Contents
Introduction
The shoulder is a ball and socket joint with a wide range of movement. The joint is somewhat unusual, in that the “socket” (glenoid) is very shallow, and as-such, much of the stability of the shoulder joint is provided by the rotator cuff muscles and surrounding ligaments and soft tissues, rather than the bony structures. This is what gives the shoulder its unique wide range of movement.
Along with the knee, the shoulder is one of the most commonly presenting joint pathologies. Common shoulder pathologies include rotator cuff injury (usually Supraspinatus – typically associated with a shoulder impingement), AC (acromioclavicular) joint injury, osteoarthritis and shoulder dislocation.
Like all examinations you should have a systematic approach. The most commonly used approach is the Look, feel move approach:
- Look
- Feel
- Move
- Special tests
Explain the examination to the patient, and once you have their consent, wash your hands and ask the patient to expose the shoulders and clavicles bilaterally.
Starting off the examination
Start with the basics:
- Wash hands
- Introduce yourself
- Greet the patient
- Explain the nature of the examination
- Gain consent – which usually involves asking the patient to remove the clothes from the upper half of the body
Inspection (Look)
Look for scars (particularly keyhole), deformity and muscle wasting. Compare both shoulders, and have a good look around from all angles. Make sure the patient is adequately exposed to view the shoulder from both the front and the back!
Also assess the skin. Are there any scars? Is the skin red indicative of infection? Are there any other rashes?
Wasting
- Wasting at the side – likely to be deltoid. This could cause the shoulder to become flattened. Often secondary to nerve lesion.
- Wasting at the back – likely to be trapezius
Deformity
- Deformity over the middle of the clavicle – suggests previous fracture
- Deformity over the distal part of the clavicle – may suggest AC joint pathology or subluxation
- Generalised swelling – most likely caused by effusion
- Flex the arm at the elbow – look for ruptured biceps tendon. You will see a large mass of muscle, that can either be near the elbow joint, or anywhere further up the humerus. The “popeye sign”.
- ‘Winged scapula’ – asking the patient to push against a wall can exaggerate this. It is where the scapula is abnormally laterally rotated. It is the result of a lesion of the long thoracic nerve, or of the muscle this nerve supplies – serratus anterior.
Palpation (Feel)
Ask the patient if they have any pain before you start palpating. As you palpate, look at the patients face to see if you elicit any pain.
Start at the sternum, and move laterally along the clavicle, until you reach the acromio-clavicular joint. Feel this joint, then move along and feel along the spine of the scapula. Then feel the greater tuberosity and in the anterior and posterior joint lines of the gelnuhumeral joint. Also feel around the joint for general muscle tenderness. Also comment on the temperature of the joint.
- Acromio-clavicular joint – common site of arthritis. To find this part of the joint, move laterally along the clavicle. It is also commonly damaged in injuries that result from a blow to the shoulder – e.g. falling from a bicycle, rugby injuries to other contact sports or falls
- Greater tuberosity – the insertion point of the rotator cuff muscles
- General Palpation – feel (and sometimes you can also hear it!) for any creptius. This is a crunching, grating feeling inside the joint, indicative of degeneration.
- The subacrominal space – specific tenderness hear can help localise an impingement pathology
- Swelling – feel for any generalised swelling. This can be caused by:
- Effusion
- Bursitis
- Dislocation
- Previous fractures
- Palpation of the dorsal spine and interscapular area – this area is sometimes called a trigger point for fibromyalgia. Palpating this area in individuals with this condition can elicit pain.
Tenderness on examination of the shoulder is often not especially specific, however certain points are more suggestive of certain pathology. AC joint tenderness is often a sign of AC joint injury or arthritis.
Movement
Begin with active movements – get the patient to move their arm by themselves – to assess the full ROM.
- Abduction and Adduction – 180 degrees is normal
- Supraspinatus and deltoid. Deltoid assists from 15 to 90 degrees of abduction, but Supraspinatus does the first 15 degrees all by itself.
- Suprapsinatus is a common cause of restricted abduction
- Flexion – 180 degrees is normal
- Extension – 180 degrees is normal
- Internal rotation – Ask patient to put the their thumb as high up their back as they can reach. You can measure this in relation to the scapula (should be able to reach inferior border) or the level of thoracic vertebra.
