.

63
Q

What rotator cuff landmark does the scarf test assess the function of?

A

● The scarf test assesses the function of the acromioclavicular joint.

64
Q

Describe how you would perform a Scarf test during a shoulder exam?

A
  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.
65
Q

What would a positive Scarf test be and what would this potentially indicate?

A

● If the patient experiences pain the test is considered positive.
● Suggestive of acromioclavicular joint pathology (e.g. osteoarthritis).

66
Q

What further assessments and investigations could be performed after a shoulder exam?

A

● 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).

Phase 2b Sheffield Medicine (17 decks)

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