Introduce yourself, confirm the patient's name and date of birth. Explain the examination, obtain consent and a chaperone and then proceed to wash hands.
Ask whether the patient is in any pain, especially in the shoulder area, and ask them to report if they have any pain at any point of the examination. Expose both upper limbs entirely so that the shoulders are completely visible, allowing women to keep their undergarments on.
For all orthopaedic examinations remember: Look Feel Move Test.
The anatomical definition of the shoulder includes the shoulder girdle, the humerus and all associated tissues and organs including the muscles, ligaments and tendons. The “shoulder girdle” is made up of the clavicle, the scapula, three synovial joints and two physiological joints.
Inspection
General inspection
Check if the patient is comfortable at rest. Ask them to stand and face you.
Closer inspection of the shoulder
Ask the patient to stand still whilst you move 360° around them to assess for any shoulder alignment deformity or assymmetry, muscle wasting, swelling and scars.
A good acronym to remember what to look for is DAWSS. This stands for deformity, asymmetry, wasting, swelling or scars.
Alternatively, you can ask the patient to turn 90° at a time so that you do not need to circle them to inspect.
When performing an examination of both limbs, it is usually best practise to start by examining the “good” limb first, as this way you gain an appreciation for what is considered as “normal” for that patient.
Anterior view
Look for any shoulder malalignment or assymmetry. One or both of the shoulders may look stiff and in a fixed position. This may be due to inflammatory pathologies such as the arthritides, shoulder impingement syndrome or adhesive capsulitis (frozen shoulder). If there has been an anterior dislocation of the glenohumeral joint, then the bony prominence of the scapula, the acromion will be very visible. Similarly, a patient with a clavicular fracture may also have a visible bony prominence, usually closer to the neck.
Observe the scalenus anterior and deltoid muscles for any wasting. This may be due to muscle injury, or damage to the long thoracic and axillary nerves respectively. Look for any swelling, which occurs in arthritis. Finally check for any incisional or arthroscopic scars which are present following shoulder surgery.
The glenohumeral joint is often referred to simply as the “shoulder joint.” Therefore, if one describes anterior dislocation of the shoulder joint or a “frozen shoulder”, they are in fact referring to the glenohumeral joint.
If you see a scar, identify its precise anatomical location, size, shape (if nonlinear), contour and appearance of surrounding skin.
Arthritis means inflammation of a joint (arthron in Greek). It is a disorder that can is present in a whole multitude of diseases. The patient may present with the typical features of inflammation, a hot, red, swollen and painful joint, or just some of these, depending on the cause.
Common causes include osteoarthritis, rheumatoid arthritis, gout and pseudogout, septic arthritis, the seronegative spondyloarthropathies, fibromyalgia, systemic lupus erythematosus to name a few.
Also known as painful arc syndrome, shoulder impingement syndrome (SIS) involves irritation of the tendons of the rotator cuff muscles as they contract against resistance. The most commonly involved tendon is that of the supraspinatus muscle; as the shoulder abducts, there is narrowing at the subacromial space, this causes impingement of the supraspinatus tendon leading to inflammation (tendonitis).
SIS may result in pain and weakness of the rotator cuff muscles and hence limited movement at the glenohumeral joint. The onset may be subacute, usually after vigorous use of the joint in an unaccustomed activity (for example, weightlifting). In this case, there is usually a painful arc during abduction of the shoulder between 60° and 120°. SIS may also present with a chronic, progressive onset, in which there is course crepitation and a dull, lingering pain, often worse at night.
Adhesive capsulitis is a condition in which there is inflammation and thickening of the capsule of the glenohumeral joint. The cause is unknown, and the presentation is in three stages:
1. Freezing phase: The patient will experience progressive pain with movement of the shoulder, most commonly during external rotation and abduction at the glenohumeral joint. The pain will increase and then gradually subside over time, usually lasting up to nine months.
2. Adhesive phase: As the pain begins to subside the joint will begin to . This usually occurs four months after onset of the disease. Eventually, the shoulder will feel locked in place.
3. Recovery phase: After the pain has subsided and the joint is frozen in place, there will be a gradual recovery phase over the next one to two years as the joint returns to normal.
