How to Perform a Shoulder Examination: Tips for Healthcare Professionals

Introduction

The shoulder is a complex and highly mobile joint, making its examination both crucial and challenging. A thorough shoulder examination is essential for diagnosing various pathologies, including rotator cuff injuries, shoulder impingement syndrome, dislocations, and arthritis. This guide provides a step-by-step approach to conducting a comprehensive shoulder examination, ensuring you cover all the necessary aspects to arrive at an accurate diagnosis.

1. Patient History

Before beginning the physical examination, it is essential to take a detailed history from the patient. This step helps to identify the nature of the shoulder problem and guide the examination process.

• Onset and Duration: Ask about when the pain started and how it began (suddenly or gradually). Was there any trauma or specific incident?
• Location: Determine where the patient feels pain. Is it localized to the shoulder, or does it radiate to the neck or arm?
• Nature of Pain: Ask the patient to describe the pain (sharp, dull, burning, or aching). Is the pain constant or intermittent?
• Aggravating and Relieving Factors: What activities or movements exacerbate the pain, and what provides relief?
• Impact on Function: Assess how the pain affects daily activities, work, and sleep.
• Past Medical History: Inquire about any previous shoulder injuries, surgeries, or conditions like diabetes or rheumatoid arthritis that might affect the shoulder.

2. Inspection

The inspection is the first step in the physical examination and provides valuable clues about the underlying pathology.

• Symmetry: Compare both shoulders for symmetry. Look for any visible deformities, swelling, or atrophy of the muscles.
• Skin Changes: Observe the skin over the shoulder for any discoloration, scars, or signs of infection (redness, warmth).
• Posture: Note the patient's posture. A drooping shoulder could indicate nerve injury, while a protracted scapula might suggest scapular dyskinesis.
• Muscle Wasting: Look for atrophy of the deltoid, supraspinatus, or infraspinatus muscles, which could indicate chronic rotator cuff pathology or nerve injury.

3. Palpation

Palpation helps to identify areas of tenderness, swelling, and deformities. Perform this step systematically, starting from superficial structures and moving deeper.

• Bony Landmarks: Palpate the clavicle, acromion, coracoid process, and the spine of the scapula. Tenderness over these areas may indicate fractures or AC joint pathology.
• Rotator Cuff Tendons: Palpate the insertion of the rotator cuff tendons on the greater tuberosity of the humerus. Tenderness here may suggest rotator cuff tendinopathy or tears.
• Subacromial Space: Palpate the subacromial space for tenderness, which could indicate subacromial bursitis or impingement syndrome.
• Biceps Tendon: Palpate the long head of the biceps tendon in the bicipital groove. Tenderness here may suggest biceps tendinitis.

4. Range of Motion (ROM)

Assessing the shoulder's range of motion is crucial for identifying functional limitations and potential causes of pain.

• Active ROM: Ask the patient to perform movements actively, including:
  • Flexion: Ask the patient to raise their arm in front of them as high as possible.
  • Extension: Ask the patient to move their arm backward.
  • Abduction: Ask the patient to raise their arm to the side.
  • Adduction: Ask the patient to bring their arm across their body.
  • Internal Rotation: Ask the patient to rotate their arm inward, placing their hand on the lower back.
  • External Rotation: Ask the patient to rotate their arm outward.
• Passive ROM: If active ROM is limited, perform passive ROM by moving the patient's arm for them. This helps differentiate between joint stiffness and muscle weakness.

5. Strength Testing

Testing the strength of the shoulder muscles helps to identify any deficits that may indicate nerve injury or muscle tears.

• Deltoid Muscle: Test the deltoid by asking the patient to abduct their arm against resistance.
• Rotator Cuff Muscles:
  • Supraspinatus: Test the supraspinatus by asking the patient to abduct their arm with the thumb pointing downward against resistance (empty can test).
  • Infraspinatus and Teres Minor: Test these muscles by asking the patient to externally rotate their arm against resistance.
  • Subscapularis: Test the subscapularis by asking the patient to internally rotate their arm against resistance (lift-off test).

6. Special Tests

Special tests are used to confirm specific diagnoses based on the findings from the history, inspection, and basic examination.

