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Shoulder

Expose patient down to waist

Observe patient whilst undressing

  • Comment whilst patient is undressing

Stand near examiners

Look

Clues

  • Splint
  • Sling

Anterior Aspect

Make statement regarding patient overall health

  • e.g. rheumatoid habitus
  • cushingoid
  • no obvious signs of systemic disease

Skin:

  • scars, sinuses, swelling
  • Pigmentation, Ecchymosis, Erythema

Symmetry

  • Bone
    • Clavicle, Sternoclavicular Joint, ACJ, Acromion, Coracoid Process
  • Muscle Wasting
    • Trapezius, Deltoid, Pectoral contour, deltoid, Popeye deformity(more easily seen with elbow flexed)

Posture

  • Arm internally rotated
    • Posterior dislocation

This patient has no obvious signs of systemic disease

There is no obvious skeletal deformiy, muscle atrophy or asymmetry.

There are no scars , swellings or skin changes.

Please straighten your elbow

  • There is no popeye deformity

Lateral Aspect

Please turn around sir

  • Muscle Wasting
    • Deltoid, Biceps, triceps

There are no further scars or abnormalities

Posterior Aspect

Please turn around & face the back wall

  • Skin
  • Symmetry
    • Bone
      • Scapula
        • Height
        • Winging of scapula
        • Sprengel’s deformity:
          • congenital malformation
          • scapula is smaller & carried higher than on the uninvolved side
        • Lateral scapular slide
          • Soft tissue contracture draws the dominant arm scapular away from midline, common in throwing athletes
          • ↑ 1.5cm correlates with posterior shoulder pain & anterior impingement syndrome
      • Spine
    • Muscle Wasting
      • trapezius
      • Atrophy of supra / infraspinatus fossae
        • supraspinatus
        • infraspinatus
      • triceps

There are no obvious skin changes,

there is normal symmetrical scapular contours

no wasting in the supraspinatus or infraspinatus fossae

Feel

ask patient “where is it painful ?”

stand to side of patient at 45°, so as to face patient & examiner

look at pts face whilst palpating

could you please point with one finger to where it hurts the most.

I’m going to feel around your shoulder, please let me know when it hurts.

Anterior

  • Skin:
    • Warmth
  • inflammation rarely influences skin temperature, as the joint is well covered

Bony prominences

  • SC joint
  • Clavicle
  • AC joint
    • chronically enlarged AC joint
      • painless osteophytes
      • painful ACJ arthritis
    • if you can’t find ACJ
      • pushing down on clavicle & look for motion
  • Acromion
  • Tenderness
    • os acominale is painful in overuse or trauma
      • usually non tender
    • cuff defect
  • Subacromial bursa
  • tenderness just anterior to acromion
    • Subacromial bursitis, RC impingement or tear
    • passively extend patient’s shoulder brings the subacromial bursa anterior to acromion & ↑ ease of palpation
    • passively forward flex shoulder & see if it ¯ pain
  • Anterior capsule
  • Long head biceps tendon / bicipital groove
    • IR shoulder 10 deg
    • The groove then faces anteriorly
    • Palpate 1 to 4cm distal to anterior acromion
    • Painful
      • Biceps tendonitis

Posterior Aspect

  • Spine of scapulae
  • supraspinous fossa
    • ganglion
    • Osteochondroma
    • Muscle mass
  • infraspinous fossa
  • Medial aspect of scapulae
    • Osteochondroma / bursitis

Move

  • From Front
    • 1. Abduction
    • 2. Forward Flexion
    • 3. Adduction
    • 4. External Rotation
  • From Behing
    • 5. Internal Rotation
    • 6. Scapulothoracic motion if Abduction abnormal

STAND IN FRONT OF PATIENT

TEST BOTH ARMS AT SAME TIME

  • 1. Active
  • 2. Passive
    • if Active is restricted
    • stop immediately if painful
  • 3. Power (MRC grading)

Lateral Elevation / Abduction 0 –160/180°

  • Note glenohumeral & scapulothoracic
  • Put hand on shoulder to stabilize shoulder
  • Note ROM
  • Active then Passive
    • Active
      • elevate both arms in coronal plane
      • comment on:
        • 1. initiation
        • 2. scapulohumeral rhythm
          • Scapula moving too early & creating a shrugging effect (R/C path, GH Osteoarthritis)
          • (60° Scapulothoracic, 120° GHJ)
        • 3. painful arc syndrome (impinged or torn RC)
          • Pain in midrange of abduction suggests minor rotator cuff tear or supraspinatus tendonitis
            • Ask if any pain during this movement
            • Can’t watch face from behind!
        • 4. Pain at the end of abduction (AC arthritis)
        • 5. range (160°-180°)
    • Passive (if active not restricted due to pain)
      • if not full, passive to 180° comment on:
        • active vs passive
      • Warn patient about movement
      • Hold patients shoulder & elbow
        • If passive is more than active
          • ? R/C pathology
    • Observe arm lowering comment on:
        • arc of pain
        • drop arm

Forward Flexion 160/180°

  • Active
    • both arms raised forward
    • comment on:
      • NEER’s Impingement
      • range
      • ability (trick movements)
      • check contour of axilla
  • Pathology
    • ↓ in arthritis, adhesive capsulitis, R/C tears
    • R/C impingement limits abduction more than forward flexion
    • ↑ passive over active – RC pathology, weakness of scapular stabilizers

Adduction

  • Adduction by cross body/cross chest adduction
    • Forward flex shoulder to 90deg
    • Try to touch opposite shoulder
    • Measure the distance from the cubital fossa to opposite acromion
    • Normal: cup hand over other shoulder at least, often more
    • ↓ in ACJ pathology
  • Option
    • Adduction by swinging extended arm across body (30deg)

External Rotation 45 – 90°

  • Active with shoulder adducted
    • elbows flexed to 90° and arms by side
    • start with arms forward
    • rotate arms outwards (90°)

Passive

    • if not full, passive
  • Option
    • Active with shoulder abducted 90°
      • do not do this if patient had pain on abduction!
      • arms abducted to 90° and elbows flexed 90°
      • external rotation (90°)
      • internal rotation (90°)
        • usually 20° greater in dominant arm
        • Watch for compensatory arching of back
        • In this position, it may be falsely limited in pts at risk of involuntary subluxation, dislocation
        • ↓ ER – massive RC tear
          • in massive RC tears, passive motion with ↑ ROM but pts arm will drift back on letting go

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