Shoulder Examination

Introduction

• Wash hands

• Introduce yourself

• Confirm patient details – name / DOB

• Explain the examination

• Gain consent

• Adequate exposure - undress from the waist upwards (expose the shoulders)

• Positioning - stood up is the best position to assess the shoulders

• Check understanding with the patient, ask if they have any question

---

MSK Exam Principals - Look, Feel, Move

• General inspection --> Patient (age/mobility/trauma/risk factors) Bedside (mobility aids, a sling)

• Ask about pain

• Start on the patient's good side

---

Look

From front, sides & behind

• Alignment & posture: asymmetry of shoulders (winged scapula due to long thoracic nerve injury and scoliosis) [Best seen from behind]

• Arm position: rotation (internal = posterior shoulder dislocation)

• Bony prominences: ACJ and SCJ

• Skin : scars, bruising, sinuses,

• Swelling - effusion, anterior dislocation, inflammatory joint disease

• Muscles : wasting (deltoid, supraspinatus, infraspinatus, pectorals) - may be due to axillary nerve injury

• Axilla : lymphadenopathy, large joint effusions

• Muscle wasting in the supraspinatus and infraspinatus fossa – nerve injury / chronic rotator cuff tear

---

Feel STTC (Swelling, Temperature, Tenderness, Crepitations)

REMINDER: Check pain first and start on the unaffected side

• Skin: Palpate the area feeling for temperature & effusions - inflammatory arthropathy/infection

• Bony landmarks: run hand from sternoclavicular joint along clavicle to acromio-clavicular joint. Then over greater and lesser tuberosities and around glenohumoral joint. Next feel spine of scapula then around inferior part back to acromio-clavicular joint.

• Watch patients face for tenderness.

• Muscle bulk: supraspinatus, infraspinatus, deltoid

• Tendons: flex biceps and feel tendon; push arm back and feel just anterior for supraspinatus tendon

• Evidence of wasting: compare sides

Shoulder bone landmarks

---

Move

Screening movements: (if the patient can do these, there may be no need to carry out all movements)

1. Put your hands behind your head – external rotation and abduction

2. Put your hands as far up your back as you can (like unhooking a bra) – internal rotation 

Actively first

• Forward flexion (180˚) : raise arms forward, keep them straight

• Extension (65˚) : swing arms back, keep arms straight

• Abduction (180˚) : lift arms away from the midline/their sides as far as possible

• Adduction (50 ˚) : bring their arms across their trunk to the opposite sides

If any pain, note which angle this occurs at

1. High arc pain = acromio-clavicular pathology e.g. arthritis

2. Middle arc pain = rotator cuff pathology e.g. supraspinatus tendinitis or partial rotator cuff tear

3. Passive movement (no pain = muscular; still painful = mechanical)

• External rotation (70˚) : patient to hold their elbows to their body flexed at 90° and then move their forearms outwards in an arc-like motion

• Internal rotation : patient try to touch their scapula with their fingers behind their back (normal to base of scapula - T6/7)

1. Loss of external rotation = frozen shoulder

PASSIVE MOVEMENTS : hold shoulder and move in all directions passively (feel for crepitus).

Shoulder muscle anatomy

---

Special tests

Supraspinatus assessment – “Empty Can Test”

1. Abduct the arm to 90° and angle the arm forward by ~30 ° (so that the shoulder is in the plane of the scapula).

2. Internally rotate the arm so that the thumb points down toward the floor. Now push down on the arm whilst the patient resists the pressure.

3. Repeat the assessment on the other arm.

• Supraspinatus weakness may represent a tear in the supraspinatus or pain due to impingement.

The painful arc (impingement syndrome)

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/supraspinatus tendonitis typically causes pain between 60-120° of abduction, however this test is not specific.

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.

• Pain on resisted external rotation may suggest infraspinatus tendonitis.

• If the arm falls back to internal rotation or there is a loss of power it may suggest a tear in the infraspinatus tendon or muscle wasting.

Internal rotation against resistance (“Gerber lift-off test”)

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.

4. An inability to do this indicates pathology of the subscapularis

---

To complete exam

• Exam completion - joint above (cervical spine) and joint below (elbow joint), and also do a full neurovascular exam distal to the joint

• Summarise and suggest further investigations you would do after a full history

---

Common shoulder pathology (see our 'clinical cases' section)

• Supraspinatus tendinitis (impingement syndrome)

• Rotator cuff tears

• Frozen shoulder (adhesive capsulitis)

• Idiopathic

• Anterior shoulder instability (dislocation)

• Osteoarthritis
  

---

Questions:

1. Give 3 differentials for shoulder pain?

2. Name an occupational hazard for frozen shoulder

3. Label a shoulder x-ray