OSCE - MSK Shoulder

Question 1

Describe the introduction steps in the shoulder examination.

Answer 1

1. Introduce self: Name, role and type of examination
2. Confirm the patient’s name and age
3. Briefly explain the examination using patient-friendly language
4. Gain consent and ask if patient is in any pain
5. Patient positioning (standing)
6. **Wash hands **

Question 2

What 3 steps should always be undertaken prior to moving to general inspection?

Answer 2

1. Ask the patient if they have any pain before proceeding with the examination
2. Also tell the patient to inform you if they experience any pain throughout
3. Wash hands

Question 3

On General inspection, what signs are being looked for?

Answer 3

Clinical signs
- Alertness
- Distress Level
- Body habitus
- Scars/skin changes
- Muscle wasting
- Swelling at the shoulder joints

Objects or equipment
- Aids and adaptations

Question 4

Closer inspection of the shoulder includes (3 steps)?

Answer 4

Anterior inspection
Lateral inspection
Posterior inspection

Question 5

Anterior inspection of the shoulder involves inspecting for (4)?

Answer 5

1. Head and neck posture abnormalities
2. Muscle (anterior deltoid) wasting
3. Alignment of shoulders/shoulder girdle
4. Scars/skin changes

Question 6

Lateral inspection of the shoulder involves inspecting for (2)?

Answer 6

1. Scars/Skin changes: indicative of previous trauma or surgery
2. Muscle (middle deltoid) wasting:
   Any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary nerve injury

Question 7

Posterior inspection of the shoulder involves inspecting for (5)?

Answer 7

1. Scars: Look for scars indicative of previous trauma or surgery
2. Trapezius muscle asymmetry: suggestive of muscle wasting secondary to disuse atrophy or a spinal accessory nerve lesion
3. Supraspinatus and infraspinatus asymmetry:
4. Scoliosis: lateral curvature of the spine that may be congenital or acquired.
5. 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.

Question 8

Temperature is felt at what areas in a shoulder examination and how?

Answer 8

Sternoclavicular, Acromioclavicular, Glenohumeral joints
Assess and compare shoulder joint temperatures (backs of hands)
- Increased temperature of a joint (+ swelling and tenderness) = septic arthritis or inflammatory arthritis

Question 9

Shoulder joint palpation

What areas are palpated in a shoulder examination (8)?

Answer 9

1. Sternoclavicular joint
2. Along Clavicle
3. Acromioclavicular joint: the joint between the acromion and the clavicle.
4. Acromion Process
5. Sub-acromial space: find the edge of the acromion and palpate immediately below until a space is felt
6. Greater tuberostity of humerus - palpate directly below subacromial space
7. Biceps tendon: anterioly from the greater tuberosity. tendon sits in between the greater and lesser tuberosities
8. Scapula spine

Question 10

Name the movements tested in a shoulder examination?

Answer 10

Flexion
Extension
Abduction
Adduction
External rotation
Internal rotation

Question 11

When are passive movements indicated on a shoulder examination?

Answer 11

If abnormalities are noted on active movements (e.g. restricted range of movement), assess joint movements passively.
Repeat the shoulder movements, feeling for any crepitus during the movement of the joint.

Question 12

What are passive movements?

Answer 12

Refers to a movement of the patient, controlled by the examiner.
This involves the patient relaxing and allowing examiner to move the joint freely to assess the full range of joint movement.

Question 13

Further assessments and investigations for the shoulder would include (3)?

Answer 13

1. Neurovascular examination of the upper limbs.
2. Examination of the joints above and below (cervical spine and elbow joint).
3. Further imaging if indicated (e.g. X-ray and MRI).

Question 14

Outline the steps involved in completion of a shoulder examination

Answer 14

1. Explain to the patient that the examination is finished.
2. Thank the patient for their time.
3. Dispose of PPE appropriately and wash your hands.
4. Summarise your findings.

Question 15

Name the 3 Special Tests assessed in a shoulder examination?

Answer 15

1. Supraspinatus assessment (empty can test/Jobe’s test)
2. External rotation against resistance
3. Internal rotation against resistance (Gerber’s lift-off test)

Question 16

Define: Active movement:

Answer 16

Refers to a movement performed independently by the patient.

As the patient performs each movement, note any restrictions in the range of the joint’s movement and also look for signs of discomfort.

Passive testing is then done if restrictions are found

Question 17

Describe the following movement in terms of
a) Normal range
b) how to perform it

Shoulder Flexion

Answer 17

Active shoulder flexion
a) Normal range of movement: 150°- 180°
b) Instructions: Ask the patient to raise their arms forwards until they’re pointing up towards the ceiling.

Question 18

Describe the following movement in terms of
a) Normal range
b) how to perform it

Shoulder Extension

Answer 18

Active shoulder extension
a) Normal range of movement: 40 - 60°
b) Instructions: Ask the patient to stretch out their arms behind them.

Question 19

Describe the following movement in terms of
a) Normal range
b) how to perform it

Shoulder Abduction/Adduction

Answer 19

Active shoulder Abduction
a) Normal range of movement: 180°
b) Instructions: Ask the patient to raise their arms straight out to the sides in an arc-like motion until their hands touch above their head.

Active shoulder Adduction
a) Normal range of movement: 30°- 40°
b) Instructions: directly after the abduction test. While patient has their hands above their head, Ask the patient to keep their arms straight and move them across the front of their body to the opposite side.

Question 20

Describe the following movement in terms of
a) Normal range
b) how to perform it

Shoulder External rotation

Answer 20

Active external rotation
a) Normal range of movement: 80° – 90°
b) Instructions: 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 21

Describe the following movement in terms of
a) Normal range
b) how to perform it

Shoulder Internal rotation

Answer 21

Active internal rotation
a) Normal range of movement: 90 degrees
b) Instructions: Done after shoulder external rotation. With arm flexed at 90 degrees, bring the arm back into body, crossing over the chest with elbow tucked the entire time.

Question 22

Supraspinatus assessment (empty can test)

a) What does this assess
b) how is it performed

Answer 22

a) This clinical test assesses the function of the supraspinatus muscle.
b)
1. Abduct the patient’s arm to 90° and then angle the arm forwards by approximately 30° so that the shoulder is in the plane of the scapula.
2. Internally rotate the arm so that the thumb points down towards the floor.
3. Now push down on the arm whilst the patient resists.

Question 23

How is the supraspinatus test interpreted?

Answer 23

This test assesses for weakness and/or impingement of supraspinatus.

Weakness may represent a tear in the supraspinatus tendon or pain due to impingement.

Question 24

External rotation against resistance
a) What does it test?
b) How is it performed?

Answer 24

a) This clinical test assesses the function of the infraspinatus muscle and teres minor.

b)
1. Position the patient’s arm with the elbow flexed at 90°and in slight abduction (the abduction tests whether the patient can keep the arm externally rotated against gravity).
2. Get patient to externally rotate against resistance

Question 25

External rotation against resistane test interpretation

Answer 25

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) A tear in the infraspinatus or teres minor tendon B) Muscle wasting and/or a lower motor neurone lesion (suprascapular or axillary nerve).

Question 26

Internal rotation against resistance (Gerber’s lift-off test) a) What does this assess? b) How is this test performed?

Answer 26

a) This clinical test assesses the function of the subscapularis muscle. b) 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 off their back.