RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in

Éirinn

Musculoskeletal Education IC3

The Shoulder Examination
RCSI
 LEARNING OBJECTIVE

Perform a shoulder examination
Remember the 4 letter words

• Look
• Feel
• Move
• X-ray
Before starting
• Introduce yourself
• Wash hands
• Ask permission to perform examination
• Explain what the examination entails
• Ask the patient if they have any pain. Never hurt the
patient, be gentle and always ask & inform patient before
moving the limb
• Expose the patient appropriately
• Tell the patient to let you know if anything you do is
uncomfortable
• Remember - always watch the patients face
• Remember - examine both normal and affected limbs
Look
Watch patient undress noting limitation or pain

Stand back and compare both sides

• Arms should be at the same level
• Outlines of the AC joint should be the same
• There should be no wasting of the deltoids and they should appear equivalent

Look at the joint

• Swelling anterior if a large effusion is present
• Laceration
• Clavicular alignment (?Fracture)
• look for asymmetry (?Dislocation)
• look for previous scars (Arthroscopy/open)
• Muscle Wasting (?Long standing tear)

Ask Patient to stand & push against a wall

• Asses for Scapular Wigning
– ? Nerve to Serratus Anterior Damage
Feel
Assess for Temperature (Backs of hands)
?RA, ?Effusion

Palpation
1. Start at Sternoclavicular Joint
2. Move along bony prominences
3. Feel for Acromion & Coracoid Process
4. Feel Spine of Scapula

Feel for tenderness/ swelling

• Bicipital tendonitis
– is localised tenderness over the bicep groove
• Supraspinatis tendonitis
– is under the anterior surface of the acromion - placing a finger over the head of the tendon while the
shoulder is in extension
• Rotator cuff Pathology
– Tenderness over Greater Tuberosity

Move the arm into different positions and feel the AC joint, clavicle, and sternoclavicular joint
Movement
Zero position is when the arm is hanging by the side of the body and palms face forward

Active Movement First

1. Flexion (180 deg):
- the arm is brought forward as if marching
2. Extension (50-60) deg):
- the arm is brought backward as if marching back and try to scratch as high up as possible
3. Abduction:
- tests glenohumeral abduction (90 deg)
- is possible to 180 deg when preformed actively as scapular movement is included
4. Adduction (50 deg):
- arm is carried forward across the front of the chest
5. External rotation (60 deg):
- with the elbow bent to 90 deg the arm is turned laterally as far as possible
- Also hand behind head
6. Internal rotation (90 deg):
- tested actively by asking the patient to place his hand behind his back
- patiens with rotator cuff problems will find this painful
- Measuer by noting which Vertebra the patient can reach

Did movement stop due to Pain or Weakness

Then, assess Passive Movement

Special Tests
Apley’s scratch test:

- rapid assessment of shoulder

movement
-The patient is asked to scratch his
or her back while reaching over
the head with one hand and
behind the back with the other
hand

-The test requires abduction and

ext rotation of one shoulder and
adduction and int rotation of the
other shoulder
Special Tests

Lift off test – subscapularis

Patient is asked to internally

rotate affected arm behind back.

Palm facing outward

Patient is asked to actively push

against examiners hand

Inability to do so (or internally

rotate arm) points to subscap tear
 Special Tests
Empty Can Test - Impingement (Jobe’s
test)

Assesses the supraspinatus for instability

and the presence of tears

The patient raises his arm to 90 degrees

and angles the arm forward 30 degrees at
the shoulder joint.

The shoulder is then internally rotated as if

pouring a can on the floor

Resistance is applied looking for weakness

or pain
Special Tests
Scarf Test –
Osteoarthritis

Patients arm is Flexed to

90 and forcibly Adducted
across the chest

Pain (over the AC joint) or

reduced movement is a
sign of Osteoarthritis.
Special Tests
Apprehension Test

Anterior shoulder stability

Stand behind the patient , abduct,

extend, and externally rotate the
shoulder

While pushing the head of the

humerus forward with the thumb

Patient will resist this manoeuvre if

there is impending dislocation
Conclusion

• X-Ray
– Request for AP and lateral views of the shoulder in question and
the normal side
– Remember: Proper x-rays of any limb must include the joint
above and below
• At the end of the exam
– Offer to examine the distal pulses and a lower limb neurological
exam
– Offer to examine the joint above and below
– Wash your hands
– Thank the patient