Shoulder Examination

Question 1

Introduction

Answer 1

Wash hands, PPE

My name is An, I’m a 4th year medical student
May I confirm your name and DOB?

I’ve been asked to conduct a shoulder examination. I’ll look, feel and move your shoulder. Will this be ok?

Do you have any questions for me?
Do you have any pain in your shoulders?

Would you be able to stand for me?

Question 2

General inspection

Answer 2

Bedside
-slings
-prescriptions - analgesia

Patient
-habitus - obesity
-scars
-muscle wasting - disuse atrophy from joint pathology, LMN lesion

Question 3

Anterior, lateral inspection - shoulder and upper limb

Answer 3

Scars, bruises - past trauma, surgical Hx
Asymmetry of shoulder girdle - scoliosis, arthritis, fractures, dislocation
Swelling - effusion, inflammatory arthropathy, dislocation

Abnormal bony prominence - fractures (clavicular, GHJ dislocation?)
Deltoid wasting - disuse atrophy, axillary nerve injury

Question 4

Posterior inspection - shoulder and upper limb

Answer 4

Scars - past trauma, surgery

Trapezius muscle asymmetry - disuse atrophy, CN11 nerve lesion
Supraspinatus, infraspinatus asymmetry - muscle wasting from a chronic rotator cuff tear, suprascapular nerve lesion

Press wall with both hands - winged scapula (thoracic nerve injury)

Question 5

Palpation - general

Answer 5

Temperature
-tenderness, swelling - septic/inflammatory arthritis?

Question 6

Palpation - shoulder joints and bony prominences

Answer 6

Sternoclavicular joint
Clavicle
Acromioclavicular joint
Acromion
Coracoid process of scapula
Head of humerus
Greater tubercle of humerus
Spine of scapula and borders

Question 7

Move - active

Answer 7

Screening
EXT ROTATION + ABD - hands behind head, push elbows back

INT ROTATION + ADD - hands behind back, with hands going as far as you can up spine

If needed
FLEX - raise arms forward until they’re pointing to the ceiling
EXT - stretch out arms behind them

ABD - raise arms out to sides until hands touch above their head
ADD - straight arms, across front of body to the opposite side

EXT ROT - elbows at 90deg, move forearms to the sides
INT ROT - elbows at 90deg, move forearms across body

SCAPULAR - palpate inferior pole of scapula
-abduct shoulder => GHJ should move 50-70deg before scapula does

Question 8

Passive movement - if abnormalities found on active

Answer 8

Repeat the above movements passively
-crepitus, pain

Adhesive capsulitis - significant reduction in active and passive movement. palpation not painful
Axillary nerve palsy - from shoulder dislocation
-lost sensation over regimental patch
-deltoid weakness

Question 9

Special tests

Answer 9

Supraspinatus/empty can - supraspinatus weakness/impingement from tear?
-abduct arms and forward by 30deg
-INT ROT arm so thumb faces floor
-push down on arm whilst patient resists

Painful arc - inpingement/supraspinatus tendonitis
-passive ADB to maximal point
-ask patient to slowly lower arm to neutral
Positive - pain at 60-120deg

External rotation against resistance - infraspinatus, teres minor
-passive ABD test
Pain on resisted EXT ROT - tendonitis?
Passive return to INT ROT or loss of power - tear/wasting/LMN lesion in suprascapular or axillary nerve?

Internal rotation against resistance - subscapularis
-patient to place dorsum of hand
-apply resistance to hand, ask patient to move hand off their back
Unable to move hand - subscapularis issue/subscapular nerve lesion

Scarf test - acromioclavicular joint
-passive flexion of shoulder to 90deg, ask patient to place hand on contralateral shoulder
-resistance on elbow in direction of other shoulder
Pain - ACJ pathology

Question 10

Further assessments

Answer 10

NV exam of upper limb
Examine joints above and below (cervical spine, elbow joint)
Imaging if needed - Xray, MRI