Shoulder OSCE Exam Flashcards
What are the first 3 things you should do as part of your introduction?
Wash hands
Introduce yourself
Confirm pt details (name / DOB)
How would you explain the examination?
“Today I need to examine your shoulder joints. This will involve looking, feeling and moving them.”
How would you check your pt’s understanding & gain consent?
“Does everything I’ve said make sense?”
“Are you happy for me to examine your shoulders?”
How would you like to position the pt?
Expose pt’s upper body appropriately.
Position the pt standing.
What should you do before you examine the pt?
Ask if the pt currently has any pain.
What 4 things are you looking for when assessing the pt anteriorly?
Scars: previous surgery / trauma
Asymmetry of the shoulder girdle: Scoliosis / Arthritis / Trauma
Swelling: Inflammatory joint disease / effusion / anterior dislocation
Muscle wasting: Deltoids (axillary nerve injury -> traumatic / iatrogenic??)
What 3 things are you looking for when assessing the lateral aspect of the pt?
Scars: previous surgery / trauma
Muscle wasting: deltoid
Alignment of the shoulder girdle: misalignment - dislocation / scoliosis
What 5 things are you looking for when assessing the posterior aspect of the patient?
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
Look for muscle wasting in the supra- and infra- spinatus fossa: wasting of supra / infraspinatus (nerve injury / chronic rotator cuff tear)
Which muscles are you assessing for wasting when looking from the anterior aspect?
Deltoids
Which muscles are you assessing for wasting when you look from the posterior aspect?
Trapezius
Para-vertebral muscles
Supraspinatus
Infraspinatus
When you feel the shoulder joints, what are the 2 main things you should be doing?
- Assess the temperature of shoulder joints. Warmth suggests inflammatory arthropathy / infection.
- Palpate the various components of the shoulder girdle. Note any swelling / tenderness
What are the 7 components of the shoulder girdle that you should palpate?
Sterno-Clavicular joint Clavicle Acromio-clavicular joint Coracoid process Head of humerus Greater tuberosity of humerus Spine of scapula
What are ‘compound movements’ used for?
Screening.
Compound mvts are used as a rapid screening tool for shoulder joint pathology as they test a number of the rotator cuff muscles in one go.
If pt experiences pain or is unable to perform these mvts, you would then proceed to perform a more detailed examination of the shoulder joint.
What are the 2 compound movements?
What are they testing?
Put your hands behind your head: external rotation & abduction
Put your hands as far up your back as you can: internal rotation & adduction
What type of movement are ‘compound movements’?
Active movement
When conducting a full shoulder examination, what movements should you test first?
Active movement.
How would you assess a pt’s flexion ability?
What is the normal range?
Ask pt to raise their arms forwards until they point upwards
Normal: 150-180o
How would you assess a pt’s extension ability?
What is the normal value?
Ask pt to keep their arms straight and extend them behind them.
Normal = 40o
How would you assess a pt’s ABduction ability?
What’s the normal value?
Ask pt to lift their arms away from their sides as far as possible.
Normal: up to 180o
How would you assess a pt’s Adduction ability?
What’s the normal range?
Ask pt to bring their arms across their trunk to opposite sides.
Normal: 30 - 40o
How would you assess a pt’s external rotation ability?
What’s the normal range?
Ask pt to hold their elbows to their body, flexed at 90o, and then move their forearms outwards in an arc-like motion.
Normal: 80 - 90o
How would you assess a pt’s internal rotation ability?
What’s the average?
With the pt’s elbow flexed at 90o (arm by their side), as them to place their hand behind their back & reach up as far up the spine as they can manage.
Normal average: T4 - T8
How would you assess the movement of the scapula?
- Ask pt to abduct their shoulder.
- Simultaneously palpate the inferior pole of the scapula.
- Assess the degree & smoothness of movement of the scapula
- On average, 50 - 70% of the first movement occurs at the glenohumeral joint.
If glenohumeral joint movement is reduced due to injury / inflammation, how is abduction affected?
The majority of abduction will occur via increased scapula movement over the chest wall.
What instructions should you give your pt when you assess a pt’s passive movements?
Ask pt to fully relax & allow you to move their arm for them.
If they experience pain, they should let you know.
Repeat all active movements passively.
When passively moving a pt’s joint, what should you be feeling for?
Feel for any crepitus during movement of the joint.
What are the 5 ‘Special tests’ for assessing the shoulder joint?
- Jobe’s test (supraspinatus assessment)
- The painful arc (impingement syndrome)
- External rotation against resistance.
- External rotation in abduction
- Internal rotation against resistance (Gerber lift off test)
How would you conduct a supraspinatus assessment (Jobe’s test)?
- Abduct the arm to 90o & angle the arm forward by ~30o (so that the shoulder is in the plane of the scapula).
- Internally rotate the arm so that the thumb points down toward the floor. Now push down on the arm whilst the pt resists the pressure.
- Repeat the assessment on the other arm.
What does ‘Jobe’s test’ test for?
Weakness in the supraspinatus and/or impingement. Weakness may represent a tear in the supraspinatus or pain due to impingement.
How would you assess for impingement of supraspinatus?
The painful arc test:
- Passively abduct the pt’s arm to its maximum point of abduction.
- Ask the pt to lower their arm slowly back to a neutral position.
Where does impingement / supraspinatus tendonitis cause pain between (angles)?
60 - 120o
What is a limitation of the painful arc test?
It is not specific. Many other conditions can cause pain in this arc of motion. The test should not be used in isolation for diagnosis.
Which test assesses the function of infraspinatus?
External rotation against resistance.
Describe how you would assess the function of infraspinatus.
- Position the pt’s arm with the elbow flexed at 90o and in slight abduction. (Abduction tests whether the pt can keep the arm externally rotated against gravity).
- Passively externally rotate the arm to its maximum.
When assessing the function of infraspinatus, you find pain on resisted external rotation. What does this suggest?
Infraspinatus tendonitis.
When assessing the function of infraspinatus, you find a loss of power (or the arm falls back to internal rotation). What does this suggest?
A tear in the infraspinatus tendon OR muscle wasting.
Which test assesses the function of Teres minor?
External rotation in abduction.
How would you assess the function of teres minor?
- Position the arm in 90o of abduction & bend the elbow to 90o.
- Passively externally rotate the shoulder to its maximum degree.
What is a ‘Hornblower’s sign’?
Pathology in teres minor.
When passively externally rotating the shoulder to its maximum degree, the pt is unable to keep the arm in this position (the arm falls back to internal rotation).
Which test assesses the function of the subscapularis muscle?
Internal rotation against resistance
“Gerber lift off test”
How would you assess the function of the subscapularis muscle?
- Ask pt to place the dorm of their hand on their lower back.
- Apply light resistance to the hand (pressing it towards their back).
- Ask the pt to move their hand off their back.
On conducting the ‘Gerber lift off test’, a pt is unable to move their hand off their back. What does this indicate?
Pathology of the subscapularis.
Tendonitis / tear.
To complete the examination, what 3 things are you going to do?
Thank patient (they can now get dressed)
Wash hands
Summarise findings
What further investigations might be required?
- Full neurovascular examination of the upper limbs
- Examine the Cervical spine & elbow joint (the joint above & below)
- Perform further imaging if indicated (eg. X-ray, MRI)