A shoulder dislocation occurs when the head of the humerus disarticulates from the glenoid cavity. The patient’s arm will be fixed in position and they will be in pain. The cause is most often traumatic in nature. Dislocation tends to occur in two main directions:
Anterior dislocation: The most common shoulder dislocation in which the humerus moves antero-inferiorly out of the glenoid cavity, most commonly resting just inferior to the coracoid process. This may occur due to a fall on a backward-stretching hand, or any mechanism which causes forced abduction and external rotation of the shoulder.
Posterior dislocation: Occurring in less than 5% of cases, this dislocation occurs when the humerus moves posteriorly. The causative mechanism is a forced internal rotation of an abducted arm. It is the common dislocation in an epileptic fit. On an anteroposterior X-ray the head of the humerus will be rotated such that it looks like a “lightbulb.”
Lateral view
Wasting of the deltoid muscle and postoperative scars may be more easily observed from the side.
Posterior view
Observe the trapezius muscle, innervated by the spinal accessory nerve, for any wasting, again suggesting injury or nerve damage. Look above the spine of the scapulae for wasting of the supraspinatus muscle and below for wasting of the infraspinatous muscle. Both muscles are innervated by the suprascapular nerve.
If a scapula is clearly protruding posteriorly, then this is described as scapular winging, and is due to weakness or wasting of the serratus anterior muscle.
Before continuing, it is important to appreciate where to palpate the different parts of the shoulder girdle and humerus.
The joint between the sternum and clavicle is the sternoclavicular joint. Lateral to that is the clavicle, which distally articulates with the acromion of the scapula, forming the acromioclavicular joint. The acromion is the most superolateral bony prominence of the shoulder, is lateral to the clavicle, is in line with the axilla and will remain stationary with movement of the arm.
2cm inferior and medial to the acromion is the coracoid process of the scapula. This requires deeper palpation but can be easily found. The coracoid will also remain stationary with arm movement.
Immediately inferior to the coracoid process is the glenoid cavity which articulates with the head of the humerus to form the glenohumeral joint. You can palpate the head of the humerus just 1cm inferior and lateral to the coracoid process. On its anterolateral aspect you will feel a prominence which is the greater tubercule. The head of the humerus and its greater tubercule will move as the arm does.
On the posterior aspect of the shoulder girdle is the spine of the scapula. This is easily palpable and runs from the acromion to the T3 vertebra.
Assessment of temperature
Using the dorsum of your hands, palpate the sternoclavicular joint, acromioclavicular joint and just below the coracoid process. Crudely assess for an increase in temperature on either side, as this may suggest an underlying inflammatory process such as septic arthritis, or reactive arthritis.
Septic arthritis is joint inflammation due to infection, most commonly by bacteria such as staphylococci, streptococci or Neisseria gonorrhoeae. The joint will be warm, painful and swollen, with the patient often having a fever. The joint pain can be so severe that the patient is unwilling to move it.
Reactive arthritis is a sterile joint inflammation which occurs due to a bacterial infection taking place elsewhere in the body. The infection will result in cross-reactivity resulting in a warm, painful and swollen joint. Often there will be multiple extra-articular features such as conjunctivitis or urethritis.
Joint palpation
During this part of the examination, remind the patient to report if they feel any pain.
Palpate the sternoclavicular joint, the clavicle, the acromioclavicular joint, the acromion, the coracoid process, the head of the humerus, the greater tubercule and the spine of the scapula. Tenderness or swelling at the joints suggests an inflammatory process or dislocation, whilst tenderness at the bones may imply a fracture.
Range of movement
Active movement
Screening
Quickly screen for any pain or limitation in range of motion. First, ask the patient to place their hands behind their head and flare their elbows out. This crudely assess external rotation and abduction at the glenohumeral joint.
Following this ask them to place each hand behind their back and reach up as high as they can. This crudely assess internal rotation and adduction at the glenohumeral joint.
Specific testing
Test the active range of movement at the glenohumeral joint, starting with the “good” shoulder.
Flexion: Ask the patient to bring their arm anteriorly and as high as they can. Expect an arc of 150°-180°
Extension: Ask the patient to move their arm posteriorly as far as they can. Expect an acute angle of 40°.
