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Shoulder examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This shoulder examination OSCE guide provides a clear step by step approach to examining the shoulder, with an included video demonstration. Check out the shoulder examination mark scheme here.

Introduction

Wash hands

Introduce yourself

Confirm patient details – name / DOB

Explain examination:

“Today I need to examine your shoulder joints, this will involve looking, feeling and moving them.”

 

Check understanding and gain consent:

“Does everything I’ve said make sense?  Are you happy for me to examine your shoulders?”

 

Expose patient’s upper body appropriately

Position the patient standing

Ask if the patient currently has any pain

Look

Look around bed for aids and adaptations –  e.g. a sling 

Inspect the patient 

Anterior

Scars – previous surgery / trauma

 

Asymmetry of the shoulder girdle:

  • Scoliosis
  • Arthritis
  • Trauma – clavicular fracture/humeral fracture/anterior dislocation of the humeral head

Swelling – inflammatory joint disease / effusion / anterior dislocation

Muscle wasting – deltoids – axillary nerve injury (traumatic/iatrogenic)

 

Lateral

Scars – previous surgery / trauma

Muscle wasting – deltoid 

Alignment of shoulder girdlemisalignment – dislocation / scoliosis

 

Posterior

Scars – previous surgery / trauma

Asymmetry / Deformity – winged scapula (long thoracic nerve injury) / scoliosis

Assess muscle bulk of trapezius – symmetry / wasting

Para-vertebral muscles – note any swelling / wasting

Look for muscle wasting in the supra and infraspinatus fossa – wasting of supra or infraspinatus (nerve injury / chronic rotator cuff tear)

  • Inspect the patient from the front.

Feel

Assess temperature of shoulder joints – warmth may suggest inflammatory arthropathy/infection

Palpate the various components of the shoulder girdle (note any swelling / tenderness)

  • Sterno-clavicular joint
  • Clavicle
  • Acromio-clavicular joint
  • Coracoid process – 2cm inferior and medial to the clavicular tip
  • Head of humerus
  • Greater tuberosity of humerus
  • Spine of scapula
  • Assess & compare joint temperature.

Move

Active movement

Ask the patient to perform each of the following movements.

Compound movements (screening)

Compound movements are often used as a rapid screening tool for shoulder joint pathology as they test a number of the rotator cuff muscles in one go. If the patient experiences pain or is unable to perform these movements you would then proceed to perform a more detailed examination of the shoulder joint as shown in the “full shoulder examination” section below.

Put your hands behind your head – external rotation + abduction

Put your hands as far up your back as your can – internal rotation + adduction

  • Internal rotation & Adduction.

 

Full shoulder examination

Test active movements first: Ask the patient to move their arm themselves ‘actively’:

Flexion – ask the patient to raise their arms forwards until they points upwards  (Normal = 150°- 180°)

Extension – ask the patient to keep their arms straight and extend them behind them – (Normal = 40°)

ABduction – ask the patient to lift their arms away from their sides as far as possible  (Normal up to 180°)

ADduction – ask the patient to bring their arms across their trunk to the opposite sides (Normal = 30°- 40°)

External rotation – ask patient to hold their elbows to their body flexed at 90° and then move their forearms outwards in an arc-like motion (Normal 80° – 90°)

Internal rotation –  with the patient’s elbow flexed at 90° (arm by their side) ask them to place their hand behind their back and reach as far up the spine as they can manage (Normal average = T4-T8)

Assess the movement of the scapula:

  • Ask the patient to abduct their shoulder
  • Simultaneously palpate the inferior pole of the scapula
  • Assess the degree and smoothness of movement of the scapula
  • On average 50-70% of the first movement occurs at the glenohumeral joint

If the glenohumeral joints movement is reduced due to injury or inflammation then the majority of abduction will occur via increased scapula movement over the chest wall.

  • Active shoulder flexion.

Passive movement

Ask the patient to fully relax and allow you to move their arm for them.

Warn them that should they experience any pain they should let you know immediately.

Repeat the above movements passively – feel for any crepitus during movement of the joint

  • Passive shoulder flexion.

Special tests

Supraspinatus assessment  – Jobe’s test

This clinical test assesses the function of supraspinatus.

1. Abduct the arm to 90° and angle the arm forward by ~30 ° (so that the shoulder is in the plane of the scapula).

2. Internally rotate the arm so that the thumb points down toward the floor. Now push down on the arm whilst the patient resists the pressure.

3. Repeat the assessment on the other arm

This test assesses for weakness in the supraspinatus and/or impingement. Weakness may represent tear in the supraspinatus or pain due to impingement.

  • Assess Supraspinatus - early abduction against resistance

 

The painful arc (impingement syndrome)

This clinical test assesses for impingement of supraspinatus.

1. Passively abduct the patient’s arm to its maximum point of abduction.

2. Ask the patient to lower their arm slowly back to a neutral position.

Impingement/supraspinatus tendonitis typically causes pain between 60-120° of abduction, however this test is not specific as many other conditions can cause pain in this arc of motion and therefore it should not be used in isolation for diagnosis.

  • Passively abduct the patient's arm.

 

External rotation against resistance

This clinical test assesses the function of infraspinatus.

1. Position the patient’s arm with the elbow flexed at 90°and in slight abduction (the abduction tests whether the patient can keep the arm externally rotated against gravity).

2. Passively externally rotate the arm to its maximum.

Pain on resisted external rotation may suggest infraspinatus tendonitis.

If the arm falls back to internal rotation or there is loss of power it may suggest a tear in the infraspinatus tendon or muscle wasting.

  • External rotation against resistance.

External rotation in abduction

This clinical test assesses the function of teres minor.

1. Position the arm in 90° of abduction and bend the elbow to 90°.

2. Passively externally rotate the shoulder to its maximum degree.

If the patient is unable to keep arm in this position (i.e the arm falls back to internal rotation) this may represent a positive “hornblower’s” sign (pathology in the teres minor).

Internal rotation against resistance (“Gerber lift off test”)

This clinical test assesses the function of the subscapularis muscle.

1. Ask the patient to place the dorsum of their hand on their lower back.

2. Apply light resistance to the hand (pressing it towards their back).

3. Ask the patient to move their hand off their back.

4. An inability to do this (loss of power) indicates pathology of the subscapularis (e.g. tendonitis/tear).

  • Internal rotation against resistance (Gerber's "Lift off" test).

To complete the examination

Thank patient

Wash hands

Summarise findings

Suggest further assessments and investigations

  • Full neurovascular examination of the upper limbs
  • Examine the cervical spine and elbow joint (the joint above and below)
  • Perform further imaging if indicated – e.g. X-ray / MRI

Further reading

Arthritis research UK provides some excellent free guides to musculoskeletal examination and history taking [LINK]

Comments and suggestions