Look

Look around bed for aids & adaptations e.g. a sling

Inspect the patient

Anterior
Scars previous surgery / trauma
Asymmetry of the shoulder girdle scoliosis / arthritis / trauma
Swelling inflammatory joint disease / effusion
Muscle wasting deltoids axillary nerve injury / chronic joint disease

Lateral
Scars previous surgery / trauma
Muscle wasting deltoid
Alignment of shoulder girdle misalignment dislocation / scoliosis

Posterior
Scars previous surgery / trauma
Trapezius assess symmetry / wasting
Para-vertebral muscles note any swelling / wasting
Scapula assess symmetry e.g. winged scapula (long thoracic nerve injury)

Feel

Assess temperature of shoulder joints warmth may suggest inflammatory

arthropathy/infection

Palpate the various components of the shoulder girdle (note any swelling / tenderness)
Sterno-clavicular joint
Clavicle
Acromio-clavicular joint
Coracoid process 2cm inferior & medial to the clavicular tip
Head of humerus
Greater tuberosity of humerus
Spine of scapula

Move

Active movement

Ask the patient to perform each of the following movements.

Compound movements (screening)

Compound movements are often used as a rapid screening tool for shoulder joint pathology
as they test a number of the rotator cuff muscles in one go. If the patient experiences pain or
is unable to perform these movements you would then proceed to perform a more detailed
examination of the shoulder joint as shown in the Full shoulder examination section below.

Put your hands behind your head external rotation + abduction

Put your hands as far up your back as your can internal rotation + adduction

Full shoulder examination

Flexion ask the patient to raise their arms forwards until they points upwards 150-170
Extension ask patient to keep their arms straight and extend them behind them 40
Abduction ask the patient to lift their arms away from their sides as far as possible 160-
180
Adduction ask the patient to bring their arms across their trunk to the opposite sides 30-
40
External rotation ask patient to hold their elbows to their body flexed at 90 and then move
their forearms outwards in an arc-like motion 70
Internal rotation with the patients elbow flexed at 90 (arm by their side) ask them to place
their hand behind their back and reach as far up the spine as they can manage Average =
T5

Assess the movement of the Scapula:

Ask the patient to abduct their shoulder
Simultaneously palpate the inferior pole of the scapula
Assess the degree and smoothness of movement of the scapula
Normally 50-70% of movement occurs at the glenohumeral joint

If the glenohumeral joints movement is reduced due to injury / inflammation then the majority
of abduction will occur via increased scapula movement over the chest wall.

Active shoulder flexion.

Active shoulder extension.

Active shoulder abduction.

Active shoulder adduction.

Active shoulder external rotation.

Active shoulder internal rotation.

Assess movement of scapula during abduction (degree of movement & smoothness of

motion)

Passive movement

Ask the patient to fully relax and allow you to move their arm for them.
Warn them that should they experience any pain to let you know immediately.

Repeat the above movements passively feel for any crepitus during movement of the joint

Passive shoulder flexion.

Passive shoulder extension.

Passive shoulder abduction.

Passive shoulder adduction.

Passive internal rotation of the shoulder.

Passive external rotation of the shoulder.

Special tests

Supraspinatus assessment

This clinical test assesses the function of supraspinatus.

1. Ask the patient to abduct their shoulder from the neutral position against resistance.

2. Loss of power suggests a supraspinatus tear. Pain in early abduction suggests tendonitis.

Assess Supraspinatus - early abduction against resistance

The Painful Arc (Impingement syndrome)

This clinical test assesses for impingement of supraspinatus.

1. Passively abduct the patients arm to its maximum point of abduction.

2. Ask the patient to lower their arm slowly back to a neutral position.

3. Impingement / supraspinatus tendonitis typically causes pain between 60-120 of

abduction.

Passively abduct the patient's arm.

Ask them to slowly lower their arm. Pain felt between 60-120 degrees of abduction suggests
impingement.

External rotation against resistance

This clinical test assesses the function of infraspinatus & teres minor.

1. Position the patients arm with the elbow flexed at 90 and the shoulder flexed at 30
(reducing contribution of deltoid).

2. Ask the patient to externally rotate their shoulder whilst you apply light resistance.

Pain on resisted external rotation suggests infraspinatus / teres minor tendonitis.

Loss of power suggests a torn infraspinatus / teres minor ligament.

External rotation against resistance.

Internal rotation against resistance (Gerber lift off test)

This clinical test assesses the function of the subscapularis muscle.

1. Ask the patient to place the dorsum of their hand on their lower back.

2. Apply light resistance to the hand (pressing it towards their back).

3. Ask the patient to move their hand off their back.

4. An inability to do this (loss of power) indicates damage to subscapularis (e.g. ligamentous

tear).
Internal rotation against resistance (Gerber's "Lift off" test).

To complete the examination

Thank patient
Wash hands
Summarise findings

Suggest further assessments & investigations

Full neurovascular examination of the upper limbs
Examine the spine and elbow joint (joint above & below)
Perform further imaging if indicated e.g. X-ray / MRI