Abduction: Ask the patient to abduct their arm laterally as high as they can. Expect an arc of 150°-180°.
Adduction: Ask the patient to adduct their arm, moving it across the front of their body. Expect an acute angle of 40°.
External rotation: With the patient’s arm by their side, ask them to flex their elbow to 90° such that their forearm is parallel to the ground and their fingers are pointing anteriorly. Next, ask them to point their thumb to the ceiling, and whilst keeping their elbows by their side, move their arm outwards such that their palm faces forwards. Expect an arc of 70°-90°.
Internal rotation: Ask the patient to place their hand behind their back and reach up as high as they can. Expect them to reach at least the T8 vertebrae.
Remember to explain clearly and plainly, avoiding jargon. Often it is easiest to simply demonstrate these movements first for the patient to simulate.
Passive movement
Following this, passively move each arm individually with one hand, attempting to elicit maximum range of movement at the glenohumeral joint. Whilst doing so, palpate the shoulder with the other hand to feel for crepitus. Crepitus is common in the elderly and can be entirely normal. It may however be a symptom of osteoarthritis, especially if there is associated shoulder pain.
Special tests
Proceed to performing the special tests on each shoulder. Remember to always start with the “good” shoulder.
There are a large number of tests that can be performed in the shoulder examination, many of which may check for the same thing. The precise tests you choose to perform should be based on the patient’s history and the findings you already have.
Joints
Acromioclavicular joint
The scarf test assesses the integrity of the acromioclavicular joint; a positive test suggests pathology such as osteoarthritis affecting the joint. To perform, passively flex the patient’s glenohumeral joint by 90° and ask them to place their hand on their opposite shoulder. Push the arm such that their elbow moves more medially. If there is pain, the scarf test is positive.
Glenohumeral joint
The apprehension test assesses the integrity of the glenohumeral joint capsule; a positive test may suggest inflammation of the join, tearing of the glenoid labrum or tearing of the joint capsule. It may also indicate anterior joint instability, suggesting that that joint is prone to anterior dislocation.
To perform, lie the patient supine in a bed at 45°. With your hand on the patient’s wrist, passively abduct the glenohumeral joint by 90° and then the elbow joint by 90°. The patient’s forearm should now be perpendicular to thorax body. Very slowly begin to externally rotate the glenohumeral joint such that the patient’s hand moves in line with the top of their head. If there is joint pathology or instability the patient will be suddenly apprehensive and will most likely resist the movement and attempt to withdraw. This is a positive finding. If on the other hand there is pain but no apprehension, the test is negative and the glenohumeral joint is intact (it is likely that there is some other pathology at play causing the pain).
In an OSCE scenario you may be stopped from performing this test as if positive, it is frightening for the patient.
Muscles
Serratus anterior
The wall-push test assesses the function of the serratus anterior muscle, which causes protraction of the scapula. Ask the patient to stand with their hands against a wall roughly shoulder-width apart. Ask them to push into the wall. If you see scapular winging, this is due to wasting or injury of the serratus anterior muscle, or otherwise damage to the long thoracic nerve.
Supraspinatus
The empty can (Jobe’s) test assesses the function of the supraspinatus muscle, which causes abduction at the glenohumeral joint when fully adducted. Passively abduct the glenohumeral joint by 90° and then horizontally adduct it by about 30° such that the arm is in line with the spine of the scapula (the scapular plane). Ask the patient to point their thumb downwards such that they internally rotate at the glenohumeral joint. Finally, push down on the forearm and ask the patient to resist.
Weakness may be due to injury or wasting of the supraspinatus muscle, or otherwise damage to the suprascapular nerve. Pain on the other hand suggests shoulder impingement syndrome.
Infraspinatus
The infraspinatus muscle causes external rotation at the glenohumeral joint alongside the teres minor. This muscle is difficult to isolate. To test it, ask the patient to externally rotate their glenohumeral joint in the same manner as in the “range of movement” section, whilst applying resistance. Weakness may be due to injury or wasting of the infraspinatus or teres minor muscles, or otherwise damage to their respective nerves, the suprascapular and axillary nerves. Pain on movement suggests tendonitis.