- External rotation – Ask the patient to keep their elbows tucked into their abdomen and external rotate their shoulders. External rotation is particularly badly affected in frozen shoulder (adhesive capsulitis), although this condition limits all movements, and is also affected in glena-humeral joint arthritis. Another test of external rotation is to ask the patient to put their hand behind their head.
If patients cannot complete a full range of active movements – ask if this is due to weakness or pain. Then you can assist the limb to assess if it is able to complete a full range of passive movement. In weakness, a full range of passive movement should be achievable. In very painful conditions, then passive movement may also be very limited.
- Restriction of active movements only – suggests pathology of the muscles and tendons of the rotator cuff. In this case, active movement is also often painful.
- Restriction of both active and passive movements – suggests pathology of the shoulder joint itself. In these cases, limitation can be due to pain, inflammation or mechanical problems, and often a combination of these factors.
- Capsulitis is an exception to the above. In this condition, there is inflammation of the joint capsule, restricting both active and passive movement, but the joint itself is normal. Signs of capsulitis include:
- Positive scarf test
- Loss of external rotation
Assessing individual muscles
Assessing individual muscles is best done against resistance.
Movements against resistance (isometric contractions)
- Supraspinatus (abduction) – Arms flexed and abducted to 30’, with palms pointing laterally, and thumbs pointing downwards. Patient tries to flex arms further against resistant.
- Infraspinatus / teres minor (external rotation) – Elbow tucked into chest well, flexed at 90’. Patient tries to move palms apart (external rotation) against resistance
- Subscapularis (internal rotation) – Elbow tucked into chest well, flexed at 90’. Patient tries to move palms together (internal rotation) against resistance OR
- The lift off test – patient has hand behind back (“lifts off” their hand form their back) and pushes backwards against resistance
Special Tests
There are literally hundreds of special tests for the shoulder. At Undergrad level, I wouldn’t worry too much, and learning 3-4 should be plenty.
Empty Can Test
Probably the most useful specialist test – especially as shoulder impingement is such a common presentation. The empty can test is a useful test for shoulder impingement. Ask the patient to hold a straight arm in 90 degrees of forward flexion (and up to 30 degrees of abduction – although sources on this are variable – some abduction probably increases the amount of internal rotation when the can is emptied), as if they are holding a “can” (or a wine glass). Then, ask the patient to “empty the can” – internally rotating the shoulder. Then the patient should push upwards against resistance.
Pain elicited by this test is a positive result and is somewhat specific for shoulder impingement.
For further information, see the article on Shoulder Pain
Hawkins-Kennedy Test
Also tests for for shoulder impingement – which is essentially inflammation of the tendons of the rotator cuff – specifically the supraspinatus tendon. Ask the patient to flex their arm to 90’. Then flex the elbow to 90’ so that this forearm is parallel to the floor. Now, press down on the patient’s wrist and at the same time try to forcibly inwardly rotate the shoulder joint. This is a passive movement, so the patient should be relaxed. This basically presses the tendons of the shoulder cuff against the coraco-humeral ligament. you may also want to repeat the test with external rotation to check the tendon of subscapularis.
- Positive test – pain is elicited. Particularly if the pain is greater, the greater the degree of internal rotation
- Negative test – no pain
The test is not specific enough to give an exact diagnosis – but may help to confirm the diagnosis when there is a strong degree of clinical suspicion.
Scarf Test aka cross-arm test
Ask the patient to rest their hand on the top of their contralateral shoulder. Then basically press on the elbow, trying to push the hand backwards over the shoulder. Pain suggests pathology of the AC joint – such as OA, or capsulitis.
Apprehension Test
This is so-called because it asks if the patient is ‘apprehensive’ about certain shoulder movements – i.e. they feel their shoulder joint is unstable in some positions.
Ask the pati
Then place your hand on the patient’s wrist, and your other hand near the head of the humerous, on the posterior surface of the arm. Try to push the humerous forwards against the shoulder joint. If this elicits discomfort, it is a positive apprehension test.
- You can double-check your findings. If you repeat the test, but instead, push the patient’s arm backwards, this should releive/not elicit any pain. This is known as the relocation manouvre.
- This tests for shoulder instability / anterior dislocation of the shoulder