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 for

• Skin changes (e.g. erythema that may indicate septic arthritis*)
• Scars (i.e. previous surgery)
• Swelling (suggesting potential joint effusion*)

*As the shoulder is a deep structure, both skin changes from erythema and joint swelling from effusions are not always apparent

Palpation

• Check temperature
  • Compare both sides
• Feel for muscle bulk
  • Especially the deltoid, supraspinatous, and infraspinatous
• Feel for bone and joint tenderness, working systematically from medial to lateral:
  • SCJ → clavicle → ACJ → coracoid process → acromion process → scapular spine → greater tuberosity of the humerus

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
  • Internal rotation (hands behind back) and 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 Gerber’s ‘Lift Off’ test)
    • Hand placed in the small of the back with palm facing outwards and attempt to push against examiners hand
  • Infraspinatus
    • Assess resisted external rotation. Ask the patient to tuck their elbows into sides and externally rotate their forearm against your hand
  • Teres Minor (by ‘Hornblowers tests’)
    • Abduct the shoulder to 90 degrees and flexing elbow to 90 degrees and attempting to externally rotate against resistance

Special Tests

• ‘Painful Arc’ test (positive in supraspinatous tendinopathy, subacromial bursitis, and ACJ osteoarthritis)
  • When the patient abducts their shoulder, the pain is worst during the middle arc
• Scarf Test (positive in 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
• Hawkins-Kennedy test (positive in shoulder impingement)
  • Flex the shoulder to 90^owith the elbow flexed to 90^o. Internally rotate the shoulder – pain is indicative of impingement.
• Neer test (positive in for shoulder impingement)
  • Maximally internally rotate the shoulder and the passively forward flex it. Pain is indicative of impingement.
• Winging of the scapula (positive in 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.