Tendonitis is inflammation of a muscle tendon. This may be due to overuse, or injury due to a sudden stretching or movement of the tendon. Commonly affected tendons include:
The supraspinatus and less commonly infraspinatus tendons in shoulder impingement syndrome.
Achilles (calcaneal) tendon.
Biceps brachii tendon.
Wrist tendons.
Tendons attached to the lateral epicondyle (“Tennis elbow”).
Tendons attached to the medial epicondyle (“Golfer’s elbow”).
Thumb extensor tendons (“De Quervain’s tenosynovitis).
Digit flexor tendons (“trigger finger”).
Teres minor
Hornblower’s test can partially isolate and assess the function of the teres minor muscle. With the patient standing, abduct the glenohumeral joint by 90o, flex the elbow by 90o, and externally rotate it such that the patient’s hand is in line with the top of their head. Next, try to internally rotate the glenohumeral joint by pushing the forearm downwards and ask the patient to resist. Weakness may be due to injury of the teres minor muscle or the axillary nerve.
Note that at the start of Hornblower’s test, the upper limb is in the same position as it is at the end of the apprehension test.
Subscapularis
The lift-off test assesses the function of the subscapularis muscle, which causes internal rotation at the glenohumeral joint. Ask the patient to place the dorsum of their hand on their lumbar spine. Then, place your palm on theirs and ask them to push out. Weakness may be due to injury of the subscapularis muscle or the upper and/or lower subscapular nerves.
Tendons
Shoulder impingement
Neer’s test is one test which is reasonably sensitive and specific for shoulder impingement syndrome. Passively internally rotate the patient’s glenohumeral joint whilst keeping it in full adduction. Then, hold the wrist and flex at the glenohumeral joint, bringing the arm and forearm upwards in an anterior arc. If there is pain, then this suggests shoulder impingement syndrome.
Another less specific test is the Hawkins-Kennedy test, in which you passively flex the patient’s glenohumeral joint and then rest the entire weight of their arm on your forearm, by placing your hand on their opposite shoulder. Using your free hand, push down on the patient’s forearm to internally rotate the glenohumeral joint. Again, pain will suggest shoulder impingement syndrome.
Completion
Conclude your examination and offer to help the patient get dressed. Wash your hands. Offer to take a full history, examine the cervical spine and elbow, look at any old radiographs and assess the neurovascular status of each upper limb.
Interactive markscheme
When assessing each other, please click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end.
We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:
Introduction: “Hello, I’m SimpleOSCE and I am a medical student. I've been asked to examine your knee today, would that be ok? Can I confirm your name and DOB? Thank you.”
Ask if the patient is in any pain and identify which is their “good” and “bad” shoulder.
Wash your hands.
For all steps, where appropriate, examine the “good” shoulder first.
Inspection ("look")
With the patient standing, inspect all sides of the shoulder girdle for deformities, asymmetry, muscle wasting, swellings or scars (DAWSS).
Palpation ("feel")
Using the back of your hands, crudely assess the temperature of each shoulder.
Palpate the sternoclavicular joint, the clavicle, the acromioclavicular joint, the acromion, the coracoid process, the head of the humerus, the greater tubercule and the spine of the scapula.
Movement ("move")
Screen the glenohumeral joint for pain or limitations in range of movement.
Assess active flexion, extension, abduction, adduction, external rotation and internal rotation at the glenohumeral joint.
Passively assess the same movements whilst feeling for crepitus.
Special tests ("test")
Optional: Assess the integrity of the acromioclavicular joint (for example, with the scarf test).
Optional: Assess the integrity and stability of the glenohumeral joint with the apprehension test.
Assess the function of the serratus anterior muscle (for example, with the wall-push test).
Assess the function of the supraspinatus (for example, with the empty can [Jobe’s] test).
Assess the function of the infraspinatus.
Assess the function of the teres minor (for example, with Hornblower’s test).
Assess the function of the subscapularis (for example, with the lift-off test).
Assess for shoulder impingement syndrome (for example, with Neer’s test).
Thank the patient and ask if they need help getting dressed. Wash your hands again.
"To complete my assessment, I would like to examine the cervical spine and elbow joints, look at any old radiographs and assess the neurovascular status of each upper limb."
Present your findings.
Patient manner: Enquire about pain at all appropriate points of the examination.
