Shoulder joint

Check patient details - name / DOB

Look

Feel

Explain examination
Gain consent
Expose patients upper body
Position standing
Ask if patient has any pain anywhere before you begin!

Look around bed for aids & adaptations walking stick / wheelchair / sling
Inspect patient from 3 angles:
Front
o Scars
Asymmetry of shoulder girdle - scoliosis / arthritis / previous trauma
Swelling - inflammatory joint disease / trauma
Muscle wasting deltoids
Side
o Scars previous joint operations / trauma
Muscle wasting - deltoid
Alignment of shoulder girdle misalignment noted in shoulder
dislocation/scoliosis
Back
o Scars previous surgery / trauma
Trapezius assess symmetry and observe for any wasting of the muscle
Para-vertebral muscles - note any wasting
Scapula assess symmetry asymmetry noted in winged scapula
serratus anterior paralysis
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 & medial to the clavicular tip
Head of humerus
Greater tuberosity of humerus
Spine of scapula

Palpate muscle bulk of deltoid note any wasting pathology/ligamentous injury

Move

Active movement
o Ask the patient to perform each of the following movements (note range of
movement)
o Flexion raise your arms forward above your head 150-170
o Extension straighten your arms backwards as far as possible - 40
o Abduction move your arms away up from the side until they point at the
ceiling - 160-180 (pain at 60-120 may indicate impingement syndrome)
o Adduction move your arm across your body as far as you can 30-40
o External rotation hold elbows to your body flexed at 90, then move apart in
an arc motion 70 (adhesive capsulitis (frozen shoulder) has reduced
external rotation)

Internal rotation move your arms back across your body, keeping your
elbows at your side 70

Passive movement
o Ask the patient to fully relax and allow you to move their arm for them.
o Warn them that should they experience any pain, to let you know
immediately.
o Repeat the above movements passively - feel for any crepitus during the
movement of the joint

Function
Put your hands behind your head - external rotation + abduction
Put your hands as far up your back as your can - internal rotation + adduction
Rotator cuff strength (empty can test)
Special Tests
The Painful Arc
o Ask patient to abduct their arm whilst you apply light resistance
o Pain in early abduction (40-120) suggests a rotator cuff lesion / inflammation
o This finding is often associated with supraspinatus tendonitis / rupture
Gerber lift off test (Internal rotation against resistance) This clinical test assesses
the function of the subscapularis muscle
o Ask the patient to place the dorsum of their hand on their lower back
o Apply light resistance to the hand (holding it against their back)
o Ask the patient to move their hand off their back by internally rotating their
shoulder
o An inability to do this indicates damage to subscapularis (e.g. ligamentous
tear)
External rotation against resistance. This clinical test assesses the function of
infraspinatus & teres minor
o Ask the patient to position their arm in the neutral position by their side
o Ask the patient to externally rotate their shoulder whilst you apply light
resistance
o Pain on resisted external rotation suggests infraspinatus / teres minor
tendonitis
o Loss of power suggests a torn infraspinatus / teres minor ligament
o To complete the examination:
Thank patient
Wash hands
Summarise findings
Say you would:
Do full neurovascular examination of the upper limbs
Examine the spine and elbow joint
Take plain radiographs of the joint if indicated
Empty Can Test
o Abduct the arm to 90 in a scapular plane with thumbs pointing up
o Patient pushes up against resistance
o Repeat with thumbs pointed down as if emptying a can
Scarf Test
o Pain may be indicative of OA of the AC joint

The history for the shoulder joint should include the following enquiries:
pain:
o determining the onset (acute, sub-acute, recurrent), site, nature, exacerbating
and relieving factors and any associated symptoms of the pain.
o may be referred from the cervical spine, myocardium, mediastinum or
diaphragm
o joint pain is felt anterolaterally at the insertion of deltoid from which it may
radiate down the arm
o pain on top of the shoulder may particularly suggest acromioclavicular or
cervical spine disorders
o specifically enquiring about the relationship of the pain to movement. Does it
occur at rest?
o is the shoulder pain nocturnal?
o while nocturnal pain may be due to difficulty finding a comfortable sleeping
position, consider nerve root pain, bony pain or malignancy, particularly if
there is a history of cancer and/or systemic symptoms
stiffness
deformity
o prominence of the AC joint or winging of the scapula
loss of function:
o what activities are impaired e.g. may be difficulty reaching behind the back,
combing the hair or dressing
o what is the impact on function of the joint? Is the dominant or non-dominant
arm affected?
Other issues that should be covered include
o are any other joints affected?
o enquiring about tasks undertaken at work and sporting activities.
o enquiring about systemic symptoms of illness (fever, night sweats, weight
loss, generalised joint pains, rash, new respiratory symptoms)
o enquiring about whether there is a past history of shoulder pain or other
musculoskeletal problems - what was the response to treatment?
o enquiring about significant co-morbidity (diabetes, stroke, cancer; respiratory,
gastrointestinal, or renal disease; ischaemic heart disease)
o checking current drug treatment and adverse drug reactions
o Past history of carcinoma
o Constitutional symptoms, e.g. fever, chills, or unexplained weight
o Recent bacterial infection
o IV drug use
o Immune suppression
o Constant/worsening rest pain
General rules
Intra-articular diseasepainful limitation of movement in all directions; tendonitispainful
limitation of movement in one plane only; tendon rupture or neurological lesionspainless
weakness.

Osteoarthritis of the Shoulder

Common symptoms include:
Sore or stiff joints particularly the hips, knees, and lower back after inactivity or
overuse.
Stiffness after resting that goes away after movement.
Pain that is worse after activity or toward the end of the day.
Frozen Shoulder
Affects patients aged 4060y.
Painful stiff shoulder with global limitation of movementnotably external rotation.
Pain is often worse at night.
Cause unknown but in diabetics and those with intra-thoracic pathology (MI, lung
disease) or neck disease.
Rotator Cuff
Rotator Cuff impingement syndrome:
rotator cuff muscle tendons pass through a narrow space between the acromion
process of the scapula and the head of the humerus
symptoms include pain, weakness and loss of motion
anything which causes further narrowing of this space can result in impingement
syndrome
clinical features:
o pain, weakness and loss of motion are the most common symptoms reported
o pain is exacerbated by overhead or above-the-shoulder activities
o a frequent complaint is night pain, often disturbing sleep, particularly when
the patient lies on the affected shoulder
o onset of symptoms may be acute, following an injury, or insidious, particularly
in older patients, where no specific injury occurs
o there may be a grinding or popping sensation during movement of the
shoulder
o range of movement may be limited by pain
o a painful arc of movement may be present during forward elevation of the
arm from 60 to 120
o passive movement at the shoulder will appear painful when a downwards
force is applied at the acromion but the pain will ease once the downwards
force is removed