Examination of Shoulders

EXAMINATION OF SHOULDERS

Introduce yourself, explain what you are about to do and obtain consent

Hello, My name is Annabelle, I am a final year medical student. Can I confirm your name and date of birth please? Ok Mr X,  I have been asked to examine your shoulders. This will involve me looking at your shoulders, feeling and asking you to do a few movements. Is that ok with you? Brilliant.

Do you have any pain at all? If you feel any pain during my examination please let me know ok

Ensure privacy and ask for chaperone
Ask patient to undress to the waste. If female, the shoulder should be exposed whilst maintaining her dignity



LOOK

Good idea to first look at the normal sid. Note any scars, obvious asymmetry, discolouration, swelling or muscle asymmetry

From the front
- Attitude of limbs and shoulder in specific
- Any asymmetry, limb length discrepancy, soft tissue abnormality like loss of muscle bulk and swelling, scars, erythema or lacerations
- Shape of shoulders; the shoulder has a rounded contour to it due to the head of the humerus within the glenoid an the bulk of the deltoid muscle. The shoulder should be examined from the front back and the side.
Inspect from the sternum medially moving laterally sternoclavicular joint, clavicle may process
 

a) Clavicle:  a subcutaneous bone. Deformity in the middle of the clavicle can suggest a previous clavicular fracture, whereas protrusion of the distal end of he clavicle may suggest a AC joint subluxation
b) Supraclavicular area
c) The front of the chest- pectoral muscles for wasting
d) The anterior axillary fold
      - swelling
      -  level of the fold as compared to the opposite side
e) Swelling, scars, sinuses, deformity; details of all these.

From the side

The shape, alignment of shoulder girdle, swellings on the anterior posterior or lateral aspect of the shoulder.
See for arthroscopy scars, inflammation
Wasting of the deltoid muscle

From the back

Examination of the scapula and upper back for swellings scars sinuses, deformity
Spine of scapular: deformity
Wasting of the suprascapular and/or infrascapular muscle (seen as hollow grooves wasting above and below the spine of the scapula).
Angle of the scapula: superior and inferior: level on comparison to the opposite side






Ask the patient to press onto the wall with straight arms.

winging of scapula due to injured long thoracic nerve

Medial border of the scapula: evidence of winging of scapula- damage to the long thoracic nerve.
Level of the posterior axillary fold: compare with opposite side.


Examine axilla

Swelling in the axilla: in traumatic situations it may well be the dislocated head of the humerus
Scars and sinuses.

FEEL

Feek for any local rise in temperature. Ensure you compare the temperature on both sides

Do you have any pain at all? Let me know if you have any pain

Palpate from the sternum, sternoclavicular joint move along clavicle to acromioclavicular joint, coracoid process, acromion process, spine of scapula and feel along the medial border to the inferior angle of the scapula.

          



Look for

Tenderness-
 - at acromioclavicular joint--- osteoarthritis
 - at greater tuberosity---- impingement or rotator cuff patholody

Confirm all inspectory findings
Look for evidence of bony irregularities

MOVEMENT

Look for pain and rotator cuff muscle strength

All range of movements of both shoulders, both active and passive to be recorded in all direction in degrees

"Now I am going to do some movements. I would like you to copy me and let me know if you have any pain at any point. Is that alright?"

First do active movement by asking the patient to do the movement on their own. If they have any difficulty establish if this is due to weakness or pain. Then assess the patient and assess the passive movement.


Flexion- 180 degrees
Extension- 50-60 degrees



Abduction- 180 degrees
Adduction



External rotation- 60 degrees

------ Abduction and external rotation: Ask the patient to place their hand behind their head and instruct them to reach as far down their spine as possible. Note the extent of their reach in relation to the cervical spine, with most being able to reach C7 level.

Internal rotation
 or  




 Ask the patient to turn away from you so you see their back. Ask patient to reach up and touch as far up with the thumb the back as possible. Normally should be able to reach up to T7 (inferior border of scapula). TO confirm, place a finger at T7 and ask to touch it.


--- showing adduction and internal rotation (Apley's scratch test): Ask the patient their hand behind their back, and instruct them to reach as high up their spine as possible. Note the extent of their reach in relation to the scapula or thoracic spine. They should be able to reach the lower border of the scapula (T7 level)


Passive Motion

If there is pain with active ROM, assess the same movements with passive ROM. Have the patient relax and place one of your hands on their shoulder. Gently grasp the humerus in your other hand and move the shoulder through the range of motions described above. Note if there is pain, and if so which movement(s) precipitates it. Also note if you feel crepitus with the hand resting on the shoulder.

