Examination: Shoulder

There are 6 main concepts that need to be remembered for ALL of the regional examination of the musculoskeletal system:

1. Position – always position your patient as you would like to examine them before you begin
2. Look – inspect and observe the patient and around the patient's bedside
3. Feel – for example, feeling a joint to see if it is hot or swollen
4. Move – actively (the patient moves the joint) then passively (you do the movements for them)
5. Function – can the patient move their joints in order to complete day to day tasks?
6. Special tests – if applicable

• Standing up

• Inspect front, sides and back
• For muscle bulk, asymmetry
• Redness or rashes, scars from previous shoulder surgery

• For warmth of shoulder, swelling, tenderness
• Palpate from the sternoclavicular joint -> clavicle -> choroid process -> acromioclavicular joint -> glenohumeral joint -> deltoid muscle -> spine of scapula -> muscle bulk above and beneath the spine of scapula (supra and infra spinatus)

• Actively:
  • Flexion, extension, abduction, adduction, internal (move hands up the back – normal is mid-thoracic reach) and external rotation
  • Then ask patient to abduct, internally and externally rotate under your force
• Pain on internal rotation suggests subscapularis pathology
• Pain on external rotation suggests infraspinatus pathology
• Pain on abduction suggests supraspinatus pathology
• The patient is positioned sitting with arms straight out, elbows locked, thumbs down, and arm at 30 degrees (in scapular plane). The patient should attempt to abduct his arms against the examiner's resistance
• Passively:
  • Flexion, extension, abduction, adduction, internal and external rotation
  • N.B.: In rotator cuff injury, active ROM is limited, but passive ROM is full. In frozen shoulder, both active and passive ROM is limited
  • When assessing passive movement, hold shoulder and feel for crepitus

• Hand to mouth

• Scarf test
  • Ask patient to put one hand on opposite clavicle. Pain suggests AC pathology
• Apprehension Test
  • Have the patient in the supine position, with the arm abducted 90 degrees and elbow flexed. Rotate the shoulder externally by pushing the forearm posteriorly. If patient feels instability, they typically will balk when the test is performed
• Laxity test
  • Have the patient in the supine position. Stabilize the scapula, and slide the humeral head anteriorly and posteriorly within the glenoid fossa to evaluate the stability of the joint. Note the axial load being applied to the elbow.
• Impingement test
  • Position the patient sitting. Internally rotate the arm with the thumb facing downward, and abduct and forward flex the arm. If impingement is present, the patient will experience pain as the arm is abducted

The complete examination of the musculoskeletal system includes:

• Examination of the hand and wrist
• Examination of the elbow
• Examination of the shoulder
• Examination of the spine
• Examination of the hip
• Examination of the knee
• Examination of the ankle and foot

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