Shoulder Examination

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Inspection

• From the front
  • prominent sternoclavicular joint
  • prominent acromiclavicular joint
• From the side
  • swelling of the joint
• From behind
  • scapulae normally shaped and situated
• From above
  • swelling of the shoulder
  • deformity of clavicle
  • asymmetry of supraclavicular fossae

Palpation

• anterior and lateral aspects glenohumeral joint
• upper humeral shaft and head via axilla
• acromioclavicular joint

Movement

• Abduction & Adduction - both arms noting:
• range of movement
• pain
• Flexion
• Extension
• Rotation screening
  • place arm behind opposite shoulder blade
  • ask patient to draw hand away from back
  • place both hands behind neck
  • compare two sides
  • crepitus - - place hand over shoulder, abduct arm

Special tests

• Rotator cuff
  • abduction and drop arm test- lift pt’s arm abduct and ext rotate, at 90 deg, release, if drops, +ve for supra and infraspinatus,
  • teres minor & infraspinatus test
  • Neer impingement sign- depress scapula, internally rotate arm , forced flexion, anterior pain subacromial , posterior pain internal impingement
  • Hawkin’s test – rest your arm across the other shoulder, elbow flexed, internally rotate- - subacromial bursitis if +ve, 80 % sensitivity, 60% specificity
  • Lift off test –subscapularis testing, check power
• Anterior glenohumeral instability
  • apprehension test- patient supine, abduct arm ,add gradual ext rotation until pain or fear of subluxation
  • Posterior glenohumeral instability
  • apprehension test- supine, 1 hand support behind scapula, 90 dg flexion arm, adduct and int rotate with axial loading
  • Inferior glenohumeral instability- arm by side, grab elbow and pull distally. if sulcus present under acromion +ve ( if unilateral, some ppl have both sides – not pathological)
  • sulcus sign
• Biceps tendinitis & sup labral tear- speed test (weak test)- extend elbow, flexed arm to 90 deg then resistance from examiner
  • Yergasson’s test – arm by side, palpate bicipital groove, resisted supination
  • Integrity of the long head of biceps /subluxation
• Deltoid power
• Suprascapular nerve
  • supraspinatus
  • infraspinatus
• Long thoracic nerve
  • lean with both hands against the wall
• Axillary nerve and NV status distally
• AC joint provocation
  • Cross body adduction test
  • AC shear test
  • Active compression test

Subscapularis tear test performances [LOE 1b]

Subscapularis Tear Tests
Test	Sensitivity	Specificity	+LR	-LR	Kappa
Bear hug test	0.74	0.97	25	-0.3	-
Napoleon test	0.84	0.96	21	-0.2	-
Liftoff test	0.65	0.95	13	-0.4	-
Internal Rotation Lag Sign	1.0	0.5	2	-0	-

Paediatric Examination

A consensus approach to the MSK examination in children was developed by Foster et al in 2011. The underlined components are those that are additional to the adult examination The italicised components are those that the doctor should be aware of but not necessarily competent in.

With the patient standing or sitting:

• Look at the shoulders, clavicles and sternoclavicular joints from the front, side and behind and assess shoulder height
• Look at the skin in axillae and palpate for lymphadenopathy
• Assess skin temperature
• Feel bony landmarks and surrounding muscles
• Assess movement and function: hands behind head, hands behind back
• Assess (actively and passively) external rotation, flexion, extension and abduction
• Observe scapular movement
• Options – hypermobility syndromes, muscle power, instability

Resources

Shoulder Examination by Dr Amanjeet Toor

References

Other general resources

• Cleland J, Koppenhaver S, Su J. Netter's orthopaedic clinical examination: an evidence-based approach: Elsevier Health Sciences; 2015.
• Wheeless III C. Shoulder: Physical exam. Wheeless’ textbook of orthopaedics Retrieved from Wheelers 2010.