11/13/24, 7\:10 PM Guide | Shoulder examination

Shoulder examination

Table of contents
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Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Adequately expose the patient’s upper body and provide a blanket to cover the patient when not being examined.
Position the patient standing for initial inspection of the shoulders.
Ask the patient if they have any pain before proceeding with the clinical examination.

Look

General inspection

Clinical signs
Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology\:
Body habitus\: obesity is a signi
Scars\: may provide clues regarding previous upper limb surgery.
Wasting of muscles\: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron lesion.
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Objects or equipment
clinical status\:
Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
Aids and adaptations\: support slings are often used to manage shoulder joint pathology.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications (e.g. analgesia).

Closer inspection of the shoulder

Ask the patient to stand and turn in 90° increments as you inspect the upper limbs from each angle for evidence of pathology.
Anterior inspection
Inspect the anterior aspect of the shoulder joints and upper limbs, noting any abnormalities\:
Scars\: note the location of the scar as this may provide clues as to the patient's previous surgical history or suggest previous
joint trauma.
Bruising\: suggestive of recent trauma or surgery.
Asymmetry of the shoulder girdle\: may be caused by scoliosis, arthritis, fractures or dislocation.
Swelling\: note any evidence of asymmetry in the size of the shoulder joints that may suggest unilateral swelling (e.g.
e
Abnormal bony prominence\: may indicate fracture (e.g. clavicular fracture) or anterior dislocation of the glenohumeral joint.
Deltoid wasting\: note any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary
nerve injury.
Lateral inspection
Inspect the lateral aspect of the shoulder joints, noting any abnormalities\:
Scars\: again look for scars indicative of previous trauma or surgery.
Deltoid wasting\: note any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary
nerve injury.
Posterior inspection
Inspect the posterior aspect of the shoulder joints, noting any abnormalities\:
Scars\: again look for scars indicative of previous trauma or surgery.
Trapezius muscle asymmetry\: suggestive of muscle wasting secondary to disuse atrophy or a spinal accessory nerve
lesion.
Supraspinatus and infraspinatus asymmetry\: suggestive of muscle wasting secondary to chronic rotator cu
suprascapular nerve lesion.
Scoliosis\: lateral curvature of the spine that may be congenital or acquired.
Winged scapula\: ask the patient to push against a wall with both hands spaced shoulder-width apart whilst you inspect the
back. The protrusion of a scapula (known as scapular winging) is suggestive of ipsilateral serratus anterior muscle weakness,
typically secondary to a long thoracic nerve injury.
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Inspect the patient from the front

Feel

Temperature

Assess and compare shoulder joint temperature using the back of your hands.
Increased temperature of a joint, particularly if also associated with swelling and tenderness may indicate septic arthritis or
in

Shoulder joint palpation

Palpate the various components of the shoulder girdle, noting any swelling, bony irregularities and tenderness\:
Sternoclavicular joint\: the joint between the sternum and the clavicle.
Clavicle\: extends between the sternum and the acromion of the scapula.
Acromioclavicular joint\: the joint between the acromion and the clavicle.
Acromion\: a continuation of the scapular spine and the most superolateral bony prominence of the shoulder.
Coracoid process of the scapula\: a small hook-like bony prominence located 2cm inferior and medial to the clavicular tip.
Head of the humerus\: located 1cm inferolateral to the coracoid process.
Greater tubercle of the humerus\: located slightly anterolateral to the head of the humerus.
The spine of the scapula\: easily palpable on the posterior aspect of the scapula, running from the acromion towards the
thoracic vertebrae.
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Assess and compare joint temperature

Move

The shoulder joint of each arm should be assessed and compared.
If the patient is known to have an issue with a particular shoulder, you should assess the 'normal' shoulder

