The shoulder is one of the most mobile joints in the body. As a result, it is also one of the least stable, and hence more prone to injury and dislocation. The shoulder is stabilised by the rotator cuff muscles (supraspinatus, infraspinatus, subscapularis and teres minor) and damage to any of these will make the joint more prone to dislocation. Examination of the shoulder follows the same order as all other orthopaedic examinations: look, feel and move. This article guides you through each of these areas, and finishes with a section on special tests.
The shoulder joint is collectively made up of four individual joints:
Attention should be paid to each component joint.
Before starting your inspection, make sure that both the affected and the contralateral joint are adequately exposed. It is best to have the upper limbs, chest and neck fully exposed. Remember to inspect from all different angles and to compare both sides. The seven main things to look for are:
- Skin discolouration
- Muscle wasting
- Deformity/abnormal posture
- Winging of the scapulae
Before you move onto the ‘feel’ section of the examination, it is extremely important to elicit from the patient whether or not he or she is experiencing pain or discomfort in any region before you start palpating or moving, as it looks very unprofessional to cause the patient any pain. Further, in an exam scenario, this has the potential to ‘cost’ you the station.
- Assess temperature over the patient’s shoulders with the dorsum of the hand, making sure to compare both sides.
- Palpate all around the joint for any areas of tenderness, for example, the sternoclavicular joint, clavicle, acromioclavicular joint, acromion process and the scapula. Pay particular attention to the joint lines, as tenderness may often be elicited here.
- Assess the muscle bulk (deltoid, infraspinatus and supraspinatus), remembering to compare sides.
Start with passive movement.
Stand behind the patient and place one hand on the patient’s shoulder. Then, with your other hand, move the patient’s shoulder through its full range of movements. Make sure to note any limitation of movement, the presence of pain, and whether crepitus is detected. Next, examine active movement, assessing the following:
- Abduction – Say to the patient, while demonstrating the required movement yourself, “Please raise your arms in the air and touch your palms together”.
- Adduction – “Please swing your arms across in front of your body”.
- Flexion – “Please raise your arms forward out towards the wall”.
- Extension – “Please raise your arms backwards towards the wall behind you”.
- External Rotation (assessed with the elbows in 90 degrees of flexion) – “Whilst keeping your elbows flexed and tucked into your sides, please see how far you can move your arms sidewards”.
- Internal Rotation plus Adduction – “Please put your arms behind your back and see if you can reach your shoulder blades”.
- External Rotation plus Abduction – “Please put your hands on the back of your head”.
For both active and passive movements note the degree of movement achieved, for example, ‘abduction was reduced to 30 degrees’. Record the presence or absence of pain. As a general rule, limitation of active movement is suggestive of pathology in the muscles and tendons, whereas limitation of active and passive movement suggests pathology in the shoulder joint itself. One notable exception to this rule is capsulitis, where the glenohumeral joint is normal but where there is loss of both active and passive movement.
There are a number of special tests which accompany the basic shoulder examination and these should be carried out to complete the examination:
- Apprehension Test: To perform this test, place the patient in a supine position with the arm abducted to 90 degrees, the arm hanging over the side of the examining couch. Then, grasp the elbow and gently rotate the shoulder externally by applying a posterior force on the forearm. With your other hand, push the head of the humerus anteriorly. In a positive test, the patient will resist movement, as they will be compensating for the humeral head instability.
- Neer’s / Impingement Test: For this test, the patient should be seated. With one hand, hold the patient’s scapula, and with the other, hold the patient’s forearm. Internally rotate the arm, with the thumb facing inferiorly. Then, gently abduct and forward flex the arm. If there is pain on abduction the patient is suffering from impingement. This is suggestive of a rotator cuff tendonitis and/or subacromial bursitis.
- Winged Scapula: For this test, ask the patient to push against a wall, using the palm of the hand, and exerting a moderate degree of force. Observe the patient’s scapulae. ‘Winging’ is suggestive of weakness of the serratus anterior, which is supplied by the long thoracic nerve.
- Sulcus Sign (for inferior instability): For this test, the patient should be standing with their arms by their sides. Grasp the arm and pull downwards. If a depression is seen then this is suggestive of inferior laxity of the shoulder joint, as a space has opened up between the acromion and the humeral head. Make sure to compare both sides as a positive finding is more significant if the sign is absent on the good side.
- Jerk Test (for posterior instability): For this test, the patient should be standing. Position the patient’s arm in 90 of flexion and internal rotation. Grasp the elbow and apply an axial force on the humerus, in a proximal direction. Whilst still applying this force move the arm horizontally across the patient’s body. A sudden jerk as the humeral head slides off the gleniod denotes a positive test. A second jerk may be observed when returning the arm to the original position. This occurs as the humeral head is returning to the gleniod.
For completion of the shoulder examination you should additionally perform:
- A neurovascular examination of the upper limb.
- Examinations of the elbow and spine (joints above and below).
For further reading, and for pictures to accompany the movements and special tests, please refer to:
Pocketbook of Orthopaedics and Fractures (2nd Edition), McRae R, Churchill Livingstone Elsevier
Apley’s System of Orthopaedics and Fractures (9th Edition), Solomon et al, Oxford University Press