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
- 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.
- Bickley L. Bate’s Guide to Physical Examination and History Taking. 11th ed. New York: Lippincott Williams & Wilkins; 2013.
- Filate W, Leung R, Ng D, Sinyor M, eds. Essentials of Clinical Examination Handbook. 5th ed. Toronto, ON. University of Toronto, 2005.
- Hurley K. OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.