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. The patient is asked to flex the shoulder to just under 900 in the plane of the scapula (laterally and 300 forward). With the patient holding their arm straight out in this position, push down gently on the arm so that they have to maintain the position against resistance (Fig. 20.28). If they experience sharp pain in the subacromial area they have an impingement problem.

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).