OnExam

Inspection

  • Inspect patient's shoulder anteriorly and posteriorly
    • Note
      • Swelling, deformity, muscle atrophy, fasciculation, abnormal posturing
  • Anterior
    • Sternoclavicular (SC) joint
    • Clavicular alignment and shape
    • Acromioclavicular (AC) joint (Note: prominent with OA/previous separation)
    • Contour of shoulder capsule
    • Humerus dislocation
      • Anterior: lateral aspect of shoulder flat
      • Posterior and from above: anterior aspect of shoulder flat
  • Posterior
    • Shoulder height
    • Scapular winging
      • Lifted medial border of scapula
    • Scapular alignment

Palpation

  • Note areas of pain, swelling, spasm, atrophy, ligamentous laxity, deformity, bogginess or crepitus in the following structures
  • Ask patients to point to the area of pain
    • Top shoulder with radiation to the neck: AC joint
    • Lateral aspect of shoulder and radiates toward deltoid insertion: Rotator cuff
    • Anterior shoulder: Bicipital tendon
    • Deep: Glenohumeral osteoarthritis, Multidirectional shoulder instability
  • Palpate when anterior to patient
    • Sternal notch
    • Sternoclavicular (SC) joint
    • Clavicle
    • Acromioclaviular (AC) joint
    • Acromion
    • Coracoid process
    • Greater and lesser tubercles
    • Biceps tendon
      • Place fingers in the bicipital groove and have the patient externally rotate the shoulder; feel tendon slip under fingertips
    • Glenohumeral joint
  • Palpate when posterior to patient
    • Scapular spine
    • SITS muscles (Rotator Cuff)
      • Supraspinatus
      • Infraspinatus
      • Teres Minor
      • Subscapular (non-palpable)
    • Bursae
      • Subacromial
      • Subdeltoid
        • Passively extend shoulder to expose bursa anterior to acromion process

Range of Motion

  • Flexion (normal = 180°), “With palms inward, raise arms in front of you and overhead”
  • Extension (normal = 60°), “With palms inward, raise arms behind you”
  • Abduction (normal = 180°), "Raise arms outward and overhead”
  • Adduction (normal = 30°), “Bring arms down to side of body, then bring arm inward across body”
  • Internal rotation+extension (normal = 70°), Apley scratch test, “Reach hand behind back toward contralateral shoulder blade”
    • The degree of rotation may be noted according to the spinal level reached (e.g. inferior angle of scapula, T7)
    • Dominant arm often reaches 1-2 vertebral levels below non-dominant arm
  • External rotation+abduction (normal = 70°), Apley scratch test, “Reach hand behind head, as if washing hair, toward contralateral shoulder blade”

Special Shoulder Tests

Rotator cuff pathology:

Shoulder instability:

AC joint pathology:

References

  1. Baxter S, ed., McScheffrey G, ed. Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
  2. Bickley L. Bate’s Guide to Physical Examination and History Taking. 11th ed. New York: Lippincott Williams & Wilkins; 2013.
  3. Filate W, Leung R, Ng D, Sinyor M, eds. Essentials of Clinical Examination Handbook. 5th ed. Toronto, ON. University of Toronto, 2005.
  4. Hurley K. OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.