Examination of the Shoulder Joint

Introduction

  • Introduce yourself to the patient
  • Wash your hands
  • Briefly explain to the patient what the examination involves
  • Ask the patient to remove their top clothing, exposing the shoulders fully
    • Offer the patient a chaperone, as necessary

Always start with inspection and proceed as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by the examiner.


Inspection

  • Assess symmetry, scars, or deformity
    • Scars may indicate previous surgery
    • Deformities may be caused by dislocation or previous trauma
  • Assess skin changes
    • Septic arthritis will should erythematous skin overlying the joint
  • Assess muscle bulk
    • Loss of muscle bulk can show long-standing neuromuscular damage

Palpate

  • Check temperature around the joint
    • Compare both sides
  • Feel for muscle bulk
    • Especially the deltoid, supraspinatous, and infraspinatous
  • Feel for bone and joint tenderness, working systematically through the joint
    • Sternoclavicular Joint, Clavicle, Acromioclavicular Joint, Acromion, Coracoid Process, Scapular Border, Spine of the Scapula, Glenohumeral Joint, Humeral Head, and the Humeral Tuberosities

Movement

  • Check active movements
    • Flexion and Extension
    • Abduction and Adduction
      • Observe the patient from the back to note symmetry and smoothness of scapula-thoracic movements
    • Medial/internal Rotation (hands behind back) and Lateral/external Rotation (hands behind head)
  • Assess rotator cuff muscles
    • Supraspinatous by ‘Empty Can Test’
      • Shoulder flexed forwards to 90 degrees and slightly abducted with internal rotation so that thumb is pointing to the ground (as if emptying a can) and attempt to continue bringing the arm up against resistance
    • Subscapularis by ‘Lift Off Test’
      • Hand placed in the small of the back with palm facing outwards and attempt to push against examiners hand
    • Infraspinatous
      • Tuck the elbows into sides and opposing resistance of lateral rotation
    • Teres Minor
      • Abduct the shoulder to 90 degrees and flexing elbow to 90 degrees (the ‘halting policeman’ position) and attempting to externally rotate against resistance

Special Tests

  • Painful Arc Test (positive in supraspinatous tendinopathy, subacromial bursitis, and ACJ osteoarthritis)
    • Pain worst during the middle arc of shoulder abduction
  • Scarf Test (assesses for ACJ osteoarthritis)
    • Ask the patient to place the hand of the side you are examining on the contralateral shoulder and then push the elbow superiorly to compress the acromium against the lateral end of the clavicle
  • The Hawkins-Kennedy test (assesses for shoulder impingement)
    • Abduct the arm to 90o with the elbow flexed to 90o and point the arm upwards (the halting policeman position). Warn the patient and then quickly internally rotate the arm to bring the greater tuberosity of the proximal humerus up and narrow the subacromial space, with sharp subacromial pain positive for shoulder impingement
  • Winging of the scapula (assesses for long thoracic nerve palsy)
    • Get the patient to push hand against a wall whilst standing and look for lifting of the scapula off the thoracic wall due to weak serratus anterior muscle

Complete the Examination

Thank the patient and allow them to redress. Remember, if you have forgotten something important, you can go back and complete this.

State to the examiner that to complete your examination you would also like to examine the joint above and below (elbow and cervical spine), the contralateral shoulder, and reviewing any relevant imaging available.

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