Shoulder examination

Shoulder examination

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HISTORYIt is important to bear in mind the following points when performing a shoulder examination:

Age of the patient

Younger patients - shoulder instability and acromioclavicular joint injuries are more prevalent

Older patients - rotator cuff injuries and degenerative joint problems are more common

Mechanism of injury

Abduction and external rotation - dislocation of the shoulder

Direct fall onto the shoulder - acromioclavicular joint injuries

Chronic pain upon overhead activity or at night time - rotator cuff problem.

CLINICAL EXAMINATIONFollow thescheme 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 knowif anything you do is uncomfortable

Remember - always watch the patients face

InspectionGeneral observation Does the patient look well?

Does the patient suffer from any obvious medical conditions?

Hands (Rheumatoid arthritis?)

Patient StandingRemember to inspectfromthe front, side and above:

Skin

Scars

Bruising

Skin changes

Sinuses

Inflammation

Asymmetry - supraclavicular fossa

Muscle wasting

Especially of the deltoid (disuse or axillary nerve palsy)

Periscapular muscles (supraspinatus and infraspinatus)

Deformity

Sternoclavicular (SCJ) (prominent - subluxation)

Acromioclavicular (ACJ) joint (prominent - subluxation or osteoarthritis)

Clavicle (old fractures)

Shoulder dislocation

Popeye muscle (rupture of proximal portion oflong head of biceps)

Swelling of the joint

Axilla

From behind, lookfor:

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)

PalpationAsk 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

MovementsBefore examining shoulder movements, it is important to examine the cervical spine first:

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

Extension - "Canyoulook up at the ceiling?

Rotation - "Can you look over the shoulder?" Test both sides

Lateral Flexion - "Can you bring your left ear toyour left shoulder?" "Can you bring your right ear toyour right shoulder?"

Test active then passive movements

Quick screening test "Arms above the head and behing the back"

Activemovements 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 themstraight?"

Adduction(0-50o )- "Can you bringyour 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 movementsRepeat themovements again.

When testingabduction and adduction passively, stabilise the scapula so thatmovement at the gleno-humeral joint is noted. For all movements, check for crepitaton.

Testing StrengthThere 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 thearms 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 longhead 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 PathologySubacromial Impingement Hawkin's test: Shoulder flexed to90o, 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 theirpalms flat and their fingers pointing downwards.

Acromioclavicular joint Scarf test: Forced cross body adduction in 90oof flexion, with painat the extreme of motion over the ACJ beingindicative of ACJ pathology.

Finally Check the distal neurovascular suppy and reflexes (biceps (C5-C6) and triceps (C7) tendons).