Shoulder examination

Question 1

What angles should you look at the patient from?

Answer 1

Front, both sides, behind

Question 2

Give 5 examples of signs to look for in the patient’s fully exposed shoulder, from the posterior view?

Answer 2

Scars, muscle wasting (trapezius, supraspinatus, infraspinatus), bruises, symmetry of shoulder girdle, posture, abnormal bony prominences, winged scapula

Question 3

How can you look for and identify a winged scapula, and why does winged scapula occur?

Answer 3

Ask the patient to push against a wall with both hands spaced shoulder-width apart whilst you inspect the back, look for protrusion of a scapula

suggestive of ipsilateral serratus anterior muscle weakness, (typically secondary to a long thoracic nerve injury), so medial scapula separates from ribcage

Question 4

What is the main abnormal finding to look for, from the lateral view of the shoulder?

Answer 4

Deltoid muscle wasting as this could indicate axillary nerve injury

Question 5

What 8 structures should you palpate, moving from the sternum to the humerus?

Answer 5

Sternoclavicular joint
Clavicle
Acromioclavicular joint
Acromion process
Coronoid process
Greater tuberosity of humerus
Scapula spine
Glenohumeral joint

Question 6

What 2 aspects of the glenohumeral joint line should be palpated?

Answer 6

Anterior and posterior glenohumeral joint line

Question 7

What joint should you palpate for temperature, over the front of the shoulder?

Answer 7

Glenohumeral joint

Question 8

What 3 muscles should you palpate for muscle bulk and any wasting?

Answer 8

Supraspinatus
Infraspinatus
Deltoid

Question 9

How do you test active flexion of the shoulder, and what is the normal angle?

Answer 9

Ask patient to raise arms until they’re pointing at the ceiling

Normal angle is 90 degrees without scapula, 180 degrees with scapula

Question 10

How do you test active extension of the shoulder, and what is the normal angle?

Answer 10

Ask patient to swing arm back

Normal angle is 40 degrees

Question 11

How do you test for active abduction of the shoulder, and what is the normal angle?

Answer 11

Ask patient to raise arms at their sides

90 degrees without scapula movement, 180 degrees with scapula movement

Question 12

What shoulder movement indicates painful arc syndrome?

Answer 12

Abduction between 60 and 120 degrees, when arm is lifting and not fully abducted yet patient feels pain

Question 13

What is painful arc syndrome, and what are the 2 most common underlying causes?

Answer 13

Supraspinatus tendonitis or bursitis of shoulder joint reduces space between acromion process and rotator cuff, so when the arm abducts the subacromial components (bursa and rotator cuff) are compressed, which is painful

Shoulder impingement

Question 14

How do you test for active adduction of the shoulder, and what is the normal angle?

Answer 14

Ask patient to move arm across chest

Normal angle is 40 degrees

Question 15

How do you test active external rotation of the shoulder?

Answer 15

Ask patient to put their hand on the back of their head

or Ask the patient to keep their elbows by their sides flexed at 90° whilst they move their forearms outwards in an arc-like motion

Question 16

If there is loss of external rotation of the shoulder, what conditions can this suggest?

Answer 16

Adhesive capsulitis or other glenohumeral joint problems

Question 17

What is adhesive capsulitis, and what shoulder movement does it affect?

Answer 17

Adhesive capsulitis is inflammation of the shoulder (glenohumeral joint) joint capsule

Question 18

How do you test internal rotation of the shoulder?

Answer 18

Ask patient to put hand on the middle of their back

or Ask the patient to keep their elbows by their sides flexed at 90° whilst they move their forearms inwards in an arc-like motion

Question 19

What should you feel for during passive shoulder movements?

Answer 19

Crepitus in glenohumeral joint

Question 20

What resisted movement tests for supraspinatus injury?

Answer 20

Abduct arm to 90 degrees and internally rotate so that thumb is pointing at floor, then push down on arm whilst patient resists

Abduction

Question 21

What resisted movement tests for infraspinatus and teres minor injury?

Answer 21

Flex elbow to 90 degrees with slight abduction and elbows tucked in, push on patient’s forearm whilst they resist and externally rotate arm

External rotation

Question 22

What resistance movement tests for subscapularis injury?

Answer 22

Ask patient to place dorsum/back of hand on back, push on their hand and ask them to push hand away from back

Internal rotation (Gerber’s lift-off test)

Question 23

What special test can you do to indicate underlying pathology of the acromioclavicular joint?

Answer 23

Scarf test

1. Passively flex the shoulder joint to 90° and ask the patient to place the hand on the side you are examining on to the contralateral shoulder.
2. Apply resistance to the elbow in the direction of the contralateral shoulder.

Positive: Patient feels pain

Question 24

For further evaluation, what 2 joints would you investigate?

Answer 24

Above: Cervical spine

Below: Elbow