The
shoulder
The examination of the shoulder is most easily performed if the patient
is standing with their shirt and vest removed. It is not necessary to remove the
brassiere.
Look
Look at the patient standing both from in front and from behind.
Skin
Look for scars. Check in the axilla for sinuses.
Soft
tissue
Check for wasting of the deltoid (increased angularity of the shoulder)
(Fig. 20.26). This is commonly caused by damage to the axillary nerve during an
anterior dislocation of the shoulder.
Wasting
of the supraspinatus and infraspinatus (hollows above and below the spine of the
scapular) occurs with a tear of the rotator cuff. Check for a bulge low in the
upper arm which is especially prominent when the patient flexes their elbows.
When the long head of the biceps ruptures the body of the muscle retracts back
down the arm.
Use
the other side of the patient’s body for comparison.
Bone
The commonest deformity is a subluxed acromioclavicular joint, which
appears as a prominent lump on the distal end of the clavicle (Fig.
20.27). An
anterior dislocation of the shoulder itself is first noticeable because of the
loss of the rounded contour of the shoulder. The bulge in front of the shoulder
(the humeral head lying anteriorly) is easier to see when you start looking for
it. Otherwise, it can easily be masked by the swelling of the acute injury.
Feel
Problems in the shoulder can be referred from the neck or arise from the
shoulder complex itself.
The
epaulette sign
Before starting the examination, ask the patient to show you where they
are feeling pain. If they are able to localise the pain with the tip of one
finger then the pathology is probably in the shoulder. If, however, they rub the
whole hand over the top of the shoulder then the pain is likely to be referred
from a lesion in the neck. The patient rubs their hand over the position of
epaulettes on a soldier’s uniform, hence the name of the test.
Localisation
in the shoulder
Within the shoulder complex problems commonly arise either from the
acromioclavicular joint, from problems in the rotator cuff including the
subacromial bursa or from the glenohumeral joint itself. The examination should
be designed to distinguish between these possibilities.
Skin
Feel for heat. Test distally for loss of sensation, comparing soft touch
on both sides. Test the outer and inner side of the upper and lower arm, then
the medial and lateral side of the hand.
Soft
tissue
Feel the trapezius muscle for tenderness (common in referred pain from
the neck). Tenderness under the margin of the acromion suggests problems with
the rotator cuff complex.
Bone
Feel along the clavicle starting at the sternoclavicular joint palpating
for tenderness, particularly at the junction of the clavicle with the acromion.
Palpate the outlines of the acromion and feel for tenderness immediately
beneath the acromion in the subacromial bursa starting anteriorally, moving
laterally and finishing posteriorally. Note any tender sites.
Move
Active
Ask the patient to put their hands first behind their head, and then
behind their back. These two movements effectively test the functional range of
movement in the shoulder. Record how far they can reach towards the back of
their heads and up their backs.
Stand
behind the patient and ask them to raise both arms from their sides out
laterally and 300 forward (in the plane of the scapula) vertically up above
their heads. Watch the movement of the scapula in relation to the humerus.
There should be a scapulohumeral rhythm. In the first part of abduction the
scapula moves very little, perhaps only 10 for every 20 that the humerus moves.
In the second part of movement the scapula and humerus tend to move almost
together. That is a normal rhythm. Note if there is a catch in this movement,
and ask them to point where they experience pain if they get a catch. Pain under
the lower margin of the acromion suggests an impingement.
Passive
With their arms at their sides, flex their forearms to 900 pointing
their hands straight forward. Put one hand on the shoulder joint and use the
other hand gently to turn the forearm outwards externally rotating the shoulder.
Crepitus in the shoulder suggests arthritis in the glenohumeral joint. Pain and
complete stiffness is associated with adhesive capsulitis (frozen shoulder).
Stability
Thumb-down test. This test is specific for problems of impingement and
inflammation in the subacromial bursa.
Apprehension
sign. The shoulder commonly dislocates anteriorly when the arm is above the head
and externally rotated. If the patient has ever experienced a previous
dislocation,
putting the patient in that position makes them feel as if the shoulder is about
to dislocate (Fig. 20.29). Only do this test gently, and watch the patient’s
face. You do not want to dislocate the shoulder.
Sulcus
test. In patients who have had a previous dislocation the shoulder joint tends
to be lax. Drawing down on the patient’s arm when they are relaxed allows the
humerus to drop away from the acromion, producing a sulcus (groove) in the
unstable shoulder which is more prominent than on the normal side (Fig.
20.30).