Shoulder examination

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Introduction

  • Wash Your hands
  • Introduce yourself by name and role
  • Check the patient’s identity – name and Date of Birth
  • Explain the procedure – why you need to do it and what does it involve
  • Ask for consent
  • Expose the patient appropriately
  • Check if the patient is currently in any pain
How to Introduce Yourself

“Good morning, my name is .. and I am a medical student. Can I just check your name and date of birth?

– I have been asked to do an examination on your shoulder, which would involve me looking, feeling and moving the shoulder joint. Is that okay?

-For the purposes of this examination would you mind removing your shirt?

– And before I start, can I just check whether you are in any pain?”

Bedside Inspection

  • Bedside examination paraphernalia of MSK conditions 
  • Observe the patient by standing at the end of the bed.
  • Comment on whether the patient is ABC:

A – Alert         B – (normal) Body habitus         C – Comfortable at rest

  • Observe the surroundings and comment about objects of note 

Describe the objects or items around a patient’s bedside that will give you an idea into the condition that they might have. It is important to highlight this to the examiner as this can give you many clues about the patient’s underlying diagnosis. Things to look for include

  • Medication – can you see any medication on the patient’s bedside e.g. pain relief?
  • Mobility aids – gives an idea about the functional status of the patient.

     

    Observation

    Action: Ask the patient to stand upright with their arms by their side. Observe them from the front, side and back for any signs of musculoskeletal disease.

    FROM THE FRONT:

    Assess for:

    –> Scars: examine for any scars indicating a potential prior surgery. 

    –> Asymmetry of shoulder girdle:  This could be due to a spinal problem (scoliosis) or due to problems with the shoulders.

    –> Swellings: The shoulder can be swollen due to trauma or an inflammatory arthritis

    –> Deltoid wasting: This is indicative of damage to the axillary nerve which innervates the deltoid muscle.

    –> Abnormal shoulder position: In a shoulder dislocation the shoulder will likely be held in an internally or externally rotated position. 

    FROM THE SIDE:

    Assess for:

    –> Scars: Indicative of previous shoulder surgery

     

     FROM THE BACK:

    Assess for:

    –> Scoliosis: a sideways curvature of the spine.

    –> Muscle bulk of trapezius:  Decreased bulk is a sign of sarcopenia. 

    –> Winging of scapula: This is when the scapula protudes outwards due to damage to the long thoracic nerve which innervates serratus anterior. 

     

    Feel

    Action: Check for pain first and start on the normal side

    Assess for:

    –> Temperature: Using back of hands, check temperature medially and laterally by patting down both legs. Compare shoulders against each other: increased temperature in inflammation

     

    Action: Assess the shoulder girdle

    – Feel sternoclavicular joint –> along the clavicle –> acromio-clavicular joint 

    Palpate coracoid process – 2cm inferior and medial to clavicular  

    Feel head of humerus –>  greater then lesser tuberosity 

    Work around the glenohumeral joint  

    Start from spine of scapula working upwards back to the acromio-clavicular joint  

    • Assess the muscle bulk of supraspinatus, infraspinatus and deltoid 
    • Ask patient to flex the biceps and feel tendon –> feel for biceps tendonitis.  

     

    Move

    ACTIVE MOVEMENT:

    Action: Ask patient to raise arm keeping it straight 

    –> Flexion: ask patient to raise arms forward (normal to 180 degrees.) 

    –> Extension: ask patient to swing arms back (normal 65 degrees.) 

    –> Abduction: raise each up sideways (separately). Ensure you hold inferior pole of scapula. High arc pain (arthritis), middle arc (rotator cuff pathology.) 

    –> Adduction: move arms across body (50 degrees.) 

    –> External rotation: place patients arms flexed to 90 degrees, then turn outwards (affected by frozen shoulder.) 

    –> Internal rotation: place hand on back and reach up as far as possible.

    PASSIVE MOVEMENT:

    Ask patient to relax and allow you to move the joint freely taking the weight, whilst feeling for crepitus.  

    Assess for:

    –> Passively assess flexion and extension 

    –> Abduction and Adduction

    –> External Rotation

    –> Internal rotation (in front of chest this time) 

     

    Special tests

    Supraspinatus: 

    – Empty can (= video) test – flex shoulder to 90 degrees, thumbs pointing down, bend elbow slightly, try and resist downward movement placed on their ulnar. Tests for weakness or impingement of the supraspinatus tendon. 

    Infraspinatus: 

    – Resisted external rotation in neutral adduction. If pain may suggest infraspinatus tendonitis 

    Teres Minor: 

    – Position the arm in 90 degrees of abduction and bend the elbow to 90 degrees. 

    – Passively externally rotate the shoulder to its maximum degree. 

    Subscapularis: 

    – Ask the patient to place the dorsum of their hand on their lower back. 

    – Apply light resistance to the hand (pressing it towards their back). 

    – Ask the patient to move their hand off their back. 

    – An inability to do this (loss of power) indicates pathology of the subscapularis (e.g. tendonitis/tear). 

    Scarf Test: 

    – Put patient hand over the contralateral shoulder. Pain over ACJ indicates osteoarthritis 

    Thank the patient and wash your hands again.

     

    On Completion

    You must remember that the physical examination is only one part of the overall assessment of your patient. Therefore, when completing your exam, state that you would do the following in order to complete your assessment of the patient. Much of this will depend on whether you have discovered any particular findings or have an idea about the overall diagnosis. However, some essential things to talk about are:

    “To complete the examination, I would do a number of steps…”

    Bedside: 

    • (History) Take a full history
    • (Observations) Examine neurovascular state of the shoulder e.g. pulse, sensation, proprioception
    • (Corresponding examination)  Examine joint above and below (cervical spine and elbow)

    Bloods – FBC, inflammatory markers including CRP, rheumatoid factor etc. 

    Imaging – AP and lateral radiographs of the shoulder

    How to Present Your Findings

    “I conducted a shoulder examination on … who seemed well and comfortable at rest.

    • On inspection there were no peripheral signs or paraphernalia of MSK disease
    • There were no visible abnormalities on inspection
    • On palpation, there were no obvious swellings and no tenderness
    • There were normal range of movement on passive and active flexion and extension
    • Special tests were negative 

    In summary, this is a normal examination.”

    Sources

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