• Neer Impingement Test: This test is used to diagnose shoulder impingement syndrome. The examiner stabilizes the patient's scapula while passively flexing the arm. Pain during this maneuver suggests impingement.
• Hawkins-Kennedy Test: Another test for impingement. The examiner flexes the patient's arm to 90 degrees and internally rotates it. Pain indicates a positive test.
• Drop Arm Test: Used to assess rotator cuff tears. The patient is asked to slowly lower their arm from full abduction. Inability to control the descent or sudden dropping of the arm suggests a rotator cuff tear.
• Apprehension Test: Used to assess shoulder instability. The examiner abducts and externally rotates the patient's arm. A positive test is indicated by the patient expressing apprehension or fear of dislocation.
• O'Brien's Test: Used to diagnose a labral tear (SLAP lesion). The patient flexes the shoulder to 90 degrees with the elbow extended and the thumb pointing downward. The examiner applies downward pressure. Pain with the thumb down and relief with the thumb up suggests a labral tear.

7. Neurological Examination

A thorough neurological examination is essential to rule out nerve injuries that may present with shoulder pain.

• Sensation: Test the sensation over the shoulder, arm, and hand, focusing on the dermatomes of the cervical spine (C4-T1).
• Reflexes: Check the biceps and triceps reflexes to assess the integrity of the C5 and C7 nerve roots.
• Motor Function: Assess the strength of the muscles innervated by the brachial plexus, including the deltoid, biceps, triceps, and intrinsic hand muscles.

8. Joint Stability Assessment

Assessing joint stability is crucial, especially in patients with a history of dislocation or subluxation.

• Sulcus Sign: The examiner applies downward traction on the patient's arm while the patient is seated. The presence of a sulcus (gap) under the acromion indicates inferior shoulder instability.
• Load and Shift Test: The examiner stabilizes the scapula and applies an anterior and posterior force to the humeral head to assess anterior and posterior shoulder stability.
• Anterior Drawer Test: The examiner pulls the humeral head forward while stabilizing the scapula to assess anterior instability.

9. Functional Tests

Functional tests help to assess the impact of shoulder pathology on daily activities.

• Apley Scratch Test: The patient is asked to touch the opposite scapula from above and below. This test assesses combined movements of the shoulder and is useful for identifying functional limitations.
• Cross-Body Adduction Test: The patient is asked to adduct the arm across the body. Pain during this maneuver suggests AC joint pathology.

10. Imaging and Further Investigation

While a thorough physical examination is crucial, imaging studies may be necessary to confirm the diagnosis.

• X-rays: Useful for assessing bony abnormalities, such as fractures, dislocations, or osteoarthritis.
• MRI: Provides detailed images of soft tissues, including the rotator cuff, labrum, and biceps tendon. MRI is the gold standard for diagnosing rotator cuff tears and labral injuries.
• Ultrasound: Useful for evaluating soft tissue structures and dynamic assessment of the shoulder, particularly in diagnosing rotator cuff pathology.
• CT Scan: Used in complex fractures or when detailed bony anatomy is needed, such as in cases of glenoid fractures or chronic dislocations.
• Electromyography (EMG) and Nerve Conduction Studies: These tests are indicated if there is suspicion of nerve injury or neuropathy contributing to shoulder pain.

11. Documentation and Reporting

After completing the shoulder examination, it is essential to document the findings accurately. This includes:

• Detailed History: Summarize the patient’s history, including symptoms, onset, duration, and impact on daily activities.
• Examination Findings: Document findings from the inspection, palpation, range of motion, strength testing, and special tests.
• Imaging Results: If available, include a summary of any imaging studies performed.
• Diagnosis: Based on the clinical examination and investigations, provide a provisional or definitive diagnosis.
• Plan: Outline the next steps, whether it involves further testing, referral to a specialist, or initiation of treatment.

12. Common Shoulder Pathologies

Understanding common shoulder pathologies helps in correlating clinical findings with potential diagnoses.

• Rotator Cuff Tendinopathy: Presents with pain during overhead activities, weakness, and positive impingement tests.
• Shoulder Impingement Syndrome: Characterized by pain during active abduction and positive Neer and Hawkins-Kennedy tests.
• Shoulder Instability: Often presents with a history of dislocations, positive apprehension test, and signs of joint laxity.
• Adhesive Capsulitis (Frozen Shoulder): Presents with limited active and passive range of motion, particularly in external rotation.
• Acromioclavicular (AC) Joint Pathology: Presents with localized pain over the AC joint, positive cross-body adduction test, and tenderness on palpation.

Conclusion

A thorough and systematic shoulder examination is vital for accurately diagnosing shoulder pathologies. By following the steps outlined in this guide, healthcare professionals can ensure they cover all aspects of the examination, leading to better patient outcomes. Remember, a good examination not only identifies the pathology but also helps in planning appropriate treatment or further investigations.