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Shoulder Examination

Matt

Emeritus Staff
Emeritus Staff
The principles of musculoskeletal examination remain relevant for the shoulder. Look, feel, move, and special tests are typically performed in that order.

Look
It is useful to review the anatomy of the shoulder for this examination. Be clear on the position of the sternoclavicular joint, course of the clavicle, the acromioclavicular joint, the glenohumeral joint, the deltoid muscle, the muscles of the rotator cuff, and the scapulothoracic articulation.

You will be looking first for scars (rotator cuff repair), redness (over joints, swelling, and muscule bulk (especially of the deltoid and muscles over the scapula (supraspinatus, rhomboids). Also note winging of the scapula if obvious as well as any malalignment (dominant shoulder usually sits lower than the non-dominant shoulder).

This should take about 20 seconds.

Feel
Start at the sternoclavicular joint and examine the normal side first to gauge landmarks and review the normal anatomy. Feel from the sternoclavicular joint along the length of the clavicle for bony tenderness and heat or for any discontinuity of the bone. When you reach 2/3 along the clavicle drop your thumb half and inch to find the bony point of the coracoid process, this is where the short head of the bicips tendon attaches and you should feel for biceps tendonitis (more tender than opposite side). Just lateral to this point is the joint margin of the glenohumeral joint feel along these margins for malalignment as you move back up toward the clavicle.

Feeling, again, along the clavicle toward the acromioclavicular joint and feeling for bony tenderness, heat and discontinutity. In the centre-point of the acromion is the attachment point for the long head of the biceps tendon. Place your thumb over this, flex the elbow to 90 degrees and externally rotate the shoulder joint, you should feel the tendon rotation underneath your thumb. Again, compare for tenderness with the opposite side for tendonitis, it will normally be slightly tender.

Underneath the acromion is the subacromial bursa and this should be felt for the tenderness of bursitis. The best way to palpate this bursa is to extend the arm 40 degrees (in full elbow extension i.e. straight arm), which will bring the bursa forwards. Palpate for tenderness and heat.

Feel the muscle bulk of the deltoid muscle for wasting.

Move back toward the acromion and along the superior border of the scapula for bony tenderness and then along the medial scapula spine. Having review this anatomy you should be able to picture the muscles of the rotator cuff in your mind's eye feel the supraspinatus, infraspinatus, and teres minor for muscle bulk. Also take this opportunity to palpate the cervical spine, trapezius muscle (for tightness), and the paravertebral muscles as these are common sources of referred shoulder pain.

Repeat with the opposite side. You should be able to do this in under a minute with a practised technique.

Move

This comprises both active and passive range of motion. Active first. Start with abduction ask the patient to raise both arms to a full 180 degrees. Pain between 60-120 degrees is likely due to impingement or rotator cuff pathology (painful arc). Patients may use their trapezius to bypass this first 120 degrees by externally rotating and extending their arm if they have rotator cuff pathology, the last 120 degrees is not problematic since >120 degrees is more likely to be from the acromioclavicular joint. Drop the arms slowly watching the smoothness and quality of the movement (e.g. pain).

Next test flexion to 180 degrees with both arms at the same time. You should face the patient's lateral side (not the front of the patient to best gauge this movement). From flexion move backwards toward extension to about 55 degrees. Test interal rotation and adduction by asking the patient to reach for the small of the back with each arm sequentially. Test external rotation by asking the patient to flex the elbows to 90 degrees and then rotate first externally then internally.

The best way to get the patient to perform the manouveres is to perform them yourself and ask the patient to copy you.

Passive motion is performed to see if any defecit of active range of motion is lesser with passive motion. If there is no defecit of active motion proceed to feel for crepitus. Do this by taking the weight of the arm, flexing the elbow to 90 degrees and abducting the shoulder to 90 degrees. Internally and externally rotate and with one hand while the other hand rests on the shoulder to feel for crepitus.

Special tests

  1. Near's test: For impingement. The straight arm is raised to 180 degrees full flexion, passively, with the left hand while the examiner's right hand presses down superiorly on the ipsilateral shoulder joint. The straight arm is internally and externally rotated and the test is positive if pain beyond normal discomfort is elicited.
  2. Hawkin's test: Also for impingement and performed as Near's test is completed. As the flexed arm is brought down to 90 degrees (following Near's) flex the elbow to 90 degrees in a medial direction. Internally rotate the arm with the same hand that is carry the patient's arm's weight while the right hand supports the upper arm for stability. Positive if pain beyond normal discomfort.
  3. Empty can test: Tests for supraspinatus tendon. The striaght arm is flexed to 90 degrees and the hands positioned as if they were holding a can of softdrink. The 'imaginary' can is then emptied by turning it upside-down, achieved by internally rotating the straight arm. In this position the straight arm is held against downwards pressing resistance. Positive is pain beyond normal discomfort. Test both arms at the same time.
  4. Resisted isometric internal and external rotation. Using the same position to test active versions of these movements, apply resistance isometrically (arms don't move). Pain on external rotation suggests the infraspinatus and teres minor. Pain on internal rotation suggests subscapularis tendon pathology.
  5. Yergason's test: Tests for bicipital tendon pathology. Find the attachment of the long head of the biceps like before thumb it with you're right arm, elevate the elbow to 90 degrees of flexion and support it with your left arm. Supinate the arm and then ask the patient to hold this position while you attempt to pronate. Positive if pain elicted above that expected from normal discomfort.
  6. Scarf test: Tests for acromioclavicular joint pathology. Passively throw (slowly and controlled) the arm over the shoulder as if it were being worn as a scarf. Hold this position and then push gently at the area of the olecranon to push the arm futher back behind the head. Positive if pain beyond normal discomfort.
  7. Glenohumeral joint stabilty testing 'Apprehension test': As name suggets. Stand behind the patient, abduct the 90 degrees flexed elbow to 90 degrees. Externally rotate the arm 90 degrees. Positive if patient becomes apprehensive about impending dislocation of the shoulder and if this apprehension is relieved (somewhat) by counterpressure applied anteriorly (though from behind).
 
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