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Shoulder examination
HISTORY
It is important to bear in mind the following points when performing a shoulder examination:

Age of the patient


o Younger patients - shoulder instability and acromioclavicular joint injuries are more
prevalent
o Older patients - rotator cuff injuries and degenerative joint problems are more common
Mechanism of injury
o Abduction and external rotation - dislocation of the shoulder
o Direct fall onto the shoulder - acromioclavicular joint injuries
o Chronic pain upon overhead activity or at night time - rotator cuff problem.
CLINICAL EXAMINATION

Follow the scheme below:

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

Does the patient look well?


Does the patient suffer from any obvious medical conditions?
Hands (Rheumatoid arthritis?)

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

From behind, look for:

Rotator cuff wasting


Scapula normmaly shaped and situated (Sprengel's shoulder, Klippel-Feil syndrome)
Webbing of the skin at the root of the neck (Klippel-Feil syndrome)
Winging of the scapula (paralysis of the serratus anterior muscle due to long thoracic nerve palsy)

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

Flexion - "Can you bring your chin to your chest?"


Extension - "Can you look up at the ceiling?
Rotation - "Can you look over the shoulder?" Test both sides
Lateral Flexion - "Can you bring your left ear to your left shoulder?" "Can you bring your right ear
to your right shoulder?"

Test active then passive movements

Quick screening test

"Arms above the head and behing the back"

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)

Intraspinatus + teres minor / posterior cuff

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

Check for rupture of long head of biceps tendon


Supinated arm flexed forwards against resistance pain felt in the bicipital groove indicates biceps
tendon pathology (Speed's test) (Yergason's test and AERS test are other tests for biceps tendon)

Special Tests according to Pathology

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).

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