Spine and shoulder examination

Question 1

Spine: Look

Answer 1

General inspection
Closer inspection of spine (anterior/posterior/lateral)
Adam’s forward bend (accentuates scoliosis)

Question 2

Spine: Feel

Answer 2

-Temperature
-Spinal processes and sacroiliac joints
-Paraspinal muscles
-Sacroiliac joints
-Chest expansion if kyphoscoliosis

Question 3

Spine: Move

Answer 3

Cervical spine: Flexion, extension, lateral flexion, rotation
Lumbar spine: Flexion, extension, lateral flexion
Thoracic spine: rotation

Question 4

SPine: Special tests:

Answer 4

-Schober’s
-Sciatic stretch
-Femoral stretch

Question 5

Spine: To complete examination:

Answer 5

-Neurovascular examination of the upper and lower limbs.
-Examination of the hip and shoulder joints.
-Bloods if indicated
-PR and bladder scan if concerned
-Further imaging if indicated (e.g. X-ray/MRI).

Question 6

Carrying out schober’s test

Answer 6

1. Identify the location of the posterior superior iliac spine (PSIS) on each side-follow iliac crest
2. Mark the skin in the midline 5cm below the PSIS.
3. Mark the skin in the midline 10cm above the PSIS.
4. Ask the patient to touch their toes to assess lumbar flexion.
5. Measure the distance between the two lines.

Question 7

Shober’s test interpretation

Answer 7

If a patient has normal lumbar flexion the distance between the two marks should increase from the initial 15cm to more than 20cm.

Reduced range of motion is associated with conditions such as ankylosing spondylitis.

Question 8

Sciatic stretch test (Straight leg raise)

Answer 8

1. Position the patient supine on the clinical examination couch.
2. Holding the patient’s ankle, raise their leg by passively flexing the hip whilst keeping the patient’s knee fully extended.
3. The normal range of movement for passive hip flexion is approximately 80-90º.
4. Once the patient’s hip is flexed, dorsiflex the patient’s foot.

Ask pt: it it worse on dorsiflexing
Is it better on flexing knee

Question 9

Sciatic stretch test interpretation

Answer 9

The sciatic stretch test is considered positive if the patient experiences pain in the posterior thigh or buttock region.

A positive test is suggestive of sciatic nerve irritation (e.g. secondary to lumbar disc prolapse).

Question 10

Carrying out femoral stretch test

Answer 10

1. Position the patient prone on the clinical examination couch.
2. Flex the patient’s knee to 90º and then extend the hip joint.
3. Finally, plantarflex the patient’s foot.

Question 11

Femoral stretch test interpretation

Answer 11

The femoral nerve test is considered positive if the patient experiences pain in the thigh and/or inguinal region.

Question 12

Define kyphosis

Answer 12

Kyphosis refers to an anterior curvature of the spine.

It should be assessed when inspecting the lateral aspect of the spine.

Question 13

Describe three abnormalities which may be noted on posterior inspection of the spine

Answer 13

Spinal alignment: inspect for lateral curvature of the spine indicative of scoliosis
Abnormal hair growth: spina bifida occulta
Scars: discectomy, laminectomy, spinal fusion

Question 14

Name the sign and describe its typical clinical features

Answer 14

Scoliosis involves abnormal lateral curvature of the spine.

Clinical features:

Mild disease is usually asymptomatic
Severe scoliosis can be associated with back pain and impaired respiratory function

Question 15

Describe how movement of the thoracic spine is assessed during a spine examination

Answer 15

Rotation of the thoracic spine is assessed during a spine examination.

To assess rotation of the thoracic spine:

Ask the patient to sit on the side of the clinical examination couch and cross their arms across their chest
Then ask them to turn to the left and the right as far as they are comfortably able to

Question 16

Describe the movements of the lumbar spine which are assessed during spine examination and explain how you would instruct the patient to perform these movements

Answer 16

Movements of the lumbar spine assessed during a spine examination include:

Flexion: ask the patient to touch their toes whilst keeping their legs straight.
Extension: ask the patient to lean back as far as they are comfortably able
Lateral flexion: ask the patient to slide their hand down the outer aspect of the ipsilateral leg as far as they are able

Question 17

Describe three things that are assessed during the posterior inspection of the spine

Answer 17

Things to assess on posterior inspection of the spine include:

Spinal alignment: inspect for lateral curvature of the spine indicative of scoliosis
Iliac crest alignment: leg length discrepancy, hip abductor weakness, scoliosis
Muscle wasting: wasting of the paraspinal muscles
Abnormal hair growth: spina bifida
Bruising: recent trauma or surgery

Question 18

Describe the purpose of Schober’s test

Answer 18

Schober’s test is used to identify restricted flexion of the lumbar spine.

