Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Shoulder examination
HISTORY
It is important to bear in mind the following points when performing a shoulder examination:
Inspection
Palpation
Movement
Before starting
Introduce yourself
Explain what the examination entails
Ask permission to perform examination
Expose the patient appropriately - from the waist above exposing both the upper limbs, but leaving
the underwear on
Preserve dignity bu using a blanket appropriately
Tell the patient to let you know if anything you do is uncomfortable
Remember - always watch the patients face
Inspection
General observation
Patient Standing
Remember to inspect from the front, side and above:
Skin
o
o
o
Scars
Bruising
Skin changes
o
o
Sinuses
Inflammation
Asymmetry - supraclavicular fossa
Muscle wasting
o Especially of the deltoid (disuse or axillary nerve palsy)
o Periscapular muscles (supraspinatus and infraspinatus)
Deformity
o Sternoclavicular (SCJ) (prominent - subluxation)
o Acromioclavicular (ACJ) joint (prominent - subluxation or osteoarthritis)
o Clavicle (old fractures)
o Shoulder dislocation
o Popeye muscle (rupture of proximal portion of long head of biceps)
Swelling of the joint
Axilla
Palpation
Ask the patient...'Does it hurt anywhere?'
Skin temperature
SCJ to the ACJ (tenderness - dislocations and osteoarthritis) and acromion (tenderness sternoclavicular dislocations, infections (TB), tumours (rare) and radionecrosis)
Greater and lesser tuberosity, feel for rotator cuff defects and cuff tenderness
Gleno-humeral joint: anterior aspect (diffuse tenderness - infection or calcifying supraspinatus
tendinitis)
Biceps Tendon / Bicipital Groove
Coracoid
Spine of Scapula
Vertebral border
Gleno-humeral joint: posterior aspect
Axilla (Humeral shaft and head) - exostoses
Movements
Before examining shoulder movements, it is important to examine the cervical spine first:
Cervical spine
Active movements
Flexion (0-180o ) - "Can you bring your arm forwards as high as they can go?"
Extension (0-60o ) - "Can you being your arms backwards as far as possible?"
Abduction (0-180o ) - "Can you being your arms away from the body, keeping them straight?"
Adduction (0-50o ) - "Can you bring your arm across your body?"
Internal rotation (T4) - "Can you go up your back as high as you can?"
External rotaton (0-70o ) - "Keepng your arms tucked in tight against your body, can your move your
forearms away from you?"
Passive movements
Repeat the movements again.
When testing abduction and adduction passively, stabilise the scapula so that movement at the glenohumeral joint is noted. For all movements, check for crepitaton.
Testing Strength
There examination follows three steps:
"Put it there!"
"Keep it there!"
"Dont let me push it!"
Supraspinatus/anterosuperior cuff
Arm abducted to 20o , in the plane of the scapula, thumb pointing down (Jobe's test)
Resisted external rotation with the arms by side (A Lag test, Patte's test and Hornblower's sign are
other tests that can be used)
Subscapularis/anteroinferior cuff
Push examiner's hand away from 'hand behind back position' (Gerber's lift off test)(Internal
rotation lag sign and Napoleon / LaFosse Belly-Press test are other tests for subscapularis)
Biceps tendon
Subacromial Impingement
Hawkin's test: Shoulder flexed to 90o, elbow flexed to 90o; internal rotation will cause pain
Neer's test: Pain eliminated by local anaesthetic injection into the subacromial bursa
Copeland impingement test: Passive abduction in internal rotation (in the scapula plane) painful;
pain eliminated with passive abduction in external rotation
Winging Scapula
Ask the patient to push against a wall, with their palms flat and their fingers pointing downwards.
Acromioclavicular joint
Scarf test: Forced cross body adduction in 90oof flexion, with pain at the extreme of motion over
the ACJ being indicative of ACJ pathology.
Finally
Check the distal neurovascular suppy and reflexes (biceps (C5-C6) and triceps (C7) tendons).