Shoulder Exam Good morning my name is Dr Taitt. Can I ask what your name is? Great! Today I will be examining your shoulder, and this involves me asking you to take your shirt off, touching and moving your upper limbs. Is that okay with you? Before I begin the physical exam, I would like to ask you a little bit about the pain. FIFE and SOCRATES Are you feeling any pain currently? SOCRATES Tell me about your feelings/concern regards the pain? Any ideas regarding what might be causing the pain? How has it affected you day to day? Do you have any thoughts as to how we could tackle this issue together? Inspection Can I now ask you to remove your shirt please? As the patient removes his shirt I’d like to pay attention to any difficulties doing so or any stigmata of pain during raising the arms. Anterior: Shoulder symmetry, Signs of fracture (swelling, deformity, skin changes e.g. hematoma) Lateral: Deltoid muscle wasting or overuse (atrophy and hypertrophy) Posterior: symmetry of shoulders, supraspinatus, infraspinatus and trapezius muscle atrophy or hypertrophy, skin changes e.g. scars or hematoma. Palpation I will now be touching you. Is that ok? Signs of inflammation: warmth, swelling or tenderness Muscles and bony structure Anterior I’d like to start by palpating the surface of the sternoclavicular joint paying attention to if there is any tenderness that may suggest osteoarthritis or a trauma. Moving along through the length of the clavicle until I get to the acromioclavicular joint again assessing for tenderness, warmth and swelling. Now on to the coracoid process of the scapula in the infraclavicular fossa (move arm forward). Now on to the greater tubercle (SIT pathology) - rotate upper arm in and out. Posterior Scapular spine, borders (medial and lateral), inferior angle I would now like to ask you to brace hands on wall as I observe for any stigmata of a winged scapula which would suggest long thoracic nerve injury ROM: if significantly decreased: frozen shoulder (adhesive capsulitis) or osteoarthritis. Place patient in anatomical position. Flexion-extension-abduction-adduction-circumduction Stability Pull down on arm and look for sulcus sign which would suggest some amount of instability. Special Tests Rotator Cuff Muscles Supraspinatus: Supraspinatous muscle assists with abduction. To assess for tears I would like to perform the Empty Can/Jobe’s Test. Empty Can/Jobe Test: ask patient to “empty can” then press down on arm. Other: Drop arm Test Infraspinatus: rupture of muscle. Infraspinatus muscle is responsible for external rotation of upper arm. Ask to externally rotate limb (infraspinatus test) Teres minor: externally rotates. Hornblower’s Sign: let patient wave hi with arm at 90 degrees. SuBscapularis: Main function is to internally rotate. Lift-off Test: hand behind back giving thumbs up then ask to lift off. Other: Belly Press Test: place hand on belly and press palm on belly. Impingement Which is basically when a tendon- band of tissue- inside your shoulder rubs on nearby tissue or bone as you lift your arm. Tests that can be used: the Hawkins-Kennedy, painful arc and Neer’s which all test for subacromial impingement (Narrowed subacromial space) today I will perform the Neer’s Test. Neer’s Test (near to ear!): Internal rotation and raise patient’s arm near to their ear while asking about pain. Bicipital Tenderness Yergason’s Test (resistant supination): Locate bicipital groove- ask patient to put limb at 90 degrees and pronated- ask patient to supinate and externally rotate as you place hand on wrist AC Joint Pathology Crossover/Scarf Test: Ask pt to put hand on opposite shoulder like a scarf (this movement compresses the AC Joint) Other Pathologies: Anterior Dislocation: abduction, external rotation, unable to internally rotate Posterior Dislocation: Adduction, internal rotation, unable to externally roatate. Frozen Shoulder Osteoarthritis To complete my exam, I would examine the joint above and below, ask about prior films and/or treatment that helped/did not help. Let patient know exam is over and thank he/she, tell them got get dressed.
