EXAMINATION OF THE

SHOULDER

OLADUNNI E. KAYODE (MBChB. V)

OAUTHC ILE-IFE.

OUTLINE

INTRODUCTION
ANATOMY
EXAMINATION
DIFFERENTIAL DIAGNOSIS OF SHOULDER
PAIN
CONCLUSION

Introduction

The shoulder joint forms an important

part of the human pectoral girdle.It is a
very mobile and highly unstable
joint.Shoulder dislocation and pathologies
are common experience in clinical
practise ,hence the need to have a good
knowledge of shoulder examination.

Anatomy

Shoulder Muscles Movements

Fwd Flex - Deltoid, Pec maj, Coracobrach, Biceps

Extension -Deltoid, Teres maj, Teres min, Lat dorsi,

Abduction - Deltoid, Supraspin, Infraspin, Subscap,

Adduction - Pec maj, Lat dorsi, Teres maj, Subscap

Int rotation - Pec maj, deltoid, Lat dorsi, Subscap

Ext Rotation - Infraspin, Deltoid, Teres min

Examination

Greeting, introduction, Obtaining

permision
Look
Feel
Move
Compare
Examination is most easily & best
performed if the px is standing & his/her
shirt & vest removed.

LOOK

WITH PX STANDING, look both in front &

behind.
Look- @
Skin
Soft tissue
Bone

Skin

ForScars
Swellings
Erythema
Sinuses (axilla)

Soft tissue

Deltoid wasting- inc angulation of

shoulder, commonly due to damage to
the axillary nerve.
Supraspinator & infraspinator wastingsee hollows above & below the scapular
spine. Due to tear of the rotator cuffs
Rupture of the long head of biceps- see
bulge in the upper arm when elbow is
flexed.

Bone

Subluxed acromio-clavicular joint- hump

in the distal end of clavicle.
Ant dislocation of shoulder- loss of
rounded contour.
Dislocation- bulge (humerus) in front of
shoulder, look out for this.

Feel
Be careful not to elicit inappropriate
tenderness & cause discomfort....be
gentle!
Referred or LOCAL?
EPOULETTE SIGN
Test to diff referred from local pain. A test of
pain localisation.

Localisation in the
shoulder

Shoulder complex- problems usually arise

from either
Glenohumeral joint,
Acromio-clavicular joint,
Rotator cuff + subacromial bursa.
Aim is to distinguish btw them.

Feel

Skin- for heat

Sensations- soft touch, check distally.
Test the outer & inner side of the arms,
medial & lateral side of hand

Soft tissue

FEEL
Trapezius Ms for tenderness- common in
referred pain from neck.
For tenderness along the margin of
acromion suggest problem with the cuffs

Bone

Clavicle- feel along its margin, for

tenderness particularly @ the AC joint
Acromion- palpate its outline for
tenderness, subacromial bursa

MOVE

1.

2.

3.

4.

ACTIVE & PASSIVE.

ACTIVE
Pxs asked to put her hand behind her head & later
@ the back. Record range of movt.
Standing behind px, ask her to place arm in the
plane of the scapular (arm lat & 30 forward), & then
vertically over the head.
There should be scapulohumeral rhythm- aBduction
(10% for 20%), in 2nd movt both should move
together.
if there is a catch, px should localize it. If acromial its
an impingement.

Isolated Active Movement

Abduction
Observe for hesitancy and break in
smooth rhythm and note the point at
which pain is detected
Place your hand on the shoulder to detect
crepitations originating from subacromial
region due to degenerative tendinitis of
rotator cuff.

Difficulty initiating abduction- Rotator

cuff tear
Painful arc from 60-120 Consider rotator
cuff tendinitis
Painful arc from 140-180:Consider a
painful high arc,Osteoarthritis of the
Acromioclavicular jt

Adduction
Instruct the patient to bring his hand
across the chest as in reaching for the
opposite shoulder
Normal value is 45 deg.
Flexion and extension
Ask the patient to lift both arms forward
and then backwards.
Normal value is 180 of flexion and 45 of
extension

External rotation
With the elbow maintained by the side
and forearm pointing straigthforward,
instruct the patient to move the forearm
away from the body.External rotation is
about 45
Internal Rotation
In the position above, instuct the patient
to bring the fore arm towards the
abdomen.Internal rotation is about 55

PassiveWith arm @ rest

Elbow is flexed @ 90, & hand straight
forward.
Put hand pxs shoulder
With the other hand, gently turn the
forearm outwards exteriorly, this rotates
the shoulder
Arthritis- crepitus @ Glenohumeral joint
Capsulitis- pain & stiffness (frozen
shoulder)

Rotation
Flex the patients elbow with the forearm
supported by the examiner, maintain the
elbow by the side of the body,internally and
externally rotate the shoulder using the
forearm as a lever.
Adduction
Anchor the patient by placing the hand
across the top of the shoulder,adduct the
upper arm across the front of the body,
noting the range of motion.

Flexion and Extension

Anchor the scapular by placing the hand
across the top of the shoulder, grasp the
patients upper arm just above the elbow
and passively flex the shoulder by
bringing the upper arm anteriorly. Bring
to neutral position and extend. With
scapular anchored, true glenohumeral
flexion is only 90, while true
glenohumeral extension is 45

Power

Deltoid:
Test abduction against resistance. Axillary
nerve palsy can result in decreased
deltoid power.There is also loss of
sensation in the regimental badge area of
the shoulder.
Serratus anterior: Pushing against the
wall may demonstrate winging of the
scapular secondary to palsy of the long
thoracic nerve of Bell.

stability

Thumb down test

Apprehension test
Sulcus test

Thumb down

For impingement & inflammation in the

subacromial bursa.
Flex hand to 90 in scapular plane, with
arm held straight in this position.
Push down gently on the arm, such that
px maintains her position against
resistance
A sharp pain in the subacromial area
indicates impingement.

Apprehension test

Test at a jt earlier dislocation.

With the limb placed above head, gently
rotate it externally. Or while standing @
pxs back aBduct to 90 & gently pull the
elbow posteriorly. Ant dislocation usually
results. Px WILL ASK YOU TO STOP
Be gentle, don't dislocate.

Sulcus test

Tests laxity in a previously dislocated

joint.
With arm relaxed, gently draw down on
the arm. The humerus drops away from
the acromion, producing a groove(sulcus)

Special Tests

Impingement test- Supraspinatus

tendinitis
Resisted supination test: Tell the patient
to supinate against resistance with his
elbow flexed(the examiner pronating)Pain in the bicipital groove signifies
bicipital tendinitis
Test for rotator Cuff tear: Ask px to
abduct and maintain the arm at
90.Attempt to push down both hands
from behind.The side with the pathology
gives way.

Drawer test of Gerber and Ganz for

dislocations.
Examination of the neck(joint above) and
the elbows(joint below)
Assess the neurovascular status of the
upper limb.

Differential Diagnosis Of Painful

Shoulder

Joint disorders- Glenohumeral arthritis,

Acromioclavicular arthritis
Instability- Dislocation, Subluxation
Rotator cuff disorders- Tendinitis,Rupture
Capsulitis- Frozen shoulder
Referred pain-Cervical spondylitis, cardiac
ischaemia, mediastinal pathology
Bone lesions- Infections , tumours
Nerve injury-Suprascapular nerve
entrapment

Conclusion

With proper knowledge based

examination of the shoulder, a lot could
be discovered about the various
pathologies of the shoulder and help in
the management of the patient.

THANKS.....