Shoulder examination

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent
• Expose upper body (but leave bra on in women)
• General inspection: patient, e.g. age, pain/discomfort, signs of trauma; around bed, e.g. mobility aids, sling

Look

You should inspect from the front, sides and behind:

• Deformities of joint/bones/alignment (abducted and externally rotated shoulder = anterior dislocation; adducted and internally rotated shoulder = posterior dislocation)
• Skin: scars, sinuses, swelling around joints
• Muscles: deltoid wasting, scapular winging

Feel

Ask about any pain and then start by examining the normal side.

• Skin: palpate general area for temperature and soft tissue swelling/tenderness
• Bony landmarks: run hand from sternoclavicular joint along clavicle to acromioclavicular joint; acromion process; then feel over the greater tuberosity of the humerus and around the glenohumeral joint. Next feel the spine of the scapula, then around its inferior part back to the acromioclavicular joint. Watch the patient’s face for tenderness.
• Muscle bulk: supraspinatus, infraspinatus, deltoid
• Tendons: look for biceps ‘Popeye’ sign/lump (biceps tendon rupture); flex elbow and feel long head of biceps tendon in bicipital groove while internally and externally rotating shoulder (painful = tendinopathy; check tendon is in groove and there is no subluxation); push arm posteriorly and feel the supraspinatus attachment at the greater tubercle just laterally

Move

Test active movements first, demonstrating them yourself beforehand:

• Forward flexion (180˚): raise straight arms forward 
• Extension (60˚): extend straight arms backward
• Abduction (180˚): raise each straight arm up sideways separately

If there’s pain on abduction

Note at what angle it occurs:

Pain at end of abduction = acromioclavicular joint pathology, e.g. arthritis
Middle arc pain (60-120 degrees) = rotator cuff pathology

Passive movements will also help determine cause:

No pain on passive movement = muscular
Still painful on passive movement = mechanical/joint

• Adduction (45˚): move straight arms across front of body in opposite direction 
• External rotation (80˚): flex patient’s elbows to 90˚ anteriorly, with their elbows fixed against their torso. Then ask them to turn their forearms outwards (external rotation lost early to <30˚ in adhesive capsulitis).
• Internal rotation: ask patient to place their hands on their lower back then move them upwards to try to touch their shoulder blades (normal = can touch base of scapula, i.e. T6/7)
• PASSIVE MOVEMENTS: from behind, hold the patient’s shoulder with one hand and their wrist with the other, then move their arm in all directions passively (feel for crepitus at acromioclavicular and glenohumeral joints)

Special tests

Serratus anterior

Patient should press hands on wall and lean forwards – look for scapula winging

Deltoid (C5/6, axillary nerve)

Abduct shoulder against resistance at 90˚

Supraspinatus

Resisted ‘empty can’ test: patient should slightly forward flex their shoulder with their elbow extended, and pronate wrist (‘empty a can of coke’); then ask them to push their wrist upwards against resistance

Infraspinatus / teres minor

Resisted external rotation: arm in neutral position for infraspinatus; arm in 90˚ abduction for teres minor

Subscapularis

Patient should place the dorsum of their hand over their lumbar spine; then move hand away posteriorly

Neer’s impingement test

From behind, stabilise the scapula with one hand, and use the other hand to internally rotate the patient’s straight arm and passively forward flex it as high as possible. Pain is a positive test (impingement syndrome).

Hawkins test

Patient should forward flex their shoulder to 90˚, pronate hand (‘empty a can of coke’) and flex elbow medially to 90˚. Now passively internally rotate shoulder (push their wrist downward while holding patient’s elbow steady). Pain is a positive test (impingement syndrome).

Apprehension test

Ask patient to hold hand out like a ‘high five’, then pull back elbow and push proximal humerus forward. Positive if patient shows fear of instability (shoulder stabilisation problems, i.e. dislocation or subluxation).

Scarf acromioclavicular joint test

Position patient’s hand over their opposite shoulder and push their elbow posteriorly (pain = acromioclavicular joint pathology)

Function

• SCREENING: test getting hands behind head and behind back 

To complete

• Thank patient and restore clothing
• ‘To complete my examination, I would examine the cervical spine and elbows, and perform a distal neurovascular examination.’
• Summarise and suggest further investigations you would consider after a full history

Common shoulder pathology

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Here’s some viva questions for you

A patient presents with a winged scapula. Which nerve is most likely to be damaged?

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What are the four rotator cuff muscles?

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Please discuss the management options for adhesive capsulitis

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What is shoulder dystocia and which palsies may complicate this?

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And a practice station

1. Shoulder examination
2. Find more OSCE stations here