A positive test is commonly associated with a diagnosis of ankylosing spondylitis.

Question 19

Name three abnormalities which may be identified when examining the spine of a patient with ankylosing spondylitis

Answer 19

Clinical signs associated with ankylosing spondylitis include:

Stooped posture and/or loss of a normal lumbar lordosis (between 20-45º) on lateral inspection
Sacroiliac joint tenderness
Reduced range of motion of the lumbar spine (commonly assessed using Schober’s test)

Question 20

Describe three things to assess during lateral inspection of the spine

Answer 20

Assess the following during lateral inspection:

Cervical lordosis: hyperlordosis is associated with chronic degenerative joint disease (e.g. osteoarthritis)
Thoracic kyphosis: normally between 20-45º (hyperkyphosis is associated with Scheuermann’s disease)
Lumbar lordosis: loss of normal lumbar lordosis is associated with sacroiliac joint disease (e.g. ankylosing spondylitis)

Question 21

List 5 causes Kyphosis

Answer 21

Causes of kyphosis include:

Congenital kyphosis
Postural kyphosis
Osteoporosis: compression fractures
Scheuermann’s disease: congenital wedging of the vertebrae
Spinal tumours

Question 22

Describe normal curvature of the spine

Answer 22

-Cervical and lumbar: lordosis
-Sacral and thoracic: kyphosis

Question 23

Shoulder: Look

Answer 23

General inspection (clinical signs, objects or equipment)
Closer inspection of shoulder (anterior, lateral, posterior)

Question 24

Shoulder: Feel

Answer 24

Temperature
Shoulder joint

Question 25

Shoulder: Move

Answer 25

Compound movements Active: -Flexion -Extension -Abduction -Adduction -External rotation -Internal rotation -Scapular movement Passive -Repeat above movements passively

Question 26

Shoulder: Special tests

Answer 26

-Supraspinatus assessment -Painful arc (impingement syndrome) -External rotation against resistance -Internal rotation against resistance (Gerber's lift off test) -Scarf test

Question 27

Describe how you would complete examination (shoulder)

Answer 27

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

Question 28

Components of the shoulder girdle which should be palpated in a shoulder examination include:

Answer 28

Sternoclavicular joint Clavicle Acromioclavicular joint Acromion Coracoid process of the scapula Head of the humerus Greater tubercle of the humerus The spine of the scapula

Question 29

What compound movements are used in shoulder examination

Answer 29

External rotation and abduction of the shoulder joint: Ask the patient to put their hands behind their head and point their elbows out to the side. Internal rotation and adduction of the shoulder joint: Ask the patient to place each hand behind their back and reach as far up their spine as they are able to.

Question 30

Describe how you would test shoulder adduction

Answer 30

Instructions: Ask the patient to keep their arms straight and move them across the front of their body to the opposite side.

Question 31

Describe how you would test shoulder internal rotation

Answer 31

Instructions: Ask the patient to place each hand behind their back and reach as far up their spine as they are able to.

Question 32

Describe how you would assess scapular movement

Answer 32

Instructions: Ask the patient to abduct their shoulder, whilst you simultaneously palpate the inferior pole of the scapula. Assess the degree and smoothness of scapular movement. On average 50-70% of the scapula’s initial movement occurs at the glenohumeral joint. If the glenohumeral joint’s movement is reduced due to injury or inflammation then the majority of abduction will occur via increased scapular movement over the chest wall.

Question 33

Describe supraspinatus special test assessment

Answer 33

This clinical test assesses the function of the supraspinatus muscle. 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 34

Describe interpretation of supraspinatus test

Answer 34

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 35

Describe The painful arc (impingement syndrome)

Answer 35

This clinical test assesses for impingement of supraspinatus. 1. Passively abduct the patient’s arm to its maximum point of abduction. 2. Ask the patient to lower their arm slowly back to a neutral position.

