Shoulder Clinical Examination


The clinical examination of the shoulder involves a thorough assessment to diagnose conditions such as instability, adhesive capsulitis, rotator cuff tears, and osteoarthritis. This step-by-step guide provides a systematic approach to the shoulder examination, making it interactive, engaging, and clinically practical.

Step-by-Step Guide

  1. Stand the Patient

    • Start by positioning the patient in a comfortable standing position. Ensure that the patient’s shoulders are relaxed.

  2. Look

    • Front View:
      • Inspect for any asymmetry, muscle wasting, swelling, or deformity.
      • Ask the patient to perform quick neck movements to see if they reproduce shoulder pain.
    • Side View:
      • Check for any abnormal posturing or muscle wasting.
    • Back View:
      • Look at the scapulae for winging or muscle atrophy.
      • Inspect the axilla for any masses or lymphadenopathy.

  3. Feel

    • Palpate the following bony landmarks and soft tissues for tenderness or abnormalities:
      • Sternoclavicular Joint: Start from the sternoclavicular joint and move along the clavicle.
      • Coracoid Process: Palpate the coracoid process.
      • Acromioclavicular Joint: Check for tenderness.
      • Biceps Tendon: Palpate the biceps tendon in the bicipital groove.
      • Spine of Scapula: Palpate along the spine of the scapula to the acromion.
      • Rotator Cuff Insertions: Feel for tenderness or defects.

  4. Move

    • Demonstrate the movements to the patient and ask them to replicate:
      • Forward Flexion: Raise the arm in front.
      • Abduction: Lift the arm sideways.
      • External Rotation: With the elbow at 90°, rotate the forearm outward.
      • Internal Rotation: With the elbow at 90°, rotate the forearm inward.



  5. Impingement Tests

    • Perform these tests to assess for subacromial impingement:
      • Neer’s Test: Internally rotate the arm and elevate it. Pain at >75° indicates a positive test.
      • Hawkins-Kennedy Test: Flex the shoulder to 90°, then internally rotate. Pain indicates a positive test.
      • Scarf Test: Cross the arm over the chest. Pain at the acromioclavicular joint indicates a positive test.
      • Speed’s Test: Extend the elbow and supinate the forearm. Pain in the bicipital groove indicates biceps tendonitis.
      • O’Brien’s Test: Flex the shoulder to 90° and adduct 15°. Apply downward force with the arm in internal rotation, then external rotation. Pain more pronounced in internal rotation suggests a SLAP lesion.

  6. Assess the Muscles

    • Rotator Cuff Muscles:
      • Supraspinatus: Perform Jobe’s test. Abduct the arm to 90°, forward flex to 30°, and pronate. Resist downward pressure.
      • Infraspinatus & Teres Minor: Test external rotation strength with the elbow at the side.
      • Subscapularis: Perform the Gerber’s Lift Off test. Place the hand behind the back and lift away from the body.
    • Other Shoulder Muscles:
      • Deltoid: Test by abducting the arm and applying resistance.
      • Pectoralis Major: Test by asking the patient to press their hands together.
      • Latissimus Dorsi: Test by asking the patient to push down and backward against resistance.
      • Trapezius: Test by asking the patient to shrug their shoulders against resistance.
      • Rhomboids: Test by having the patient push their elbows backward with hands on hips.
      • Serratus Anterior: Test by having the patient push against a wall with an outstretched arm and look for scapular winging.



  7. Instability Tests

    • For these tests, the patient should be sitting or lying down:
      • Anterior Draw Test: Assess anterior stability by applying anterior force on the humerus.
      • Posterior Draw Test: Assess posterior stability by applying posterior force on the humerus.
      • Sulcus Sign: Traction on the adducted arm. A visible sulcus indicates inferior stability.
      • Apprehension Test: Abduct and externally rotate the shoulder. Look for signs of apprehension or discomfort indicating instability.

Clinical Tips

  • Patient Comfort: Ensure the patient is comfortable and relaxed during the examination.
  • Comparison: Always compare the affected shoulder with the contralateral side.
  • Detailed History: Combine examination findings with a thorough patient history to guide diagnosis.

Interactive Elements

  • Patient Participation: Explain each step to the patient and what sensations they should expect.
  • Use of Diagrams: Incorporate diagrams and models to help the patient understand their anatomy and the examination process.
  • Feedback: Encourage patients to provide feedback on any discomfort or unusual sensations during the examination.

Conclusion

A systematic approach to shoulder examination allows for accurate diagnosis and management of shoulder pathologies. Utilize this guide to enhance your clinical skills and ensure comprehensive patient care.