Pain/limitation on active ROM but not present with passive suggests a structural problem with the muscles/tendons, as they are firing with active ROM but not passive. Crepitus suggests DJD. Limitations in movement in any of the directions should be noted. Where exactly in the arc does this occur? Is it due to pain or weakness? How does it compare with the other side? Determining the precise etiology can be defined using the tests below, though realize that there is often a significant amount of overlap between several conditions.

MEASURE

Any limb length discrepance?

From acromion process to medial condyle and radial styloid.

Segmental length

Axillary circumference- for wasting of muscles

Hamilton's ruler test.

TESTING THE ROTATOR CUFFF

Subscapularis:
Apply pressure to the hand and ask the patient to push back on your hand as hard as possible.

Gerber's Lift off test.

OR

Napoleon belly press: If the patient is unnable to reach behind the back, the elbow is kept anterior to the hand to minimise extension.



Infraspinatus - Extenal rotation

The external rotation lag sign is performed by passively externally rotating the patient;s arm at the side. Inability to actively maintain external rotation is a positive result, signifying weakness or a tear of the infraspinatus tendon.


Teres minor- external rotation.

- External rotation.

- Hornblower test: Passively abduct and externally rotate the patients arm. A positive test result is indicated by a patient's inability to actively maintain external rotation, signifying their is a teres minor injury or tear.




Supraspinatus : Connects the top of the scapula to the humerus. Contraction allows the shoulder to abduct. This is the most commonly damaged of the muscles.

Empty can test= Jobe's test

1. Have the patient abduct their shoulder to 40 degrees, with 30 degrees forward flexion and full internal rotation (i.e. turned so that the thumb is pointing downward). This position prevents any contribution from the deltoid to abduction.
2. Direct them to forward flex the shoulder, without resistance.
3. Repeat while you offer resistance.

Interpretation: If there is a partial tear of the muscle or tendon, the patient will experience pain and perhaps some element of weakness. Complete disruption of the muscle will prevent the patient from achieving any forward flexion. These patient will also be unable to abduct their arm, and instead try to shrug it up using their deltoids to compensate.

Drop Arm Test (codman's test)

1. Fully abduct the patient's arm, so that their hand is over their head.
2. Now ask them to slowly lower it to their side.
3. If the suprapinatus is torn, at ~ 90 degrees the arm will seem to suddenly drop towards the body. This is because the torn muscle cant adequately support movement thru the remainder of the arc of adduction.

Impingement tests: These test are for subacromial impingement or rotator cuff tendinitis. Not for a muscle in particular.

Hawkin's test- Hawkins Kennedy Test

Abduct the shoulder and flex the elbow to 90 degrees, Passively rotate the patient's arm downwards and repeat while adducting the humerus. Downward rotation (internal rotation) of the shoulder exacerbates impingement pain . Varying degree of adduction increases the sensitivity of this test.

Neer's test

From the starting position the examiner internally rotates the patients arm and forcefully moves the arm through the full range of forward flexion or until reports of pain.The Neer test is considered positive if pain is reported in the anterior – lateral aspect of the shoulder.

TESTING FOR ACROMIOCLAVICULAR ARTHRITIS

Identify by palpation the point at which the end of the clavicle articulates with acromion. 

Gently push on the area, noting if it causes pain similar to what the patient was describing.

Cross arm test aka Scarf test

TESTS FOR INSTABILITY OF GLENOHUMERAL JOINT

Anterior Drawer Test:  With patient sitting, stand behind him. Stabilise the shoulder with one hand and grip the proximal humerus with the other. Apply anterior traction force to the humerus to assess laxity of the movement.

Posterior drawer test: With patient sitting, stand behind him. Stabilise the shoulder with one hand and grip the proximal humerus with the other. Apply posterior traction force to the humerus to assess laxity of the movement.

Sulcus test: Apply downwards traction to the humerus and the examiner waters for a depression lateral or inferior to the acromion.

Clunk test:

Glenoid labral tears assessed with the patient supine. The patient's arm is rotated and loaded (force applied) from extension through to forward flexion. A clunk sound or clicked sensation can indicate a labral tear even without instability.

Apprehension test= Crank test

Ask the patient to lie down supine

Explain that you are going to move the arm back and to let you know if there is any pain or sensation that the arm is going to pop out. 

Abduct the shoulder and flex the elbow to 90 degrees.

The externally rotate the shoulder whilst watching the patients face carefully 

A positive sign is a look of apprehension on the patient's face as to show he is scared of dislocation. Can relieve this feeling by applying pressure on the humerus.