Question 36

Describe interpretation of the painful arc

Answer 36

Impingement or supraspinatus tendonitis typically causes pain between 60-120° of abduction, however, this test is not specific as many other conditions can cause pain in this arc of motion and therefore it should not be used in isolation for diagnosis.

Question 37

Describe external rotation against resistance

Answer 37

This clinical test assesses the function of the infraspinatus muscle and teres minor. 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. Passively externally rotate the arm to its maximum.

Question 38

Describe interpretation of external rotation against resistance

Answer 38

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

Question 39

Internal rotation against resistance (Gerber’s lift-off test)

Answer 39

This clinical test assesses the function of the subscapularis muscle. 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.

Question 40

Internal rotation against resistance (Gerber’s lift-off test) Interpretation

Answer 40

This clinical test assesses the function of the subscapularis muscle. 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.

Question 41

Internal rotation against resistance interpretation

Answer 41

If the patient is unable to move their hand off their back this may indicate pathology of the subscapularis muscle (e.g. tendonitis/tear) or a subscapular nerve lesion.

Question 42

Scarf test

Answer 42

The scarf test assesses the function of the acromioclavicular joint. 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.

Question 43

Scarf test interpretation

Answer 43

If the patient experiences pain the test is considered positive and suggestive of acromioclavicular joint pathology (e.g. osteoarthritis).

Question 44

Describe the typical mechanisms of an inferior shoulder dislocation

Answer 44

Direct loading force onto a fully-abducted arm Forceful hyper-abduction of the arm (e.g. sudden grasp of an object above their head while falling)

Question 45

Name the sign and describe its aetiology

Answer 45

Scapular winging is characterised by the protrusion of the scapula as a result of ipsilateral weakness of the serratus anterior muscles secondary to a long thoracic nerve injury. Scapular winging is most noticeable when patients push against a wall with both hands spaced shoulder-width apart.

Question 46

Name the sign present and some possible causes

Answer 46

Deltoid wasting can be caused by disuse atrophy (e.g. after a stroke) or secondary to an axillary nerve injury.

Question 47

Describe the clinical features of shoulder impingement syndrome (SIS)

Answer 47

Shoulder impingement syndrome (SIS) involves the inflammation of tendons of the rotator cuff muscles as they pass through the subacromial space. SIS is most often associated with supraspinatus tendonitis. Symptoms of SIS include pain, weakness and a reduced range of active movement in the affected shoulder (normal passive range of motion is preserved). Symptoms are usually exacerbated by overhead movement of the limb, typically during abduction between 60-120°, which is referred to as a ‘painful arc’ of movement.

Question 48

Describe axillary nerve palsy

Answer 48

Axillary nerve palsy is typically caused by shoulder dislocation. Clinical features include loss of sensation over the lateral deltoid region (known as the regimental patch) and deltoid muscle weakness (loss of shoulder abduction).

Question 49

Describe adhesive capsulitis

Answer 49

Adhesive capsulitis involves stiffness and pain in the shoulder joint associated with a significant reduction in the range of both active and passive movement. Palpation of the joint does not typically cause pain and clinical examination reveals a significantly reduced range of active and passive movement. The underlying aetiology is unclear however risk factors include surgery, prolonged immobility and trauma.

Question 50

Describe abnormalities found on posterior inspection of shoulder

Answer 50

Scars: look for scars indicative of previous trauma or surgery Trapezius muscle asymmetry: disuse atrophy, spinal accessory nerve lesion Supraspinatus and infraspinatus asymmetry: chronic rotator cuff tear, suprascapular nerve lesion Scoliosis Winged scapula: long thoracic nerve lesion

Question 51

Describe abnormalities noted on lateral inspection of shoulder

Answer 51

Abnormalities of the shoulder which may be noted on lateral inspection include: Scars: previous trauma or surgery Deltoid wasting: disuse atrophy, axillary nerve injury

Question 52

Describe abnormalities noted on anterior inspection of the shoulder

Answer 52

Abnormalities of the shoulder which may be noted on anterior inspection include: Scars: surgery, joint trauma Bruising: trauma, surgery Asymmetry of the shoulder girdle: scoliosis, arthritis, fractures, dislocation Swelling: effusion, dislocation Abnormal bony prominence: fracture, dislocation Deltoid wasting: disuse atrophy, axillary nerve injury