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Shoulder Examination for Medical Student OSCE

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Shoulder joint consists of glenohumeral joint and acromioclavicular joint; movement also occurs between scapula and posterior chest wall. Shoulder pain frequently referred to upper arm. Meanwhile, pain at the shoulder could be referred from elsewhere – cervical spine, diaphragm, and sub-diaphragm via phrenic nerve. Most commonly: cervical spondylosis (disc space narrowing and osteophytes cause nerve root impingement and inflammation).

1. Inspection – front and back, incl. axilla

   1. Deformity: dislocation – anterior glenohumeral / complete acromioclavicular joint dislocation; posterior glenohumeral dislocation harder to spot

   2. Swelling: in dislocations, proximal humeral fractures, haemarthrosis and inflammatory conditions

   3. Muscle atrophy: supraspinatus/ infraspinatus usually = chronic tear of their tendon

   4. Scapula size and position: ‘winging’ in paralysis of nerve supplying serratus anterior

2. Palpation

   1. Clavicle, from sternoclavicular to acromioclavicular joint. Deformity and tenderness caused by fractures and acromioclavicular joint injuries

   2. Acromion and coracoid processes, scapula spine, biceps tendon in bicipital groove

   3. Supraspinatus tendon: extend shoulder to bring tendon anterior to acromion. Tenderness present with

      1. Ligamentous tears

      2. Calcific tendonitis

3. Move (active before passive)

   1. Screening for shoulder dysfunction: stand behind pt, ask to put hands behind head, then down and behind to reach shoulder blades. Pain, swelling, limited movement ? full examination

   2. Range of movement:

      1. Flex + extend shoulder fully

      2. Abduction. 50-70% occurs at glenohumeral joint (the rest with movement of scapula across chest wall); to determine how much exactly, place hand on lateral clavicle and acromion. Note degree and smoothness of scapular movement. Painful arc ? test rotator cuff

      3. Internal + external rotation: arm alongside body, elbow at 90?

      4. Ability of deltoid to abduct against resistance

   3. Rotator cuff problems:

Abduct shoulder against resistance to upper arm. Weakness – tear, pain – tendonitis

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      1. Impingement: suggested especially by pain on active movement, against resistance.

Painful arc: passively abduct arm fully. Ask patient to adduct slowly. Painful arc: between 60? and 120?

If pt cannot initiate abduction: internally rotate and passively abduct to 30-45?, checking there is no scapular movement. Ask patient to continue abduction.

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      1. Ligamentous tears and injuries: tendinous tear suggested by discrepancy between active and passive ranges. Subscapularis and pectoralis major: internal rotators; with patient’s hand behind back, internally rotate ? lost power suggests tear, pain suggests tendonitis. Supraspinatus: test abduction ? loss of power – tear, pain on forced abduction at 60? – tendonitis. Infraspinatus and teres major: test external rotation with the arm 30? flexed (reducing contribution of deltoid) ? loss of power – tear, pain on forced external rotation – tendonitis

      2. Bicipital tendonitis: tenderness in bicipital groove; supinate forearm, and flex against resistance ? pain in bicipital tendonitis

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by: Admin
Total views: 0
Word Count: 720
Date: Fri, 22 Jan 2010 Time: 4:02 PM
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