Guide to Shoulder Clinical Examination
This comprehensive guide refines the shoulder clinical examination for the FRCS exam, incorporating detailed explanations and key points.
History: Briefly inquire about neck pain and its potential correlation with shoulder pain. Inquire about any history of instability (subluxation or dislocation) before performing special tests.
Inspect Posture ( Ask patient to stand up):
Observe the patient’s posture from front, back, and sides for:
Asymmetry (e.g., one shoulder drooping lower than the other).
Swelling (localized or generalized).
Scars (may indicate previous surgery or trauma).
Palpation :
Systematically feel the bony prominences: Sternoclavicular joint, Clavicle (entire length), Coracoid process, Biceps tendon and Scapular spine.
Movements:
Demonstration: Demonstrate each movement (flexion, abduction, internal/external rotation) for clear patient understanding.
Observation:Observe the range of motion in each direction.Assess for any pain or limitations during movement.
Scapulothoracic Movement: Observe abduction from both front and back to evaluate coordinated movement between the scapula and thorax.
Special Tests:
Neer’s Sign/Hawkins Test:
Neer’s Sign: Internally rotate the arm and passively elevate it in the scapular plane. Pain exceeding 75 degrees suggests subacromial impingement.
Hawkins Test: With the arm at 90 degrees of flexion and adduction, passively internally rotate. Pain indicates impingement-like discomfort.
Scarf Test: Assesses the acromioclavicular joint. Passively adduct the arm across the midline so the hand reaches towards the contralateral shoulder. Pain suggests AC joint pathology.
Speed Test: Evaluates potential biceps tendonitis. With the elbow extended and forearm supinated, ask the patient to flex the humerus as if bowling. Pain in the bicipital groove suggests biceps tendon involvement.
O’Brien Test (if indicated): Evaluates for labral tears (SLAP lesions). With the shoulder flexed to 90 degrees and adducted 15 degrees, apply a downward force on the arm with internal rotation (thumb down) and then external rotation (palm up). Increased pain on internal rotation suggests a SLAP lesion.
Muscle Testing:
Rotator Cuff: Test each muscle (supraspinatus, infraspinatus, teres minor, subscapularis) individually for strength and isolation.
Shoulder Girdle Muscles: Consider testing additional muscles if weakness or wasting is present:
Anterior: Deltoid (anterior, middle, and posterior fibers), pectoralis major.
Posterior: Latissimus dorsi, trapezius, rhomboids, serratus anterior.
Instability Tests (Sit or Lie)
Positioning: Due to potential instability concerns, comfortably position the patient either sitting or lying down before proceeding.
History: Inquire about any history of instability (subluxation or dislocation) before performing these tests.
Other common Tests:
Anterior and Posterior Drawer Tests (Toad and Shift):
Fix the scapula with one hand.
Passively displace the humeral head anteriorly (anterior drawer) and posteriorly (posterior drawer) to assess for abnormal laxity.
Sulcus Sign:
Apply traction on the adducted arm.
Look for abnormal inferior displacement of the humeral head, manifested as dimpling of the skin below the acromion, which suggests inferior instability.
Anterior and Posterior Apprehension Tests:
Anterior Apprehension Test: Abduct the shoulder to 90 degrees with external rotation to 90 degrees. Apprehension (fear of dislocation) by the patient suggests anterior instability. Posteriorly directed pressure on the humeral head relieves apprehension (relocation test).
Posterior Apprehension Test: Hold the arm in adduction and internal rotation, then apply an axial force along the humerus. Apprehension by the patient suggests posterior instability.
Additional Considerations
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- Thoracic Outlet Syndrome: If shoulder pain might be related to thoracic outlet compression, consider tests like Adson’s test (vascular) and Roos’ test (neurological) to rule out or confirm the diagnosis.
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- Adson’s Test: Extend the head and rotate it to the affected side. Abduct the ipsilateral arm 30 degrees and feel
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- Thoracic Outlet Syndrome: If shoulder pain might be related to thoracic outlet compression, consider tests like Adson’s test (vascular) and Roos’ test (neurological) to rule out or confirm the diagnosis.