Examination of the Shoulder Joint - Podcast Version 0:00 / 0:00 1x 0.25x 0.5x 0.75x 1x 1.25x 1.5x 1.75x 2x OSCE Checklist for Examination of the Shoulder Joint 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 90owith the elbow flexed to 90o. 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. Frequent questions What are the key steps in examining the shoulder joint? The examination of the shoulder joint involves inspection, palpation, movement assessment, and special tests. Start with inspecting for skin changes, scars, and swelling, then proceed to palpate the joint and assess active movements. How do you assess the rotator cuff muscles during a shoulder examination? To evaluate the rotator cuff muscles, specific tests are performed: the ‘Empty Can’ test for supraspinatous, the ‘Lift Off’ test for subscapularis, resisted external rotation for infraspinatus, and the ‘Hornblowers’ test for teres minor. Each test checks for strength and function of these critical muscles. What is the significance of the 'Painful Arc' test in shoulder examinations? The 'Painful Arc' test is significant as it helps identify conditions like supraspinatous tendinopathy, subacromial bursitis, and acromioclavicular joint osteoarthritis. Pain during the middle arc of shoulder abduction indicates potential pathology. How can you identify shoulder impingement during a clinical examination? Shoulder impingement can be identified using the Hawkins-Kennedy and Neer tests. Pain during internal rotation in the Hawkins-Kennedy test or forward flexion in the Neer test suggests the presence of impingement. What does winging of the scapula indicate during a shoulder assessment? Winging of the scapula indicates potential long thoracic nerve palsy, which affects the serratus anterior muscle. This condition can be observed when the patient pushes against a wall, causing the scapula to lift away from the thoracic wall. Rate This Article