Active movement

Active movement refers to a movement performed independently by the patient. Ask the patient to carry out a sequence of
active movements to assess joint function. As the patient performs each movement, note any restrictions in the range of the
joint's movement and also look for signs of discomfort.
It's important to clearly explain and demonstrate each movement you expect the patient to perform to aid understanding.
Compound movements (screening)
Compound movements are often used as a rapid screening tool for shoulder joint pathology as they test a number of the
rotator cu
proceed to perform a more detailed examination of the shoulder joint including the further movements explained below.
External rotation and abduction of the shoulder joint\: Ask the patient to put their hands behind their head and point their
elbows out to the side.
Internal rotation and adduction of the shoulder joint\: Ask the patient to place each hand behind their back and reach as far
up their spine as they are able to.
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Assess external rotation and abduction
Active shoulder
Normal range of movement\: 150°
- 180°
Instructions\: Ask the patient to raise their arms forwards until they're pointing up towards the ceiling.
Active shoulder extension
Normal range of movement\: 40°
Instructions\: Ask the patient to stretch out their arms behind them.
Active shoulder ABduction
Normal range of movement\: 180°
Instructions\: Ask the patient to raise their arms out to the sides in an arc-like motion until their hands touch above their head.
Active shoulder ADduction
Normal range of movement\: 30°
- 40°
Instructions\: Ask the patient to keep their arms straight and move them across the front of their body to the opposite side.
Active external rotation
Normal range of movement\: 80°
- 90°
Instructions\: Ask the patient to keep their elbows by their sides
arc-like motion.
whilst they move their forearms outwards in an
Active internal rotation
Normal range of movement\: 80°
- 90°
Instructions\: Ask the patient to keep their elbows by their sides
whilst they move their forearms inwards across
their body.
Scapular movement
Instructions\: Ask the patient to abduct their shoulder, whilst you simultaneously palpate the inferior pole of the scapula. Assess
the degree and smoothness of scapular movement.
On average 50-70% of the scapula's initial movement occurs at the glenohumeral joint.
If the glenohumeral joint's movement is reduced due to injury or in
increased scapular movement over the chest wall.
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Active shoulder

Passive movement

Passive movement refers to a movement of the patient, controlled by the examiner. This involves the patient relaxing and
allowing you to move the joint freely to assess the full range of joint movement. It's important to feel for crepitus as you move
the joint (which can be associated with osteoarthritis) and observe any discomfort or restriction in the joint's range of
movement.
If abnormalities are noted on active movements (e.g. restricted range of movement), assess joint movements passively.
Ask the patient to fully relax and allow you to move their arm for them.
Warn them that should they experience any pain they should let you know immediately.
Repeat the above movements passively, feeling for any crepitus during the movement of the joint.
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Passive shoulder
Adhesive capsulitis (frozen shoulder)
Adhesive capsulitis involves sti
of both active and passive movement. Palpation of the joint does not typically cause pain and clinical examination
reveals a signi
factors include surgery, prolonged immobility and trauma.
Axillary nerve palsy
Axillary nerve palsy is typically caused by shoulder dislocation. Clinical features include loss of sensation over the
lateral deltoid region (known as the regimental patch) and deltoid muscle weakness (loss of shoulder abduction).

Special tests

There are a wide range of special tests that can be performed in a shoulder examination and the choice of which to include in
an assessment will depend on what the examiner has asked you to do, the patient's background and your clinical
far.

Supraspinatus assessment (empty can test/Jobe's test)

This clinical test assesses the function of the supraspinatus muscle.
1. Abduct the patient's arm to 90°
the scapula.
and then angle the arm forwards by approximately 30°
so that the shoulder is in the plane of
2. Internally rotate the arm so that the thumb points down towards the
3. Now push down on the arm whilst the patient resists.
Interpretation
This test assesses for weakness and/or impingement of supraspinatus. Weakness may represent a tear in the supraspinatus
tendon or pain due to impingement.
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Empty can test

The painful arc (impingement syndrome)

This clinical test assesses for impingement of supraspinatus.
1. Passively abduct the patient's arm to its maximum point of abduction.
2. Ask the patient to lower their arm slowly back to a neutral position.
Interpretation
Impingement or supraspinatus tendonitis typically causes pain between 60-120° of abduction, however, this test is not speci
as many other conditions can cause pain in this arc of motion and therefore it should not be used in isolation for diagnosis.
Passively abduct the patient's arm
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Shoulder impingement syndrome
Shoulder impingement syndrome (SIS) involves the in
through the subacromial space. SIS is most often associated with supraspinatus tendonitis. Symptoms of SIS include
pain, weakness and a reduced range of active movement in the a
preserved). Symptoms are usually exacerbated by overhead movement of the limb, typically during abduction between
60-120°
, which is referred to as a 'painful arc' of movement.

External rotation against resistance

This clinical test assesses the function of the infraspinatus muscle and teres minor.
1. Position the patient's arm with the elbow
and in slight abduction (the abduction tests whether the patient can
keep the arm externally rotated against gravity).
2. Passively externally rotate the arm to its maximum.
Interpretation
Pain on resisted external rotation may suggest tendonitis (infraspinatus/teres minor).
If the arm falls back to internal rotation or there is a loss of power it may suggest a tear in the infraspinatus or teres minor
tendon, muscle wasting and/or a lower motor neurone lesion (suprascapular or axillary nerve).
External rotation against resistance

Internal rotation against resistance (Gerber's lift-o

This clinical test assesses the function of the subscapularis muscle.
1. Ask the patient to place the dorsum of their hand on their lower back.
2. Apply light resistance to the hand (pressing it towards their back).
3. Ask the patient to move their hand o
Interpretation
If the patient is unable to move their hand o
tendonitis/tear) or a subscapular nerve lesion.
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